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Posted 6/14/2016 1:45 PM (GMT 0)
My husband had his 3t MRI on Thursday of last week with Dr. Busch. On Friday Dr. Busch met with us for over an hour. He identified two very tiny suspicious lymph nodes. Because of a hip replacement, there were areas the test could not see. Dr. Bush was very direct about how serious it is, which we knew. He offered a bit of a different viewpoint, which my husband liked. He suggested having the lymph nodes mapped with a Ga-68-PSMA and then to have those that are malignant removed. He seemed a little more cautious about ADT due to how quickly some 8-10s become resistant. He also seemed to prefer targeted radiation to mets rather than radiating the entire pelvic bed if we decide to go the radiation route. He is consulting with our surgeon at Hopkins and we should have the next recommended step by the end of the week. I realize that Drs. Busch and Ross know far more about aggressive PCa than we do, and that the decision on how to proceed will ultimately be up to my husband.

From what I understand, typically the next steps would be to start ADT and get scheduled for adjuvant radiation, so I am again asking for your opinions. I tend to be aggressive and pro-active in situations like this. My husband is much more laid-back and usually goes with the flow. Thank you again for being here.
Posted 6/14/2016 2:18 PM (GMT 0)
It might be worth using the PSMA scan to try and spot the source of that PSA 0.86. If they can spot something, then SBRT radiation, also known as Cyberknife, can be used to zap the identified areas without surgery..If the cancer seems to be confined to the prostate bed area then standard SRT + ADT is probably the way to go...
Posted 6/14/2016 7:25 PM (GMT 0)
There were 54 pelvic LNs removed, and there are more left to map? I've never heard of that many pelvic LNs removed before - is that number right? Did he have side effects (lymphocele, lymphedema) from the removal? I guess there's no point in whole pelvic radiation after that many were removed. And when he says there are "very tiny" ones -- how tiny? LNs are only suspicious on an MRI when they are enlarged. Anything under 8 mm is not considered suspicious, 8-11 mm is borderline, and 12 mm or more is considered to be enlarged. Enlarged doesn't mean cancerous, of course.

With all those risk factors, it is likely in the prostate bed as well. If you are going for curative treatment, I would not take that off the table. I don't see the purpose of further "mapping" imaging because it only identifies metastases big enough to see. For every met you can see there are many more cancer cells you can't see. So if you are going for the cure, you have to also treat what you can't see.

However, I do see value in ruling out that the cancer has spread distantly. That is a distinct possibility when there is SVI, a GS9, post-RP PSA already that high, and suspicious LNs after ePLND. If there is evidence of distant mets, he doesn't have to be put through the side effects of salvage radiation, but can skip to managing the disease with ADT only.

Why not get a second opinion? Have you talked to other radiation oncologists?

- Allen
Posted 6/14/2016 9:55 PM (GMT 0)
Tall Allen, from the path report:
lymph node, right pelvic (dissection)
17 lymph nodes and associated fibroadipose tissue, negative for tumor
lymph node , left pelvic (dissection)
36 lymph nodes and associated fibroadipose tissue, negative for tumor
Lymph node, anterior fat pad (excision)
1 lymph node and associated fibroadipose tissue negative for tumor
Pelvic Lymph Nodes (includes all parts): All 54 lymph nodes are negative for tumor
Extent of Invasion (7th Edition, AJCC)
pT3a: Extraprostatic extension or microscopic bladder neck invasion
pN0: No regional lymph node metastasis
Seminal vesicle invasion: none

No side effects so far. Size suggested was <5 mm - two very tiny pinpricks of light on the scan in the pelvis. As far as we know, NED on the rest of the scan. My husband has a call in to verify that. The dx radiologist has been highly recommended by some PCa forum members and has (according to my husband) one of the latest German made MRIs that can detect 5mm nodes. The dr. also mentioned that The Netherlands has a machine that can map even smaller amounts.

We're not taking anything off the table yet, and I appreciate your insight. We are waiting for this week's PSA result and then expect to consult with the surgeon, the surgeon's med/onc and the dx radiologist to see what they recommend. My husband has contacted Dattoli but hasn't sent them any records yet. I have been looking into the Prostate Oncology Specialists in Marina del Ray as a possible option for a second opinion. I am open to any suggestions. Thank you!
Posted 6/15/2016 1:42 AM (GMT 0)
Dr. Busch just called tonight. He and Dr. Ross agreed on one positive lymph node on the 3t mp MRI scan. Unfortunately, it is above the navel. Dr. Busch feels there are probably several more. My husband will talk to Dr. Ross about a clinical trial for the gallium test tomorrow. If my husband qualifies, both Drs. agreed to go that route and spot radiate what they find. They both want to hold off on lupron for a month until the testing is done. If my husband cannot get into the Hopkins trial, Dr. Busch said he can get him into a very similar trial in San Francisco. Asking prayers and thank you for your help and concern.
Posted 6/15/2016 3:19 AM (GMT 0)
That was a very thorough pelvic LN dissection!

If the size of the LN was <5 mm on an MRI, I'm very surprised that anyone would deem that suspicious. That's about as small as they come. I know you have confidence in the radiologist, but it never hurts to send it out for a second opinion.

I think you should talk to a radiation oncologist rather than a medical oncologist for a second opinion. Save the medical oncologist for when you're managing the disease rather that trying to cure it. I'm sure there are good ones locally, or at least at Vanderbilt or Emory who has the experience you need.

- Allen
Posted 6/15/2016 12:34 PM (GMT 0)
Since you mention the Netherlands, here is one experience with it. After failed salvage radiation the MRI at Radboud identified mets down to 4 mm in the common iliac and para-aorta areas. Used IMRT on those areas on the theory that a more focused approach might miss any smaller mets in the area, along with adjuvant Firmagon for four months. Once the Firmagon wore off my PSA started rising fairly rapidly. Did the MRI and resulting treatment knock back the cancer and give me more time--maybe (and I don't think I lost much in terms of side effects), but, as forum members on another site said in advance, the cancer (and yours is more advanced) was almost certainly systemic so any try for a cure probably needed to be systemic.
Posted 6/15/2016 10:39 PM (GMT 0)
Your case lends itself to call Dattoli Cancer Center in Sarasota where Dr Dattoli regularly treats mets in lymph nodes with great results. He treated all my pelvic nodes when two suspicious nodes were found on scan. So far so good.
Bob
Posted 6/16/2016 12:14 AM (GMT 0)
Thank you, Bob. My husband has been in touch with Dattoli and we do plan to get an opinion from them once all the testing is complete. He spoke with his surgeon today. The surgeon mentioned possible hot spots near the sacrum based on the scans Dr. Busch sent him. He did not mention the node above the navel and I was at work so could not remind my husband to ask. He is planning on getting my husband into the 68 gallium PSMA testing (my husband thinks - he does not ask the questions I would). We should know more Friday. PSA rose to 1.39 in three weeks time so I am anxious to get something underway.

Cigafred, thank you for sharing your experience. Dr. Busch had mentioned that he felt systemic treatment would be necessary.

Tall Allen, we will most likely be getting a second opinion from Dattoli. I think, though, that Dr. Ross has reviewed the scans and pretty much agrees with Dr. Busch. We should be traveling to Hopkins in the next week or two. At that time, we will also meet with a med/onc Dr. Ross is recommending. I think chemo may be suggested. Thank you for your help. I'm sure I'll be back with more questions soon.
Posted 6/16/2016 4:48 PM (GMT 0)
Just an update that my husband was accepted and we will be heading to Hopkins for tests scheduled for next Friday and to meet with a radiation oncologist. Thank you for all your support.
Chris
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