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Salvage radiation-with or without nodes

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Posted 2/6/2017 2:04 PM (GMT 0)
Hello All, I am to start salvage radiation seven years after RRP. Please help me decide whether I should go for pelvic bed+ hormones or whole pelvic + hormones. I have already started cassadox and luprone and am scheduled for IGRT in mid Feb. RO has left the decision if nodes to be included or not on me. I am 63 and physically very fit, fully content and not bothered about eretion etc, only worried of QOL and side effects, if nodes are radiated.Please help.
Posted 2/6/2017 4:06 PM (GMT 0)
Since there was no confirmation my PC was out of the bed, my Doc's did not want to target anything other than the bed. They were not the most aggressive in treatment protocols but without confirmation their thoughts were understood and welcome because if left up to me I would have sat on a nuclear reactor to kill those suckers! Just make sure your fight/flight response is in check, and make your decision based on all the data you can gather... there is no perfect answer, good luck!
Posted 2/6/2017 4:30 PM (GMT 0)
I was in the same situation and my RO gave me the same choice .... and said radiating the nodes would not increase the side effects, so I had it done. My case was may have been different as I did have a positive margin and was not given cassadex or lupron.
Posted 2/7/2017 1:35 AM (GMT 0)
I had SRT 7 years post radical prostectemy. I ended up radiating prostate bed plus nodes. I was a Gleason 8 so we were aggressive. Side effects were stomach issues and fatigue. Back to the new normal now.
Posted 2/7/2017 2:15 AM (GMT 0)
How many LNs did they already dissect?
Posted 2/7/2017 3:24 AM (GMT 0)
Allen, no node dissection. Going for salvage radiation and want to know if I should get the whole pelvic radiation or just prostate bed. RO has left this on me and I want your and other experts opinion about this.
Posted 2/7/2017 4:32 AM (GMT 0)
I asked because you wrote "pT3aN0M0." I guess you meant NX.

Well then, if you were trying to figure out your odds of LN invasion based on your Gleason score and initial PSA, it would be 2/3 x 8.4 + (7-6)x10 = 5.6 + 10 =15.6%. Roach recommends LN radiation when your odds are over 15 - so you are right at the cusp (no clear decision from that). Your PET/CT showed no enlargements there, so it seems to be clear. That's about all I can tell you. I see why your doctor left it up to you - only you can decide if that risk of cancer there is worth the risk of SEs from the radiation.
Posted 2/7/2017 8:00 AM (GMT 0)
ksk, I'm definitely not an expert but my RO mentioned that radiating nodes increases the risk of short-term side effects, e.g., diarrhea, if only because more of the digestive tract is exposed to radiation. This appears to conflict with what Ravineman430's doc told him (and presumably, R430 didn't have any serious side effects or he would have mentioned them).

It is difficult when the doc won't recommend one way or the other. You might want to get a remote second opinion from Johns Hopkins. If you can wait a few weeks and can afford the $550 fee, they will look at your case and give you an opinion that might help you sort this out.

Tomson
Posted 2/7/2017 8:21 AM (GMT 0)
TA,
Is that formula based on Gleason and pre-RP PSA score valid in figuring the odds of LN invasion seven years after the fact? I don't understand very much about the natural progression of PCa, but wouldn't the likelihood of nodal involvement go up over time even if the prostate is gone, in which case, the 15.6% may be an underestimate of ksk's odds of LN invasion today?
T
Posted 2/7/2017 1:51 PM (GMT 0)
I had Gleason 4+3, with perfect pathology - everything contained, and 18 nodes were removed during surgery, all negative for PCa. I had IGRT done last year and only the prostate bed was irradiated. Dr said why risk more side effects, both immediate and potential latent ones as well, when you have a good chance of getting all of the cancer cells. I figured that if my cancer returns, I would wait until PSA increased high enough for a full body scan and then deal with any suspicious nodes via radiation or surgery.
Posted 2/7/2017 6:09 PM (GMT 0)
Tomson-

I don't know if it goes up. I would guess that the risk goes down because there has been no indication of progression to the pelvic LNs in 7 years, and there were no enlarged nodes on the PET/CT. So there is no evidence that it has spread beyond the prostate bed. The Roach formula is used for the pre-RT decision as a first line therapy. There are no nomograms that I'm aware of for predicting LN involvement at the time of salvage RT, so I'm using what we have. Certainly, rapidly rising PSA and LN enlargement would be risk factors, and ksk is showing neither. There is a randomized clinical trial of salvage RT with PLN that will someday fill in the information gap.
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