Salvage prostatectomy and lymph node dissection after failed radiation.

Yarbo3 said...
My Gallium scan revealed two positive nodes

If the scan did not show any tumor in the prostate it is very likely that the two mets are the only cause of the PSA rise.

I would kill the two mets first with SBRT radiation and see what the resulting PSA is before having a a prostatectomy done. If you have lymph node mets now it is very likely that new ones will appear in the future. So the prostatectomy may turn out to be futile.

George

Did you have the pelvic nodes radiated by the IMRT? You dx is very similar to mine. Looks like a tough situation, one that I have wondered about in my own situation.

My initial reaction is that the disease is probably systemic and the removal of only two nodes and what remains of the gland may not solve the problem. Generally if two nodes show to be involved there are micro-mets elsewhere that just aren't showing up yet. It is difficult to remove all the nodes and then side effects of lymphedema become very real. The salvage prostatectomy is also a concern as I would think the prostate and bed were significantly ablated and unlikely to be where the cancer is. To my uneducated eye this looks like a lot of serious and difficult cutting that may not bring the desired results.

I find it interesting that Dr. Karnes has such extensive experience with hundreds of salvage surgeries. He certainly can provide a lot of information on post operative results. How often have these resulted in a cure? How often have the men needed to go on to other forms of drug therapy (ADT, chemo, imuno) because the salvage surgery didn't work? Has he done salvage work following the doctors you used for the initial radiation therapy? Has he reviewed your detailed radiation delivery treatment plan to determine why it might not have been effective? I would want to get as complete as possible an assessment of all this before I went under the knife.

Have you spoken to any medical oncologists? Dr. Kwan is well regarded at Mayo and no doubt Karnes works with him. I am aware of one of the HW members being treated by Dr. Kwan for metastatic disease that had surgery following chemo and ADT, but I don't remember him having radiation as a primary treatment.

Best wishes on all this and do keep us posted.

I understand that following whole gland radiation often there is some live prostate tissue left., but my understanding is that it is altered such that it doesn't express much PSA and rarely becomes cancerous. I have been PSA undetectable and have a little bit of ejaculate, so I assume some limited gland function. I understand this to be normal for radiation treatment.

If the cancer is outside the surgical field (prostate and the two nodes) then it would continue to grow in spite of the surgery. He appears to be counting on all or most of the cancer being confined to the surgical area.

Tall Allen has written about pelvic nodes removal. In the US it is not normal, though in Europe I understand that it is. I have not seen where the results are any better. But, I would defer to him on the subject.

I think the only way you will know whether the nodes can be radiated by SBRT is to speak with a SBRT radiation oncologist. For example, my wife has had breast cancer twice in the same breast. With the first she had a lumpectomy and whole breast radiation. The second was 14 years later and unrelated to the first. This time she underwent a mastectomy and some targeted radiation to a few spots the surgeon was suspicious of. A number of ro's said they wouldn't radiate because of the previous radiation. So we were referred to a cutting edge ro that developed a plan. He first got all the detailed records of the previous radiation and considered the passage of time between radiation therapies and developed a plan. That was more than six years ago and she is doing fine with no evidence of cancer.

Regarding potential life extension of salvage surgery, again I would defer to Tall Allen as to the studies that could provide you with direction. Generally it is difficult to get insurance to cover such procedures once it is shown you have metastatic disease. Have you gotten an insurance determination for the surgery?

Why are you having a prostatectomy if you have no detectable cancer in your prostate? That sounds kind of crazy to me.

Please look at your radiation treatment plan and report back exactly what was treated and to what dose level. This is called the "planned target volume (PTV)? There may have been two PTVs - one for the entire pelvic lymph nodes area and another for the prostate plus a margin around it. If your entire pelvic LN area has already been treated up to a dose of say 50-55 Gy, you cannot have more radiation there. The probability of bowel toxicity/fistula is too high. And the probability that it would accomplish anything is low anyway. If you have not had radiation to the entire pelvic LN region, it can still be done.

Another possibility at Mayo is extended pelvic LN dissection, which can be done laparoscopically. Mayo is one of few places that does this in the US.

There is no known value in zapping only LNs that you can see. You have to treat what you can't see as well. When metastases occur, and they probably occurred long before you were ever treated, microscopic metastases go everywhere. They harbor in some places and get big enough to detect eventually and cause PSA to rise. In other places they are too small and don't put out much PSA. The only way to reduce the undetectable metastases is with androgen deprivation.

If your Ga68PSMA PEt was negative, it is highly doubtful that there is anything there. If you want to have a biopsy to make sure, there is no decision to be made until you see the results. The thing you must know before any decision can be made is exactly what was treated before. Were your pelvic lymph nodes already treated? What does it say on your treatment plan?

Yarbo said...
If treating lymph nodes sometimes put patients in at least long term remission I have to proceed with it as a viable gamble.

There is not ANY evidence for that (there is a big randomized clinical trial of salvage RT to the pelvic LN area, but we won't have results for years). I don't think there is much hope if you treat only the obvious LNs - almost all guys (85%) who've tried that strategy were diagnosed with distant mets within 5 years. There may be more hope if the whole field is treated - just my guess.

Understand that detectable metastatic progression is almost always very slow at first. And with the new PET scans, there seems to be an even longer interval because they are detected earlier. It may be years before another pelvic LN becomes detectable, whether you treat some or not. That's why randomized clinical trials have to take so long.

Sorry, I wish there were more evidence to help base a decision on.

Michael,

here are a few studies which may be of interest to you:

Impact of Adjuvant Radiotherapy on Survival of Patients With Node-Positive Prostate Cancer
Management of Node-Positive and Oligometastatic Prostate Cancer
Management of prostate cancer patients with lymph node involvement
Management of Node Only Recurrence after Primary Local Treatment for Prostate Cancer
Metastasis-directed Therapy of Regional and Distant Recurrences

George

No - you need more info than that. You can just call your RO's office and ask them to email you a copy of your treatment plan.

The study links from George indicate that treatment of recurrence in lymph nodes with dissection and/or RT after failed primary treatment can reduce progression and consequently the need for Systemic treatment for selected individuals and is worthy of additional study. These studies DO NOT say such treatment is useless ; they say more study of larger groups is necessary in order to change the standard of care.
In my view any treatment that is not unacceptably toxic and delays the need for systemic treatment is absolutely worthwhile!
Bob

Thank you Allen,

It's encouraging my decision make sense to you and others here.

When I spoke to Dr. Karnes over the phone he mentioned that someone did some data work and came up with thought that the procedure does, on average extend life by a year, with some people receiving more benefit, up to possible cure. I'm not sure who or where that calculation was done.

There are so many conflicting sentiments out there it's impressive but I trust and agree with known fact and data. I am a cause and effect guy myself (it's the way I fix machines, enjoy science and raise my family in happiness) and I highly appreciate you making the muddy windshield clearer with your wiper blade swipes of current data and clear thinking.

I just had some lab tests done. My testosterone is at 890, the highest it has ever been. I wonder why? Recently I went on a strictly vegan, high fresh vegetable juice, half assed version of a Gerson diet, to see if it could effect PSA progression. It had little if any effect but could it have affected testosterone level? I have been kinda depressed, stressed out and fairly physically static lately. Maybe that's why the level is higher. I understand prostate cancer can create its own testosterone but at my PSA level I can't imagine it would read out in a lab test. More testosterone is not what I need right now.

MyPSA is now at 3.14. I now have a doubling time of 3.7 months. Not good, I know.

Do guys with higher levels of testosterone tend to have shorter doubling times / more aggressive disease?

Many thanks to all,

Michael