IMRT to pelvic lymph nodes after recurrence. Looking for info.

I've found various postings on this site (ptrs listed below) that discuss about pelvic IMRT
related to spread of pca to pelvic lymph nodes and those discussions and pointers
to studies and articles within them have been helpful.
(although it is hard for me in general to understand the wording and
terminolgy used in studies)

But since standard of care or practice sometimes changes, or that new studies
appear with perhaps different conclusions, am hoping its ok to ask your views
on what your understanding of the latest view of pelvic
imrt pros and cons for recurrent patients for which pca has spread to pelvic
lymph nodes, since the possibility of this treatment has been presented to me
due to recent spread of recurrent pca to pelvic lymph nodes as per imaging.

about my own situation:

a. I had IMRT previously done in 2011 to prostate and seminal areas
only as the primary treatment 6 years ago; no surgery has happened.
G7(4+3) 4 cores. There was 79Gy done for the imrt.

b. now its spread to multiple pelvic areas and higher toward chest -

axumin report says its focused on the para-aortic area - from the axumin report - left periaortic,
aortocaval and paracaval regions extending from below the level of the renal
vessels to the bilatieral common iliac regions. Also near left common iliac
lymph node, and perhaps near bilateral inguinal lymph nodes, and at left
posterior perirectal lymph node. (to say the least this report has been a
shock and I realize this is extremely bad news)

(Axumin scan is rather new to the center that did it and the dr who read it
was new to the center and had just read a few so I don't know how that
impacts accuracy of what they saw and wrote in report.)
Nothing was seen about spread to bone but again, I don't know about validity of scan in context of dr reading it being new.

c. psa was about 5.0 at time of axumin scan.

e. med onc suggests adt and that has recently started, and to look into possibility of pelvic imrt.
Dr. is clear that long term adt is needed in any case, there will be no chance
for intermittent.

d. I don't think spot radiation to just a few areas would be applicable since these are more areas than whats usually done,
if I'm understanding other articles/postings have read ?
(but I might be not understanding enough about differences between sbrt and imrt)

e. From what I've read - there can be concern with pelvic imrt in context
of how wide the field might need to be and what side effects might happen
in that context and in/near the areas radiated.
(and related to myself, the spread is higher than just to pelvis)


Thus to summarize my questions:

1. What is the latest view of pelvic imrt (or sbrt) for recurrence being helpful or not,
and pros/cons of pelvic imrt or sbrt in context of someone with pca recurrence
and in context of the large areas of spread to those multiple lymph nodes listed above in my situation ? (including that some spread is higher up than just pelvis itself)

or if that info is still the same as in some/all of the previous postings mentioned here, just let me know which of those are the ones to re-read.


2. What kind of side effects might happen in context of imrt to the pelvis and in areas
its spread to higher up than that as per my situation ?
I realize there could be many areas like stomach, digestive, rectal, etc, etc
that are in the area of where it has spread.


3. If not all of the areas could be done, but some could - could it make sense
to do it at all ? (ie doing it anyway might lower the tumor burden or stop
the spread from those areas done to other areas, even though it would keep spreading from the areas not radiated ?


4. If the pca has/is already spreading to other places, but those are not seen on
imaging yet since too small to be seen, would it make sense to do the pelvic imrt anyway ?
(lower the tumor burden and perhaps stop spread from those areas to other areas)
?

=========================================

search terms used - lymph node radiation

search

and some results that discussed pelvic imrt:

a. https://www.healingwell.com/community/default.aspx?f=35&m=3408657 - 5/2015



b. https://www.healingwell.com/community/default.aspx?f=35&m=2108416

c. https://www.healingwell.com/community/default.aspx?f=35&m=2972432

with TA refs:
http://www.redjournal.org/article/S0360-3016(13)01577-0/fulltext

http://www.tumorionline.it/articoli.php?archivio=yes&vol_id=1377&id=15311
http://www.redjournal.org/article/S0360-3016(13)02187-1/fulltext

d. https://www.healingwell.com/community/default.aspx?f=35&m=3547006
with TA refs:

http://jco.ascopubs.org/content/early/2014/09/17/JCO.2013.54.7893.abstract
http://onlinelibrary.wiley.com/doi/10.1111/bju.12079/full
http://jco.ascopubs.org/content/early/2014/09/17/JCO.2013.54.7893.abstract

e. https://www.healingwell.com/community/default.aspx?f=35&m=3279203

f. https://www.healingwell.com/community/default.aspx?f=35&m=2525003

g. https://www.healingwell.com/community/default.aspx?f=35&m=3739920
re horse has left the barn

Gave your thread a title -- PeterDA

Post Edited By Moderator (PeterDisAbelard.) : 8/20/2017 12:51:54 PM (GMT-6)

Tomhw....sorry to read about your complicated situation .....I can`t help , being a newbie to all this , but have a couple of questions off topic for you....could you e-mail me so I could have a private convo,,,thanks........David....(click on the envelope next to my user ID)

tomhw-

The following paragraph has the links to all the current references that I'm aware of for the situation of salvage whole pelvic treatment for recurrent PC:

Allen said...
Treatment of pelvic lymph nodes is a special case. If a patient is able to detect any metastatic pelvic lymph nodes, and he is convinced that he should have treatment at all, he should consider treatment of the entire pelvic lymph node field rather than isolated pelvic lymph nodes. One has to treat what one can't see as well as what one can see; again, provided that it is safe to do so. Safety may be questionable because of anatomy, lack of visceral fat, history of bowel inflammation, and previous pelvic radiation. The evidence for efficacy is mixed. Some retrospective data analyses (Rusthoven, Abdollah, Jegadeesh) found a survival benefit, while some did not (Kaplan and Johnstone). These retrospective studies are notoriously confounded by selection bias (i.e., the patients who got the therapy were the most likely to improve anyway). We await the outcomes of the randomized clinical trials before we have a more definitive answer.

Pro:
Rusthoven www.redjournal.org/article/S0360-3016(14)00066-2/abstract
Abdollah ascopubs.org/doi/abs/10.1200/JCO.2013.54.7893
Jegadeesh: onlinelibrary.wiley.com/doi/10.1002/cncr.30373/abstract

Con:
Kaplan: onlinelibrary.wiley.com/doi/10.1111/bju.12079/full
Johnstone: www.nature.com/pcan/journal/v10/n2/full/4500940a.html

So, you see that even these retrospective analyses come to different conclusions. We need a randomized trial to give better answers.

Given the questionable efficacy of such treatment, safety is the paramount concern. Abdominal lymph nodes are not often treated because of radiation to vital organs, and because they are not in the primary drainage pattern - they are distant metastases (M1a). It has been noticed that the pelvic field is often not broadly enough defined however:
/pcnrv.blogspot.com/2017/01/were-still-not-very-good-at-finding.html

Your specific anatomy and visceral fat are important considerations. Upper bowel toxicity is a concern. Your RO has to determine whether you can be treated without violating toxicity dose constraints to organs at risk. I don't know of anyone doing whole pelvic salvage treatment using SBRT for the purpose. Dr King is treating high risk patients (not recurrent) with pelvic SBRT (5 Gy/5 fx), and toxicity seems to be tolerable so far.
/pcnrv.blogspot.com/2017/03/sbrt-for-high-risk-prostate-cancer.html

I'd have to look at an anatomy chart. The common iliac nodes are not usually treated although they are in the pelvic area. If you read the reference on detection, they describe the pelvic nodes that should be included but often aren't. You should discuss that study with your RO.

Rick-

So, as I understand your current situation, you had one positive LN on your ePLND, and another one is suspicious but unconfirmed by Axumin. You had an ePLND and not a PLND? Where is the suspicious node? Did it shrink after you started Casodex? about a quarter of the pelvic LNs may be missed by ePLND.

/pcnrv.blogspot.com/2017/02/pelvic-lymph-node-treatment-area-is.html

I don't understand why you are now questioning Sandler's approach?

Allen,

This is OP (hwtom)

I did see rad onc recently at local radiology place (part of the local big corporation
hospital system in my area (not an academic place)

In the visit, the dr just said he would not advise the pelvic imrt. I tried to ask
reasonable questions about that, but seemed he was in a hurry or distracted
(perhaps cause it was Monday morning ?) and he did not answer any questions
at all or said why he advised against the pelvic imrt.

I followed up with electronic questions to his staff, to ask him the same kind of questions)
but got no further info.

However, I was able to get the chart notes and perhaps they give more clues, ie
1. axumin scans are new and debate on how to use those findings.

2. He does not feel there is an established role for treatment of these multiple sites
with radiation.

3. Hw states there are multiple ln areas and treatment of the para-aortic region can be associated with significant morbidity, especially true for someone like the patient with a history of IBS.

4. He believes treatment with the radiation would increase morbidity over treatment with adt, which would be happening in any case, with no demonstrated benefit with respect to survival.


I did ask him in my written questions if treatment to just the pelvic areas only might be of some help in lowering tumor burden or otherwise, but did not get an answer to that.

I will try to get a second opinion on this locally, but will first continue to read the documents and studies you pointed to in your earlier reply.

Break60,

thanks for the info on your situation. was in communication with
Dattoli office today and will get them the records and scan images and
past imrt prostate imrt records. I want to get them the actual dvd of the axumin scan images not just the report, since the axumin scan was new to the center doing it and the dr reading it was new to that center, so am hoping they will look at the images. They need all this just to be able to do the phone consult.

Meanwhile am readng the info Allen provided and just trying to get in gear with the long term ADT process.

Tomhw
Great! Dattoli is very detail oriented. Precision is very important when treating lymph nodes. Tell him I sent you!! Good luck.
Bob

Go to axumin.com and you'll find a link showing list of locations here it's available.
Bob

Break,

thanks for the ptr - that wasn't there the last time I looked at axumin site, though
that was some months ago.

Am surprised their list is not longer, or at least that they don't have more of a prescence
in some other big population states like texas or even more in NY or florida.

Also, I think there was some other place someone had mentioned where got the scan (not part of a trial) so it could be they only publish locs that give
permission. anyway I'll ask them about this.

They had given me the names of calif locs that are on that pdf page also -
they all either did not do re-reads or had not done that many scans and/or
had multiple drs reading the scans, but no one dr had that much experience
in reading axumin scans.

Sand lake in fla also does not do re-reads though said they had done lots of scans.

I'll contact the other listing on the pdf next week.

Thanks again.

Break,

re calling local center to see if they will get axumin, just to clarify - there is just one center in the area that does axumin so far,
and probably that will not change - but to clarify - I already had the axumin
done at that local center and thus in parts of this thread was discussing
just about getting a re-read of it at some place that had done a lot of them.

I realize I should not have hijacked my own thread by mentioning something
like this re-read situation, outside the scope of the original post on pelvic imrt, though I thought
it applied --- since the basis of my dr suggesting pelvic imrt was based only
on the axumin report, otherwise he would not have mentioned it at all.

BTW, in reading the small print on the pdf from the axumin.com site, it does say that the list is only of those places that gave permission to be put on the list,
and explains why for example, that only one MA or TX place is listed
(though why a place would not want to be listed is beyond me)

anyway, I started calling those places today.

But as Allen mentions, I might be getting too concerned on getting a re-read of the axumin scan. And from my own view - if I am concerned that the person
re-reading needs to have lots of experience with axumin scans, and if I can't find a place that
has that person (or that the place does not do re-reads) - then yes I need to
let this go, or else just use some online place that does re-reads in general,
but does not have axumin scan expertise if I just want any re-read.

I guess 2 reasons for getting re-read might be:

a. to see if its really spread
higher than pelvic area, in which case as discussed in this thread,
that imrt could be much more problematic if those areas were done
and would probably not be an option.

b. to see if there is any indication of spread to bones
(original scan did not report this to be the case)

In any case, thanks again your suggestions

And will continue with the adt and start to focus on learning the success criteria for it, and trying to get related labs plus labs that can help detect certain adt side effects - my luck with getting drs to approve these labs has not been good
since have been in this area, although prev mo was so good about providing
standing orders for a variety of labs, which included bone marker test - (NTX)