ASTRO Conference preliminary report supports pelvic lymph node radiation

Here is a news release that was in my email today for a study that suggests better long-term results from more extensive treatment after signs of recurrence following prostatectomy. This would be a more aggressive approach than when I had my SRT eight years ago.

The release is a summary of a presentation at this week’s annual American Society for Radiation Oncology (ASTRO) meeting released on Newswise.com yesterday. The trial – named SUPPORT – randomized 1,792 men with persistently detectable or rising PSA after prostatectomy into three groups between 2008 and 2015. This interim finding was released because preliminary outcomes based on results of 1,191 men showed statistically significant differences between the trial’s three treatment arms.

Preliminary findings show for men who have completed 5 years in the study Freedom From Progression (FFP) rates were:

71.7 percent for patients treated with prostate bed radiation therapy only,
82.7 percent for patients treated with prostate bed radiation therapy plus short-term ADT
89.1 percent for patients treated with prostate bed radiation therapy, short-term ADT, and pelvic lymph node radiotherapy

The study also shows occurrence of distant mets was statistically significantly lower in the patients who had the triple treatment approach.

The release quotes lead author Dr. Alan Pollack regarding implications and next steps: “It’s now a question of management, of whether a PSA threshold or other factors can be used to identify a patient group in which pelvic lymph node treatment is not as beneficial,” concluded Dr. Pollack. “Moreover, the role of newer PET tracers that identify pelvic lymph node involvement earlier in this decision process remains a key question. We still need more data, but we’ve taken a significant step forward with this study.”

https://www.newswise.com/articles/view/702534/?sc=sphn

Jim

I’ve always wondered about this. Why have SRT without “going all the way” by removing the guessing? You’re really only guessing at where the cancer is anyway. So why not take as much guess work out of the equation as humanly possible? Seems if one is going to treat...one would treat *everywhere* that cancer could be lurking. SRT (bed) is only treating one place while SRT + Lymph nodes is treating everywhere it could still be lurking (that still gives one a chance for cure anyway).

Maybe lymph node zapping has its own set of side effects? And if so...over treatment comes into play? But...if lymph node tx doesn’t have many if any side effects...why would over treatment be of any concern?

Those numbers don’t seem insignificant to me...especially if there’s little more to lose..

In my case, with negative lymph nodes but persistent psa, MSKCC did 6 months of ADT, 25 radiation treatments to full pelvis, and then 15 radiation treatments to prostate bed only. Hope my results match the study’s.

Jack, which makes me wonder even more why my plan does not include lymph nodes. I remember asking him how to say it because nine node I remember asking him how to say it because I’m nine s were removed at surgery and all were negative. I’m nit going to debate an RO of Zelefsky’s stature, but I am going to ask again and cite the study. He was at that conference so I’m sure he’s aware.

Imaging showed one enlarged lymph node when I had my SRT in 2010. My RO targeted that one node, but not others for about the first two-thirds of the treatments, which he said was the maximum treatments he could do to that node without risking damage to adjacent organs. He also put me on Casodex for three months, though these days I see that 6 or more months on Lupron is more common. I began having detectable PSA again in 2014 and started ADT this past May after doubling time accelerated and PSA was over 6.6.

Just before I was scheduled to start ADT I had a blockage of one kidney caused by an enlarged lymph node pressing on the ureter.

Not saying things would have been any different if more nodes had been targeted back in 2010. But if I could go back and do over I wonder if targeting other nodes and maybe more aggressive ADT at the time of SRT might have had better results -- even if not a delay of PSA recurrence at least maybe avoiding the kidney problem. The ADT - Firmagon - shrank the node back to normal size and returned my kidney function blood tests to normal within a month (actually probably within days of the first shot), but in the meantime at the insistence of my primary care doctor I'd had a plastic stent inserted from my kidney to the bladder which caused a nearly constant sense of urinary urgency. I was left with the stent for nearly three months due to, in my opinion, a needlessly long delay in getting a scheduled appointment for its removal. And now that the stent has been gone for a couple of months I have more leakage than I had before.

I suppose my experience isn't typical. But when we weigh the potential risks of zapping additional lymph nodes at the time of SRT I see my experience as one of the potential added risks of not more aggressively going after lymph nodes when there is pretty strong pathology indicating risk of local spread of PCa.

Jim

Post Edited (Bohemond) : 10/24/2018 9:45:36 AM (GMT-6)

There was also evidence of higher toxicity, with whole pelvic radiation, although I don’t know enough to know if these numbers are statistically significant...


The reported toxicity results were:
GI grade 2 or higher: 7% for sWPRT+STADT vs. 2% for PBRT
Bone marrow grade 2 or higher: 5% for sWPRT+STADT vs. 2% for PBRT
Bone marrow grade 3: 2.6% for sWPRT+STADT vs. 0.5% for PBRT
Late term bone marrow grade 2 or higher was 4% for sWPRT+STADT