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Salvage lymphadenectomy - anyone try it?

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Posted 8/29/2022 7:05 PM (GMT 0)
After my boyfriend's surgery in Dec 2012 (Gleason 3+4) at 64 years old, we had a 7 years of undetectable. Went forward with SRT last summer at .13 without ADT. It was a slow creep. He wants to avoid ADT. PSA recently came back to .07. We're not freaking out... just thinking of ways to kick the can down the road before ADT. I've read that with the better imaging scans we have today, salvage lymphadenectomy is an option for nodal recurrence. Any thought or experience? Wondering if post SRT if that complicates surgery. Thx

Post Edited (teddydog) : 8/29/2022 1:59:16 PM (GMT-7)

Posted 8/29/2022 8:24 PM (GMT 0)
Teddydog,
I don't know anything about salvage lymphadectomy, but the good news is that his PSA is apparently increasing slowly. In the past many MOs (he really should be seeing a medical oncologist now) would just monitor the PSA and do imaging, which allowed the can to be kicked down the road, in some cases for years, before needing to start ADT.

The modern scans, with high sensitivity, can sometimes identify mets for spot radiation -- further delaying the need for ADT.

No one wants an increasing PSA, but your BF's situation seems pretty manageable.
Posted 8/29/2022 8:34 PM (GMT 0)
I would suspect that he would have to find a great surgeon that has a good track record for salvage surgery. Also, the risk of urinary and rectal complications will increase.
Posted 8/29/2022 9:21 PM (GMT 0)
Clearly something to be aware of and consider, though as I understand radiating positive nodes is more common. Radiating suspected nodes is common as are biopsies, but I don’t remember anyone having them removed. I think it can be pretty tricky and may not have the advantages of radiotherapy.

Did his original surgery include any nodes? Were there scans before the SRT? Did they show anything? Did the SRT include the pelvic/abdominal nodes in the radiation plan? If so, it is unlikely that there would be positive nodes there. If not, then that area will be suspect if the PSA starts rising.

The PSA decrease from .13 to.07 without ADT is significant and at a level that scans are unlikely to find anything. You need more testing to determine the trend. Hope he is testing at least quarterly. It sounds like your question is hypothetical and that a node or nodes hav not been found to be affected. Is that correct?
Posted 8/29/2022 11:24 PM (GMT 0)
JNF, there were no scans at .13. Assumed PSA was too low to show anything. PSA tracking is a little odd after SRT because we moved and had a couple of regular PSA's and not uPSA. History is;
12/12 RALP - everything negative including nodes
3/19 .02 -became detectable
9/19 .02
5/20 .05
11/20 .07
5/21 .13
Radiation June/July/Aug
8/21 .05
9/21 .04
11/21 <.1
3/22 <.1
6/22 .07

Not sure what was happening during the <.1 test... but where we are yet is not terrible. One thing, in addition to ADT, we want to avoid more radiation. Had a little worsening of incontinence after SRT. Don't want to make that worse... hence the though of possibly removing a positive node... if there is any, rather than radiate again.
Not sure of more radiation and what the long term effect could be.
Posted 8/30/2022 12:06 AM (GMT 0)
Thanks Teddy. .07 is <.1, so maybe no difference. But why the testing report difference?

As to radiating a node, it would depend on where it would be. A positive node may be far from the pelvic area, say in the upper abdomen, or near the collar bone. Thus radiating it would have nothing to do with the areas already radiated. Until you know….you just don’t know.

It appears you have a year of PSA reduction and stability following the SRT. That appears to me to be a positive. Let’s hope it continues that way.
Posted 8/30/2022 12:36 AM (GMT 0)
Thx JNF... we moved and when we went to the new lab, for some reason they were not testing ultrasensitive. After 2x, we go it fixed. Like you said... .07 is <.1. Probably been hanging around there for the past year. Would prefer <.01, but w/o ADT, it isn't bad. Hoping for a long stretch of bobbing around at this level. Like you said, time will tell.
Posted 8/31/2022 8:57 PM (GMT 0)
Hi Teddydog,

My husband's RP was in 2014; his PSA first became detectable in 2020. In 2022, his PSA hit 0.10 and then 0.15. He had a PSMA scan that showed an involved pelvic lymph node. When we talked with the doctor about surgically removing the impacted node, we were told that it would be almost impossible. This node was not very big, and the surgeon compared it to a grain of rice in a sea of fatty tissue and scar tissue, etc. The recommended treatment was the trifecta: radiation to the prostate bed; radiation to the pelvic lymph nodes (with special attention to the known impacted node); and ADT for 12 to 18 months.

At around the same time that we were making treatment decisions, a friend's husband was also discussing an impacted LN. His, apparently, was more enlarged. Also his RP was only about 6 months prior, not 8 years prior. They were going to surgically remove the impacted node but eventually chose to do CyberKnife instead.

Anecdotally I have heard of a surgeon removing an enlarged impacted LN. This was a case where the surgeon had not done a proper LN dissection at the time of the RP. (The offending LN had even shown up on a pre-RP scan.) The surgeon went in years later and supposedly removed it. Again, this is only anecdotal info.

My guess is that, in your husband's case, much will depend on how large the LN is and the amount of scar tissue and fatty tissue he has. If you search, you will probably be able to find a surgeon who will be willing to try to remove the lymph node--but you'll also surely find surgeons who won't do it.

Good luck to you and your husband,
M
Posted 9/1/2022 3:31 PM (GMT 0)
Apart from the potential difficulty excising pelvic nodes as Melanie reports, another risk factor is developing lymphedema after the removal. When the lymphatic system is disrupted by the removal of a node, you can end up with a blocked lymphatic channel that does not properly drain. This can cause significant pain and swelling and can be quite debilitating. Several men on the board have reported on this over the years I have been here. Radiating the area is less damaging to the nodes and channels and usually does not cause lymphedema.

But all this is hypothetical until you have evidence of the source of any PSA increase. I suggest you manage this very closely and be with a great doctor that has a scan plan set at a predetermined PSA level. You really haven’t shown an increasing trend yet and the levels are too low to have high probability of finding a source on a scan yet. Get settled in on testing using the same measurement/lab and consider 60 day versus 90 day frequency for closer monitoring. What does his doctor say when asked about these items? And what doc is principal at this time? I suggest you go to a great medical oncologist with a lot of PCa experience. You mentioned you moved, are you still using the same docs or have you had to establish new ones?
Posted 9/1/2022 3:57 PM (GMT 0)
I can see where they might be willing to radiate or remove up to five. But I have them from my neck to lower abdomen, and it's no go for me. It's purely palliative treatment now.
Posted 9/1/2022 4:57 PM (GMT 0)
Hi JNF, we moved from NJ to Florida. Had a great team in NJ.... uro and mo. We found a great uro down here in Florida. uPSAs at 3 month intervals. When we hit .2 (whenever that is) we'll start scanning. Will look for a good MO down here when needed. We still have a house in NJ, so if warranted, can go back up there for any treatment, if necessary. We are hoping to kick this can down the road as long as we can before doing something else. Quality of life is a big issue for my boyfriend. Radiation caused some setbacks... little more leaking and ED. We're managing it (not the end of the world), but for him, he is not up for more making things any worse.
Posted 9/1/2022 6:06 PM (GMT 0)
Sounds like you are on top of things. For cancer clinics in Florida Moffitt is excellent as is Datolli near Tampa, leading edge PCa radiation for decades. If you let us know where you are some members may have MO suggestions. Best wishes.
Posted 9/1/2022 10:59 PM (GMT 0)
This is a delicate area and I'm hesitant to add my two cents--but I'd also hate to remain silent on something that is potentially so important. I get that your boyfriend wants to kick the can down the road for as long as possible, but sometimes it's a mistake to wait until the PSA gets to 0.2.

Don't forget that all these things take time: making appointments, getting approved for the scan, and then even scheduling the scan can add months to your timeline. Then there's the time involved (after the scan) to figure out the treatment plan, possibly get a second opinion, and then finally start treatment which might have its own preliminary steps.

You might want to pick a lower PSA trigger number so that you don't miss the window of opportunity for a durable remission. (In my husband's case, his PSA jumped to 0.15 relatively quickly so we were relieved that everything was already in place.)

Good luck to you and your boyfriend
Posted 9/1/2022 11:15 PM (GMT 0)
Melaine, thank you. I do appreciate your note. So, he did have pelvic radiation when he reached .13 last year. He got down to .04 a year ago after radiation. We then had a couple of <.1 when we moved, so we don't really know what nadir was, but today he is at .07. Other than some nodal radiation and starting ADT, I think that is our only option for next step?. I was under the impression that we have to watch PSA and do scans as follow up. You think a scan lower than .2 would show anything? Thx!
Posted 9/2/2022 12:42 AM (GMT 0)
If he had radiation to the pelvic lymph nodes, they should no longer be a concern. Thus, if in the future a lymph node shows up as affected, it would be farther distant. Only then the specifics of the lymph node found would dictate the type of treatment. Some can not be removed and some can not be radiated depending on where they are. In those cases, ADT systemic treatment would be used. A future recurrence could be found in a bone. In that case the specifics would dictate the treatment. It is far too early to try to determine the specifics of a future unknown event and try to decide on a treatment course. Please relax and trust that you have a great medical team in place and work with them and the plan.
Posted 9/2/2022 9:33 AM (GMT 0)
Hi Teddydog,

I’m sorry. I jumped on the 0.2 number somehow forgetting that your boyfriend had already had radiation. My concerns above were more for those who are trying to time salvage radiation—so not relevant for your boyfriend.
Posted 9/2/2022 10:29 PM (GMT 0)
For what it's worth--and this, again, is more for those trying to time salvage radiation after RP--the PSMA scans are showing things even when the PSA is below 0.2. In my husband's case, his PSA was 0.15 at the time of the scan. His doctor mentioned that two of his other patients also "lit up" at 0.12 and 0.13. They're seeing enough patients that he said that they might have to re-think the guidelines for PSMA scans.
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