PSMA post RALP: one peri-rectal lymph node lit up

Hi JLR. Can you post the findings in your husband's post-op path report?

Even if no nodes had been revealed, a 0.5 reading after surgery qualifies as persistent PSA, which means prostate tissue was left behind. This can be healthy and/or malignant tissue, but given the positive node, it appears cancer was left behind. Any adverse findings in the path report can also indicate local growth of the cancer out from the prostate has occurred, namely growth through the capsule, into one or both seminal vesicles, or into the bladder neck. If his post-op path staging in the report was pT3a or pT3b, then one or more of these adverse findings were present; if none was seen, then the staging should be listed as pT2. I'm assuming that all the lymph nodes removed at surgery turned out to be negative. His path report will also state the number of lymph nodes removed and examined.

Gleason 9 men with adverse findings and/or persistent PSA are usually advised to have adjuvant therapy in the form of radiation, often along with ADT. This of this step as completing the primary treatment of his cancer. The hope, of course, is that surgery also will suffice, but unfortunately in many cases this isn't the case with Gleason 9 disease.

After successful surgery, one's PSA is expected to drop to a level below 0.1. You husband should have another PSA test to confirm that his PSA is still above 0.1 The reason biochemical recurrence (BCR) doesn't enter the picture in this case is that BCR is a return to a PSA of 0.2 or greater after first dropping to an undetectable level, i.e. less then 0.1., after surgery.

Your husband should discuss with his docs, including a radiation oncologist, whether that particular node can be included in the radiation field given its location. Please post his post-op report findings and keep us posted with his doctors' recommendations. All the best to you both!

Djin

Thank you. So yes, the pT3a staging was assigned because the tumor was found to have grown through the thin prostate capsule, although only at one small point ("focal" extraprostatic extension). Did your husband have a post-op visit with his doctor to discuss the path findings and was the subject of adjuvant therapy brought up? IMO the combination of G9 (4+5), EPE, a positive regional node, and persistent PSA mean it's time to formulate an adjuvant treatment plan.

Djin

Stay positive -- the cancer may very well be limited to the region and there are many weapons in the arsenal. For advanced disease that has escaped the prostate, but is still likely localized, I personally think that surgery followed by RT+ADT is the best approach. The adjuvant plan may need some fine tuning, such as the length of any ADT and the size of the radiation field. By all means seek additional consultations if he feels they may be beneficial in decision-making.

Chin up!

Djin

Post Edited (DjinTonic) : 1/24/2023 6:05:51 PM (GMT-8)

Is he going to get a 3 month PSA to get the confirming test?

Adjuvant radiation tends to aggravate incontinence issues and stop ED progress so most like to get some time between surgery and RT. You can’t wait too long though with his numbers.