Cyberknife for 'involved' Lymph Gland: New Treatment Planned

As my profile below indicates I am post prostatectomy & post IMRT radiation with rising psa - currently treating aggressive metastatic situation with casodex and pomegranate extract.

Have had very good results after 7-8 weeks of medication start, psa down from 2.0 to 0.2 and significant shrinkage of my involved lymph gland...

Just back from hospital in Boston this afternoon - they want to treat my involved lymph gland with the cyberknife...

Thoughts?

_

Age 63, dx age 60, PSA 2.9 ; detected by dre
Stage t3b Gleason 7 (4 +3) tertiary pattern 5
11/09 Post-prostatectomy path: extensive extra-prostatic growth 60% tumor both lobes; perinural + l seminal vesicle and lympho-vascular tumor invasion; Lymph nodes:14 right obturator; 9 left pelvic (no regional lymph node metastasis)
10/11 adjuvant IGRT radiation 8 weeks
4/10/12 psa rise from 0.3;0.5;0.9 indicated ineffectiveness of SRT – on to medical oncology
5/30/12 negative bone scan; ct scan showing enlarged adrenal gland and 1 pelvic lymph node "involvement"...
6/5/12 initial meet with med oncologist began daily use of pomegranate extract; need baseline psa w/same protocols
6/5/12 psa rising to 1.5…then again on 7/10/12 psa 2.0
7/17/12 doc confirmed diagnoses of “aggressive metastatic” pc;
Prescribed 50mg Casodex (Bicalutamide) for 6-7 weeks + pomegranate extract before new psa blood test + ctscan
9/4/12 ctscan and psa blood tests first since casodex treatment began
9/11/12 results indicate psa drop from 2.0 to 0.2; ctscan shows significant improvement in lymph gland...to continue same regimen for next 90 days.
9/27/12 radiation team at hospital indicates they can treat my lymph gland with the cyberknife

Post Edited (Bridgewater) : 9/27/2012 4:31:12 PM (GMT-6)

Hey Southern Comfort,

I agree even if the use of the cyberknife to treat recurrent pc in a lymph node is apparently questionable by some.

As it is with me, after two back to back and very recent ctscans, the only indicative spread has been to the one lymph gland, which reacted to the casodex, (+ pomegranate) by shrinking while my psa dropped significantly after this short initial treatment period.

Of interest is that this area was NOT treated when I had my adjuvant IMRT post-surgery - I was given traditional prostate bed radiation only, not the wider treatment now being urged by some radiation specialists. Had it been, this option would not be on the table (I think).

The medical oncology teams agrees; the radiation team thinks it could "work" - I am with you in that it is, (right now) the only visible/reactive area of cancer involvement. Could it "cure"? Maybe...who really knows? But again, even if not, my thinking and attitude is aligned with yours on that it could help and has little downside. Getting to it as "a major source of the cancer cells" could be beneficial even if their is additional microscopic spread beyond this one node.

There is much more to learn before this all takes place but it is a new treatment approach I did not anticipate/expect having been told my post-surgery & post-IMRT psa rise meant I was heading strictly into medical oncology and that was just about it for me in terms of any further treatment.

Interesting is that I was told before any ck treatment I should stop taking the pomegranate; not sure why just yet but I did find that interesting...

As I progress with new adventure, I will update all here on the Forum.

_

Age 63, dx age 60, PSA 2.9 ; detected by dre
Stage t3b Gleason 7 (4 +3) tertiary pattern 5
11/09 Post-prostatectomy path: extensive extra-prostatic growth 60% tumor both lobes; perinural + l seminal vesicle and lympho-vascular tumor invasion; Lymph nodes:14 right obturator; 9 left pelvic (no regional lymph node metastasis)
10/11 adjuvant IGRT radiation 8 weeks
4/10/12 psa rise from 0.3;0.5;0.9 indicated ineffectiveness of SRT – on to medical oncology
5/30/12 negative bone scan; ct scan showing enlarged adrenal gland and 1 pelvic lymph node "involvement"...
6/5/12 initial meet with med oncologist began daily use of pomegranate extract; need baseline psa w/same protocols
6/5/12 psa rising to 1.5…then again on 7/10/12 psa 2.0
7/17/12 doc confirmed diagnoses of “aggressive metastatic” pc;
Prescribed 50mg Casodex (Bicalutamide) for 6-7 weeks + pomegranate extract before new psa blood test + ctscan
9/4/12 ctscan and psa blood tests first since casodex treatment began
9/11/12 results indicate psa drop from 2.0 to 0.2; ctscan shows significant improvement in lymph gland...to continue same regimen for next 90 days.
9/27/12 radiation team at hospital indicates they can treat my lymph gland with the cyberknife

Thanks Special Lady,

Here is my understanding regarding the mets stage - the reactive change to the medical oncology treatment was in the lymph gland - nothing else changed from scan to scan. This indicates to them that is where the cancer is - (hopefully) it is what is called a focal or local mets at this point.

Now this does not rule out microscopic spread but does look like I am not at the systemic mets stage yet, thus the treatment approach and use of the cyberknife.

I am well aware of Dr. Kwon and Mayo and the C-11 pet scan but that actually requires a psa over 1.0 to be able to be utilized. My psa has dropped from 2.0 to 0.2.

askdrbarken.wordpress.com/2011/12/25/c-11-choline-petct-scan-dr-eugene-kwon-mayo-clinic/

And as Dr. Kwon has also stated, this cancer can change due to treatments.

I have a lot of confidence in the team treating me in Boston and I feel sure they will be doing additional tests, etc. We are just in the beginning stages of this new approach, which caught me by surprise as I was told back in the Spring that all indications were medical oncology going forward.

Bridge

_

Age 63, dx age 60, PSA 2.9 ; detected by dre
Stage t3b Gleason 7 (4 +3) tertiary pattern 5
11/09 Post-prostatectomy path: extensive extra-prostatic growth 60% tumor both lobes; perinural + l seminal vesicle and lympho-vascular tumor invasion; Lymph nodes:14 right obturator; 9 left pelvic (no regional lymph node metastasis)
10/11 adjuvant IGRT radiation 8 weeks
4/10/12 psa rise from 0.3;0.5;0.9 indicated ineffectiveness of SRT – on to medical oncology
5/30/12 negative bone scan; ct scan showing enlarged adrenal gland and 1 pelvic lymph node "involvement"...
6/5/12 initial meet with med oncologist began daily use of pomegranate extract; need baseline psa w/same protocols
6/5/12 psa rising to 1.5…then again on 7/10/12 psa 2.0
7/17/12 doc confirmed diagnoses of “aggressive metastatic” pc;
Prescribed 50mg Casodex (Bicalutamide) for 6-7 weeks + pomegranate extract before new psa blood test + ctscan
9/4/12 ctscan and psa blood tests first since casodex treatment began
9/11/12 results indicate psa drop from 2.0 to 0.2; ctscan shows significant improvement in lymph gland...to continue same regimen for next 90 days.
9/27/12 radiation team at hospital indicates they can treat my lymph gland with the cyberknife[url]

Jitters99,

I am very sorry to hear what you report regarding your husband's battle with this nasty disease. Hopefully they can treat the lumbar region successfully and then consider additional options.

Apparently the use of the cyberknife for mets is perceived to be limited to use for focal vs systemic spread. That is the chance being presented to me right now and even though it is a new approach, with some risks, I am going to pursue the treatment as it is a "chance" - beyond medical oncology and that is the first time I have heard that since my diagnoses last Spring when I was told I had aggressive metastatic pc.

It is my understanding that some new treatments have just been announced for systemic situations that could be worth looking into for your husband. My prayers are with you...and with everyone else here facing difficult stages of treatment.

_

Age 63, dx age 60, PSA 2.9 ; detected by dre
Stage t3b Gleason 7 (4 +3) tertiary pattern 5
11/09 Post-prostatectomy path: extensive extra-prostatic growth 60% tumor both lobes; perinural + l seminal vesicle and lympho-vascular tumor invasion; Lymph nodes:14 right obturator; 9 left pelvic (no regional lymph node metastasis)
10/11 adjuvant IGRT radiation 8 weeks
4/10/12 psa rise from 0.3;0.5;0.9 indicated ineffectiveness of SRT – on to medical oncology
5/30/12 negative bone scan; ct scan showing enlarged adrenal gland and 1 pelvic lymph node "involvement"...
6/5/12 initial meet with med oncologist began daily use of pomegranate extract; need baseline psa w/same protocols
6/5/12 psa rising to 1.5…then again on 7/10/12 psa 2.0
7/17/12 doc confirmed diagnoses of “aggressive metastatic” pc;
Prescribed 50mg Casodex (Bicalutamide) for 6-7 weeks + pomegranate extract before new psa blood test + ctscan
9/4/12 ctscan and psa blood tests first since casodex treatment began
9/11/12 results indicate psa drop from 2.0 to 0.2; ctscan shows significant improvement in lymph gland...to continue same regimen for next 90 days.
9/27/12 radiation team at hospital indicates they can treat my lymph gland with the cyberknife

Bridge,
I assume the lymphnode was detected by CT scan. The issue I would have is that there may be other lymphnodes infected too small for the 10mm sensitivity of the CT scan.
Sandlake imaging can go to 1 or 2mm so it would be wise to see all the infected nodes before treating. I would guess that Cyberknife would be a good method to target the node.
Dr Myers has had some very good luck treating patients with fewer than 5 infected nodes for a curative treatment.

Thanks to all for the well thought out and well stated feedback here.

As this was just discussed last Thursday, I am sure there will be more preliminary testing and time for Q&A's, etc. I will certainly bring up all that has been suggested here on the Forum. I do have a lot of confidence in the care I am getting as it is at one of the leading teaching hospitals in Boston. There they have well experienced doctors with a very solid and dedicated prostate specific care center.

UPDATE: Still taking 50 mg of casodex (generic) and 500 mg of pomegranate extract daily. I had two gold seeds implanted in the small tumor in my lymph gland on 10/13 in a procedure that lasted over an hour. It was OK, I was "out' with a dose of propofil and then it was done by the docs by a precise needle process under the ctscan machine.

Today I had my planning session with another short non-diagnostic ctscan and I will begin 5 cyberknife treatments on 11/12 through 11/17. Told to stop the pomegranate about 7 days before 1st treatment but OK to continue with the casodex...docs in Boston think they have a real chance of zapping my focal metastatic pc...

Bridge
_

Age 63, dx age 60, PSA 2.9 ; detected by dre
Stage t3b Gleason 7 (4 +3) tertiary pattern 5
11/09 Post-prostatectomy path: extensive extra-prostatic growth 60% tumor both lobes; perinural + l seminal vesicle and lympho-vascular tumor invasion; Lymph nodes:14 right obturator; 9 left pelvic (no regional lymph node metastasis)
10/11 adjuvant IGRT radiation 8 weeks
4/10/12 psa rise from 0.3;0.5;0.9 indicated ineffectiveness of SRT – on to medical oncology
5/30/12 negative bone scan; ct scan showing enlarged adrenal gland and 1 pelvic lymph node "involvement"...
6/5/12 initial meet with med oncologist began daily use of pomegranate extract; need baseline psa w/same protocols
6/5/12 psa rising to 1.5…then again on 7/10/12 psa 2.0
7/17/12 doc confirmed diagnoses of “aggressive metastatic” pc;
Prescribed 50mg Casodex (Bicalutamide) for 6-7 weeks + pomegranate extract before new psa blood test + ctscan
9/4/12 ctscan and psa blood tests first since casodex treatment began
9/11/12 results indicate psa drop from 2.0 to 0.2; ctscan shows significant improvement in lymph gland...to continue same regimen for next 90 days.
9/27/12 radiation team at hospital indicates they can treat my lymph gland with the cyberknife
10/13/12 Gold fiducial seeds implanted in affected lymph gland
10/23/12 Planning session for cyberknife completed

One week before cyberknife treatment to begin at BIDMC in Boston; stopping daily 500mg pomegranate extract today - must also stop/reduce smoking.

Treatment will be for 1 hour + every day for 5 consecutive days - told to expect no pain minor side effects but will take week off due to daily timing of flex treatment scheduling. Doc's believe this could zap/"cure" my pc met...

We will see.

Not anxious but hopeful/curious - family/friends all keyed up - me not so much. I remain positive and calm with an 'OK - show-me' approach.

_

Age 63, dx at 60, PSA 2.9 ; biopsy t3b Gleason 7 (4 +3)
11/09 Post-prostatectomy: ext-prostatic growth 60% tumor both lobes; perinural + l sem ves w/lympho-vascular tumor; nodes:14 right; 9 left (no mets)
10/11 adjuvant IGRT 8 weeks
4/10/12 psa rise from 0.3;0.5;0.9 post-SRT –to med onco
5/30/12 neg bone scan; ct – enl. adrenal gland + 1 pelvic node "involvement"...
6/5/12 500mg daily use of pom extract 6/5/12 psa to 1.5… 7/10/12 psa to 2.0
7/17/12 diagnosed w/ of “aggressive metastatic” pc; start 50mg Casodex (Bicalutamide) + 500mgpom extract
9/11/12 ct scan + psa drop from 2.0 to 0.2; shrinking lymph gland
9/27/12 radiation team to treat my lymph gland with the cyberknife
10/12/12 Gold fiducial makers as prep for cyberknife treatment
10/23 planning session 11/12 cyberknife begins - 5 day course

UPDATE:
Had yet another ctscan before my post-cyberknife consult with the BIDMC Boston radiation-oncologist yesterday with a preliminary positive take. There will be another ctscan and consult with him scheduled for 3 months.

PSA drawn showing further drop from 0.2 to 0.1 (after dramatic drop from 2.0 to 0.2 in September). Continuing with casodex/pomegranate with consult with medical-oncologist scheduled for 1/15/13.

Still awaiting formal radiological analysis from yesterday's ctscan so it is hard to say if new psa drop is result of cyberknife or from continuing with current meds or a combination of both - that will take time to determine.

The radiation-oncologist who ordered the cyberknife treatments was smiling and happy after he took a cursory "lookie-see" at my ctscan done about 1/2 hour earlier and that was something I took as a good sign.

He assured me the entire prostate team will review carefully and I will know a lot more after Jan. 15 appt. when med-onco doc will present the larger picture from larger team back to me.

Really like how these BIDMC docs work together; I am blessed to have such care.

For now I am quite happy to see psa down to 0.1 as I really didn't think I would ever see that number again.

The adventure continues...

bridge
_

Age 63, dx at 60, PSA 2.9 ; biopsy t3b Gleason 7 (4 +3)
11/09 Post-prostatectomy: ext-prostatic growth 60% tumor both lobes; perinural + l sem ves w/lympho-vascular tumor; nodes:14 right; 9 left (no mets)
10/11 adjuvant IGRT 8 weeks
4/10/12 psa rise from 0.3;0.5;0.9 post-SRT –to med onco
5/30/12 neg bone scan; ct – enl. adrenal gland + 1 pelvic node "involvement"...
6/5/12 500mg daily use of pom extract 6/5/12 psa to 1.5… 7/10/12 psa to 2.0
7/17/12 diagnosed w/ of “aggressive metastatic” pc; start 50mg Casodex (Bicalutamide) + 500mgpom extract
9/11/12 ct scan + psa drop from 2.0 to 0.2; shrinking lymph gland
9/27/12 radiation team to treat my lymph gland with the cyberknife
10/12/12 Gold fiducial makers as prep for cyberknife treatment
10/23 cyberknife planning session 11/12 cyberknife to begin 1 week
11/12 -11/16 underwent 5 days of cyberknife treatments
11/23/12 - continuing with oncology meds (as above)
12/14/12 - ctscan and radiation-oncology consult positive outlook post-cyberknife follow up in 3 months; psa now at 0.1
1/5/13 medical-oncology consult scheduled.

UPDATE 3-9-13

Heading in to have yet another psa blood test at BIDMC-Needham, (MA) in about an hour, this in advance of my scheduled ct-scan and related exam/tests coming up this week in Boston. Called ahead even as this is Sunday and they said to come on in so...

Have been "free-falling" without meds (or any pomegranate supplement) since mid-January oncology exam. My two post cyber-knife readings have been 0.1 but I was still on casodex/pomegranate.

This will be my first psa reading since stopping the meds so we will see...(and of course [somewhat anxiously] also waiting to see what the ct-scans will show this week).

The journey continues...

bridge

_

Age 63, dx at 60, PSA 2.9 ; biopsy t3b Gleason 7 (4 +3)
11/09 Post-prostatectomy: ext-prostatic growth 60% tumor both lobes; perinural + l sem ves w/lympho-vascular tumor; nodes:14 right; 9 left (no mets)
10/11 adjuvant IGRT 8 weeks
4/10/12 psa rise from 0.3;0.5;0.9 post-SRT –to med onco
5/30/12 neg bone scan; ct – enl. adrenal gland + 1 pelvic node "involvement"...
6/5/12 500mg daily use of pom extract 6/5/12 psa to 1.5… 7/10/12 psa to 2.0
7/17/12 diagnosed w/ “aggressive metastatic” pc informed I am now 'treatable not curable"; start 50mg Casodex (Bicalutamide) + 500mgpom extract
9/11/12 ct scan + psa drop from 2.0 to 0.2; shrinking lymph gland
9/27/12 radiation team to treat my lymph gland with the cyberknife
10/12/12 Gold fiducial makers as prep for cyberknife treatment
10/23 cyberknife planning session 11/12 cyberknife to begin 1 week
11/12 -11/16 underwent 5 days of cyberknife treatments
11/23/12 - continuing with oncology meds (as above)
12/14/12 - ctscan and radiation-oncology consult positive outlook post-cyberknife follow up in 3 months; psa now at 0.1
1/5/13 new psa result still at 0.1 – taken off 50mg Casodex (Bicalutamide) for now to monitor
3/9/13 psa testing (results pending)
3/12/13 ctscan and related exam is scheduled

Bridge,

Here is to you having nothing but positive results this week, or maybe negative as that would mean mets shrinkage and a drop in PSA. You are exploring new territory not all of us have thought about with CyberKnife for post surgery RT. In the last year we got our first CK treatment facility in Birmingham, AL and I have heard nothing but good results from them. Good to know if I ever need it, I have it available now.

Terry

Well, my long anticipated follow-up has been postponed until 3-22-13 and today I found out my my psa is back up to 0.2...

Thanks Allen - you have provided me with some new info and I will certainly review it all carefully and discuss with my care giver team at BIDMC. I have no problem considering collaborating with the Doc at Mass General and I am confident my current docs will agree.

Interesting and certainly worth exploring - THANKS!

Bridge