Hey fellow G9s.... micrometastatis, possible lymph node involvement, so pelvic radiation?

I've done some searching, but don't seem to find much direct info about this. There seem to be a number of people on this forum that have some pretty difficult diagnoses, G9, locally advanced, that sort of thing, and may have already done some research on this topic.

My 3T-MRI diffusion-weighted super-whoopie scan said the seminal vesicles showed "normal signal", and that the lymph nodes did not show any adenopathy (so, "clear"). I've read that at best MRIs are only about 35% effective at seeing small amounts of cancer in lymph nodes.

My risk of them actually being involved is pretty significant, with about half of my prostate involved in G9, much of it 5+4, PNI, ECE indicated (cT3a by image study), and so on. Rather aggressive case at this point. My radiation oncologist suggested the whole pelvic treatment add-on to address this risk, which apparently is study supported or for sure he wouldn't recommend it.

So, I'm wondering about my plan of having whole pelvic radiation "just in case" the lymph nodes are involved. That's indicated for instance in the NCCN guidelines, for what that's worth. On the other hand, apparently some say that if they really are already involved, then there's little point in irradiating them since the cancer would very likely have spread even further already. Because it wouldn't be helpful enough for the added side effects.

Has someone else found some decent papers on this? Thanks in advance for any help!

Oh, and halfway into my 4th week on Lupron I'm beginning to feel some "warm spells" :)

For high risk like yours, the standard of care is combo therapy: ADT+IMRT+brachy boost. With ECE & PNI, I think messing with surgery is highly risky because it doesn't treat anything outside of the capsule.

There may be more, but I know of two ROs who are treating high risk cases with SBRT monotherapy - Dr Chris King at UCLA (who is just starting it) and Dr Alan Katz in Flushing, NY. The 5-yr freedom from biochemical (PSA) recurrence on the high risk group has been 81% (presented at ASTRO). The nice thing about SBRT monotherapy is that the SEs are quite low. Dr. Katz reports that after 5 years, 75% of men with good baseline sexual function retain full potency. Katz finds no added benefit to ADT.

What about high dose rate IMRT monotherapy? At Memorial SloanKettering they compared the results of high-risk men treated with ultra-high dose IMRT (86 Gy) vs treatment with IMRT (50Gy) + HDR boost (21 Gy). The 5yr freedom from biochemical recurrence was 93% for IMRT+HDR vs 71% for the ultra-high dose IMRT monotherapy.

Comparison of PSA relapse-free survival in patients treated with ultra-high-dose IMRT versus combination HDR brachytherapy and IMRT.

A similar study at Schiffler & UMich compared high dose IMRT (78Gy) to combo therapy with LDR brachy + IMRT(45 Gy). The 8-yr freedom from biochemical recurrence was 86% for the combo therapy vs 60% for IMRT alone. This study also showed significantly better outcomes with longer ADT treatments.

The addition of low-dose-rate brachytherapy and androgen-deprivation therapy decreases biochemical failure and prostate cancer death compared with dose-escalated external-beam radiation therapy for high-risk prostate cancer.

They also found at UMich that high dose IMRT with ADT gave good results - 74% freedom from biochemical recurrence after 8 years, but not as good as when brachy was added.
Continued benefit to androgen deprivation therapy for prostate cancer patients treated with dose-escalated radiation therapy

Preservation of sexual potency with combo therapy was 43% with combo therapy in this study:
www.ncbi.nlm.nih.gov/pubmed/15062181

- Allen

SpecialLady: thanks for the link. Perfect! It directly supports what my RO told me, and adds support of studies.