Results From Mayo

I'm not smart enough to comment. But I can say I'm happy you know where the enemy is and that you've got several tools to fight it. Good luck with the appointments next week...

Robert:

The first one is a abdominal external iliac node .
I've given up listing my profile -- just not enough space anymore.

But, in short:
G 4+3.
Failed surgery. Failed SRT. Guess I'm just a lousy student.
I have been on intermittant HT (Casodex + Lupron).
I'm just finishing my second HT vacation.
PSADT when off HT is very fast (usually 1 month -- but a bit longer now).

Hope this is helpful to you. I just turned 70 -- we are the same age!

Mel,

I'm sorry I don't remember your situation in detail, and you didn't provide a signature. If all your mets have been PLN mets, then whole pelvic radiation may be beneficial. But if you have had bone or visceral mets, then it is already systemic, and there is no evidence that there is anything to be gained by undergoing potentially toxic radiation. As I said the last time you asked, CHAARTED only showed a survival benefit to early chemo among men who had 4 or more mets.

What are you talking about?

Hi Mel-

What was your PSA when before you had the scan?

How long had you been off HT before the scan?

Bobby Mac

Some responses:

Tall, my ONLY mets are the two pelvic nodes. One is barely showing up on the C11 scan. I can look up the exact uptake figures if that will be helpful. That is the new one found, in the left femoral node chain. The other original one found 2 years ago as a very small uptake has now double the uptake, but is still considered small, I think. That one is an external iliaac node.

My PSA taken on 8/1 was 1.28. Then taken on Thursday just before the scans, it was 3.1. My PSADT historically when off HT was less than a month, so this was actually somewhat "better." Meaningfully better? I doubt it!

Dr. Kwon did not mention cyberknife. He mentioned either surgery or doing the full IMRT on a large number of nodes (maybe all of them). He suggested this could effect a cure.

Tall, I am going to see what Dr. Lam thinks. I am strongly leaning against chemo Dr. Kwon didn't mention it but I asked him just before he was leaving and he did say that was a possibility along with HT and surgery or radiation if I really wanted to "swing for the fences." As I get older, QOL becomes increasingly important.
Frankly, I would not opt for chemo in my current situation. If I had distant/many mets., then I would possibly go that way. I am also very much afraid of doing surgery or such a wide amount of radiation (my SRT, incidentally, was to the prostate bed only).

Tall -- I am thinking of going with Chris King and doing the SBRT to the impacted nodes. I know you used to be very positive about that, but subsequent results made you less enthusiastic. If King thinks there is a reasonable chance of extending an HT-less remission with close to zero SE (he said zero when I only had the one node), it may be worth a shot. I know King said the SE profile could go way up if there were many more nodes, especially on opposite sides. This was one more node, near the first on the same side. I do feel King is honest, a straight shooter. But, then again, radiation is his thing!

I always welcome your thoughts, TA!



Mel

Mel -

Mel said...
Dr. Kwon did not mention cyberknife. He mentioned either surgery or doing the full IMRT on a large number of nodes (maybe all of them). He suggested this could effect a cure.

I would imagine, given a node was cancerous two years ago, that more than one additional node is positive and Choline is not picking up uptake. Even though you may have been on HT for much of that time castrate resistant cells are always working.

If it were my call, I probably would choose IMRT to radiate all the Nodes and base radiation coverage on the study TA mentioned. I don't have the link, but the conclusion was:

Conclusions:
"Pelvic LN failures frequently occur superior to the commonly used L5/S1 landmark for PRT coverage, and use of ADT may be protective of more superior LN failures. The current RTOG 0924 trial is evaluating the benefit of PRT with extended superior coverage to L4/5 when possible, which, according to our data, should significantly improve the coverage of potential sites of failure."

Bobby Mac

Mel,

You are right that I do not see any value in treating individual lymph nodes. But I do think there's value in treating the entire pelvic LN area. The reason is that lymph is a fluid, fortunately a slow moving one, so if cancer is present in the LNs you can see, it is undoubtedly present in those you can't see as well.

Surgically, what Kwon is proposing to you is called an "extended pelvic lymph node dissection" or ePLND. What they do at Mayo is they use a fluorescent dye to help find all the LNs. This is very difficult. Unlike blood vessels, which branch predictably, lymph vessels network haphazardly. They try to get 20+ LNs out of the area, but they can't know if they got them all. As you know the dangers are lymphocele or lymphedema.

Using radiation, they can target the whole area and possibly get more of them. But there are toxicity dangers as well. The problem is that the small bowel comes into that area and the radiation can get pretty high for some of it. Bowel (enteric) tissue often has a late response to radiation that may not show up for years. A lot depends on your individual anatomy and visceral fat. This should be decided by an RO after a very careful look at your pelvic CT.

Neither surgery nor radiation will be useful if the cancer is already systemic because they provide local control only. But, so far, your evidence from the PET scans is that it is still locoregional.

There is no evidence that spot radiation of individual LNs is a good idea; it may accomplish nothing while raising toxicity risk. Accumulating evidence of doing that showed that within 5 years more mets popped up elsewhere in 85% of men who tried it. There is no evidence that it even slows it down. As you see from your own experience (which is typical) LN-only progression proceeds very slowly at first anyway, taking years for new detectable mets to appear.

I liken this to picking mushrooms from under an oak tree. The mushroom is only the visible portion of the fungus whose mycelium extends down to the roots of the tree and throughout the soil. You can pick as many mushrooms as you like, but they will just keep coming and will have no impact on the fungus's growth. To get rid of it, you have to treat the whole area systemically with a fungicide. You seem to have an opportunity now to get rid of it, but I don't think it serves any purpose to treat only what you can see.

Thanks for the input. Not what I want to hear, of course.
Right now, I have not had a single PC symptom.
Unfortunately, the assorted txs take a large toll.

Hence, I am hesitant to do the dissection or the radiation of the entire pelvic region - very hesitant.

SBRT to the bad nodes sounds so much better. Kind of like wack a mole every time it comes up.

I will be chatting with Dr. Lam on Friday.

He might just suggest chemo, too.

I'm finding this decision to be difficult.

Mel

This has been a fascinating discussion, which I've followed with some interest.

The recent kerfuffle with my first "new" oncologist was based on exactly that whack-a-mole idea. His concept was that if this very small increase in PSA was due to a lymph node "lighting up", which he considered likely, that I should see Dr. Kwon to find it and then have it removed or whatever. Exactly what you're discussing! Some I respect here very much have been doing precisely that, so the discussion is fascinating.

My theory all along has been that if my PSA actually trends up in a biochemical recurrence (hopefully never), and we do a scan finding it's not "local" in the prostate itself, then there won't be any focal treatments. My G9 cT3a case is fairly likely to be metastatic if it recurs anyway, local or distant, so I've never considered any sort of surgery or additional radiation to be likely. Even if it's local in the prostate (which is also reasonably possible per some links TA has shared) I'm not very excited about the available salvage local treatments. Surgery, cryo, HIFU, none too good post RT. It would take a great deal of convincing for me to take a chance with any of those, in light of my very high risk situation.

That's largely why I've been having my follow up care with a medical oncologist. Follow up care will likely be something systemic if it becomes necessary. I'm not excited about HT either, but to me it beats QOL risk of the others.

Mel,

Just my opinion...I am with Allen and Jim. If it was or becomes me, I would do SBRT or IMRT to all potentially affected nodes. If there are cancer cells in nodes that did not show up on the C-11, I would not want to take the chance of missing them doing spot RT and have to go back again. Kwon said, if IMRT, he would probably do all LN's and possibly get a cure. Will be interesting to see what Dr. Lam says.

Robert

Mel -

It looks like full text of the article you are interested in is available on Researchgate. Take a look at

/www.researchgate.net/publication/303595181_Stereotactic_body_radiotherapy_in_oligometastatic_prostate_cancer_patients_with_isolated_lymph_nodes_involvement_a_two-institution_experience

I'm not all that familiar with that site, but it looks like access to content is charged for corporate entitles but not individuals (unless I missed something), but one has to sign up as a site member (with whatever that involves, and if you want to bother) to get it.

But maybe worth a look.