Need advice - radiation to inguinal lymph nodes and rib

[45yrsDenmark]

Diagnosed Nov 29th 2019 with PSA 88 and mets to 3 bones i pelvic area, lymph nodes and 1 rib (via PSMA-pet/ct scan). Gleason 7 (4+3) in all 12 biopsies. Started Eligard + Zytiga and had during March 2020 RapidArc 20x with 3Gy per fraction to prostate + 13x with 3Gy per fraction to bone mets in pelvic area (controversial thing). PSMA pet/ct from June 2020 showed still some activity in caudal part of prostate, 2 of the radiated bone mets showed decreased activity and the 3rd no activity. 2 lymph nodes still showed activity (one of them decreased - they might have hit that during the radiation, but the one with unchanged activity is a little higher and has for sure not been hit.. so it makes sense).. The rib (costa 8 left, in the side, a little more to the front) had increased it's activity (only a shadow during initial PSMA-scan). My PSA has dereased steadily and is now 0.24.

My danish doctors do no see any meaning with further treatment of the mets. So I got a 2nd opinion from Finland (Docrates) and they say that more treatment should be done to the inguinal lymph nodes + the two possivie lymph nodes and rib. I am a little worried of possible side effects e.g. lymphedema in my legs. Here is what the finnish doctor says:

Treatment: Radiation therapy for inguinal lymph nodes, 15 x 2.5 Gy (e.g.) and those with positive PET-CT scan 15 x 3 Gy (e.g.). Change in rib should be treated with stereotactic RT dose e.g. 3 x 9 Gy,

Risk assessment:

The change in the rib is in the side, a little more to the front. Radiation can be targeted very closely to the target and there should be no danger to your lung capacity. The dose to the lung is not expected to be big. Radiation therapy to other areas e.g. spine can be done without any issues in the future.

Radiating the positive lymph nodes only is not a viable option as there are cancer cells in other locations in the lymph node chain that won't show positive at this stage in the PSMA-PET. There would be new metastases in the region later if we don't radiate this region now. I don't expect issues with your legs or lymph drainage. There are other lymph vessels in this region that will be used more after the radiation of inguinal area lymph nodes.

Radiating the prostate region with this additional dose is really not an issue. We will take into account the previous doses and plan the area so that it is as safe as possible for you. Also you should be aware that doses well over 100 Gy can be given to the prostate. we are not there yet.

SO... Anyone who have had something similar done and what do you think??? I am willing to take some risk as I am young and want to see my kids start in school etc... I have read about the SSPORT trial ascopost.com/News/59414 about this.. What do you think of this approach????

[Hidden]

For a future early sRT I am researching hospitals that offer MR-linac guided irradiation. There are less than ten Elekta Unity units scattered over Europe. One of them is in your country. I came to understand that they use these machines primarely for the precision targeting of lymph nodes, as MR is apt in imaging soft tissues. You may want to check this out.

[45yrsDenmark in reply to Hidden]

Is it proton radiation you are referring to?

[Hidden in reply to 45yrsDenmark]

No. It is photon guided by MRI. The photon beam is shaped and targeted in almost real time with irradiation. As I wrote earlier there are few such machines in the field and they prefer to use them in treatments that would else use SBRT. They want to demonstrate that this is a better way as to beam guidance, because the beam actually tracks the target, compared to relying into fiducials having a looser tie with the target.

[Tall_Allen]

I think that playing whack-a-mole with multiple metastases is a waste of time, money, and raises safety concerns. There is no evidence that what you are doing adds anything to your survival. I'm glad Zytiga is working well for you.

[45yrsDenmark in reply to Tall_Allen]

Is the SSPORT not indicating some better outcome?

[Tall_Allen in reply to 45yrsDenmark]

No - SSPORT was among men who were recurrent but not metastatic:

prostatecancer.news/2018/10...

[45yrsDenmark in reply to Tall_Allen]

OK.. thanks... but if done, do we have any statistics regarding side effects like lymphedema? And the level of harm of that?

[Tall_Allen in reply to 45yrsDenmark]

Lymphocele and lymphedema are well-known side effects, as in this case study:

tcr.amegroups.com/article/v...

Why risk it for no benefit?

[tango65]

Have you discussed having lu 177 PSMA and/or Ac 225 PSMA treatment? It could help to control the metastases and it is a systemic treatment without significant side effects in most of the patients.

I had multiple lymph node metastases and I had treatment with Lu 177 PSMA in 2016 at Munich. One round made all the metastases PSMA negative according to 3 Ga 68 PSMA PET/CTs done in 2016 after treatment and then in 2019 and in January 2020.

[Shanti1]

My husband and I are contemplating SBRT to 5 bone mets, 4 in the pelvis and one in the rib. We know that there is little evidence that it will increase his survival, but we also don't find that there is evidence that it won't. Since in his case, the mets are small and the side-effect profile is minimal, we are considering it. We know he has micromets and we aren't expecting this to be a cure, but reducing tumor burden is appealing. In your case, with the lymph nodes, I can see how lymphedema could be a concern. Here is a retrospective study on 91 men who recieved SBRT to lymph nodes:

link.springer.com/article/1... and this table shows the treatment related side-effects: link.springer.com/article/1....

Although I didn't read it myself, this study titled, "Steriotactic Radiotherapy for Oligometastasies in Lymph Nodes-A Review" might also provide some guidance. ncbi.nlm.nih.gov/pmc/articl...

Best to you!