Gleason 5+4=9, surgery scheduled soon (robotic), PSA 11.3. 68 years old, healthy. I had a PSMA scan late Dec 2017, and last week I found out I have 10 or so nodes that were enlarged on CT and lit up on PSMA, so they are metastatic, but there are no bone mets.
The surgeon says he can't get all the bad nodes (some are perirectal, behind the prostate), he recommends getting all he can followed by adjuvant radiation plus adt afterwards.
I think the radiation oncologist will recommend just adt and radiation, and I will need to decide fairly quickly. The case for surgery is to debulk the tumor and get out as many nodes as you can, even if you don't get them all; the case for radiation is 'why do both when radiation + ADT is just as effective?'
Since PSMA is so new, there's not a lot of studies on what to do with confirmed LN+
One other idea I had was to try and get abiraterone with the radiation and ADT like the STAMPEDE trial did in Dr James' July 2017 NEJM article. They had a cohort of nonmetastatic high risk subjects (some with positive lymph nodes) and the ones who got abiraterone +adt+radiation did a lot better than those with just adt+radiation (but they only had 56 months of data).