Advanced Prostate Cancer
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After RP what is the best step for lymph node inv?

Hi,

My hubby 53 years old had RP on 17 oct 2017. Gls (3+4)7 but %5 5 pattern involved. Also 4 out of 21 lumph nodes were cancerous. He Had psa tests every month and the psa came 0.02 each time ( not changing) He is only taking lifta 5 mg. since the surgery.

Yesterday our dr called and said that according to new studies my husband should get caspdex50mg +RT asap.

Now i am wondering where will the RT done? İf prostate bed , is it going to be the best thing to do since lymph nodes positive ?

İ mean should the dr do chemo+adt as it could be systemic because of lymph nodes?

I am also searching for the hospital to get RT . What should i look for ? Are the machines used different in some hospitals? ( not in US)

Pls give your advice since it is very important for me . We have apointment with the oncologist on thursday to see what he says but i trust you more than i trust them since dr didnt know about the trials came out this summer but you all did.

My regards to you all

Kamile

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As my own SRT was explained to me - 25 sessions irradiated the entire pelvis...15 focused on the "fossa" only/mainly. Every plan is different - a physicist and dosimetrist, along with the RO make a plan based on need - many men have lymph nodes irradiated at the same time

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İ will check what the oncologist say.

Thank you and best

Kamile

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Hi Kamile-

All very good questions. At his very low PSA, he will not be able to detect metastases, so his best guess is that it is still in the prostate bed and pelvic LNs. BOTH areas will be treated. A recent analysis suggests that whole pelvic radiation with ADT can increase survival by 59%

pcnrv.blogspot.com/2017/12/...

In that study, the ADT used was more than 50 mg of Casodex - they used a GnRH agonist (like Lupron or Zoladex) or orchiectomy. I can understand why his oncologist would only recommend a light dose of casodex because his PSA is so low. I think Lupron would be better, but that is arguable.

The hormone therapy IS the systemic therapy. In the Touijer study, they used it very long term. There is no evidence of benefit (and a high risk of toxicity) to chemo when the cancer is confined to soft tissue in the pelvis.

It is important that the extent of the radiation is wide enough to include the common iliac nodes and other nodes that have not been traditionally irradiated.

pcnrv.blogspot.com/2017/02/...

As for which linac is best... in general, faster is better because organs have less time to move out of position during each session. The fastest linacs are VMAT (like RapidArc). You also want a good image guidance system to prevent excess toxicity. Tomotherapy has continuous image guidance. Look elsewhere if all they offer is 3D-CRT. For VMAT linacs, that means either a cone beam CT or stereo X-rays used at the start of each session. Ideally, they would align soft tissue and not just bone. To prevent bowel toxicity, no margins should be planned around the pelvic LNs. The prescribed dose to the prostate bed should be 70 Gy or more, and the whole pelvic dose should be at least 50 Gy. most important is a full bladder and empty rectum for each treatment, and treatments should be cancelled for the day if the bowels are markedly distended.

A place close to home is important because there will be 35-40 daily sessions, and especially towards the end of treatments, urinary irritation may make a long drive difficult.

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Thank you so much.

I will read all the links you post.

I feel like crying to be able to see this info so dear for me. I couldnt sleep last night trying to figure out where to start.

Thank you again.

My prayers for you 🙏

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In this case İ should also ask for lupron or zoladex to replace casodex to make it work better.

Kamile

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Hi Tall_Allen , (and hello & prayers to Kamile) I have been reading through your posts, Allen (And your links.) thank you so much for sharing a plethora of info to newbies like myself. Does the above info apply to “proton” beam radiation? Does this mean, that given the location of the pelvic lymph nodes (that cancer has spread to), that “regular” radiation would be most beneficial due to possibly “hidden” cancer in the pelvic area? If I read that correctly, attempting to pinpoint areas shown to light up on PET scans may not in fact be the “only” cancerous area(s)? And “regular”, vs “proton beam”, radiation is probably the better choice? Because it would blast more areas, including hidden ones. (Depending of course on the mans current cancer status.) I feel like I just typed myself into circles there, so excuse any jib jab.

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The use of protons for salvage is strictly experimental - I'm aware of only a couple of clinical trials, although some places may do it outside of a clinical trial. So far, protons have not proven to be any more effective or any less toxic compared to IMRT. I'm not aware of anyone using it on lymph nodes.

Metastases spread slowly in lymph, so that MAY be an opportunity to catch it before it spreads distantly. Metastasis-directed therapy is unproven. The ONLY randomized clinical trial EVER had questionable results. IF there is an opportunity to still cure prostate cancer after it has got to the pelvic LNs, I believe it will only happen if one treats the entire area and includes hormone therapy. You have to treat what you can't see as well as what you can.

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You are absolutely outstanding at explaining things on here. I wish I could sit inside your brain & take notes, if even for an hour! Thank you so very much. I can now put my mothers question to rest. You’re the best Allen. ((Throws flowers towards you as the crowd cheers)) 🙏🏼👏🏻🌷

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I'll take the flowers, but don't sit inside my brain -- it's a scary place. ;-)

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I also recommend finding a facility that uses Tomotherapy.

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The hospital we are about to go has rapidarc IGRT.

Do you know if it is better than tomotheraphy ?

I thank you very much for your time.

My best

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I do not know that answer. Tall_Allen might know. I underwent therapy with Tomotherapy and had virtually no side effects. That was about 10 years ago. Disclosure: I also sat on the Board of Directors of Tomotherapy.

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They are both very good.

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Hi Allen

You said the best RT machine is Rapidarc ,right?

I found one and trying to get an appointment.

Thank you and my prayers for you.

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Kamile, Where do you live?

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I live in TURKEY

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A Turkish dr Odel Was said to be curing cancer with oleander in the 60s Supposedly suppressed by big pharma and the Turkish government.

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Yes i have heard of him but i dont know if he is still alive.

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He is long gone. There is a naturalpathic belief that his serum worked but was buried by big pharma. Peace to you and good luck figuring this all out..

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Thank you💐

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Kamile, I was hoping that you were in the US...I was going to suggest getting a second opinion in California. Not everyone will agree with me; however, I have been extremely pleased with my surgeon/oncologist's conservative approach to dealing with my PCa. He has kept me alive with an excellent quality of life for 13 plus years... no ADT, radiation, or chemo. Only two painless robotic surgeries that I recovered from in a couple of days. I have no idea what my future holds, but as of today I am symptom free doing all of the things that I did 40 years ago. If this nasty disease gets me soon, I still have to be thankful for the wonderful years that I've enjoyed since my doctor in Dallas, TX predicted I would never see. I will never forget his words after getting the results of my biopsy. "Ron, you have the real deal!" We are all here to help your "hubby" and you through these difficult times. My best, Ron

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Thank you and my regards

Kamile

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You are very fortunate indeed, amazing.. being grateful is a high quality..

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