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Advanced Prostate Cancer
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Seeking Seattle pc surgeon

I am scheduled for end of September surgery for node removal, am considering going to Seattle from Vancouver to have it done sooner. Can anyone recommend a surgical oncologist in Seattle?

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Salvage Extended Pelvic Lymph Node Dissection (ePLND) isn't all that popular in the US because of the difficulty in finding and removing all the cancerous LNs:

pcnrv.blogspot.com/2017/01/...

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

There is some recent evidence that whole pelvic radiation with ADT is a better idea than picking off lymph nodes one at a time (for which we have no evidence of survival benefit);

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

In the US, Mayo specializes in salvage ePLND.

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I had a GA 68-PSMA scan at UCLA on July 26th. It presented PC in just one lymph node near the prostate bed. My surgeon has recommended removal and has put me on Zoladex to delay further spread. I feel the wait between scan and surgery is too long and do not trust the Zoladex. So frustrating.

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The Ga-68-PSMA PET at UCLA is only capable of finding cancerous LNs that are more than 4 mm long. What about all the rest where there is cancer that has not yet grown big enough to be detected by that PET scan? You should seek a second opinion from a radiation oncologist.

Zoladex will stop any further spread in the meantime. I don't understand why you suspect it won't. That's what it does. If you decide to have whole pelvic salvage radiation, you would start Zoladex at least 2 months before radiation begins in order to radio-sensitize the cancer.

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Have already had 33 sessions of radiation targeted to the prostate bed following recurrance after RP. Is whole pelvic bed radiation different than that? I found long term effects from the radiation were almost worse than the surgery.

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In your case, what they would do is target the pelvic LNs only - they would NOT include the prostate bed in the treatment field. There is no question the prostate bed radiation is more toxic than prostate only radiation - the tissue motion and inability to accurately target without a prostate in the middle makes SRT worse. (I always advise patients to never go into surgery thinking - "well I can always do salvage radiation if it doesn't work." SRT is NOT a walk in the park.

They usually give the pelvic LNs 50 Gy, which is quite a bit less than the 80 Gy they give for prostate RT, or the 70 Gy they give for prostate bed SRT. The risk is from the radiation that hits the small bowel. A good RO will program it to have zero margins in those places.

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Thanks for the 'sifted' info...so much to know and think about.

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Allen,

Your post caught my attention as my situation is similar to Flydoggy - recent Ga-68 PET scan at UCLA with mild uptake in a prominent left external iliac LN, just deep to the inguinal ligament. I have been wrestling with the decision between surgery and radiation. Yes, I've seen your posts that surgery may only slow down the disease due to micro mets being elsewhere. Admittedly, radiation scares me a little - particularly lasting side effects that may take years to show up. Perhaps these are less likely when just radiating the LNs. I do know from regularly attending a PCa support group that some folks end up with significant bladder issues from radiating the bed at recurrence.

Specifically, my question relates to your statement " The risk is from the radiation that hits the small bowel. A good RO will program it to have zero margins in those places." I assume the radiation that might damage the small bowel is that which passes through the LN field being radiated. So would any LNs not be radiated because the bowel sits behind them? Sorry, I am a retired engineer and not strong on internal pelvic anatomy. Finally, what question(s) should I ask the RO to address the concern you bring up. The UCLA RO I am talking to is David Khan in El Segundo and he has also discussed my case with UCLA RO docs King and Lee. He's been great and very tolerant of my questions.

Thanks in advance for taking the time to respond.

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I think it depends on individual anatomy - we are all different. I know they can contour the beams to the precise shape of the field, specify the margins, and the dose constraints to organs at risk. If you've got Dr Chris King working on your case (he was my RO), he wrote the book on how to do this.

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Much appreciated.

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Dr. Chris King from where?

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UCLA

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You might consult with Dr. Daniel Lin at the U of W. He’s the go to for surgery and highly respected. He would consider nodal surgery depending on your specific disease. The other option is Dr Jeffrey Karnes at the Mayo Clinic in Rochester, Minnesota. He’s more convinced of the efficacy of that type of surgery. (I’ve seen both). Good Luck Brother.

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I have been doing some research on this topic. My short list is based on folks that have been doing it often for a LONG time.

Dr. Ellis U.W.

Dr. Porter Swedish

Dr. Kozlowski Virginia Mason

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Thanks.

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EricE had a robot-assisted radical prostatectomy on 4-12-18 by James Porter, M.D., at the Swedish Urology Group. He is no-nonsense and a straight shooter.

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