Mets to External iliac and also peri-... - Advanced Prostate...

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Mets to External iliac and also peri-aortic lymph nodes

outdoors48 profile image
25 Replies

Are these considered distant to (removed) prostate and thus upgraded from stage t3B to stage 4?

Jim

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outdoors48 profile image
outdoors48
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25 Replies
Tall_Allen profile image
Tall_Allen

Pelvic lymph node mets change the stage to N1. If they are outside of the pelvic region (e.g., in the abdomen), it changes the stage to M1a.

outdoors48 profile image
outdoors48

Thanks, TA. Not sure whether ext. iliac and para-aortic nodes are pelvic area. Seems iliac is, not sure para-aortic are pelvic

tango65 profile image
tango65 in reply to outdoors48

There is not aorta in the pelvis. The bifurcation of the aorta into the common iliac arteries is at the level of L4 vertebral body.

teachmeanatomy.info/pelvis/...

outdoors48 profile image
outdoors48 in reply to tango65

Thanks, Tango. That's a good anatomy diagram.

Dayatatime profile image
Dayatatime

Outdoors48 when I was diagnosed I had masses on both pelvic and abdominal nodes, PSA 286 and Gleason 9 cancer. The nodes affected were right internal iliac, right perirectal, multiple nodes enlarged in bilateral iliac chains, lower para aortic and left obturator chain. What wasn't in my pelvis the doctor referred to them as abdominal.

My local team gave me 3 to 5 years however the one thing they did do correctly is sign me up for 6 rounds of docetaxel 4 months after I was first diagnosed. Would not budge on a localized treatment. I then sought a specialist and landed in the hands of a brilliant surgeon named Dr. Jeffrey Karnes at Mayo Clinic who made no promises and said he would give me 10 years if debulking surgery was done. He gave me a chance when several other doctors told me surgery was not a possibility.The open surgery was done 11 months after initial diagnosis and Karnes removed prostate and 42 nodes. Come to find out all the large nodes showing in preoperative scans were scar tissue from where cancer was. Only 1 tested positive.

You and others can take a few things from this. Early chemo works, debulking works and there are benefits to surgery over radiation. All doctors are not created equal and the right surgeon will lesson the chances of possible side effects. There would have been no way of knowing that scar tissue was causing my nodes to still look infected and there is the benefit of a pathology report. In my case I would not have done it any other way. My PSA since surgery has been stable at <0.01 and scans are clean.

You have a chance at beating this and you have to put the odds in your favor by seeing a specialist in a major hospital. They can get away with being more aggressive and the right doctor will be. I highly recommend Karnes. Feel free to read my profile as it gives more detailed information.

Ron

outdoors48 profile image
outdoors48 in reply to Dayatatime

Thanks, Dayatatime, Tango, and everybody. I have learned a lot. Before I make a decision to remove the 4 mets(iliac and aortic) I will meet with my RO and my MO and the surgeon. I am wary of major abdominal surgery for this since I believe, being systemic(t3b, GL 8) , i am likely to get more mets, and how often can I do this surgery? I've heard it has high complication percentage.

Dayatatime profile image
Dayatatime in reply to outdoors48

My nodes were removed within the same incision a normal open prostatectomy takes. So from navel to pubic area. I was informed they would be cutting to my sternum but lucky for me I am thin and Karnes was able to stretch skin high enough to get at them without making a long incision. It is imperative to have an experienced surgeon. No incontinence issues and recovery wasn't terrible. First week was rough. The only side effect I have is ED and nerve sparring on one side was done. There is a glimmer of hope in that department. I knew the possible side effects going in to it but also knew I wasn't getting out of a Stage IV diagnosis unscathed. As a father at 46 it was a chance I was willing to take. Risk vs reward.

tango65 profile image
tango65

I had 2 pelvic nodes and 3 abdominal nodes that lighted up very bright in a Ga 68 PSMA PET/CT done in August 2016. My PSA was 10. I started ADT and 2 months later I went to Munich and I got treated with Lu 177 PSMA. No side effects. One treatment took care of the nodes. They were PSMA negative 5 weeks after the first Lu 177 PSMA treatment. I continue in ADT and my PSA is 0.06.

GP24 profile image
GP24 in reply to tango65

I thought in Germany they offer the Lu 177 PSMA treatment only to patients who are castratation resistant?

Do you take Bicalutamide for ADT?

How did you determine that the treatment took care of the nodes?

tango65 profile image
tango65 in reply to GP24

I was treated in Munich in 2016 and I was hormone sensitive at that time. Heidelberg rejected me because I was hormone sensitive.

We know that the nodes were cancer free because they did a Ga68 PSMA PET/CT five weeks after the initial treatment. The nodes did not expressed PSMA. When the cancer was not visualized anywhere in the body they suspended the second Lu 177 treatment. They treat only if the cancer can be seen in a PSMA PET/CT.

Since my PSA is 0.06 and stable my MO decided to stop the Bicalutamide. I continue with a low testosterone (around 30) even when Lupron was stopped in November 2016.

GP24 profile image
GP24 in reply to tango65

Thank you very much for your reply tango! I think you can be very happy with the results of your therapy.

My last PSMA PET/MRI shows several affected lymph nodes in a recurrent situation. I currently try to get the same treatment done, debulk the mets with PSMA therapy and continue with ADT after that. Being hormone sensitive, it is very difficult to find a clinic that will treat me. I contacted Bad Berka for that but got no response yet. I assume you were treated by Dr. Eiber at TUM in Munich?

cancervictim profile image
cancervictim in reply to tango65

Tango so you continued with Bicalutamide and Lupron after the Lu-177 treatment but stopped both 2 yrs ago? Thanks for sharing your experience.

tango65 profile image
tango65 in reply to cancervictim

Lupron was stopped 1 month after the treatment (November 2016) and I continue with bicalutamide. My testosterone never recovered, it is around 30. Last month we decided to stop bicalutamide since my PSA is stable around 0.05-0.06. They want to see if it starts going up with a testosterone a castration level. If it starts going up, when it gets around 0.2-0.4 they want to have a Ga 68 PSMA study. If there are no metastases, they will probably indicate apalutamide. If there are metastases I will have treatment with Lu 177 PSMA again.

cancervictim profile image
cancervictim in reply to tango65

Thank you. Very insightful. Just wondering- If mets were located in a place where they could be easily surgically removed or radiated, would you consider this compared to Lu 177?

tango65 profile image
tango65 in reply to cancervictim

The lymph nodes I had around the aorta were impossible to irradiate and it had been required a very extensive retro peritoneal dissection, I had nodes up to the kidneys between the vena Cava and the aorta.

If I had had only nodes in the pelvis I would have preferred surgical removal.

It is known that Ga 68 PSMA PET/CT misses lymph nodes with metastases smaller than 2-3 mm. My feeling is that Lu 177 PSMA will not affect these small metastases but nobody knows for sure.

If they do a surgical removal of PSMA positive nodes in the pelvis or abdomen they could do an extensive lymph node removal. I believe it could be more effective than the Lu 177 PSMA treatment and perhaps make a difference in survival.

In summary the answer is yes, I would prefer extensive surgical removal of the lymph nodes, if the nodes could be easily removed.

cancervictim profile image
cancervictim in reply to tango65

Two more questions please! Isn't apalutamide for castrate resistant M0 Pca? Do you have indication that bicalutamide and/or Lupron are no longer effective? Also, if the Ga 68 PSMA doesn't find anything, how do you know if it is because there is nothing big enough to be found or that your cancer is not responsive to PSMA? My husband is planning to stop ADT and have a PSMA scan in a few months so I've been thinking a lot about this.

tango65 profile image
tango65 in reply to cancervictim

Your are right, Apalutamide is approved for non metastatic castration resistant prostate cancer.

If having a testosterone below 50 with or without bicalutamide, the PSA is going up, the cancer is castration resistant.

If in this situations when the PSA is around 0.4 or higher and a Ga 68 PSMA does not show metastases, the cancer will be considered non metastastatic castration resistant and Apalutamide could be used..

It does not really mean that there are not metastases. Ga 68 PSMA seems to be the most sensitive PET/CT but It t could miss metastases. If nothing is found one can still have cancer that is not detected.

If the PSA is 2 or more metastases should be detected with this study (sensitivity around 95% or higher). Some PC do not express PSMA, (around 10% to 15 of the PCs). In this situation clinical judgement has to be used to interpret the study.

If a patient has a PSA of 2 or more and the PSA is going up rapidly (short PSADT) and a Ga68 PSMA PET/CT is negative, then another study with Axumin or 11C Choline should be done to determine if there are metastases.

cancervictim profile image
cancervictim in reply to tango65

Thanks for your comments Tango

GP24 profile image
GP24 in reply to tango65

The European Prostate Cancer Guidelines define castratation resistance as:

6.5.1.Definition of Castration-resistant PCa

Castrate serum testosterone < 50 ng/dL or 1.7 nmol/L plus either;

a.Biochemical progression:

Three consecutive rises in PSA one week apart resulting in two 50% increases over the nadir, and a PSA > 2 ng/mL

b.Radiological progression: .....

Therefore, with a PSA below 2 ng/mL you are not castration resistant yet according to this definition.

uroweb.org/guideline/prosta...

sammamish profile image
sammamish in reply to tango65

Hey Tango, did you have any salivary issues after? I've heard salivary glands carry PSMA and can be damaged by Lu treatment.

tango65 profile image
tango65 in reply to sammamish

No, I did not have any problems with the salivary glands. They made me put ice packs on the salivary and lachrymal glands for about 10 hours after the infusion. Problems with these glands are more frequent with Actinium 255 PSMA than with Lu 177 PSMA. It could be a side effect but apparently it could be managed with the ice packs.

BruceSF profile image
BruceSF

I had a Gleason 5+4=9 dx in 9/2017. Ct Scan showed:

"At least 8 bilateral enhancing perirectal lymph nodes measuring up to 11 mm in short axis. Enlarged lymph node at the inferior aspect of the sigmoid mesentery measuring up to 11 mm in short axis. Enlarged right external iliac chain lymph node measuring 11 mm in short axis, and left external iliac chain lymph node measuring 8 mm in short axis." Psma PET confirmed at least 9 of the nodes, 2 of the perirectal nodes could not be reached by surgery. my PSA was 11.5.

I started Lupron and Zytiga (see Dr James STAMPEDE article in July 2017 Jama) in February 2018, and in July 2018 my PSA had declined to <0.015 (undetectable).

I had a "reverse" HDR brachytherapy boost (see Kishan article march 6, 2018 JAMA) on 8/6/18 and have finished three weeks of Imrt (2 more weeks left), which includes whole pelvic radiation. This is at UCSF.

This is pretty much contemporary standard of care for high risk Gleason, we'll see how it compares with Ron and Tango"s outcomes in 5 or 10 years ;-). I wish I had taken Ron"s advice and gone to see Dr Karnes, I think a "super" EPLND followed by Lu177 (to hit the unresectable perirectal nodes) would have been an attractive option. The negative there is that there have been at least a couple of fatalities with Lutetium so I figured I'd go with the cutting edge SOC instead since i'm still hormone sensitive and not quite metastatic. I guess I can always get lutetium (or actinium) later, at which time they might have a better ligand.

Best of luck whatever you do, keep posting and I'll keep following!

BruceSF profile image
BruceSF in reply to BruceSF

Ps here is what is included in whole pelvic radiation: diaphragm, Peri-aortic, commons, internal iliac, external, pre-sacral and peri-rectal. Dr Roach at UCSF uses Tomotherapy. 60gy to bulky nodes, 45 to others.

usually when after a bicopy you find out u have cancer thats the time to remove the prostrate. not saying by doing it might help but u or he all ready have it and the cancer is in your body. i had mine radiated but again when my gleason score was 7 and the other i forgot. a couple cell got out and after 10 yrs still fighting it until i die. good news after 10 yrs my psa is only 28. taking a new treatment called PROVENGE check it out with your doc

outdoors48 profile image
outdoors48

Thanks, Charles. I've already been through RALP and ART, both failed to get all the cancer. Now in mets category

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