Recurrent Prostate cancer post prostatectomy, salvage radiation and now 1 pelvic lymph node metastasis. What to do?

[Ddjms]

My husband had a prostatectomy in 2007 at MSK, age 57 with Gleason 7, contained to the prostate. PSA was 0.01 through 2013. Unfortunately, his primary doctor did not notice a rising psa over the next few years. In 2016 he discovered his psa had risen to 1.4. He had salvage radiation because an MRI showed a nodule in the prostate bed. PSA dropped to .1. Over next 2 years, psa rose again to 1.4. We went to UCLA for 68GaPSMA-11 in March and 1 6 mm pelvic lymph node in the internal iliac chain was found with a moderate SUV max 6.4. A surgeon/urologist did a lymph node dissection in May but his psa rose to 2.39 by August. Surgeon/urologist said systemic treatment was only option. My husband wanted to know where the cancer was so we went back to UCLA for another scan. It appears that the same 6mm lymph node was still there, now with an SUV max 16. We live in Long Island, New York. My husband wants to take another shot at surgery but now he is very concerned about who will be successful. Initially, the radiologist who did the the salvage radiation suggested surgery followed by radiation. We never got to the radiation because of the rising psa. Any suggestions would be greatly appreciated. Thank you in advance!

[Tall_Allen]

I think it is a mistake to go after lymph nodes one by one. If there is cancer in one lymph node, lymph will carry it to other lymph nodes. It is likely that the cancerous LN detected on the Ga-68-PSMA PET scan is nearby the one that was removed. Just because you can detect the bigger mets, that doesn't mean that's all that's there. Since he has already had pelvic lymph node salvage radiation (with some ADT?), his best option is systemic therapy.

[Ddjms in reply to Tall_Allen]

Thank you Tall_Allen for your insight. Actually he never had salvage radiation of the pelvis, just the prostate bed, with no ADT. We just got a call from the radiologist who did the scan at UCLA and he is recommending a group in Marina Del Rey to treat my husband. While we know that it is likely that there are very small cells that are undetectable, he feels this one lymph node is what’s driving the psa, so maybe radiation with ADT will at the very least buy him some more time before complete systemic therapy. And so this prostate cancer saga continues.....

[Tall_Allen in reply to Ddjms]

He is better off having the entire pelvic LN field irradiated. PSA is a measuring tool - not the disease. It is a mistake to treat PSA instead of the disease.

Prostate Oncology Specialists (Scholz/Lam/Turner) are in Marina Del Rey. They are all medical oncologists, not radiation oncologists. I recommend you speak to an RO about this - Chris King (my RO) or Amar Kishan at UCLA would be good choices.

[Ddjms in reply to Tall_Allen]

Interesting. He mentioned those doctors as well. So you live in the Los Angeles area? We are in New York so if it’s radiation we will probably stay here with Dr. Haas from Winthrop hospital. Surgery is a few days, but radiation is 6-8 weeks. That’s a long time to set up shop away from home. A friend of ours who is a cancer scientist at NCI suggested proton therapy as it is less caustic than radiation. Bottom line is time is not on our side. We need to make a decision.

[Tall_Allen in reply to Ddjms]

Dr King can do the entire pelvic LN area in 5 sessions (at 5 Gy each). I assume Dr Haas can as well. Proton is no better than IMRT.

[GP24]

Unfortunately it is not uncommon that a surgeon misses the affected lymph node seen with a PSMA PET/CT. During surgery he cannot see which one is affected.

You can destroy the affected lymph node with SBRT/CyberKnife radiation with a very low risk of side effects. The radiation plan can be based on the PSMA PET/CT result. However, you should combine the radiation with ADT. Otherwise new mets will usually appear six to twelve months after the radiation.

[Ddjms in reply to GP24]

Thank you GP24. This sounds like very good advice.

[j-o-h-n]

How about Dr. Michael Zelefsky (Radiation Oncologist) at MSKcc in NYC?

Good Luck and Good Health.

j-o-h-n Wednesday 10/03/2018 6:36 PM EDT