Treatment Options for Lymph Node Metastasis

[dac500]

A 18F-DCFPyL PET/CT scan has found about ten pelvic lymph light up with abnormal intense and intense signals. A T3 MRI didn't find anything significant. The prostate is completely clear of malignancy. PSA (3.26 on 10/22/18) is rising rapidly with a doubling time around 2 months. A biopsy of one of the lymph nodes (peri rectal) will be performed on November 9 under the NIH clinical study.

Sooner or later I will have to decide on a treatment option. The decision will probably depend on the result of the biopsy. In an appointment with my URO following possibilities came up

1. Removing suspicious lymph nodes combined with ADT

2. Radiating pelvic lymph nodes combined with ADT

3. Combining chemotherapy and ADT

4. Intermittent ADT only

I have an appointment with a MO on November 16. Let us see what he says.

I had brachytherapy of my prostate in 2011 and cyber knife for a extra-capsular nodule in 2017. Is radiating the lymph nodes a good idea? Does my age (78) rule out some of the possibilities? Should I go on intermittent ADT alone?

[Tall_Allen]

Unless you have other comorbidities, I don't think your age rules out anything. Why not go for the cure? Considering the volume of positive lymph nodes, I think ePLND would require pelvic LN radiation anyway, so why not go after them with external beam straight away if you can? That would probably be accompanied by about 2 years of ADT.

[dac500 in reply to Tall_Allen]

TA, thanks for the excellent advice. After I have the biopsy at NIH, I have an appointment with an MO followed by an appointment with a team of URO, MO, and RO. All these are going to happen in a time frame of about three weeks.

[Hawk56]

Combination therapy may provide you the best outcomes - an elusive "cure," a long progression free survival (PFS) and increased overall survival (OS).

In my case, after BCR 18 months after surgery (T2CnoMx), GS 8,, margins, ECE and seminal vesicle negative, 10% prostate involvement, failure of SRT I headed to Mayo where a C11 Choline scan showed four pelvic lymph nodes light up.

My medical team agreed that surgery itself may not work due to micro-metastatic disease. We decided on six cycles of taxotere, 24 months of ADT and 25 more radiation treatments (45Gya). My radiologist was able to build a treatment plan that included boosts to the four lymph nodes, wider margins around them and cover the other pelvic lymph nodes.

My PSA was 4.88 when we kicked off the treatment, dropped to .88 after the first chemotherapy and undetectable with the next treatment where it has stayed. We stopped ADT at 18 months based on studies such as the RADAR study given my response to the combined therapy. My last Lurpon shot was in May 18, August PSA was undetectable and awaiting results of my PSA test this week.

Since I started my treatment in Jan 17 there has been discussion about whether to do ADT, Zytiga and radiation or the combination I did. One of the advantages to what I did is the chemotherapy is 18 weeks and then 2-3 months after with recovery versus perhaps 18 -24 months of Zytiga (there is an insurance and cost factor too). Zytiga or chemotherapy may also depending on your age, health, physical status...

For me, the combination therapy has worked, am I cured, who knows, how long will my PFS be, have I increased my OS only time will tell!

So, I would consider the trifecta - ADT for 18-24 months, radiation to the pelvic lymph nodes and either Zytiga or taxotere.

Kevin