Salvage lymph node dissection for nodal recurrent prostate cancer.

[tango65]

For those considereing salvage lymph node treatment. We still do not know if dissection helps on long term endpoints.

ncbi.nlm.nih.gov/pubmed/303...

[Tall_Allen]

Well, we DO know that salvage lymph node radiation + ADT is beneficial:

pcnrv.blogspot.com/2018/10/...

[sandy4510 in reply to Tall_Allen]

After an auxumin scan showed my husbands pc had spread to three lymph nodes we asked his dr about salvage radiation and he acted like it was not a good option. He said that a psma scan might show 20 more nodes lit up... and so blew it off. I was thinking later that wouldn’t it be worthwhile to somehow get a psma scan and know that? To know if 3 or if more.

[tango65 in reply to sandy4510]

I think it is worthwhile to know were the metastases are located and if they can be treated with radiation or LND. I had a PSMA PET/CT in 2016 and it showed several nodes in pelvis and abdomen. Nobody wanted to irradiate them or do a LND. I went to Munich and got them treated with Lu 177 PSMA. One treatment took care of these metastases.

[Tall_Allen in reply to sandy4510]

It sounds like he misunderstands this therapy. It is NOT targeted just to the lymph nodes that have been detected. It is targeted to ALL pelvic lymph nodes. You should talk to a radiation oncologist about it. There is no need for more scans - you already know it is in his pelvic LNs - it does not matter how many and where - you have to treat what you can't see.

[tallguy2 in reply to Tall_Allen]

Exactly what my RO told me. I start next week.

[George71 in reply to Tall_Allen]

Allen, I have seen you post several times that the SRT is to ALL pelvic lymph nodes. I have been unable to find any radiation OC that will do or recommend radiating ALL pelvic lymph nodes. they only will do the 2 rows adjacent to the prostate bed and the prostate bed.

[Tall_Allen in reply to George71]

Just to clarify - I said that IF the SRT is to ANY pelvic LNS, it should be to ALL the pelvic LNs (prostate bed only is adequate in many cases). The RTOG guidelines have been found to be inadequate:

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

The treatment field should be expanded to the common iliacs. If you can email your RO, you might want to send that article (it has to be email because the links are important). Again, this is only when there is reason to treat the pelvic LNs.

[GP24 in reply to sandy4510]

Sandy,

if the doctor just wants to treat with ADT, as the guidelines recommend, he does not need to know how many mets there are and where they are located.

GP24

[packfan in reply to sandy4510]

If only lymph nodes are involved (and this can be hard to know) then salvage lymph node radiation to the whole pelvis still has curative potential. This is not discussed quite as often as I would expect, but it may be that MO's are assuming probability of spread beyond the lymph nodes. It's something I would talk to the MO about - curative treatments should be exhausted before moving to lifelong ADT treatment. Great to see tango65 had positive results with Lu 177.

[sandy4510 in reply to packfan]

I am thinking the only way to best know that is a psma scan?

[packfan in reply to sandy4510]

Unfortunately today's scans are limited, and you'll miss micromets. You don't know for certain if it's lymph nodes only, or if there are small mets somewhere else. Also, if there is enough PCa in a lymph node to show up on a scan there is a chance that other lymph nodes are involved, but are not showing up yet. The good news is scanning technology is improving.

[tango65 in reply to sandy4510]

The PSMA scan is the most sensitive PET/CT scan but it will miss nodes if the cancer is less than than 4 mm in diameter. There is another technique, the combidex scan that uses ferromagnetic nanoparticles and MRI which could detect node metastases if they are 2 mm or larger. It is only available in the Netherlands.

If a PSMA scan shows only nodes in the pelvis then radiotherapy has curative potential and it could be implemented before starting ADT for life.

[sandy4510 in reply to tango65]

Thanks we really really need to check that out before he starts adt.

[tango65 in reply to sandy4510]

One should be aware that it could be nodes outside the pelvis that are not detected by the PSMA scan. Only way to know is doing the PSMA scan and if nodes only in the pelvis do the radiation treatment to the pelvis and see what happens.

[sandy4510 in reply to tango65]

Yes there are no guarantees in any of this you are right.

[StayingOptimistic in reply to sandy4510]

Can you please let me know what your plans are after you check things out. I am in the same situation. Thanks a lot

[sandy4510 in reply to StayingOptimistic]

Will do

[GP24]

In this trial they included patients with LND. They report a delay of the disease by 8 months.

ascopubs.org/doi/abs/10.120...

LND is not curative, however, Zytiga and Docetaxel cannot cure as well.

Dr. Tran says in this short article that LND for lymph node recurrences is "not unreasonable". So this is the best evidence we have at the moment.

redjournal.org/article/S036...

The best results apparently has PSMA radioguided LND:

thieme-connect.com/products...

They report: "in 19 of 31 patients even a complete biochemical response was observed."

[scarlino]

Are there any studies that show benefit to patients having had radiation to the prostate instead of removal? Does it matter? Initial treatment was proton therapy. I have lymph node activity (positive via biopsy). I have been on Zytiga+prednisone+apalutimide for a clinical trial. My PSA has risen to 16 from 4 three months ago and I have three additional pelvic lymph nodes, besides the one above, have shown slight enlargement.

[GP24 in reply to scarlino]

I do not think three lymph nodes can cause a doubling time of three weeks. It is likely that you have remote mets too. If you want to know that, you have to get a PSMA PET/CT. How to treat what you see then - it may not be possible with radiation or surgery.

[scarlino in reply to GP24]

I have always had a fast doubling time as treatments started to fail. My prostate was biopsied and nothing showed up (recognizing they can’t hit every spot). I agree the lymph nodes are not causing the fast doubling time. I sure would like to know what is as CT and body scans have never located anything other than the lymph nodes.

[bostonmac]

In 2013 after a choline PET/CT it was determined that my prostate cancer had spread to my lymph nodes. In 2014 I underwent extensive lymph node dissection. I had 46 iliac lymph nodes removed and nine of them came back positive. Only two had shown up on the PET/CT is positive so the extensive surgery was beneficial. My PSA dropped from 12 to .02 and remained at that level for over a year and a half. When my PSA started to increase again but participated in a clinical trial for a year and it was pretty successful. In 2017 after a PSMA PET/CT showed a reoccurrence I underwent a second extensive lymph node dissection and had 26 retroperitoneal lymph nodes removed. 14 of the 26 came back positive and my PSA dropped only temporarily. Another PSMA PET/CT showed a reoccurrence in my super claviclular lymph nodes and I underwent cyber knife radiation. Although the treatment was successful my PSA continue to rise. My understanding is that my disease is systemic and the value of additional surgery or radiation would be limited. And in June of this year I started on androgen deprivation therapy in the treatment has been successful. Much like everybody else on the site I have multiple side effects from all the different courses of treatment. The multiple lymph node dissections have left me with a fairly significant case of lymphedema in both legs.

I had a really good surgeon and was very happy that for 18 months my PSA was well-managed after the surgery and I did not have to have any additional treatment. I was able to postpone hormone therapy for four years. Best of luck

[GP24 in reply to bostonmac]

If you would find a clinic which does a Lu177 PSMA therapy like tango65 did, you could postpone ADT even further. However, probably combining this with intermittent ADT will work best.