RP medical update

[Northcaptain]

One month after surgery, the pathology results from dissection of the prostate and lymph are out :

-Gleason 7 in the prostate (was previously Gleason 9 at biopsy)

-Beginning of capsular invasion but negative operative margin

-3 lymph found positive on 25 lymph removed

PSA currently .36 down from 20.1 prior to surgery. Not nadir yet because Dr with half life calculation says there could be variation...so new PSA required in 2 weeks.

Continence control is very good with being dry from 10pm to noon the next day... and 1 pad required for the dribbling while i'm at work and playing with the cat

Dr says if PSA goes to non measurable within 2 weeks then you're free to go. But if there is still some i want me to pass a PSMA imagery and then decide for adjuvant treatment.

[Tall_Allen]

Unfortunately, where there are 3 positive lymph nodes, there is probably more cancer in your pelvic lymph nodes that was undetected. It doesn't matter if your PSA becomes undetectable for now, or if an Axumin scan fails to pick them up. You have to proceed as if they are there (see the Touijer study below). I think you should talk to a radiation oncologist (not a urologist) about this. You may have a short window of opportunity to be cured.

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

[Northcaptain in reply to Tall_Allen]

So I should ask immediately for a PSMA scan... it could show where these are located before trying to irradiate everything?

[Tall_Allen in reply to Northcaptain]

Even the best PSMA scans cannot detect metastases smaller than about 4 mm, so you have to radiate all the pelvic lymph nodes, not just the ones you can see. There is a kind of scan, available only in the Netherlands, that can detect mets as small as 2 mm. But, even so, you have to get rid of all the cancer cells, or it will grow back.

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

If you want to give a boost dose to the ones you can see, that may be useful (there is no evidence for it - but why not?)

[Northcaptain in reply to Tall_Allen]

Allen as you wrote, my final PSA and it’s trend over the next month could be an indicator to procede: The researchers found that the benefit of salvage whole pelvic treatment and ADT was not maintained in men with very low PSA. There are further analyses expected based on patient risk characteristics and genomic biomarkers. We previously saw in a retrospective study that prostatectomy Gleason score had a significant influence. With better PET scans now, we can have more assurance that whole pelvic radiation is necessary. But at very low PSA (<0.2), even our best PET scans may not find the cancer. Also, it may be that long-term ADT may improve results even further, and that dose escalation may improve results. While this changes the standard of care for many men with persistent PSA and recurrences after prostatectomy, the patient and his radiation oncologist still must rely on judgment.

[Tall_Allen in reply to Northcaptain]

You misunderstood the study. In RTOG 0534, which you are referring to when you talk about men with low PSA, they screened out all men like yourself that were found to have cancerous lymph nodes - they had to be stage pN0 to be included in the trial. So none of that applies to you. Only the Touijer study is relevant to you.

[Northcaptain in reply to Tall_Allen]

Hi Tall_Allen there has been a quite informed response to the original Touijer publication, have you seen it:

europeanurology.com/article...

[Tall_Allen in reply to Northcaptain]

Thanks. And here's the Touijer response:

europeanurology.com/article...

I very much agree that SEER database analyses are problematic,and I too was skeptical of the Kaplan study when it came out (in conflict with two other database analyses). That's why I was happy to see the Touijer study with much more reliable data. I have a preference for LN radiation over surgical LN dissection - not because I'm worried it spreads the cancer, but because radiation covers a wider area and the drainage patterns of the pelvic LNs are indeterminate. The toxicity is also much lower with radiation.

[Northcaptain in reply to Tall_Allen]

Thanks Tall_Allen i'm on watch for the next move, i see my oncologist next tuesday i will ask him the full report and by the same time this is a way of checking if he had read it LOL

[Tall_Allen in reply to Northcaptain]

I always give them fair warning - I send an email before the appointment with the link and write "I'd like to discuss this with you when we meet."

[Northcaptain in reply to Tall_Allen]

Good idea i will do ! I already send him the link you provided about the value of imaging versus PSA. I will add the Touijer.

thanks for all the insights

[Northcaptain in reply to Northcaptain]

Had my visit with the oncologist this week and he was positive about the PSA decrease and he hope that the trend will continue. He says, no other treatment for the moment because we want to put the more time for healing possible between the RP and another adjuvant. So go and enjoy your life, next PSA in 2 months, next visit in 4 months and we see from there where we are heading.

In the meantime i have downloaded the full TOUIJER study about treating men with LN1 with eBRT and ADT and I found that it use a COX model with points adjusted for increased risk over 10 years (all cause mortality) . So i put my parameters in:

Gleason 7 0+

Negative margin 0+

P3Ta 0+

3 Nodes 0+

With 0+ everywhere i see i'm on the low risk side of their COX model with :

17 % chances of all cause death over 10 years "as is" (no ADT+ EBRT)

12.3 % chances of all cause death over 10 years with ADT + EBRT

4.7 % of difference, and with all the morbidity and secondary effect of ADT+EBRT, no sure i want to go that way for a "proactive 5 % probability".

Unless i misunderstood the Cox model and the overall Touijer study.

What i mean to me is that if the PSA stay within its current parameters i'll do nothing. But if it increase and goes over a to be defined threshold then of course we will act.

[j-o-h-n in reply to Northcaptain]

I'd go with what Tall_Allen suggests.... But make sure you get a good radiologist...(and the paddle?).

Good Luck, Good Health and Good Humor.

j-o-h-n Saturday 03/30/2019 12:38 PM EDT

[keepinon]

Congrats on the good news so far! I am kind of the exact opposite. Went from Gleason 7 before surgery 5 weeks ago to Gleason 9. My continence is non existant. If i am vertical, i am leaking. Still waiting for some improvement.

It appears with lymph node involvement you will need RT. Good luck.

[tallguy2]

Wow did this bring back memories. Thanks for posting. I too get by with one to two pads a day (if I stay off the red wine).

If PSA is measurable you should expect to start ADT immediately. Welcome to the club!

[geo52]

I'm doing what RTOG 0534 showed. 6 month post rp rapid doubling t2bn0m0 4+3 started ADT and radiation to the bed and pelvic lymphs a couple weeks later. In second week RT (of 7) will let you know. Tall Allen knows the business.