Update on Lymph Node Metastatic Prostate cancer

[dac500]

Today, I had bloodwork, CT Scan, Bone Scan, and Chest Xray.

First, my PSA is down from 0.17 on Feb 28 to 0.1 today, a decrease by 41%. Previously, my PSA was 4.48 at the start of Casodex and Lupron in Nov '18. It went down by 96% by end of Feb '19. Should my PSA gone down to undetectable by now?

The CT Scan contains:

Abdominal lymph nodes: There are small retroperitoneal lymph nodes that are not enlarged by size criteria.

Pelvic lymph nodes: There are small pelvic lymph nodes that are not enlarged by size criteria.

These are the lymph nodes that showed abnormal intense intake in PET/CT scan in October 2018.

Can CT can show healthy normal lymph nodes?

I am still waiting for Bone Scan result. The chest X Ray doesn't show anything unusual.

I have appointment with oncologist on Monday. Is there anything specific I should ask him?

[tango65]

yes, CT scan can show normal lymph nodes. They can suspect cancer if they are enlarged.

ncbi.nlm.nih.gov/pmc/articl...

"

The most widely used CT and MR criteria to determine if a node is benign or malignant is nodal size. Nodal enlargement can result from reactive nodal hyperplasia or coincidental diseases. The following parameters should be taken into consideration when evaluating nodal disease.

Size

Currently, the only widely accepted method for discriminating between normal and pathologic nodes is by size. There is considerable interobserver variation in lymph node assessment and therefore nodes must be measured using a reproducible method. The short axis diameter of a lymph node should be measured as it has been demonstrated that this is constant despite orientation because it is likely to become rounder before it elongates. The short axis diameter is measured perpendicular to the longest diameter of the lymph node.

In the abdomen, the upper limit of the short axis diameter of normal nodes varies from 6 to 10 mm[8,9]. For example the upper limit of a normal retrocrural node is 6 mm, a retroperitoneal node is 10 mm[10] and 8–10 mm for nodes in the pelvis[10,11]."

[Tall_Allen]

CT just shows size of any lymph node, not if cancerous.

I suppose your abdominal lymph nodes were untreatable?

There is no set PSA that you "should" hit - lower is better.

[dac500 in reply to Tall_Allen]

All the lymph nodes producing abnormal intense intake in the NIH PET/CT scan were sub-centimeter size. These are the lymph nodes mentioned in the CT scan. I suppose the lymph nodes didn't change much in size. In November 2018, MO suggested Zytiga might be added to Lupron. In view of the low volume of metastasis, he agreed it might be alright not to include Zytiga. Now my question is, should I ask for adding Zytiga at this point. Will that make any difference in time to becoming castrate resistant?

[Tall_Allen in reply to dac500]

The size of your lymph nodes doesn't matter. I was asking why they were not treated by radiation - unsafe? Zytiga improves survival over ADT alone.

[dac500 in reply to Tall_Allen]

I think the RO who did my brachytherapy mentioned something about radiation resistant cancer. Is there anything like that? I think I will ask MO when I go form my appointment on Monday. I am thinking about making a list of questions and concerns. Some of the lymph nodes in the PET scan are two close to an artery. Can that make it unsafe for radiation?

[Tall_Allen in reply to dac500]

My friend just had his para-aortic lymph nodes safely treated - that's as close as they come. It's usually location near visceral organs that preclude radiation. Prostate cancer is relatively radio-resistant compared to other cancer, so it requires high doses. Some rare kinds of prostate cancer (like neuroendocrine) do not respond to radiation at all. You have to talk to an RO about these things.

[tango65]

Metastatic lymph nodes may remain the same size even when the cancer is not longer present. I had several lymph node metastases in August 2016 that were treated with Lu 177 PSMA (October 2016). I had 2 post treatment Ga 68 PSMA PET/CT (the most recent in Janurary 2018) and they were PSMA negative but the lymph nodes have the same size than in 2016. IMO the only way to know if you have metastases is to do a new PET/CT.

[pakb]

My husband is almost 2 years since diagnosis and isn't undetectable. Lupron + chemo, now lupron + Prednisone + Zytiga. It has gone from >677 to 9 at lowest- but continues to trend downward.

There us no timeline for when your PSA "should" be undetectable. According to our MO- it is the trend down that is important.

[RonnyBaby]

I'm no doctor, but a few thoughts come to mind.

My PSA started above 300 with a Dx of G9 / T3B. I was also node positive (N1).

I was given a bout 9 weeks of RT (the max) with treatment to the 'pelvic' nodes' (there were

a few hot spots that were mentioned). In addition, I was told to take ADT for an undetermined length of time (which turned out to be 16 months when I quit on my own).

First diagnosed (initial treatment started in July of 2017) It took until April of 2018 to get to <0.002.

It was interesting to note that getting from 300 + to 0.4 happened in about 6 months.

That number seems to correspond with many others who report a substantial drop in a few months.

IF you can get to 'undetectable', you're on the path of a better prognosis, longer term.

Apparently, the sooner the better - IF you can't get to the undetectable state, then there's probably further aggressive intervention that might need to be needed to truly bottom out

to the best number(s) possible (nadir). You certainly would like to get to, or go below 1.0.

We wish you well on your path to significant healing ....