I am evaluating my next steps following biochemical recurrence post radical prostatectomy 2 years ago (see background data notes below).
While I met with my local radiation oncologist 2 weeks ago this week I met with the department head at a medical college hospital - Dr. Colleen Lawton from Froedtert / Medical College of Wisconsin.
The one key insight that she made that was not discussed locally was the addition of lymph nodes to the salvage radiation treatment plan. I researched this and found the following relevant article that appears to support her recommendation:
Diagnosed with Gleason 7 (3+4) in July 2018. Radical prostatectomy in October 2018. PSA rising to .38 on August 12 2020. Decipher post RP test score was .37 (low risk). Determining next steps. I am located in Wisconsin. I had my robotic prostatectomy perfomed by Dr. Kenneth Jacobsohn at Froedtert near Milwaukee. I am looking at the University of Wisconsin Madison Dr. David Jarrard as the urologist/oncologist.
Axumin scan results from last week (September 17, 2020) were negative to any definitive metastases.
•Prostatic adenocarcinoma, Gleason 3+4 (score =7, Grade Group 2; 15% is pattern 4, not cribriform), bilateral and multifocal, within 2% of gland
•Tumor forms a dominant nodule in the left posterior peripheral zone (levels 8--11) measuring up to 10 mm (at level 8 or 9); also present in the right posterior levels 2—6
•Negative for extraprostatic extension (Stage pT2) - Organ confined
•Resection margins negative for tumor
•Seminal vesicles and vasa deferentia negative for tumor
As you see, "The researchers found that the benefit of salvage whole pelvic treatment and ADT was not maintained in men with very low PSA." I do not know if your PSA qualifies as "very low." Unfortunately, the full trial results have not yet been published. Perhaps Dr Lawton can call Dr Pollack and ask what PSA cutoff he used. If she does, please let me know.
The fact that your Axumin scan was negative and your low Decipher score suggests that whole pelvic radiation may not be necessary.
Thank you as always for your response. The Decipher test seems not to have much impact with the oncologists that I talk to. I meet with UW Madison university hospital on Monday for their advice. I am doing my due diligence.
Hi again, Rick who used to live in Fond du Lac & Stevens Point. Was the addition of lymph nodes discussed by the RO the lymph nodes in the pelvis or the peri-iliac region lymph nodes or both?? If you will recall I had both microscopic Extra Prostatic extension & microscopic pos Sg Margins and received Adjunctive RT to the Prostatic Bed, Pelvic area & peri-iliac regions. The following is my reasoning but makes sense to me. Since your cancer cannot be seen by scans, being sure all the cancer is included in the RT is important and some protective radiation margins will likely occur just to be sure all the cancer is included in the RT fields.
Thank you Rick! I visit with Madison on Monday and then will circle back to my local radiation oncologist after that. I have talked to some people who have been treated locally and they facilities here are new and state of the art so they have ameliorated some of my concerns about ThedaCare.
Were Submitted From your surgery. That leaves a hole in the information despite everything else being favorable. So that might be a consideration in decision to add PLNs to the SRT.
I agree. And in the lack of information one might tend to lean towards treating the lymph nodes even given the increased risk of GI and GU morbidities. I am wondering now if maybe a lymph node biopsy can be performed? I will need to research that.
Have you started ADT? My LN literally disappeared after I started ADT and they attempted a biopsy but could not find any with ultrasound after searching for 20 minutes. I had been on Lupron for a month at the time.
I have not started ADT yet because I am still finalizing which provider to use. There are so many variables involved. At some point one has to make the best informed decision one can. Thank you for responding. Your results are encouraging.
Froedtert's recommendation is to add (in addition to the prostate bed) is: "I would include the pelvic lns only which includes the oburator lns, the internal and external iliac lns and the lower common iliac lns". I am meeting with the University of Wisconsin Madison Hospital Radiation Oncologist tomorrow. It will be interesting to see what they say and then I will have to reach a decision. Thanks for your comments.
Sounds well considered. When they do the planning CT they can show you the relationships to other “organs at risk” and how they will plan the treatment volumes in distributing / delivering the treatments. It is amazing technology so far beyond what was previously available. Even from very recently. I think you are on a wise path.
Hello STom, you had one of the best surgeons in the country. I watched quite a few vids of surgeons using the D5 robotic device. BTW my diagnosis was very similar to yours, except Gleason was 4+3.
I had a long talk with Dr. John Longo at Froedtert West Bend. He sent me all the trial data and I elected for the bed and lymph radiation along with six months ADt. Been at <0.001 for a year.
Longo is a great planner and worked with "sure shot" RO Dr. Jarred Robbins at Froedtert who cured me of stage four back of tongue cancer. They're good over there. Other guys I know with similar diagnosis treated at different facilities, have not fared as well as I. No pads, leaks, nothing. Ok. Very grateful.
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