I have mismanaged previous posts and take this opportunity to thank you for your previous responses. They were most helpful, kind and appreciated. I hope this one gets out to all of you.
Surgery is not an available option.
I have consulted with two radiation oncologists at the major cancer centres in Toronto (Princess Margaret and Sunnybrook Hospitals) and they both seem to be very conservative in their approach. Due to my positive common iliac nodes (considered extra regional), I am oligometastatic as per my PSMA/PET scan only and am classified as M1a. Princess Margaret is recommending either 6 or 20 radiation doses to the prostate and is also willing to administer a 39 treatment regimen to the prostate and all pelvic nodes including the positive mesorectal nodes. There is a possibility they could use a SpaceOar implant if I opted for the 6 treatments. They said that the positive nodes may have shrunk significantly and may never become a problem. Sunnybrook has a trial using SABR technology which would include treating the prostate as well as targeted treatments of the positive lymph nodes. Unfortunately, due to being on Lupron and Erleada for more than 3 months, I do not qualify for this randomized trial and they can only offer the 5 session SABR treatment to the prostate. Frankly, I am looking for a cure as my extra pelvic nodes are microscopic and are borderline outside of the pelvis so I would prefer to pursue all the visible mets but neither oncologist said that there is any proven benefit to that approach. The possibility of a cure is highest for me now and I am concerned about shutting that door now. The Phase 3 RC trial for which I am not eligible as well as other small trial suggest that there is growing belief that there is a benefit to killing all lymph node mets in addition to the prostate. At the same time, I am concerned with bowel toxicity. Finding it difficult to decide what to do. Any input would be extremely valuable due to your knowledge and experiences.
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Squirrel71
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There has recently been a change in what is considered a pelvic lymph node. It now includes the common iliac nodes. You have to treat the whole area - not just the ones where the cancer has become big enough to show up on the PSMA PET scan. It doesn't matter that the metastases are small- cancer cells are in your lymphatic system in the entire area and they all need treatment. According to the best data we have, treatment involves 50-65 Gy to the entire area + the extra prostate dose + 2-3 years of adjuvant ADT. You can also use brachytherapy to get the extra prostate dose.
To avoid radiation toxicity, the RO has to very carefully contour the dose and leave no margins around the pelvic treated area. SpaceOAR is possible not a good idea with your mesorectal lymph nodes. My friend had it and it squeezed some cancer against his rectum, protecting the cancer from the radiation. It became a big problem for him.
Thank you again Allen. I presume that there are many micrometastisis trapped in the pelvic area. Why do you suppose many of the new studies focus on radiating only the visible ones? I have not been able to find justification in my literature research.
Unlike melanoma and some other cancers, prostate cancer is immunologically cold. SBRT increases antigen presentation. While I suspect it may improve your response, there are no immunotherapies currently approved for your situation.
Hi Mr. Allen. Thank you for your thorough and thoughtful input. I am impressed with your knowledge and involvement. The dose that has been recommended is 54 GY in 27 days to the nodal chain and prostate and another 24 GY in 12 days to the prostate for a total of 78 GY to the prostate. The 6 day regimen would be 36 GY to the prostate, which seems low and the 5 day SABR would administer 70 GY to the prostate. BBT is not available to me. I believe you are recommending radiating the prostate and nodal chain but I wonder if the recommended dose will provide adequate benefit. Thank you.
I had 80 gy March 2020, 28 sessions to LN as far north as my waste , sorry don't feel like looking up the names, and the full 80 to the PG. 44 treatments. No space oar. I rode my bike to all treatments and afterward for a total of 742 miles in the 9 weeks. It was winter here so cold and raining most days. I had some blood for 2 days at the end and that was it. Nothing since that I am aware of. My RO said we won't know if it did any good until they take me off ADT in a year and see what happens. When I ask my MO about that he is non-committal. Maybe he doesn't want to jinx it. My PSA hit undetectable before the end of the treatments. Holding steady for now (literally just knocked on wood). So we will see what happens.
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Distant Lymph node treatment options?
