Atypical metastasis? Mediastinal lymphadenopathy - help with next steps please

[Proflac]

Anyone with experience or information about this? My profile gives the full details of my husbands journey with Pca. In brief diagnosed 2016 Gleason 8, N1 MO. Initially treated with ADT - and RT only. PSA nadir was 0.04. Discontinued ADT by oncologist Nocv2017. Recurrence Jan 2020 PSA 24. Regular CT and bone scan showed no visible bone mets but mediastinal lymphadenopathy with large right hilar node of 20mm short axis. ADT recommenced, chemo prescribed but cancelled due to covid. Arghh. ADT alone brought psa back down to 0.52 in August. Xtandi taken for short while, discontinued due to bad SEs. Zytiga commenced (with pred and ADT) Sept. PSA has now gone to 1.1 as of 4th November. New CT scan ordered for 16th November. No further bone scan has been offered, though it seems highly likely to me that there are now bone mets. Oncologist says no point in more tests if it wont change Tx and I guess that makes sense? or does it?

So. Question is - does anyone have any thoughts about this diagnosis and progression of PSA, and what should we we thinking might come next as a treatment option? I am aware this is going nowhere good (!) but like to think ahead a bit, if only to have the right questions for the oncologist. He does not have BRCA mutation. I imagine chemo? - but would it be good to do this now, or should we wait for further rise in PSA or what the scan shows up (not sure chemo available still due to Covid and oncologist has not suggested doing this at the moment - but I am wondering whether a second opinion in more specialist clinic might be a good idea - but it is not so easy here in the UK as in the US btw). Our clinic does not have Choline PET or other more sensitive scans. But would he need these anyway?

[tango65]

He has castration sensitive metastatic PC. There is not difference in overall survival between chemo and Zytiga.

pubmed.ncbi.nlm.nih.gov/295...

[Tall_Allen]

I agree that there is no point in more sensitive scans. Monitoring progression with the same kind of scan makes more sense.

Perhaps they would agree to give him Neulasta with chemo? That might help circumvent the danger of covid 19.

When you say that he does not have BRCA mutation, was that determined by a germline test (blood or saliva) or a tumor biopsy? If he has not had a biopsy of the hilar metastasis, including histology, IHC, and genomics, there may sometimes (rarely) be some useful info there. Johann de Bono at Royal Marsden is the big UK expert in that.

[Proflac in reply to Tall_Allen]

Sorry if this got sent before. I hit the wrong key! Thanks for the reply. Germline saliva test. He has not had a biopsy of the tumour. What potential treatments might that make available? or would it help with determining the kind of chemo he might have? or some other targeted treatment? I think we will ask for opinion from Royal Marsden or UCL., but there might be quite a wait. I guess when we get the latest scan result in a couple of weeks we will have to think about what next if the tumour has increased in size or more appear elsewhere. I cant find out a whole lot about this particular pattern in terms of prognosis etc. Mind you, might well be in the bones too by now I guess. Though not sure why no bone scan has been ordered - maybe because the PSA is not high enough for much to show, or maybe because it would make no difference to the treatment.

[Tall_Allen in reply to Proflac]

Histology and IHC may rule out or indicate several potential avenues, depending on the phenotype. Somatic genomics may indicate PARP inhibitors, carboplatin or several clinical trials.

[Proflac in reply to Tall_Allen]

Thanks. More reason to get second look at a hospital where these are potential treatments. Appreciate your response.

[Sisyphus]

Hi

I had bilateral lymphadenopathy revealed on a CT scan undertaken to identify if I had a pulmonary embolism after a failed cardioversion. I was diagnosed Gleason 9 NiMo prostate cancer with only extension to one external iliac lymph gland.

I was referred to a thoracic surgeon who conducted an endobronchial ultrasound known as an EBUS. This is a minor surgical procedure to take samples of the material in the enlarged lymph nodes for analysis.

Result for me was a rare actinomyces bacterial infection and not neoplastic/cancerous or inflammatory material.

So my comment is that enlarged thoracic lymph nodes are not inevitably metastatic.

If the lymph node is not enlarged due to metastasis but from another cause, there is no thoracic metastasis to treat

You will need an EBUS to determine conclusively what you have developed and the treatment required.

[Proflac in reply to Sisyphus]

Thanks that's very interesting. Presumably that's a non invasive procedure too?

[Sisyphus]

Hi

No, it is a day surgery under general anaesthetic. I suggest you use Dr Google to see how it is done. It seemed to be a minor technical procedure. I had no issues afterwards.

I would be concerned to avoid upgrading the treatment regime with additional chemo until the need to do so is established.

Regards

[sandbergc9]

I would follow your doctors advice. If you're uncomfortable with them, do consult another doctor. Unfortunately, my experience, they follow the same recipe book.

I found the advice of these members very uplifting. I quit the zytiga, but that was MY personal decision.