I updated this article to mention that a major Phase 3 randomized clinical trial (INNOVATE) in 141 locations will determine whether intensifying the hormonal side of the treatment with 2 years of Zytiga+Erleada+ADT has better outcomes than 2 years of ADT.
When prostatectomy reveals positive pelvic lymph nodes, they will confirm that it is only regional with an Axumin scan but allow PSMA and C-11 Choline too.
The whole pelvic radiation dose will be determined by the treating radiation oncologist. Prior SRT is permitted as long as the treated area doesn't overlap.
I am having a bit of trouble reading and understand your article.
Do I have it right that in instances where metastasis to lymph nodes is suspected or found, that it is an effective treatment to use focused SBRT (as opposed to less focussed IMRT) radiation to treat the general pelvic area as a precautionary measure?
Now I am fairly certain I am misunderstanding something. Can you explain what it is that may be? LOL.
So here i am sitting on a newly minted 0.07 after ralp and early salvage just to the fossa (about a year ago) and 7 months adt wore off sometime over last summer.....and im thinking to myself, spin again with whole pelvic radiation less whatever they already treated. Maybe, as Maxwell Smart says, they “Missed it by that much.” It seems though I wouldn’t qualify for this particular trial, but how hard would it be to convince a MO to do something equivalent?
I went from undetectable to 0.07 between January and April. If they just missed some indistinct node, and they pulled tbe trigger at 0.11 15 months ago....in my simple mind it seems like i am sort of finishing the job. Its like a delayed treatment to the nodes in the event the initial radiation to the fossa failed..... maybe just wishful thinking.
I dont, and its maddening. 0.07.....tiny sliver somewhere. Just like i didnt know if it was in the fossa. But i read your post/article about how radiating the nodes along with the fossa had significant advantages. So I am thinking that if I were approaching 0.10 for the first time post RALP I would ask for the nodes to be included, so I am mentally just continuing an interrupted treatment. The nodes are just getting dosed a year later.
Tom, I just finished lupron in oct 20 and Zytiga in feb 21. I’m now waiting for T to rise and see where I am. I also had margins and 3/24 nodes involved. My PSA has remained undetectable it takes awhile for T to return. Mine hasn’t moved.... I wish you the best.
Yeah I've read that if you reach extremely low T ie <1ng/dl it can be very hard to get the T up to normal levels. At my last MO visit I mention hcb injection, which I've read on this site can help increase T levels,but he wanted no part of it. My last Eligard shot is in July and I have a visit in August with the Urologist so I'll pepper him about the shot.
Good luck to you also..btw..im 55 so we are similar in other ways too
Is funny because I believe there's benefit to have all those scans upon recurrence post primary treatment. Not just lymph node involvement. I hope that this becomes normal as if there is seemingly some benefit identified and why it's used here as an example in this study, it would then be useful for any/all recurrence in order to attempt and identify what's causing the PSA rise. No? PSMA & Axium & Choline combined. It may require watching and waiting until the PSA reaches levels which would allow the tests to be effective, but still.
Most ROs believe there is stronger evidence for a cure in treating N1, while there is no evidence that M1 can be cured. There are several other RCTs for M1. Most men in this study will have had cancerous pelvic lymph nodes found by PLND during prostatectomy. They will be checking for distant metastases with an Axumin PET/CT.
Unfortunately, there are no PET scans that can reliably detect metastases at low PSA.
I waited to get the 68Ga-PSMA scan until my PSA reached slightly above 1.0, and even then (as you previously noted) it did not identify all of the LN's involved. 8 suspicious sacral LN's were removed during the surgery; however, only 5 were identified in the scan. In retrospect I would have foregone the subsequent LN surgery (which only bought me about one year of relatively low PSA's) and given the tE2 a try had I know about it back then.
A recent RCT proved that even extended pelvic lymph node dissection (ePLND) is no better than a PLND where just a few are removed. (ePLND is popular in Europe and a few centers in the US) We can combine that with the recent study from Mayo that suggests that targeted LN radiation-only has worse results than radiation to the entire pelvic LN area.
We have come to realize that the only value of surgical LN removal is to indicate that whole pelvic radiation is necessary. But it has to be combined with long-term ADT.
On behalf of everyone on this forum I would like to thank you for your extraordinary devotion to helping us battle this nasty disease! I believe you read and answer almost every post, are ‘up to date’ with every drug/treatment available, plus you are able to recommend the best hospitals and doctors worldwide. Where do you find time to eat and sleep? You are one amazing man!
can you provide the study please so I can give it to my Dad . He now has N1 2years after stage 3aRP. His current treatment is targeted lymph node radiation and not whole pelvic . He is doing xytiga and lupron in parallel. Cheers
So as a post RP (8/2019), GL9, Decipher .78, T2N1M0 patient...who has done ADT (Firmagon/Orgovyx) since October 2020 when my PSA got to .16 and it quickly went to undetectable and has stayed there since and I just finished 38 Salvage Radiation treatments. Still undetectable, T in teens....so do I just sit tight and pray for the best and await these trials?
Still on ADT. You think the counting period should start post radiation...or inclusive of radiation and pre radiation? I had just assumed it started with the start of ADT.
Yes, you're right - start when ADT started - but there are no hard-and-fast rules - we're all guessing. All we know is it seems longer is better. In the trial, they are arbitrarily using 24 months - maybe 24 months with Zytiga and Erleada is as effective as 36 months with ADT only?
I LIKE THIS TOPIC and there are wide-ranging things to consider. "toxicity has been improving", "spread may be confined to pelvic lymph nodes for some time" "optimal duration is unknown", "extent of the treated area has been questioned". I am now at 21 months on ADT monotherapy after 6 months of chemo-radio-hormonal therapy for 2nd recurrence 7 years after primary therapy. PSA now at 0.01 down from 18 prior to beginning treatment and PSADT of 2.6 months. The great experiment and I am not talking about ham radio.
Decreasing 10 yr Mortality by 31%-59% are huge numbers. I’m still hopeful of finding a Surgeon who will remove my Prostate so I may have Lymph nodes removed and whole pelvic radiation while continuing my current ADT protocol of Firmagon+Zytiga+Prednisone 10mg. I wish I knew the secret of how all these advanced PCa guys get a Prostetechtomy for a shot at longer survival. It cannot be all by accident???
Surgery followed by whole pelvic radiation has a very high risk of side effects - what is the point of surgery if you know you will be having radiation anyway.
I have listened to you for some time . I was wondering if I could contact you for a consultation on what to do next situation regarding my PCA . I’m getting very confusing answers from my current Dr , Dr Schulz in marina del Rey . Previously saw Dr Meyers and whether he was right or wrong he seemed to have a plan and I’m not getting that now plus his office his not nice , helpful , considerate nor do they seem knowledgeable . Quite frankly need some 1 on 1 help and was hoping I could get that from you . Thank you
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Lymphopenia after whole pelvic radiation
Bleeding after salvage radiation 
PSA after salvage radiation
Radiation to lymph nodes after failure of SRT to prostate bed 
Another positive lymph node
