Suspicious Pelvic Lymph Nodes. Next Action?

[GreenStreet]

I have just got back to the UK from the Netherlands where I went to Radboud University Medical Centre to have a Combidex Nano MRI scan and a PSMA Pet scan. Travel authorisation was a nightmare due to a combination of Brexit and Covid 19 but that is another story which I may post on later. But I had great support from Radboud to get there. Post RP and salvage radiotherapy (prostate bed only) plus 6 months ADT my PSA began to rise slowly and as at March 2021 reached 0.11. The protocol in the UK is to wait until PSA goes over 0.2 before getting a PSMA pet scan but I wanted to try and get a more sensitive scan before PSA increased to that level. The Combidex images suggest 4 suspicious pelvic lymph nodes on the left hand side (one of which was picked up as “equivocal “ in the Pet scan. The Combidex scan also picked up 2 equivocal pelvic lymph nodes on right side. PSMA showed no sign of local reoccurrence or sign of distant metastases with increased PSMA expression. When I get out of quarantine I will have a consultation at the Royal Marsden on what to do next. I would appreciate any preliminary views from you knowledgeable people on this site and also what questions I should put to the team at RMH,

[Tall_Allen]

Get salvage radiation of all your pelvic lymph nodes. They will exclude the prostate bed, of course. They can give a little extra to the cancerous LNs, but they ALL have to be treated (as high as the common iliac LNs). Do NOT do PLND or zap only the ones that have been identified -- there's a lot more cancer in the area that are too small for even the Combidex scan to find. You also need 2-3 years of ADT.

[GreenStreet in reply to Tall_Allen]

Thanks I have a feeling this is the route that I will go down. Not sure why I would need 3 years of ADT though. Is there any data that suggests that 3 years is any better than say 18 months? I am concerned about provoking resistance by being on ADT so long this early

[Tall_Allen in reply to GreenStreet]

Resistance is not your concern when going for a cure.

When there are detected cancerous lymph nodes, at least 2-3 years of ADT are necessary:

prostatecancer.news/2017/12...

[GreenStreet in reply to Tall_Allen]

Thanks again

[Justfor_]

I just wonder what if you had these two tests prior to the prostate bed irradiation.

[GreenStreet in reply to Justfor_]

I didn’t know about the Combidex scan back in early 2018 and I had the prostate bed radiation at a PSA of 0.06. I was concerned about going for the blind punt of early SRT but the numbers suggested it may be worthwhile but not in my case as it turned out. Recently I was advised that one should wait until PSA rises to 0.1 before a Combidex scan is worthwhile. But it is what it is I have to look forward and take it from here.

[Justfor_ in reply to GreenStreet]

I fully understand the course you have taken, though for my personal dilemma I finally opted against blind irradiation. It is a juggling of the odds, no right or wrong.

[GreenStreet in reply to Justfor_]

Yes it is difficult playing the odds. I can understand why you didn’t go for it. I hope all works out well

[Justfor_ in reply to GreenStreet]

A year and a half ago I got an offer of 4k Euros for the Combidex there. Is this the same cost today? TIA.

[GreenStreet]

Yes exactly the same. Was a hot (with mask on!) and long scan but good debrief and report. I can let you know about accommodation if you are interested. It ended up costing me more because I had to quarantine in Netherlands before I could get the scans

[Boonster]

Tall Allen's recommendation sounds right to me. (I am largely in the same position as GreenStreet.) I am concerned about the side effects of salvage radiation + 2-3 years of ADT. I've seen the list of SEs, but it is just an undifferentiated list. I wonder what the statistical probabilities are for getting specific SEs. I think hot flashes are the most probable -- and loss of libido, of course.

[GreenStreet]

I experienced both of those when I did 6 months ADT with my SRT

[Break60]

When I had two suspicious iliac lymph nodes, it was suggested I have all pelvic nodes radiated with low dose imrt . So I had 50 sessions at 1.5 grays or 75 grays . That was in 2015. No recurrence there. I don’t know if it’s now safe to do SBRT in that area. If it is it would take a lot less time.

[GreenStreet in reply to Break60]

I am glad that has worked out 👍 Sadly it turned out not to be an option for me because my physiology meant a very high risk of bowel problems if I went for full potentially curative whole lymph node radiation. I have gone for targeted CyberKnife radiation together with bicalutamide. Unlikely to be curative. PSA is down to 0.02 at last count

[Break60]

Well mine wasn’t curative either but I had no recurrence in that area.