Distant Lymph node treatment options?

[Fenix11]

I'm new here! Let me give you my background.. I'm 70 years old and was dx in September 2021,Gleason 9 - 4+5 / pT3bN1M1), PSA 198 with Pet CT PSMA F18, MR, Bone Scan.

No bone mets but multiple pelvic lymph nodes are positive and 5-6 distant lymph nodes in the abdominal region. Started ADT with Eligard shot, Abiraterone, Prednisone,Pantoprazole on Oct 15th.

On 23rd of November had new tests and PSA dropped to 6.8. I was elated by such a drop and upon a visit to my Dr he suggested radiation therapy.

I spoke with two Radiation Oncologists of which one suggested SBRT to the prostate and seminal vessels. My concern is how does that effect the lymph nodes which are not treated?

The other spoke with other doctors who confirmed being faced with a situation being out of the SOC because of the 5-6 distant lymph node mets where the STAMPEDE states max 3 distant mets. Being this situation and my excellent initial results with ADT they agreed upon continuing with ADT and beginning of February have another PET-CT PSMA to see if the distant mets reduce to 3 and then analyze what radiation will best. Probably SRBT to prostate and include distant mets.

Has anyone been through a similar situation with distant lymph node mets and what treatment was taken and how effective is it?

The situation is not easy because I understand the ADT can shrink the cancer but not kill. Is this true? If so Radiation seems like the next step.

We have LU-177 available here also but I was told to save this option only if needed.

I am doing everything I can and have the support of my wife and family but would greatly appreciate hearing about any experiences or information to help me take the right steps in this fight for survival and quality of live!

May all have a good Xmas and all the best!!

[Tall_Allen]

The trials that found that SBRT to the prostate is a waste of time if there are more than 3 distant metastases used bone scan/CT, not PSMA PET. It also was found using "de novo" metastatic patients, not patients whose metastases have been shrunken by systemic therapy. There is some early spread from the prostate, but later, most of the metastases grow from other metastases.

Abdominal metastases can be dangerous to irradiate, and it is highly doubtful that there is any benefit in doing that. Even small amounts of radiation can be very damaging to vital organs in the upper body.

When your cancer became metastatic, there were thousands of cancer cells that implanted themselves everywhere around your body. Most of them are way too small to detect with even the most sensitive scan (there is a 5mm size limit). Getting rid of some of the larger ones may or may not slow down spread of your cancer. If it is safe to "zap" them, why not? But if it is unsafe, as it may be in your case, the risk vastly outweighs the possible benefit.

However, SYSTEMIC therapy using advanced hormonals and/or docetaxel is known to slow progression and increase survival:

prostatecancer.news/2021/05...

[Fenix11 in reply to Tall_Allen]

Thank you for the information. I will consult this road with my Oncologist. The possible risks treating mets in the abdominal lymph nodes with SBRT was expressed by the Drs and the risks vs benefit seem to be questionable. The LU-177 therapy in my unknowing logic seems to be best because it targets the PSMA direct being able to avoid other areas. Still I get the idea that because it is a fairly new treatment doctors here prefer to go to SOC treatments and use LU-177 as an option when other treatments fail. Maybe because of the side effects??

[Tall_Allen in reply to Fenix11]

In the US, Lu177PSMA617 will probably be approved next year, but only among men who have already had docetaxel and at least one advanced hormonal therapy. It will also only be approved among men who have significant PSMA avidity on a PSMA PET scan scan (which seems to be your case). In men who have high PSMA avidity, the side effects are usually tolerable. There are clinical trials for using it earlier. I don't know what the restrictions are in Brazil.

[GP24]

A Lu177 therapy is very effective against lymph node mets. I had one distant lymph node met and several in the pelvis. I got rid of these using a Lu177 therapy:

healthunlocked.com/advanced...

Usually doctors do not treat hormone-sensitive patients with Lu177 though.

"We have LU-177 available here also but I was told to save this option only if needed." - If you have several distant lymph node mets you need this treatment.

[Fenix11 in reply to GP24]

Apparently while the ADT is working no LU-177. There must be some reasoning behind this. Maybe get all you can out of ADT etc. first. Still if you can get rid of the distant mets as soon as possible, why not? Maybe the risks of effect on quality of life are involved.

Now I have no symptoms, no pain, a bit of less stream urinating but all in all fine. As Tall Allen pointed out the docetaxel is another option to check out.

[MateoBeach in reply to Fenix11]

Yes, early (simultaneous) docetaxel chemo with the ADT and abiraterone shows a large survival benefit in de novo metastatic PC. Per the PEACE-1 trial. Lu-PSMA treatment appears to work better earlier in the disease rather than later. So try to get PSMA PET scan to see if yours are avid.Personally I would seek Lu-PSMA treatments soon after the course of docetaxel in that situation. Best of luck

[E2-Guy]

Buenos días Fenix,

I don't know if my anecdote will afford you any help in your decision making process; however, I'm offering it to you anyway! Seven years post RP I began experiencing asymptomatic BCF and three years later I chose the 68Ga-PSMA scan to identify the PSA rise. My MO recommended surgically removing the identified 8 sacral lymph nodes which was a big mistake. Had I talked with our resident 'PCa guru' Tall_Allen prior to submitting to the surgery, I would never have allowed this worthless $70,000 surgery to happen. His opinion regarding LN radiation or surgery is clearly explained in his above reply to you.

My LN excision simply lowered my PSA from 1.30 to 0.54 for a few months and started rising again at which time ADT was the SOC. After reading about all of the 'nightmare' Lupron experiences on this forum, I was determined to find an alternative or just allow the PCa to take its course and 'do me in' a little sooner. I started reading every article that I could find on the old , but effective oral estrogen tablet DES that kept my grandfather, father and uncles 'alive and feeing good' until it was replaced with Lupron in 1985. Many of the ladyboys here in Thailand have been using a transdermal estradiol gel (tE2) for years which drastically lowers T levels so I posted an inquiry on this site to which Richard Wassersug replied. He convinced me to start using it 43 months ago and my PSA still remains at undetectable levels with little boobs as my only side effect. Obviously my cancer is not cured; however, I consider it 'sleeping' at the moment.

IMO, your mature age is in your favor since PCa seems to be less aggressive when it attacks older men. Perhaps our decreasing metabolism rate may be a factor...not aware of any scientific data on this?

My best and happy holidays to you and yours,

Ron

[maley2711 in reply to E2-Guy]

Interesting your comment re older men.....older men with <10 PSA but Gleason 4+5 in one core, and <10% that one core? A day ago Pretty much accidntally watching a youtube presentation by a PCa Doc. A viewer asked if all 4+5 men are doomed> a surprising reply, at least for many of us......no, we actually know that approx 50% of 4+5 men who have no treatment will show no "spread" over next 10 years!!?? Problem, we don't know which men would be in that 50% group...would be a giant leap in reducing overtreatment of so many men!!!!! Of course, the same overtreatment problem almost assuredly applies to Gleason < 4+5! Further stratification of these risk groups would be a tremendous accomplishment! Doc also commented that 1-2 million men are currently living after a recurrence!!!! Is recurrence overtreated?

[E2-Guy in reply to maley2711]

My recurrence DIY treatment is very simple...just smear some clear gel on my lower abdominal area every day!

[Fenix11 in reply to E2-Guy]

Hello Ron, Thank you for your reply. All experiences and information is welcome as they provide guidelines for us to make decisions. If we can learn from mistakes made by others it makes a very big difference. Doctors sometimes do not provide the full picture for many reasons so this chat offers the liberty to ask questions and obtain opinions from people who are living the same problems. My hat goes off to 'PCa guru' Tall_Allen! Reading his posts in the past weeks I realize having a knowledgeable straight shooter in our Posts is a blessing for all. Now I know to keep away from surgical removal of distant lymph nodes as well as SBRT for this situation. I will read up on the LU-177 and investigate the guidelines for using this therapy here. KNOWLEDGE IS POWER!

Best wishes to All!

[Hidden in reply to Fenix11]

Keep that positive attitude and demeanor ! They shall serve you well in this ordeal . Until you get a better bead on things you’ll be searching . Ta knows his stuff . There are always more than one of us here that has or is in your exact shoes . Losing t is a drag in the mud for us guys . You Psa is heading in a good direction . But We want the Psa <.1 . Adt works . We suffer but it’s job is to stave off pc . Let it do so . Work out or you’ll lose everything . I did . I had bi - lateral tubes and a foley for almost two years . I went into sarcopenia and osteopena rapidly . Only weight bearing exercise will help both . Take care Sir! 🌵

[Hidden in reply to E2-Guy]

❤️🏋🏽‍♂️

[slpdvmmd]

Agree with recommendation for systemic therapy for systemic disease. Two things I think we always need to keep in mind are: 1. Prostate cancer is a heterogenous disease so it needs heterogenous treatment. 2. We are all under imaged even when we get some form of PET scan since all PET scans have some limitation that may miss one of the many different genetic variants we have in our tumor. With that said I agree with the recommendations for Docetaxel, however, if you have many other co-morbidities radioligand therapy may be better tolerated. If going to get taxanes then probably sequence should be to receive chemo before radiation to pelvis/prostate which may still have a role for local control.

[myamic]

Originally had one spot in soft tissue that was treated with SBRT. This spot showed up on a PSMA. PSA was reduced and subsequently next PSA showed six spots, still in soft tissue. Thought was to zap the spots but it was decided to start Xtandi. I need to note that my treatment journey has been out of the box at certain decision point as I have participated in clinical trials. The Xtandi is currently working. I believe that the seeding theory holds true . Have not had any scans recently. Have not done any chemo. There are a lot of treatments on the horizon so keep the faith, have grace, look around you and love life.

[j-o-h-n]

Feliz Natal e Feliz Ano Novo.... whatever that means in English.....

Good Luck, Good Health and Good Humor.

j-o-h-n Sunday 12/19/2021 2:58 PM EST

[Hidden]

Welcome aboard Fenix11! I am sorry about the dx .But you’ve found the best source of info . Good luck ! 🏋🏽‍♂️🎄

[ishitasen]

Yes it is true. The ADT can shrink the cancer but does not complete cure and radiation seems to be the next-step for you. But if you are still not eligible for the radiation therapy, or you have increased number of lymph nodes at different sites you can try for Lu-177 labelled PSMA therapy which is a systemic therapy targeted against the metastatic sites with minimal side-effects. All the metastatic sites can be targeted simultaneously with this therapy.

[Daughter17]

Fenix11 What is your situation and current treatment? I have now similar questions like you had one year ago.