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Treatment after RP with affected lymph nodes

Urogallo profile image
18 Replies

Hello!

This is my first post to this forum, which I am following from some time ago, since I have some doubts about next steps of treatment of my advanced PC and would appreciate very much your help, in order to take best grounded decisions.

My basic history on this matter is:

• 2016: 58 years. PSA 4.86. Estrone very high (89 pg/mL). Estradiol low (9 pg/mL). DHT very low (0.21 ng/mL). SHBG normal (46 ng/mL). Free testosterone very low (3.2 pg/mL). Started hypocaloric vegan diet, including also some typical supplements for prostate health.

• 2016 to 2018: PSA goes down from 4.86 to 4.61. Estrone very high and up (89 to 169 pg/ML). Estradiol continues low (9 to 11 pg/mL). DHT up, but continues low (0.21 to 0.34 ng/mL). SHBG up, until very high value (97 ng/mL). Free testosterone increases to normal (20 pg/mL).

• 2018: PCA-3 test. Score 23.

• 2018 to 2020: PSA increases from 4.61 to 6.28.

• 2020 to 2021: PSA increases from 6.28 to 8.97.

• 2021-Nov: MRI: PIRADS 5 with extravascular extension.

• 2022-Jan: Biopsy: PC confirmed.

• 2022-March: PET-TAC-Choline: No evidence of either local lymph nodes extension or metastasis. There are small slightly hypercapting foci in both pulmonary hilums, subcarinal and retrocaval pretracheal region, which in the fusion images seem to correspond to small subcentimeter adenopathies, probably reactive/residual in nature. Also, millimetric nodular images in the lingula and LII, with non-specific characteristics at present.

• 2022-March: Da Vinci Radical Prostatectomy, including 11 lymph nodes.

• 2022-April: Pathological analysis:

o 1 - Prostate: adenocarcinoma of the prostate, Gleason index 7 (4+3), tertiary pattern minority 5 (<5%). Prognostic group 3. Bilateral affectation, both compartments, from low levels, up to glandular high levels. High tumor volume. Focal presence of cribriform glands. Perineural invasion. No signs of lymph vascular invasion. Capsular invasion with extensive extra prostatic extension, mainly at the level of the posterior compartment of the prostatic lobe left, in middle levels. Tumor-ink contact in several focuses. Seminal and base vesicles: free. pT3a; PN+; LVi-; R1 (multifocal).

o 2 - Right lymphadenectomy: metastasis at one of three isolated lymph nodes (1+/3). No signs of capsular invasion.

o 3 - Left lymphadenectomy: metastasis at one of six isolated lymph nodes (1+/6). No signs of capsular invasion.

o 4 - Periprostatic fat: metastatic infiltration of prostatic adenocarcinoma in two isolated lymph nodes, (2+/2). pN1.

• 2022-April-June: Persistent PSA after RP:

o 26/04/2022 0.55

o 04/05/2022 0.46

o 11/05/2022 0.50

o 19/05/2022 0.49

o 26/05/2022 0.51

o 03/06/2022 0.49

• 2022-April: Estrone very high (99 pg/mL). Estradiol a bit high (29 pg/mL). DHT low (0.37 ng/mL). SHBG very high (115 ng/mL). Free testosterone normal (11 pg/mL).

• 2022-May: Added a natural aromatase inhibition formula to my supplements, getting reduced estrone level, to a low value of 24 pg/mL, but increased estradiol level, to a high value of 36 pg/mL. DHT continued low (0.30 ng/mL). SHBG still higher than before (147 ng/mL). Free testosterone a bit lower (7 pg/mL). No variations on PSA, all the time around 0.50, as shown above. I have stopped for the moment using it, trying to use other alternative anti aromatase supplements, since this formula has genistein, which has been found proliferative at low serum contents in some in vivo essays, according to information found in this forum.

• 2022-May: Given the persistent PSA after RP, a private MO proposed to make a CT-PET-PSMA scan, in order to try to detect residual cancer locations. If it would not detect anything, he considered that no treatment (radiation or hormone therapy) should be initiated for the moment, just observing the evolution of PSA. In case of detecting any cancer location, possible appropriate treatment should be studied.

• 2022-May: By the other side, given the persistent PSA, my insurance MO has proposed to proceed, within 6 months after RP, with adjuvant EBRT, combined with ADT. He has proposed to make first imaging with CT + scintigraphy + MRI. I asked to him why not imaging with CT-PET-PSMA, since this would be more sensible to locate possible small cancer nodes with PSA = 0.50. He agreed that PSMA would be better than CT + scintigraphy, but said that PSMA was not covered by my insurance at this stage of the illness, so I should do it by private and, anyway, combine it with insurance covered MRI.

• 2022-June: I have next week an appointment with a private MO, to program in principle an immediate CT-PET-PSMA scan. I don’t know yet if it can be selected 68Ga or 18F types, or if only one of the two types is available.

• 2022-June: I have already programmed within a few days the MRI recommended to be combined with PSMA by my insurance MO.

At this stage, I have the following main doubts, about which I would appreciate very much your opinions:

1. Do you agree that any PSMA scan (68Ga or 18F) is better than CT + scintigraphy in my current condition, to try locating as small as possible cancer nodes?

2. If possible to choose between 68Ga and 18F types, which one would you recommend for my current condition?

3. About possible radiation or hormone therapy in the near future, I understand treatment/s and best variants would be affected by the results of the PSMA scan, but I am somewhat surprised by the different opinions provided a priori by my insurance and the private MO. I have checked recommendations of the NCCN guide for my condition (with affected lymph nodes, pN1) and it says:

At this time the Panel recommends that patients with lymph node metastases found at radical prostatectomy should be considered for immediate ADT (category 1} with or without EBRT (category 2B), but that observation is also an option for these patients. (Category 1: high-level evidence, uniform consensus on appropriateness. Category 2B: low-level evidence, not uniform consensus on appropriateness).

So, although observation would be an option, ADT is highly recommended (direct estrogen reduction only would not be an option), while EBRT seems to be more questionable, taking always also quality of life in consideration. I understand that possible radiation therapy application and type should be highly affected by PSMA scan results, as the private MO suggest.

Sorry for the long post. Best regards,

L.J.

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Urogallo
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18 Replies
Tall_Allen profile image
Tall_Allen

(1) PSMA PET scans are approved for persistence/recurrence after RP, which you definitely have. Get pre-authorization, and if they say no, appeal.

(2) The main purpose of the PSMA PET scan is to rule OUT distant metastases. If it shows bone metastases, metastases in your abdomen or organs, there is no purpose in undergoing adjuvant radiation.

(3) If the PSMA scan is negative for distant metastases, you will require whole pelvic salvage radiation+ 2 years of hormone therapy. They will give a little extra radiation to known sites of cancer in lymph nodes and in the prostate bed that show up on the PSMA scan.

There is a clinical trial with hormone intensification that you may want to look into:

clinicaltrials.gov/ct2/show...

Gabby643 profile image
Gabby643 in reply to Tall_Allen

Thanks again T A

Urogallo profile image
Urogallo in reply to Tall_Allen

Thank you very much for your help T.A. Good news that the PSMA PET scan is in fact the best alternative for my condition. I will know this week which types of radioisotope they have available and which one recommend. With my PSA value it is practically sure that something will be found with PSMA, but I hope not metastases. We'll see..

Justfor_ profile image
Justfor_

If you have PSMA scanning options choose the one that employs the latest scanner. Best of all a digital scanner. They are 2-3 years into service and mainly found in major hospitals and research institutions. 68Ga or 18F should be your second deciding factor. If you are in the US there is only one 18F approved radioligant.

Urogallo profile image
Urogallo in reply to Justfor_

Thank you! No, I live in Europe, so I will know this week which radioisotopes are available here. As for the scanner technology, I hope it will be good enough.

Justfor_ profile image
Justfor_ in reply to Urogallo

The radioisotopes on Europe are 2 and a "half" Galium and Fluorine that you already know about and Zirconium in its infancy. The latter is more sensitive than the first two but only offered in a small trial in Germany. Re the 18F I had RP like you and for this I would opted for PSMA-1007. You may hear that it has erroneous positive detections but my personal research has failed to find convincing evidence substantiating it. Only 68Ga is pattent free. The rest have royalties on them, so there may be commercial interests behind them.

Urogallo profile image
Urogallo in reply to Justfor_

Thank you! I am specially worried about the "inespecific" lines found in the lungs by the previous PET-Choline scan, so I think that the more appropriate radioisotope to clarify this point would be the optimal one. Of course, false positives on that or undetermined results, as with the Choline scan, would be a problem...

MateoBeach profile image
MateoBeach in reply to Urogallo

Either will be fine. Don’t belabor the choice. Get whichever is available for PSMA PET.

Urogallo profile image
Urogallo in reply to MateoBeach

Thank you! I will take that into account. Probably not possible to choose.

Okay4now profile image
Okay4now

First of all, welcome !! Your particulars are beyond my knowledge and experience, but there is plenty of both in this forum !

Urogallo profile image
Urogallo in reply to Okay4now

Thank you! Yes, from my readings in this forum I have seen there are extraordinarily skilled members, with many years of succesfull research and generous help to others.

j-o-h-n profile image
j-o-h-n

Greeting Urogallo,

Where are you located in Europe? (city/country)...

Good Luck, Good Health and Good Humor.

j-o-h-n Sunday 06/12/2022 3:14 PM DST

Urogallo profile image
Urogallo in reply to j-o-h-n

Hello John. I live in Spain, small village near the capital.

j-o-h-n profile image
j-o-h-n in reply to Urogallo

Thank you and lucky you..... Madrid is a beautiful city....

Good Luck, Good Health and Good Humor.

j-o-h-n Monday 06/13/2022 3:22 PM DST

j-o-h-n profile image
j-o-h-n in reply to Urogallo

BTW living in a small village in Spain to you hunt for Grouse?

Keep Smiling....

Good Luck, Good Health and Good Humor.

j-o-h-n Monday 06/13/2022 3:39 PM DST

Urogallo profile image
Urogallo in reply to j-o-h-n

No hunting, anyway not allowed for urogallos, since very few of them continue existing...

MateoBeach profile image
MateoBeach

Don’t get confused over your lab tests, hormonal values and other scans.If you want to live long and prosper, the path is clear (as T_A outlined):

Get the PSMA PET scan. If no disease indicated beyond the pelvis, then get salvage external beam (IMRT) to the prostate bed and entire pelvis. Now. With adjuvant ADT for up to 2 years. That is the proper recipe. So go consult with an excellent RO and start the planning process. Delay not acceptable.

Urogallo profile image
Urogallo in reply to MateoBeach

Thank you. If EBRT is finally the best way for me, yes, I should confirm that the RO and equipment of my insurance service are excellent, because associated risks are really high.

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