Asking for ideas about course of action.

[LowT]

I have posted several times in the past.

81 y/o RARP six years ago. Complicated and convoluted history.

Brief summary regarding PCa:

Oct 2016 RARP with 24 lymph nodes removed. Severe post-op bleeding requiring week hospital stay and 2 units of blood.

Tumor uncommon location posterior mid line, standard 12 core Bx would have missed it. 7 of 7 'cross fire' cores were positive.

GS 3+4; GG 2; extensive EPE; -SV; 80 gm gland.

Residual lymph edema controlled with support hose.

Beginning Dec 2018 uPSA first become detectable and has gradually risen over the past four years, more rapid recently. Last month reached 0.115 and 0.113.

Prostate MRI ordered by internist found new enhancing nodule in left prostate bed (0.4 x 0.9 cm). Same side as as small lymphocele. Left leg more affected by edema.

The nodule was not PSMA avid with PSMA PET CT. Not surprising given level of PSA.

My thoughts are to explore whether a needle Bx is possible. If so and it confirms PCa, explore doing focal ablation (going for a cure). Cryo, proton, HIFU, etc.?

If positive do as much molecular/genetics/cell type tissue testing to guide that decision. If not able to Bx, still high likelihood of PCa given clinical setting so would still explore focal therapy.

Hesitant about doing SR to entire pelvis due to the likelihood of worsening the lymph edema.

With this approach I would still have SR available as a future treatment if needed. My age obviously factors into this decision. Health is otherwise good, swimming 50 pool lengths three time a week.

[Tall_Allen]

"My thoughts are to explore whether a needle Bx is possible. If so and it confirms PCa, explore doing focal ablation (going for a cure). Cryo, proton, HIFU, etc.?...Hesitant about doing SR to entire pelvis due to the likelihood of worsening the lymph edema."

I doubt a cure is possible, and more lymph node dissection (with focal ablation) is likely to cause more lymphedema. Once cancer has infected lymph nodes, it microscopically spreads to other lymph nodes in the pelvis. It cannot be detected with imaging.

Extensive pelvic lymph node dissection (ePLND) that you have had is hardly ever curative and it causes lymphoceles and lymphedema. It is usually not done in the US. Instead, a small sample of lymph nodes are often removed for microscopic inspection, and if any are positive, whole pelvic radiation is used to wipe out the invisible cancer. You are right that because of your previous ePLND, it is likely to add to your difficulties.

Instead, treatment with ADT + a second generation hormonal agent will shrink the cancer in your pelvic lymph nodes.

[LowT in reply to Tall_Allen]

All 24 removed node were negative even though some were 3-5cm diameter. Could the 'nodule' be local extension only?

[Tall_Allen in reply to LowT]

Sorry, I misunderstood your situation. Yes, the nodule on your MRI is probably a local extension left behind by your RP, especially because it doesn't express PSMA. Radiation to the nodule (SBRT or HDR-BT) alone, or to the prostate bed with a boost to the nodule may still be curative. I'm skeptical about whether ablation can be curative.

[tango65]

I would try to go for a cure,. I would discuss with a RO about doing radiation to the fossa with a booster to the visible tumor and about whole pelvis radation along with ADT.