Questions About Scans and Lymph Node

[FaithOverFear104]

Hello all, I apologize in advance for the length of this post - just want to share the details so some might be able to hopefully provide some helpful input. Thank you in advance for bearing with me.

My husband's history is in my bio. I think it is pretty comprehensive. My questions are related to his scans and one lymph node which remains enlarged post-chemo. We meet with his MO on Thursday and would like your impressions and perhaps input on what to ask.

When my husband was diagnosed on 1/5/2022, his PSA went from 1042 to nearly 1600 in a matter of weeks. His MO did not think we had time to wait for insurance approval for PSMA PET and/or for availability of the machine at MSK so he ordered CT Abodmen, Chest, Pelvis and Nuclear Medicine Bone Scan as baselines. Those scans showed a few suspected bone metastases (though it seemed like many were unclear as to whether they were mets or old injuries, etc.) and the report said the following re: pelvic region:

ABDOMINOPELVIC NODES: There is pelvic adenopathy. Right obturator/external iliac node measures 4.3 x 3.2 cm, right internal iliac suspected node measures 0.9 cm and node/nodule in the right ischial anal fat measures 0.7 cm.

PELVIC ORGANS: Prominent prostate with increase vascularity on the right; should be correlated with submitted MRI December 24, 2021. Suspect left pararectal node measuring 1.1 cm versus contrast filled diverticulum.

Husband went on Triplet Therapy based on PEACE 1 study right away and responded well. His PSA has been undetectable since April and remains so today. He competed the 6 rounds of Docetaxel in June and in August, his MO ordered an FDG PET Scan to see where things stood. He did not order a PSMA PET at this point either because with my husband's PSA being undetectable, it was not advised. The FDG PET was the alternative I suppose.

The results of the FDG PET were really great. It showed that most all metastases have resolved, and even noted that his prostate showed "no suspicious findings". We were so grateful to receive this news. However, it noted this regarding the lymph node:

ABDOMINOPELVIC NODES: Prior right external iliac nodal mass contracted, 1.3 x 0.8 cm previously 4.3 x 3.2 cm; minimal nonspecific activity, SUV 2.2, image 246; possibly treated disease.No suspicious adenopathy in the right internal iliac, pararectal, or right ischioanal regions

PELVIC ORGANS: Prostate demonstrates no suspicious findings, scintigraphically.

MO said there was still a small amount of "lighting up" in that one lymph node and he believed it was in the process of "dying off." He said we would do another FDG PET Scan in November to check everything again. Well, our insurance denied the second FDG PET Scan and so MO ordered another CT Abdomen, Chest, Pelvis and Nuclear Medicine Bone Scan, which my husband did on Friday. We have not gotten the bone scan results yet - but, have the report on the CT. And it says this regarding the lymph node:

ABDOMINOPELVIC NODES: No change rightcommon iliac node, 1.3 x 0.8 cm. No new pelvic lymphadenopathy. IMPRESSION: 1. Since August 9, 2022, no change right common iliac lymph node. 2. No new suspicious findings.

We were hopeful that this scan would show that this node going back to normal size and perhaps be able to say that husband is NED/full remission - but because it remains unchanged in size, we are not sure what it could mean or what to ask.

My questions are:

- Is there other testing should we ask for to find out what is going on in that lymph node? (is the only way to know to get some type of PET scan?...If so, what type of scan other than PSMA and FDG would be useful?)

- Is it possible that it could be that size and be normal anyway (I believe that "normal" is 1cm or under).

- Husband had a biopsy of that lymph node early in the year. Could that have caused it to remain enlarged?

- If it is possible that there is still active disease in that node, is there other treatment we can expect to discuss or plan to ask about?

- Anything else we should be considering/asking?

Thank you for any input and again, I apologize for the long post.

[Tall_Allen]

The fact that the enlarged lymph node did not respond further to triplet therapy may suggest that there is no longer prostate cancer in that node. That is particularly true if the biopsy showed hormone-responsive PCa in that node. It is possible that the biopsy caused benign inflammation in it.

Part of the Peace1 protocol was also using prostate radiation if there were fewer than 4 bone mets. Is that planned?

[FaithOverFear104 in reply to Tall_Allen]

Thank you so much Tall_Allen . I really appreciate your input.

The lymph node biopsy did show PCa. I assume hormone sensitive since that continues to be husband's status (?)

MO has not discussed any other treatment as of yet. I think he was waiting on results from these scans, latest labs etc ., before talking about possible next steps.

[ron_bucher]

Keep in mind that the "tiniest" tumors may not be seen on today's best scanning technology, so a negative scan just means there are no "large" tumors.

Given his young age, his PSA and Gleason, my main question for the docs would be "What (if any) are my additional curative options?". I am very glad I have used every curative tool in the tool bag since being diagnosed at age 54. I didn't want to ever look back and think "I wish I would have...". With a high Gleason, it's wise to plan on a lifetime battle while hoping for the best.

Another question for the docs is when to stop (and when to restart) ADT. One of my oncologists told me about 50% of men become hormone insensitive after ~10 years of ADT usage.

My radiation oncologist told me he has never seen cancer return to any area he radiated, and lymph nodes recover from radiation. With your husband's numbers, what do his docs say about potential prophylactic radiation and/or prostatectomy? After having both, my side effects have been minimal.

Your husband is lucky to have such an intelligent and caring wife.

Best of luck.

[FaithOverFear104 in reply to ron_bucher]

Thank you so much for taking time to give input - and for the kind words. I am lucky to have him as well and we are a team in this fight for sure. There has never been any discussion of radiation or prostatectomy. MO went straight to Triplet Therapy and has never been one to discuss if this/then that type scenarios. I think he just wanted to see how this first treatment went and then figure out whatever might be next based on what my husband's follow up testing showed. That's where we are now. Thanks again so much again.

[ron_bucher]

Many doctors are too busy to think ahead about contingency plans, but my experience and my observations attending hundreds of hours of prostate cancer support group meetings says thinking ahead is well advised for the patients. In my opinion, the best oncologists will answer any and every question you have. I would be curious why they rule out certain treatments.

[FaithOverFear104 in reply to ron_bucher]

Thanks so much!