PSMA results 6 weeks post RALP; one peri-anal lymph node

[JLR65]

My husbands PSA was . 5 at 6 weeks post RALP. It was a huge kick in the teeth. Today we got his PSMA results which I am hoping is optimistic since only one lymph node in the peri-rectal area lit up, no distant metastasis. Can you give me any ideas of what his next treatment might consist of. Is salvage radiation likely or can they just target the one lymph? Also I assume hormone therapy will be given? We have a follow up next week and any insights would be very helpful. Thank you.

Post op pathology findings;

Gleason 9 75% pattern 4 15% pattern 5 

Tumor involved 20% of prostate 

primary tumor pT3a

Regional lymph nodes pN0 (only 2 lymph nodes sampled, surgeon said they felt “Normal”)

EPE present focal left anterior 

Negative SVI and bladder neck

All margins negative

[Tall_Allen]

I'm sorry that there is still some cancer to be cleaned out, but hopefully, he can still be cured.

You have to change the way you think about metastases. From your question, I gather that you are thinking the one perianal LN is all there is. Unfortunately, that is not the case. Once cancer cells gain the ability to metastasize (=travel and thrive outside of the prostate), there are thousands, maybe millions, of such cells. The good news is that if they only have gotten as far as the pelvic LN drainage area, there is still a chance to get them all. Lymph is a fluid that carries the cancer cells away from the prostate. But it moves slowly and is restrained and clumps in the nodes. The PSMA PET scan cannot find all the cancer in the pelvic LNs. It can only detect clumps larger than about 4 mm. There is a lot more where that came from.

But 2 landmark clinical trials give us clues about optimal treatment.

(1) The SPPORT trial found that when there is a PSA recurrence, salvage radiation + ADT to the entire pelvic LN drainage area can still get it all. This is explained in the following article:

prostatecancer.news/2022/05...

(2) A STAMPEDE trial found that 2 years of ADT+abiraterone given to men getting primary radiation when a CT scan has detected enlarged pelvic LNs is optimal.

ncbi.nlm.nih.gov/pmc/articl...

(They did both trials before PSMA PET scans were available.)

I should also mention that there is a major clinical trial that has recently started. They randomize recurrent men with positive LNs to salvage radiation with 2 yrs of ADT with or without apalutamide. You can check the following to see if there is a nearby location:

clinicaltrials.gov/ct2/show...

[Howard53545 in reply to Tall_Allen]

My own experience supports Tall Allen. A PSMA scan showed cancer in lymph nodes. So we radiated entires pelvic lymph nodes. For last year I have been undetected and T is 860.

[Andy1569 in reply to Howard53545]

So? You are on ADT? And have an undetectable PSA score with an 860 T score?

[JLR65 in reply to Tall_Allen]

Thank you so much for clarifying this for me! I really appreciate you taking the time to do so and I feel better educated about what is to come. My nature is to be optimistic and I will just continue to hope for a good outcome. Thank you again.

[OzzieJ]

I had the same situation with PSA of 0.5 post RALP. The PSMA scan identifed two pelvic lymph nodes.My treatment regime is

- 3 years ADT (Decapaptyl injections every 3 months)

- 6 cycles of Docetaxel early chemo. Have completed cycle 3 and tolerating it well.

- Abiraterone to be added after chemo completed.

- 6 weeks full pelvic radiotherapy with extra dose to identified lymph nodes after chemo.

The chemo was a judgement call by my onco based on a number of risk factors plus ability to tolerate it due to age/fitness. He has set up a number of prostate cancer trials and has good awareness of what has been tested or not so I trust his judgement. The other elements of ADT + abi + pelvic radio seem to be standard as per TAs very informative post.

Best wishes.