I had a meeting with my oncologist yesterday about the findings from the PSMA Pet Scan.
This is the reply I got. Any comments?
"PSMA-PET shows a PSMA-positive lymph node medially for the iliac externa vessels on the left side.
This is located in the mesentery. The urologist states that surgery is not a possibility because it will not be possible to locate this lymph node during surgery.
The radiation oncologist states that this lymph node will be movable because it sits in the mescenteria. It is then not possible to give radiation therapy, as one will not hit the lymph node with good enough precision.
The conclusion is that unfortunately, it is not possible to give local treatment against this lymph node, neither surgery or radiation therapy.
The recommended treatment in the next line is then chemotherapy in the form of Docetaxel-21 (event Docetaxel14). No indication to start this now as the patient is clinically stable and PSMA-PET shows admission only in one lymph node. Therefore, the patient will continue treatment with Nubeqa until further. Arrange a new check-up in 2 months with blood tests in advance."
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Are you aware of this experimental radio-guided salvage surgery?
"SALVAGE ROBOT-ASSISTED PSMA-RADIOGUIDED SURGERY IN RECURRENT PROSTATE CANCER USING A NOVEL DROP-IN GAMMA PROBE
Fabian Falkenbach*, Sophie Knipper, Daniel KoehlerHamburg, Germany; Fijs W.B. Van Leeuwen, Matthias N. Van Oosterom, Leiden / Amsterdam, Netherlands; Pim Van Leeuwen, Hilda De Barros, Henk Van Der Poel, Amsterdam, Netherlands; Lars Bud€aus, Thomas Steuber, Markus Graefen, Tobias Maurer, Hamburg, Germany
INTRODUCTION AND OBJECTIVE: Positron emission tomography / computed tomography (PET/CT) directed against the prostate-specific membrane antigen (PSMA) allows detection of even small and/or atypically localized metastatic prostate cancer (PCa) lesions at low PSA values. In a subset of patients with recurrent oligometastatic localized PCa PSMA-targeted radioguided surgery (PSMA-RGS) might be of value. Recently, a DROP-IN gamma-probe for intraoperative detection of metastatic lesions was introduced to facilitate a robot-assisted minimally invasive approach. Here, we report on our experience and the outcome of the first 16 patients treated with PSMA-RGS using the DROP-IN probe.
METHODS: We assessed 16 patients treated with robot-assisted PSMA-RGS between 05/2021 and 03/2022. All patients presented with biochemical recurrence after radical prostatectomy (RP) and soft-tissue lesions on PSMA PET. Histological correlation, early PSA responses and Clavien-Dindo complications were evaluated.
RESULTS: Median age was 64 years (IQR: 56-70.5 years). Prior to PSMA-RGS, overall median PSA was 0.55 ng/ml (IQR: 0.35-0.82 ng/ml). At robotic PSMA-RGS, intraoperative blood loss was estimated with 50 ml (IQR: 50-100 ml) and OR time was 158 minutes (IQR: 139-173 minutes). Metastatic soft-tissue lesions from PCa metastases could be removed in 15 (94%) patients. Postoperatively, overall median PSA was 0.18 ng/ml (IQR: 0.05-0.27 ng/ml). During the median follow-up of 4.2 months (IQR: 1.0-5.8 months), 4 patients experienced BCR and 1 patient received further therapy. One patient suffered from a Clavien-Dindo complication grade IIIb within three months from surgery (intraabdominal fluid collection necessitating drainage in general anesthesia). Limitations are the retrospective design and lack of a control group, as well as the small cohort.
CONCLUSIONS: Robot-assisted PSMA-RGS using the novel DROP-IN gamma probe is a promising tool to enhance intraoperative detection of metastatic lesions in PCa during salvage surgery in a minimally invasive fashion. Further studies are needed to confirm our findings."
UCLA (University of California Los Angeles) is also having success with this gamma radiation approach. I can send you the link with the Dr. Running the program. PM me if interested. Mike
When there is one cancerous lymph node found, there are many more that can't be seen. The sensitivity for finding lymph nodes is only 40%. The entire pelvic region must be treated, not any single lymph node. The current dimensions are explained here:
If you have to explain this to your radiation oncologist, maybe you need a new radiation oncologist.If you are willing to travel, Datolli Clinic in Sarasota does a lot of this.
Probably worth visiting them for no other purpose than a second opinion.
"The SPPORT trial found that treating pelvic lymph nodes prophylactically improved outcomes with no increase in late-term genitourinary or gastrointestinal toxicity, and only minor increases in the short-term. This study did not examine the toxicity of the expanded coverage. Careful contouring of the pelvic lymph node area to exclude bowel, bone, bladder, and muscle seems to prevent excess toxicity at the doses usually used (45-50.4 Gy). In one recent study of high-risk patients, a pelvic lymph node dose as high as 56 Gy was used without extra toxicity. " Prostatecancer.news
Nice article.
A large number of Myers/Datolli shared patients received this type of radiation treatment. Myers found most of them had low out of range cd4 T-Cell counts.
Those are the ones that never grow back.
Myers hypothesized that it was the radiation treatment that killed off cd4 T-Cells. Those T-Cells are sensitive to radiation and tend to hang out in the lymphatic system.
Datolli, the treating Doc, begged to differ with Myers as to whether or not his treatment was the cause of this hot spot. LoL
I received that treatment and have low out of range T-Cell labs.
This was over 10 years ago. No secondary cancer to date.
BUT... anyone getting that treatment might want to get a lab test of their cd4 T-Cells done.
If they are low, maybe you need to avoid hot humid and/or desert areas (fungal infections such as so called "desert fever") and Myers said to avoid so called live virus vaccines.
If I understood correctly this lymph node is not in the lymphatic chain around the iliac artery it is in the mesenterium. It is not really a pelvic lymph node, it is much higher but it is hanging in the pelvis from the mesenterium.
The criteria for treatments of pelvic lymph nodes, I believe does not apply to your situation.
I would get a second opinion with other radiation oncologist.
There are linear acelerators which could identify the target in each session even with MRI (the Mridian machine) or with cone CT scan (Varian trilogy) etc etc before doing the radiation.
The mesentery is a major storage area for fat and acts as a protective blanket over the bowels. If you are overweight, this blanket will be thick and hard to search laparoscopically. I am not surprised that the doctor did not wish to attempt to remove the tumor. It's location indicates that there are cancer cells circulating all over your body that haven't yet found a good hiding place to grow into measurable tumors. A systemic treatment is the only way to get them while they are small before they mutate again. Good luck in finding the right treatment for your cancer.
Based on my experience, a second opinion and even a third opinion is necessary. You have a current scan, use it and see more radiation oncologists…I found it amazing how one would say they can’t do it and the other say yes, it can be done and he/she has done it before
This is one reason why lymph node radiation in the mesenteries is exclusionary to one Phase 1 trial for radiation for polymetastasis of the lymph nodes. One other reason is that those nodes are in areas where radiation has been shown to have a high potential for tissue damage outside of the targeted lymph nodes, such as the intestines.
I had only two out of seven nodes in the pelvis lite up on scans . I did imrt but the specialist purposely didn’t RT the nodes . It worked well for me so far 7 yrs .
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