Need help/input on Adjuvant vs salvage radiation after prostatectomy & extended lymph node dissection. Also studies/input on # fractions?

[StephH72]

Looking for input on following questions:

Are there any studies that show how common lymphedema is after ePLND? (25 nodes removed). Can you share them?

Would the risk of lymphedema go up with 20 fractions vs 33 fractions? Any studies on efficacy of 20 vs 33?

Lastly, based on history below, what would you do? Adjuvant now or wait and do Salvage? Extended field or no?

History: Husbands care team planned for a “multi-modality” treatment plan (ADT+Zytiga, then prostatectomy with ePLND, followed by adjuvant IMRT), for his Gleason 10, locally advanced PC. PSMA pet at diagnosis showed EPE to soft tissue around prostate, seminal vesicles, and 1 pelvic lymph node (no bone Mets). He responded well to Orgovyx and Zytiga and tumor shrank considerably (away from rectum which was a concern). PSA went from 146 to .36 in the 6 months prior to surgery.

Surgery was non nerve sparing and other then ED husband has no surgical side effects (continence was 90% by week 3 and is 99.9% now at week 12, no lymphedema). His PSA has been <.01 (lowest that assay went) at 6 and 12 weeks post op while still on ADT/Zytiga. He did have positive margins after surgery though, in soft tissue and in bladder neck. All margins were between 1-2mm (I double checked this and it is mm not cm). ePLND was 25 nodes total (12 one side, 13 the other). All nodes negative for cancer. However due to that previous avid node on PSMA pet plus the positive margins after surgery the care team is still advising adjuvant radiation somewhere between 4-5 months post op since continence is restored. Will continue orgovyx with Zytiga for 24 months total.

Our concern is for lymphedema, however we are also concerned for a reoccurrence given his age (51), positive margins and Gleason 10. His care team (as well as two other second opinions at other institutions) have said they still are taking curative intent and this would be the next step in their opinion. Plan is for 45 Gry to pelvic bed with boost up to a total of 66 Grey to Prostate bed and lymph nodes in that area, with 70 Gry to positive margins. Plan is to do extended field radiation per the new Radiaiton guidelines.

[Justfor_]

I had 20 lymph nodes removed, which for European standards don't count as extended. Was worrying regarding lymphoceles being formed, so one year post RP had CT imaging to expressly check it out. There were 3 white areas depicted that two radiologists named them as being something else (don't remember the name now). Not the info you asked for, but as much as I know.

[StephH72 in reply to Justfor_]

thank you. Did you have radiation after having the lymph nodes removed?

[Justfor_ in reply to StephH72]

No, up to this point in time. Irradiation is a procedure with serious and irreversible late toxicities including induction of second cancer that anyone should resort to only as a last measure. On top of that, blind irradiation is the ultimate gamble and gambling may sometimes pay off in movie pictures promoting Las Vegas, but very seldom in real time. For my current state, my Bicalutamide adaptive dosage experiment keeps my PSA at the limit of detectability with minimal SE. It is documented in the thread entitled: "Bicalutamide Maneuvers" month after month for 1.5 years now .

[aloha_spaceman]

You have more or less described my scenario (except that I am 58 years old and was Gleason 7 (4+3). I have been looking for outcome data on the specifics of my situation to inform my decisions, but it is understandably sparse given recent advances in imaging, drug approvals/combinations, and the niche-iness of my combination of risks. The outcomes have yet to unfold.

That said, my care team suggested and I have been undergoing a “kitchen sink” multimodal strategy that included adjuvant radiation. It has been tough, especially the radiation in my case, but I am making my way through. (Only 6 more months of ADT and Xtandi!)

At this point, my PSA is undetectable and they are optimistic about my prospects. There is nothing else to do but finish up my ADT and wait since there is no detectable cancer. I felt like adjuvant radiation, even if it’s marginally helpful, was my best shot at a cure (especially since I had positive margins). Waiting for a recurrence just didn’t seem like a great idea; I am a worrier by nature.

Sorry for the ramble, hopefully there’s something in there that helps

[StephH72 in reply to aloha_spaceman]

thank you and I’m wishing you the best. Did you have a prostatectomy prior to the radiation? What cancer center did you get your treatment at?

[aloha_spaceman]

yes. I had a prostatectomy first at Duke Cancer Center in NC.

[StephH72 in reply to aloha_spaceman]

wow small world. We are also in NC. I sent you a message

[cancerking]

I had prostatectomy with lymph node, dissection, followed by radiation one year later. I have a slight edema of the right foot and minimal on the left foot. I use 15 mm – 20 compression hose in fun colors. Otherwise, not a big deal for me. I would do it again.