Hi, first post here. I had prostatectomy 2008, G3+4, ,pT2c, now updated to pT2cN1M0. Have postponed HT with rising PSA (now 8.9). Had SRT 2011 to prostate bed. Have had Axumin scan and then had 3rd PSMA PET scan recently (this month). All so far were negative until most recent, found single inguinal lymph node positive. Am being treated by uro oncologist. I see him next Tuesday. I am inclined to ask for a referral to my radiation oncologist who did my SRT. He had told me several years ago that if we could find one or two positive lymph nodes that perhaps we could spot radiate and postpone HT for a bit longer (I am not eager to go on Lupron). At the time, no evidence and so abandoned that idea. I was wondering if you have had similar experience and if you radiated a lymph node to hopefully slow down progression. I understand this would not be for curative intent, but if it could postpone the HT for another year I would be game. Another thought might be to start HT prior to spot radiation to help its efficacy.
Thoughts are welcome - experience or knowledge about treatment options.
Thanks, Jeff
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Jeff_Piano_Man
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This spot radiation is called SBRT radiation. I had that done to my affected lymph nodes. Usually there are more lymph nodes yet too small to be detected. So these will grow to be visible in about a year's time. It is better to combine this radiation with ADT. I take bicalutamide because it has fewer side effects compared with Lupron. This stopped new mets to appear for 2.5 years now.
Unfortunately, the inguinal LN is outside of the pelvic LN drainage area. It is anyone's guess as to whether there is any benefit in spot treatment of that single LN. The risk of inguinal radiation is lymphocele and lymphedema. It is stage M1a, not N1 as you posted.
(2) Withholding ADT
IMO it is a really bad idea to withhold ADT. Because of your stage M1a prostate cancer, there is a known advantage to systemic treatment now. While spot radiation will undoubtedly lower your PSA, the cancer is already systemic and must be treated systemically. Treating PSA is not the same thing as treating prostate cancer:
Well, here's mine...as we say, my cancer is not yours...Attached is my clinical history. In April, after continually increasing USPSAs. we imaged, found a single PLN.
I met first with my radiologist who I've been with since 2016 and the only one on my medical team who gave me her personal cell phone number and encouraged me to contact her when needed. She recommended SBRT and six months of ADT. I said makes sense based on various CTs though some say 24 months, add an ARI...She directed her nurse to put me on the schedule immediately!
Next I met with my oncologist. His initials thoughts were the SBRT and 24 months of Orgovyx and Xtandi. I said ok, I can do that.
We started the SBRT and Orgovyx...my oncologist called and said he wanted to wait on the Xtandi until he saw the labs at six weeks (PSA and T). When we met at six weeks, he said based on the labs where T was <9 and PSA had dropped from .77 to .13, he again held off on the Xtandi (I had the first two months supply on hand at a cost of over $8k though my copay was $12) and said we would discuss at three months after the next labs.
At three months, USPSA labs showed <.04, the lowest their lab could measure. He said let's continue with Orgovyx only and meet again at six months which is coming up later this month. We've discussed the ARCHES trial and others.
His recommendation at this point is stay on Orgovyx, not add Xtandi, if labs continue to show PSA undetectable and T castrate, he'd consider coming off treatment at 12 months and actively monitoring. My radiologist concurs.
It's a delicate balance, aggressive treatment as I have done in the past with triplet therapy or under treating...I'm willing to take this in three month increments and if we get to the 12 month point and he recommends come off treatment and actively monitor with labs every 2-4 months, ok..
Is that the right decision...only time will tell. I told both he and my radiologist that albeit "tolerable," the hot flashes, fatigue, muscle and joint stiffness and battle with weight" are not things I enjoy. No loss of libido, I've had genitalia shrinkage but with daily Cialis, can achieve erections (now if only medical researchers could find something similar for my wife...!).
I'm going to throw in my vote for a short course ADT as well. The genie is out of the bottle so to speak, and just like inflation, needs to be jumped on.
I have been down this path a couple of times. Had cryotherapy for a PSMA + node at Mayo x2. The second time the PSA never went to zero. They elected to "watch it". After several months it bean to rise. Next scan showed lung mets. I have been on triple therapy with good response however, in retrospect, wish that they were more aggressive with the ADT after the first node spotted.
As others have stated, the cancer is no longer localized and treatment needs to be aggressive.
I appreciate each of these responses, great inputs here. Great article, Allen - I'm glad to get that perspective (M1a vs N1 - does that make me N1M1 or N0M1?) before I talk with my MO. He had originally (over 18 mo ago) recommended ADT, but I didn't want to go there until we had evidence of activity. Despite my lack of enthusiasm, I expect to start treatment presently.
Would you be kind enoughto lift your digits off of those ivories and give us your bio. Age, location, medical center? doctors? (and how we can play chopsticks) and etc. All info is voluntary but it helps us help you and helps us too....Thank you....
Old one you know but the rest of group may not.......
My ex-wife was musically inclined, she had legs like a piano.....
Although some say I have musical inclination like your ex (and I very much enjoy tickling ivories), my profession is engineering. Still working full-time, expect to slide into part-time sometime in the next couple of years although if SE end up causing me grief I could probably slide sooner. Close to 64 (in a couple weeks), and as I mentioned have been on this PC journey since I was 48. Gleason 3+4 with negative margins, PSA dropped after SRT, so Allen's comment about treating PSA vs PC is particularly germane - I expect the cows have been out of the barn for some time given failure of treatments. In San Diego, been here a long time after college. Some good docs down here although I prefer to not divulge too much at this moment.
Being an engineer, I have a tendency to research things quite a bit once they are pertinent... and prefer to understand how things work (big surprise if you know any engineers). Married, wife is the opposite, never wonders how anything works except for personal feelings. Having been married for a long while, I finally discovered that most of the time, when she complains to me about a problem, she doesn't want me to apply my "solve the problem" mentality, but rather just wants me to say "poor baby"!
Given 16 years before being compelled to go on HT, I have had a pretty good run.
I've been looking for cases similar to mine: first presentation of metastatic spread (without other LN involvement) to the inguinal LN. I've only found 3 cases, it's considered very rare evidently. Know of other cases?
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