Retroperitoneal Lymph Nodes

[JolleySprings]

Curious about the difference in Para Aortic Lymph nodes as opposed to Retroperitoneal lymph nodes in PC metastasis… other than their location in the body.

Thanks!

[103532]

Hi, My husband recently completed his radiation to this area. From my understanding, the para-aortic lymph nodes are in the retroperitoneal space. My husband had PSMA avid small retro-caval nodes, which were in the back of the abdomen near the ureter. It is an uncommon area, but we were told these small nodes are increasingly discovered thanks to the PSMA Pet scans. We are hoping the doublet ADT and the extended pelvic IMRT to incorporate this nodal chain will keep things at bay.

Stephanie

[JolleySprings in reply to 103532]

My husband has had at least 5 PSMA scans all showing NED…. With PSA continuing to rise they finally did a CT scan with contrast etc…. Just last week … they did an Auxium scan… and found MULTIPLE Nodes light up in the retroperitoneal abdominal area. He is at PSMA avid.

We see oncologist on Thursday. At this 7 yr point for us ADT has stopped working… nor did NUBEQA. Or Zytiga…. 😩😩😩😩😩😩

[103532 in reply to JolleySprings]

II am still learning and am no expert, but I am curious if you have asked about continuing ADT but adding a Parp inhibitor? That may be the next step When they dissected the para-aortic nodes, was the tissue still adenocarcinoma? The two questions I would ask the oncologist would be about the parp inhibitor and resensitizing the cancer to ADT (such as Lupron/ with dexamethasone instead of prednisone or Docetaxel chemo. Others are more knowledgeable than me. I also think there is hope and time on your side still because there is no organ or bone involvement yet.🙏 I am allways searching for patients who have a similar progression to my husband to see how they are doing. Please keep me posted!

Stephanie

[StayingOptimistic in reply to 103532]

Please keep us posted. Thanks

[JolleySprings in reply to 103532]

You are Sooo kind to respond and want to educate yourself and others with what you have learned in this journey!

My husband had RP 7 years ago. At the time his Foundation One report reported he has a CDK12 mutation. However ADT did work for a couple months f years. Then we went to Daraludimide (?) Nubequa…. And after about 8 months it failed… actually, it was never effective. Then we went to Zytiga… and all the while he has been remaining on Lupron or Firmagon injections… Yet his PSA continued to rise. In April we had AUXIUM scan and it revealed Uptake in paraaortic lymphs… Beginning of May he surgerically had 5 “C” nodes removed and fresh tissue sent to 4 different labs. The results basically were the same genomically etc. Still CDK12 and also ARv7 loss.

Our oncologists both say PARP Inhibitors are not favorable for his type mutation… more likely to respond to PD-1 Inhibitors.

So… this week we should have a more definitive plan.

It’s really scary now that we are seeing Node involvement… Plus, it seems rare for PC to mutate to the abdominal back area… from what I’ve read!

Thank you for your response! You are encouraging!!

[StayingOptimistic in reply to JolleySprings]

I have pelvic and abdomen LN Mets and was never offered any radiation or other forms of treatment aside first and second line ADT.

[103532 in reply to StayingOptimistic]

That was all that we were offered, initially, however, we pushed for radiation in an effort to throw all options at it and lower the burden.

[StayingOptimistic in reply to 103532]

Any toxics or side effects from radiation to that area please?

[103532 in reply to StayingOptimistic]

No. So far so good…he ended 39 treatments of 70 gy IMRT concentrating on the abdominal nodes first and full pelvic and prostate bed to try and zap any sleepers. There was one PSMA avid common iliac node, so we think he originally progressed in an ascending pattern. About halfway through the treatment, he took a short nap at lunchtime and had some bloating and light diarrhea, but that was it. We ended six weeks ago, and all symptoms are pretty much gone. He drove two hours round trip very early in the morning to Yale and never missed a day of work. He was able to work from home during all of this. Incidentall prior to this,, we sought a second opinion about whether or not to do the IMRT in addition to the ADT, and they said to go for it!

[103532 in reply to StayingOptimistic]

Our thought was to put them to sleep with ADT then try to kill them in the “hopes” that is their only landing spot.

[103532 in reply to JolleySprings]

Thank you, and I will learn from what they will be offering your husband, who will be in my prayers.

[StayingOptimistic]

1/2017 , I had SRT to prostate bed only at the time of recurrence. So I am not sure if I can do radiation now for these Mets. I am on vacation now for about 7 months.

[103532 in reply to StayingOptimistic]

I read through your bio, and I think you will be managed for a very long time. It appears it is being managed well and kept in good control. Enjoy your vacation. If my husband proceeds similar to your history, I would be guarded but hopeful.

[StayingOptimistic in reply to 103532]

Thank you very much for your kind and hopfull words. I am very scared to death from the day. Resistance sets in. I hope and your husband does very well. It appears so from his bio too.

[NanoMRI]

General reading suggests Retroperitoneal nodes are associated more with testicular cancer. My left paraaortic nodes were found to be cancerous in my third treatment, salvage extended pelvic lymph node dissection surgery.

[103532 in reply to NanoMRI]

Looks like your pca is really under control! We were advised two years on Abi/pred and 3 years of Lupron. My husband was psa doubling monthly albeit at low levels. Best wishes that you continue to do well!!!

[NanoMRI in reply to 103532]

Thank you. I do not have enough words to express my gratefulness. Yes, almost ten years and four treatments and it seems my beast continues to be 'idle', despite having made it to the para-aortic nodes. After my RP my very low usPSA doubled in less than a year.

I know I have taken a gamble outside of more common treatment paths with my salvage extended pelvic lymph node dissection surgery and only one year on ADT; and that being 'just' bicalutamide. This is why I continue bi-monthly usPSA testing, annual imaging and annual blood biopsy testing.

All the best for you and your husband!

[Shellhale in reply to NanoMRI]

Just found out my husband has para aortic nodes and being told that they can't do SBRT. How were para aortic nodes treated?

[6357axbz in reply to Shellhale]

I had my entire para aortic lymph node string zapped alone with some bone Mets. All good.

RO Dr Chad Tang

MD Anderson Houston

[Shellhale in reply to 6357axbz]

This is good to know. The PSMA scan showed 3 lymph nodes in common and external illiac. The RO said today that he sees more like 7 lymph nodes and saw small spots in the para aortic. He didn't want to do anything at all. After pushing him he finally agreed to SBRT to the 3 lymph nodes that showed up on the PSMA scan. I understand only wanting to do 3 at a time but why not do the other para aortic later? He also said Pluvicto only works with bone mets. We are getting a second opinion. I am glad I can get some feedback on this site. From all the studies I've read I know we are not getting the right information. I am glad everything went well for you. Do you know how many lymph nodes were zapped?

[6357axbz in reply to Shellhale]

I only had two cancer spots on my para aortic lymph node string, one at either end but he wanted to zap the entire string to be safe. Took 28 radiation sessions to do it.

[Shellhale in reply to 6357axbz]

He has 2 spots also 1 on each side. Right now they are only doing the lymph nodes on the illiac. But after they finish i think it warrants a second opinion to look at the par aortic lymph nodes. Did you do ADT to shrink the nodes before radiation?.

[6357axbz in reply to Shellhale]

I did adt but not necessarily for that purpose.

[NanoMRI in reply to Shellhale]

salvage extended pelvic lymph node surgery using frozen section pathology method. Six nodes cancerous. That was seven years ago, no ADT. Today holding very low stable 0.03X.

[Shellhale in reply to NanoMRI]

I don't know much about this kind of surgery. But your results have turned out amazingly! I am going to look into this.

[NanoMRI in reply to Shellhale]

Salvage ePLND is uncommon in US. Since mine , done in Europe, I have learned the Mayo Clinic offers it but I do not know their guidelines/policies. I consider myself most fortunate and I am certainly most grateful. All the best!

[Shellhale in reply to NanoMRI]

Attitude is everything! I am glad you have had such great results. I wish that for everyone. Thank you for your response.

[Mgtd in reply to NanoMRI]

I am no expert but after I read numerous of your postings I was curious why this is not offered very much in the US.

First let me say I am very glad that you had such a positive response from your surgery in Europe.

To the best of my ability I found out some reasons why it is not done more often here. Many younger doctors are not trained to do it. It requires a fairly complex skill set to do effectively. In general and you were an excellent example of its potential but at least in the US it was not found to be that effective so it never really became a SOC procedure.

If you have some studies that demonstrate the opposite or that show that it should be sought after I would really appreciate you listing them. I was not able to find any and the paragraph above was what I gleaned from mostly very small accounts. Almost as a passing comment in a discussion between two doctors.

[NanoMRI in reply to Mgtd]

I appreciate kind support of my efforts and the discussion. I am no expert either, just a patient not readily accepting of population-based policies for prostate cancer. (Note, I am for my metastatic melanoma).

I first learned of salvage ePLND from a paper – link below. I contacted my RP surgeon who is with a solid collegiate medical center and he said he did not have the skills. Next, I became aware the medical center was not interested nor were many other major centers I contacted.

The reasons you cited, lack of skill, complexity were common reasons. Looking behind the curtain I also saw perceived risks and costs as major deterrents. Fear of lymphedema is another but I quite easily dispelled this for me. Also, it seems limited attention/interest is given to reducing tumor burden here in US; as I see it, the favor is towards ADT.

Another reason is a historical fear of excessive lymph node dissections. But, this is in the past and was a result of excessive fears of PC – not reckless surgeons trying to make money. I was living in a market town outside of London England at the time of my diagnosis. Fortuitously, a neighbor was the late Dr. John Wickham; retired at that time. Dr. Wickman’s work in keyhole surgery was honored in many ways, including being called a godfather of robotic surgery. In his book “An Open and Shut Case – The Story of Keyhole or Minimally Invasive Surgery”, he wrote about the harms of lymph node chasing. With today’s imaging capabilities, liquid blood biopsies and better understanding of disease progression, this excessive fear is unsupported, but opponents to surgery and ePLND won’t let go of it.

That was a long way to your request for some studies. This is the one that initiated my interest: europeanurology.com/article....

After reading this paper what boosted my confidence was that the nanoparticle MRI I share about is a far more sensitive technology than the choline PET/CT cited in the paper; which yes was published way back in 2011. There are others but this is a good start.

This is from the paper: “Surgically removing pelvic and/or retroperitoneal lymph nodes (       Shellhale ) that were visible in one or two locations on [11C]choline PET/CT [4] introduces a new concept of salvage lymphadenectomy in patients with low biochemical PSA recurrence. What can salvage lymphadenectomy achieve? It is very unlikely that, even with a low tumor load in the pelvic or retroperitoneal lymphatic system, removal of one or two nodes will completely cure patients of PCa. However, it has been shown previously that patients with one or two positive nodes at the time of primary RP survive 10 yr in the majority of cases [5,6]. The driving force behind the concept of salvage lymphadenectomy is similar to the multimodal concept of treating T3 or T4 primary PCa [7]: Removal of all visible disease may improve multimodal therapy or, even better, delay subsequent systemic treatment.”     Hawk56

Further note, although the paper cites one or two locations on [11C]choline PET/CT", I had five identified on the Ferrotran nanoparticle MRI. Six cancerous nodes confirmed by my salvage ePLND, including para-aortic, at uPSA 0.13. If I had a do-over I would have this procedure at time of my RP.