BACKGORUND: RP 6/2016; SRT w/HT 6months 10/19; <.1 until 6/24 then .1; .6 now 1/25. PSMA PET Palarify 10/24 finds 2 'hot' iliac nodes. Now Stage 4.
So, I now have a .6 PSA and 2 'hot' iliac nodes. Plan is Lupron and Zytiga for 18-24 months. SBRT to the 2 nodes. I had the pelvic nodes treated during SRT, up to but not including the iliac nodes. My MO right now WILL NOT prescribe Docetaxel as part of the regimen. I asked for it, as I am younger (63) and in pretty good health. I feel I can tolerate it fairly well at this point in my journey. That will be an ongoing discussion.
So, here is my dilemma. My RO tells me that upon comparing the original SRT treatment area over the latest CT Simulation of my pelvic nodes, that the SRT came up to, and partially hit the lower 'hot' node. She tells me this is a tricky situation as any further radiation to this area can cause significant damage. She tells me she actually needs to be there in person for each treatment (5 of them) so that the radiation is targeted exactly where it needs to be. I guess the radiation techs normally handle distributing the radiation without the RO present. The dilemma.......well, I feel if the RO cannot successfully treat that one node fully, then maybe I should seek to have the node removed surgically or thru cryoablation. Has any of you went down this road? If so, any recommendations for doctors that perform these in the New York/Philly area?
Now, watching videos of Eugene Kwon at Mayo and Mark Scholz of PCRI, I find that situations such as mine should be treated with a curative attempt. I know that sounds silly, but there is a certain percentage of patients that are cured with 1 or 2 pelvic metastases with SBRT with Lupron/Zytiga and Docetaxel. I just need to be able to fully treat these two nodes and I'm not sure right now that SBRT can do it.
Thanks.
Jack (New Jersey)
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JayMot
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I was recently referred to MSK in NYC by my drs at Duke. MSK has a machine that provides precision radiation treatment with MRI guidance in real time. Tumor near rectum and bowel that was discovered with PSMA-PET (at Duke). Treated 5 days at MSK. Flew home. Dr Nagar and team were great. PSA now 0.05. Highly recommend Dr. Nagar.
Was this part of a clinical trial? Was this treatment already after radiation you had prior? I am trying to look into this but on the MSK website they say it is experimental. I'm not sure they would take me. Any further info you could provide would be great. Thanks, J
The RO's plan sounds perfect to me - maybe discuss going a little higher with the salvage radiation -- up through the para-aortic lymph nodes. If you are curable, that is your best shot. Plus 3 years of ADT and 2 years of Zytiga. Kudos to your RO for being there for the treatments - there is a lot of organ movement that he wants to see.
Docetaxel is usually ineffective when cancer is not in bone, and lymph nodes are treated with radiation. "there was no evidence of additive benefit from using both radiotherapy and docetaxel [in N1 M0 patients]"
Those 2 lymph nodes are not all there is, it is just the ones in which the tumor is large enough to detect on your PET scan (at least 5 mm). There is more cancer where that came from- which is why I suggested going up to the para-aortics. Hopefully, the radiation will get it all.
It is dangerous to your health to believe YouTube videos by Dr.Kwon (who is neither an RO nor an oncologist)- here is what he actually found at Mayo:
Is Sartor still at Mayo? I received a private message from one of our member who said that he couldn't find Sartor on the list in Mayo. (I recommended to our member to contact him but it looks that he is not available?)
"Thanks, and apologies for my late reply but I've been unwell and getting bounced from pillar to post and back. I saw the comment about Kwon. It's awfully hard to get hold of these top people. Obviously I'd like to connect with Sartor, but I don't see anywhere on Mayo's site for consulting him."
Fortunately, there are many equally good oncologists - Paul Corn at MD Anderson, Eleni Efstathiou at Houston Methodist, or Maha Hussain at Northwestern for example (in the middle of the US).
TA, do you know any RO that will do the para-aortic lymph nodes? I just go off the phone with my RO and she will not do it. I have cancelled my SBRT with her (for the time being) and going for a second opinion at MSK in NYC. I am taking profsailor recommendation of Dr. Himanshu Nagar and the MRI-LINAC guided machine. I will ask him about treating the the para-aortic lymph nodes when I secure the appt. Thanks. Jay
That area is very close to the bowels, the heart and other structures that are unsafe to irradiate. Your RO has seen your internal anatomy and knows what is unsafe to irradiate. You have to ask yourself what is the potential benefit (which is unknown but low if any) vs what is the potential risk (which seems high in your case).
TA, I dont understand. In you original response to me, you state that maybe my RO can go up to the para-aortics. Now you state that it is too risky. I'm confused.
I said "maybe." It depends on your individual anatomy. One friend of mine, who was obese, had plenty of fat covering his organs, whereas another friend who is anorexic could not have radiation there.
TA, What are your thoughts on the MR-LINAC machines that combine MRI real-time imaging and SBRT compared to the traditional CT image guided SBRT? My cancer center in central NJ does not have this machine but is currently installing one. It will not be online until summer 2025. But the NJ satellite MD Anderson Hospital does have this machine. Since that pesky lower iliac node was touched by SRT, I'm thinking the MR-LINAC might be the way to go to treat this node with minimal damage to other soft tissue. As always, thanks for your input. J
Once the cancer hits the para-aortic nodes, it is probably systemic, but possibly not. If safe, why not? But if not safe, it is a lot of risk for low probability of benefit.
TA, I have a quick question on PSADT. My PSA readings over 6 months:
June 2024 ----.1
Sept 2024 -----.3
Oct 2024 ----- .4
Jan 2025 -------.6.
My MO says that's a fast doubling time. I thought that at numbers less than 1.0, that the PSADT cannot be accurately calculated. It seems I'm going up .1 a month for 6 months. Now, I know that at some time PSA can increase exponentially, but if I continued at that same pace at a PSA over 1.0, then, I wouldn't double for over a year (ex. 1.0 to 2.2). Thoughts? Thanks. J
Ten years ago Dr. T. Hollister in Wilmette, IL., did my para-aortic lymph nodes, apparently successfully. He trained with Zelensky at MSK, now is with Metro Chicago Surgical Oncology.
were the para-aortics treated as a preventative measure as part of a larger treatment area or were they treated because they had evidence of disease? Thanks. J
I appreciate you are not considering surgery but thought this might help. My para-aortic were surgically removed after cancer was confirmed in common iliac nodes during the ePLND procedure using the frozen section pathology method. The decision to expand the treatment field including para-aortic, based on findings with common iliac, was made prior to the surgery.
doing very well , seven years post ePLND, no ADT, uPSA holding very low stable 0.03X range. Last two bi-monthly results were 0.029/8, respectively. And no side-effects from wPLND but have ureter strictures from SRT. All the best!
cigafred, Are you telling me that you had 8 lymph node metastases and treated them 10 years ago and all is good? WOW, if that's true, that's outstanding and good to hear!
Not perfect, but good. Latest PSA 0.04. I should add that I am doing a lot of other things--MCP, nattokinase, I & IP6, 35 or so more, most of which are probably worthless but I expect some are helping. Like the old joke about advertising, I know most of it is wasted, but I do not know which parts. Direct message me for more info.
My third treatment decision and current status has been called out here as anecdotal, amongst other things. As I share, after my unsuccessful SRT I had six cancerous pelvic lymph nodes surgically removed, including para-aortic, resulting in a post treatment nadir of <0.010. I then added one year bicalutamide for added insurance.
My treatment decision was and is 'scientifically' supported; just not to some folks acceptance. Was it wrong? Coming up on seven years holding very low stable uPSA 0.03X range, no ADT. Current full body scans are again NED.
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PSMA scan results 
SRT with hormonal therapy, I need your help!
My first post. Rising PSA After Surgery. 
