Whole-pelvic radiation therapy for high-risk patients

[Tall_Allen]

If you have high-risk PCa, you probably should have whole pelvic radiation:

prostatecancer.news/2021/08...

[cesces]

Why is it they can't just target specific lymph nodes?

[Tall_Allen in reply to cesces]

Did you read the article?

[cesces in reply to Tall_Allen]

No. But I just did now.

I don't think it answers why not target just the problematic lymph nodes with narrow beam radiation.

No doubt there is good reason not to. I just don't see the downside to it.

And any time you can reduce needless exposure to excess radiation. That is a good thing.

[Tall_Allen in reply to cesces]

It certainly does answer that. First of all, all patients were "high risk." High risk means localized - no detectable pelvic lymph node metastases (N1) and no detectable distant metastases (M1). Almost all patients were screened using PSMA PET scans.

But even if we were talking about patients who were N1 at diagnosis, it is certainly a very bad idea to treat only the pelvic LNs that are currently detectable. You have to treat what you can't see as well as what you can't see. Why do you suppose WPRT did significantly better than PORT in this trial? It is obviously NOT "needless."

Here's what happened when only select LNs were treated in N1 patients:

prostatecancer.news/2020/12...

[cesces in reply to Tall_Allen]

What I read there is that targeted radiation does work. But that whole pelvic works better..... but....

There remain a number of "unanswered questions"

So targeted radiation does work. Whole pelvic works better.

But it appears there is no answer to whether the reduced radiation from targeted radiation is worth it?

[Tall_Allen in reply to cesces]

You read that incorrectly. It shows that even whole pelvic radiation (ENRT) had a limited effect. It only slowed progression when there was just one recurrent LN. So, WPRT was able to slow progression but spot radiation was not. There is absolutely nothing there that suggests that targeted radiation works at all.

Read the POP-RT study again. It clearly shows that the increased radiation exposure had no discernible effect for the patients.

[cesces in reply to Tall_Allen]

Thanks for the clarification

[Gemlin_ in reply to cesces]

I think the answer is that men with problematic i.e. detectable lymph node metastases were not included. Only men with a probability of microscopic lymph node metastases were included.

[KAgolf in reply to cesces]

my husband had WPRT with Proton -- just finished the end of June. He had GL9, grade 5, Stage IV, T2b N1 M0 aggressive PCa, and considered VERY HIGH RISK---the N1 because of 3-4 "suspicious" iliac nodes which were treated as positive.

All pelvic nodes and prostate were targeted for most sessions, then for about a week ONLY the suspicious 3-4 nodes along with prostate, then the final 5-7 treatments were only prostate.

His RO didn't advise scans for about 3 months, but MO insisted on chest, Abdomen/Pelvic CTs; the ab/pelvic CT (5 weeks post) report says the "suspicious" nodes are NO LONGER SEEN!!! and a mesenteric node he had biopsied (benign) has gone from 11.3 to 6.7 in size.

We are grateful that his RO set plan for WPRT--he recommended against the brachy when I asked at beginning--said that with Proton boost would be too much. So far no bladder issues or others--he had the SpaceOar to protect rectum. The summary of his treatment shows how much radiation his bladder, colon, etc. received in total and daily.

So, yes, cesces, they CAN TARGET specific lymph nodes, and apparently very accurately with Proton pencil beam.

My "guess" is that they don't JUST target problematic nodes because if one is positive or suspicious as in Hubby's case, there are probably more with micro cancer cells lurking. Targeting all (hopefully) will take care of that.

[Hidden]

I'm hoping I fall into 95% group. G9, RRP. 39 IMRT (WPRT) and 2 years ADT wt zytiga/pred. Psa < .1 for 19 mo and counting.

[Tall_Allen in reply to Hidden]

These were all primary treatment, not salvage. But SPPORT showed a similar advantage for salvage WPRT:

prostatecancer.news/2018/10...

[Hidden in reply to Tall_Allen]

My IMRT happened with months of my RP...if I didn't have my RP and chose IMRT and ADT I would fit this study.

Is the fact that I had RP first really a factor?

[Tall_Allen in reply to Hidden]

Sounds good to me! Mostly it affects toxicity. But whether according to SPPORT or POP-RT, results of WPRT are excellent.

[Hidden in reply to Tall_Allen]

I remember my RO telling me at the time I was getting radiation that I could not have any more. There must be a maximum they will give you. Sounds like for me what I got is all I’m getting unless they have changed there minds since 2019. I didn’t hear about salvage radiation until I listened to you guys.

Wonder what is next for me if or when it returns?

Heading to see my MO in December.

[Tall_Allen in reply to Hidden]

It depends when and where. For example, if you had prostate radiation originally, you can have salvage radiation to pelvic lymph nodes because that area wasn't treated initially.

[Hidden in reply to Tall_Allen]

Nope had whole pelvic and he said he was going to cook me because of the tumor invading the rectal wall. Said he was going to turn it to dust. Last mri showed no tumor. Gone.

[KAgolf in reply to Hidden]

do you mind telling me why you are taking Zytiga? my husband is GL9, grade 5, Stage IV, T2b N1 M0 aggressive PCa---N1 because of 3-4 "suspicious iliac nodes and had Proton (see above). He does not meet criteria for chemo or Zytiga since he is M0 and he is still hormone sensitive--started ADT end of January--it's fallen as has T but neither is undetectable yet---PSA is 0.54; 1 MO is pushing Zytiga, but keep wondering if it is necessary now with no mets and no CRPC; thanks and wishing continued success with your treatment

[Hidden in reply to KAgolf]

When I was diagnosed in May 2019, the stampede trial had recently released trial data showing a benefit for M0 patients. My MO said I was going on Eligard, Zytiga and prednisone. I'm off the zytiga and prednisone and my last 3 month Eligard injection will stop working sometime in Nov 2021.

There is another member "treedown" who did IMRT, ADT + Zytiga/prednisone. Like me, he is getting ready to come of the ADT and Zytiga.

I'm a firm believer on hitting it hard early and I believe you husband should seriously consider adding the zytiga now. If he's handling the ADT well, the zytiga probably won't be too debilitating.

My post RP pathology was pt3bn1m0 ( 1 of 12 nodes positive)

[KAgolf in reply to Hidden]

thank you!! were you on Zytiga for 12 mo. or longer? cost is outrageous!!

EVERY Part D plan has the generic also as tier 5 and monthly costs are $2000 (his would be $1885); the goodrx has a month of 250mg at about $20 per month which is doable if necessary.

[Hidden in reply to KAgolf]

Started with Casodex then move to zytiga in November. So my total time in zytiga was approximately 18 months....for my prescription I paid 1500 for the 1st mont and 15 for months 2-12... total out of poc was approximately 3500

[39cancer in reply to Hidden]

Just chiming in here, I'm a GL9, t3b, N1, MO. I'm with TomTom1111. Hit it hard. I had RP in May 2021. Started hormone injections in June and then Zytiga in July. Noticed no difference in side effects from the shots alone. I've been pretty lucky there though, just the libido and hot flashes. Otherwise feeling completely normal.

[KAgolf in reply to 39cancer]

thank you

[JDKotter]

Thank you TallAllen for the information. I had whole pelvic Radiation in 2019 and just got off Abiraterone in February. So far my numbers are excellent. My Testosterone is now 58 from <7 and my PSA is undetectable. I am a Gleason nine with an initial PSA of 68 and three lymph nodes involved. I’m wondering if there is a study that shows a survival benefit for whole Pelvic radiation for guys w Node involvement?

[Tall_Allen in reply to JDKotter]

Yes, but it is retrospective:

prostatecancer.news/2017/12...

[JDKotter in reply to Tall_Allen]

Thank you for the link!

[Hidden]

Hey JD ! I had only two lymph nodes lit up so my mo didn’t radiate the nodes . Still , 8 weeks of imrt worked well with pushing the pc away now over five years …nothing last forever .

[JDKotter in reply to Hidden]

Congratulations ! I hope to be in your footsteps!

[Aodh]

Thanks TA for posting this. When I had my WPRT last year I wondered if I was being slightly over treated, I wonder no more!

I did and do take the view that to be slightly over treated is much more preferable than being slightly under treated!!

[Gemlin_]

... or ePLND if RP chosen.

[KAgolf]

THANKS for the link, Tall_Allen--makes me feel even better about my husband's Proton therapy and WPRT

[GreenStreet]

I am sure this is helpful advice but I am not sure whether the trials screened for those who were deemed suitable for whole pelvic radiation and whether this could have impacted the relative small differences in the side effects that have been reported. In my case unfortunately I have been advised not to have whole pelvic radiation because of potential damage to the small bowel which is apparently only 2ml away from a suspicious node. I am sure the thrust of this is right but it does come down to individual circumstances and treatment planning.

[Tall_Allen in reply to GreenStreet]

Yes, fortunately there are very few men who are not candidates for WPRT.

[tallguy2]

Thanks for posting this!

[Lasered]

TA, thanks for the info. I'm just finishing up 33 sessions of WPRT.

[bigbassman]

I had a similar treatment at Dattoli Cancer Center 4 years ago, Gleason 8, PSA 20, one bone met, and my PSA is still at the edge of detectability, 0.008. I am very grateful for that.

[esperandrich]

Don't know much about you but have been reading you for four months and you are helpful.

Don't want to be an elite person but I am a retired lawyer and judge so I think I can analyze information.

[esperandrich in reply to esperandrich]

I decided to reply to myself. Tall Allen provides the information you need to analyze and then make a decision unlike some other posts I have read.