Difficult decision before a robot assisted laparoscopic prostatectomy planned for March

[Hockeyforever]

PSA 3.4. Gleason 7. MRI and biopsy diagnosed prostate carcinoma left lobe.

In December 22 a PET/CT (238MBq F-18 PSMA) found moderate grade uptake involving the left peripheral zone of my prostate gland consistent with the known carcinoma and lower grade uptake involving the right lobe of my prostate gland, non-specific however raising the possibility of additional disease. The PET/CT also found low-grade uptake associated with a 6 mm diameter right distal external iliac lymph node raising the possibility of metastatic disease and low-grade uptake associated with an 8 mm lung subpleural nodule.

In January 23 a CT chest (post IV contrast helical) found subpleural opacity at the apical right upper lobe has appearances of post-inflammatory scarring. No concerning pulmonary lesion identified.

In March 23 a robot assisted laparoscopic prostatectomy is planned. But I have to decide what to do about my 6 mm diameter right distal external iliac lymph node. My right 6mm lymph node is on the opposite side to my prostate carcinoma and centimetres away from my prostate. The Urological surgeon said the team review recommended the lymph node be removed during prostatectomy. Given the 8 mm lung nodule was a false alarm I thought maybe the 6mm lymph node is also a false alarm. I asked the surgeon whether the 6mm lymph node could be spared and my PSA monitored post surgery? The surgeon replied that it was a reasonable action. A day or so later, I thought maybe biopsy the 6mm lymph node during the prostatectomy to determine whether it is a carcinoma? Over to the community here for their thoughts of, if in my shoes, what they would do.

[Justfor_]

Responded some hours earlier, but I can't see it here. Anyway, the second half part of this interview may be of interest to you.:

youtube.com/watch?v=CA7fGl0...(Not working as expected?)

[Hockeyforever in reply to Justfor_]

Thanks.

Can you remember your first response and repost?

[Justfor_ in reply to Hockeyforever]

I was mentioning the technique of mounting a radiation detector to one of the robotic arms so as to guide the surgeon to the PSMA ligant that the patient had received just before the procedure. As the detector can be brought almost into contact with the suspecious node, the sensitivity and specificity of the detection are quite high. The interviewer is an Australian urologist, so you may contact him to check if this technique is offered in your country.

[Hockeyforever in reply to Justfor_]

Thanks. Very impressive video. I will inform the urologist I see.

[Tall_Allen]

The lung nodule seems to be a false positive.

What exactly is the SUVmax on the lymph node and the sacrum? If those are positive, you should definitely not have a prostatectomy. Many patients think "I can always get radiation later" ignoring the fact that radiation on top of surgery increases the risk of permanent incontinence, urinary retention, and impotence. Do not rush into this.

[Hockeyforever in reply to Tall_Allen]

Thanks. I was thinking exactly like you commented. SUVmax is explained in this link:

sciencedirect.com/topics/me...

[Tall_Allen in reply to Hockeyforever]

I know what SUVmax is. What I'm asking is what was your SUVmax of your lymph node and sacrum?

[Hockeyforever in reply to Tall_Allen]

SUVmax isn't specified in the PET PSMA report. The report commented: " Low-grade uptake associated with a 6 mm diameter right distal external iliac lymph node raising the possibility of metastatic disease. Subtle focal activity adjacent to the S1 foramina is non-specific and may represent physiologic ganglion uptake. Subtle focal uptake anterior to the left side of the S1 vertebral body is also noted, non-specific."

[Tall_Allen in reply to Hockeyforever]

"Low grade" and "subtle" uptake are judgements by the radiologist. Ask what the actual numbers were.

[Hockeyforever in reply to Tall_Allen]

Thanks. I'll try to get the SUVmax for the lymph node.

[BobbyMac07]

I agree with Tall_Allen, radiation may be the way to go.

[Hockeyforever in reply to BobbyMac07]

Thanks

[Tigger2022]

After my husband had his prostatectomy and was getting ready for radiation, the RO at Northwestern explained to us that when there is metastasis in a lymph node, it is in the whole system of nodes in the pelvis, which is dozens. It didn’t just met to *that one node* which the surgeon happened to pluck out, in other words. And my husband’s scan had showed no mets at all, prior to surgery.

I understand the Cut It Out! mentality, but it seems like radiation and ADT is a much better way to go for you. You’re going to have to do it, anyway.

[Hockeyforever in reply to Tigger2022]

Thanks

[DiMeo10]

Some surgeons always take out lymph nodes and some do not. By taking them out (volume is a case-by-case basis) you can tell under pathology if it is spread, and proper treatment can be done if needed.

[Hockeyforever in reply to DiMeo10]

Thanks

[Hidden]

Wow, I have to agree with some of the other replies about thinking this over. Your case sounds a whole lot like mine. I had a tumor in the one side of the prostate (Gleason 7) and the MRI report mentioned something about a lymph node nearby but the RO was not concerned about that. I went through 6 months of ADT and 27 sessions of IMRT with the first eleven hitting the prostate and the seminal vesicles. That was July of 2019 so it's been almost 4 years. My last PSA was at .25 and it was low the past couple years. I still pee good, still get erections, and still have great orgasms. Just not much comes out. I've just heard so many horror stories about RP that I would stay away if at all possible. My son is a doctor so I say this without prejudice. Doctors today are out to make money and the surgeons make a great deal on an RP. They get JACK if you're doing radiation so I know there's some bias on their part. I was in the hospital 5 years ago for a breathing issue and a chest Xray exposed a mediastinal mass located near T8-T9 of my spine. Two biopsies declared it benign but the surgical team was chomping it to bits to go in there and take it out. They said they would need to break some ribs and deflate a lung to get to it. No way!

[Hockeyforever in reply to Hidden]

Thanks.

[Linebacker75]

Hello Hockyforever,

I was dx in 2012 and told my Onc “cut it out” I regret that decision today. My advice is slow down and gather as much sound advice you can about the statistics concerning microscopic PCa cells that have already left the prostate and are looking for a place to set up and grow. Also note the sexual side effects or outcome of removing the prostate. In my case I had mine removed along with the local nodes, it showed back up in a year so then pelvic radiation and Lupron. I go on a Lupron holiday every 9 months to a year and during those holidays my psa takes off upward with a 2 month doubling rate until it hits a whole number then the holiday ends and I’m back on Lupron. My last PSMA scan show PCa in 3 Supraclavicular nodes (in my neck) In short, my Genie had already gotten out of the bottle and I sure wish I had kept the bottle. Keep us informed and ask lots of questions here on HU. It’s a great ‘real life’ source of information. Good luck

Much love from the PCa Brotherhood.

[Hockeyforever in reply to Linebacker75]

Thanks

[doc1947g]

I was 72 years young when dx, G(4+3=7) with a PSA = 22.4 μg/L.

Due to many other health problems. NO RP, NO BrackyT.

VMAT-RT 3 Gy X 20 fx = 60 Gy in june 2020 and (2020/05/31)+(2020/08/24)Lupron Depot 22.5mg/12weeks X 2, due to a screw-up on 2020/04/04 when I was suposed to received Fligard 45 mg/24 weeks in the same time than my Casodex 50 mg/30 days.

So instead of having a prostate of 24.6 cc shrinking to a lower volume, my prostate doubled in size to 48.83 cc so they irradiated the whole pelvic area.

So as of Dec, 5th 2022 my PSA went down to 0.05 μg/L. So I am lucky.

[Hockeyforever in reply to doc1947g]

Thanks.