What do you do when one lymph node on PSMA is inconclusive ?

PSMA October 2024 low level of tracer para-aortic LN SUV 5; subsequent PSMA March 2025 after 2. 5 months on Orgovyx Previous tracer avid nodes not seen in this study. Plan is to radiate para-aortic node(s). Without PSMA we would not be aware of positive nodes. Question I need to ask is if Orgovyx resolved nodes completely why radiate. I will continue on hormone for another 20 months.

I’ve just been in somewhat similar situation. I’m 4-3=7, PSA of 5.6, 10 of 12 cores. PSMA Pet showed very low uptake on lymph on both sides of pelvis and 3 spots on bone areas. CT portion of test showed no lesions anywhere other than prostate. My urologist sent for consult at our NCI cancer center who took it to their multi-disciplinary tumor board. Their assessment was that they were false-positives and to proceed with treatment options believe it’s contained in prostate; RP or RT, my choice. I decided this week to go with RT with 28 treatments and 6 months of ADT. I’m fully aware and accept that this first treatment may be just the beginning of many along this prostate cancer journey. Won’t be surprised if these false-positives rear their ugly head down the road; but maybe they won’t. The science is what it is, imperfect and at times unknown as some highly regarded specialists will admit to. But on average they are able to extend life beyond what they could in the past and always trying new treatment options.

Hey Johnw, Orgovyx suppresses T, which feeds your cancer. It does NOT kill it.
It weakens it and starves it so that it is less able to “heal” itself once its DNA is ionized and scrambled.
You need the one-two punch to attempt to eradicate it.
Phil

I agree 100% with your response. I have mixed feelings regarding the PSMA findings. I feel fortunate that these findings truly represent early detection of the para-aortic nodes and at same time I’m anxious about receiving RT to that region. I can’t find anyone with PCa who has had positive para-aortic nodes and RT.

Mixed feelings?? John , let me welcome you to Prostate cancer 101!!🤣. The whole thing is one great big mess of mixed feelings, contradictions and conflicting data.
I spent my entire 42 yrs in dentistry running and shielding myself from radiation; yet, I joyously leapt onto the table 25 times to bathe my body in its toxic beams…WTF??
We’re all between a rock and a hard place and ADT is no different: it starves the cancer but take too much of it and you could wind up dead (fatal heart attack/stroke) from it’s effects.
You ought to be concerned about radiation near the aorta, but luckily advanced computer mapping and very sophisticated machines make it possible to “shape” the beam around the aorta.
You really should talk to your RO about specifics - or get a second opinion. But I don’t think you can continue on ADT forever in order to avoid radiation.
But if you are in your high 80’s and upward it is possible since life expectancy comes into play and staying on ADT might be the best solution in that case.
Phil

Thanks everybody for additional input and prospective. It is very much appreciated. I hope surgeon will have some ideas and know how to proceed.*sigh

Last night I decided to go through all MRIs my husband had over the years and read every single comment (he was on active surveillance since 2015), and I found one from 2022 that mentions this exact same lymph node and it was exactly the same size (1 cm). Now I comfort myself that if it was met. it would grow in 3 years at least somewhat ?
Does anybody know if that is correct assumption or lymph nodes with PC stay the same size no matter what ?

The node could stay the same size but the uptake should be much greater if it was a growing cancer.
So I think that suspicious node stays the same and will continue to do so. Of course, if it is one in the surgical field (some are not) it will be removed and analyzed so don’t give it too much weight right now.
Just my opinion based on hubby’s MRI history. Best,
Phil

Mine was referred to as malignant neoplasm of intrathoracic lymph nodes. Had a bronchoscope airway exam with endobronchial ultrasound biopsy of nodes on both sides of airway. Had 5 sessions of SBRT . Had two psma within a couple of months prior to biopsy and one scan showed the left brighter than the right and the next scan showed the opposite. In the end only one was positive. The psma scan also showed contradiction in pelvic and vertebrae . Because of the these PSMA's being questionable biopsy's are necessary before treatment.

My goodness that’s sounds like a lot. I’m told they can’t biopsy my node(s). Starting IMRT soon. I’ve gotten two second opinions. One said they would go head and treat the nods while the other opinion was to radiate the prostate and follow the para-aortic nodes. Guess I should have gone to medical school.

Thank you for your insight. Much appreciated. I’m 76. Diagnosed at age 70 with Gleason 6. Was on active follow up until September 2024 when path came back Gleason 9. WTF! All my care is at an NCCN/NCI designated cancer center in Ohio. Doing well on Orgovyx and starting 28 IMRT sessions soon. I’m not concerned at all about radiation to prostate but freaking out about para-aortic treatment. I wonder how many other men are out there diagnosed with Gleason 6 but harboring something much more aggressive.