Recurrence in pelvic lymph node

I don’t know if you’ve seen the PCRI conferences but Dr. Scholz was discussing this in the last meeting in March. You can catch it on YouTube. It’s the last hour and a half of the PCRI meeting.

Getting it zapped is the best thing to do.

As a Gleason 8, I would suspect six months of ADT would be minimum.

When you were originally treated where you put on ADT or just after The first reoccurrence?

A Gleason 8 would normally get 18 months of ADT. Was your PSA undetectable for the whole time after you had radiation?

Thanks for responding. After a biochemical recurrence one year after the prostatectomy, I received a six month Lupron shot (first time) and 36 rounds of radiation to the prostate bed (no lymph node radiation). Undetectable PSA for the next two years, until PSA
began to rise from .1 last September to 1.2 in March 2025. Received another Lupron shot on May 11, after PSMA showed uptake in a pelvic lymph node. Also, I'm concerned about a false positive since at the time I was recovering from a UTI. I will check out the PCIR meeting with Dr. Sholz.

A couple of things to look into and ask your doctor about:

1. How aggressive is the recurrence - that is, what is the SUVmax score of the cancer the PSMA PET scan found in comparison to the (background) SUVmax scores of your blood, liver, and parotid glands? That information will help guide you as to what to do next.

2. Also, note that just as prostate cancer is very heterogeneous when it comes to PIRADS and Gleason scores, prostate cancer is very heterogeneous when it comes to expressing PSMA. Some prostate cancers express PSMA, and some might not (even within the same body). They say that ~15% of prostate cancers do not express PSMA so, a PSMA PET scan will miss them. If there’s any concern that the PSMA PET scan might be missing some cancers, then ask your doctor about adding one of the non-PSMA PET scans (like Axumin).

I went 3 1/2 years after my prostatectomy before my PSA started rising. I had Salvage radiation like you and my PSA started rising 2 1/2 years later. At that point, I was put on Lupron, And since I had 2 reoccurrence, there was no end date. After 2 1/2 years My PSA started rising again, and I went on abiraterone which kept me under control for 2 1/2 more years. Switched to Darolutamide And for 18 months, I’ve been undetectable after 15 years of PC. What i’m getting at is that you are in a situation where the correct drugs can keep you going for decades.

Yes, a UTI can raise your PSA. Get tested again find out what’s going on, Do not wait three months for a test get one done within a month or two at the most. Because you are on Lupron your PSA should drop to undetectable again. Actually, you should probably be on monthly PSA tests, I was put on monthly tests after my second reoccurrence.as have most of the people I know.

Jeff, thanks for monitoring these forums and responding with detailed helpful information. Your experience and understanding of this disease and treatment are appreciated.

Jeff, thank you for the good advice. I have lots to discuss with my radiologist this week. Congratulations on your good results.

My meeting this week with my radiation oncologist resulted in a decision to begin 25 SBRT treatments to my full pelvis rather than 3 treatments to a recurrence in a single lymph node. A recent clinical trial with two control groups showed a statistically significant result with the full pelvic radiation showing no distant metastases. So I will begin 5 weeks of radiation on June 10.

Hey pal, personally believe you are making the right decision - where there’s smoke there’s fire.
But didn’t you already have 36 IMRT sessions of SRT the first go round? They probably only did the prostate bed.
So how can you have even more radiation after such a short interval? And many sessions of SBRT? That’s usually high dose (cyberknife, etc). Reserved for spot radiation….I’m just a bit confused. Thanks,
Phil

Phil,
I had the 36 rounds to the prostate bed plus a six-month Lupron Depot shot after a biochemical recurrence in 2023. My initial diagnosis was July 2020, Gleason 8 followed by a radical prostatectomy in January 2021. We decided against spot radiation to the single lymph node based on the clinical trial below:

Salvage metastasis-directed therapy versus elective nodal radiotherapy for oligorecurrent nodal prostate cancer metastases (PEACE V-STORM): a phase 2, open-label, randomised controlled trial
Piet Ost, Shankar Siva, Sigmund Brabrand, Piet Dirix, Nick Liefhooghe, François-Xavier Otte, Alfonso Gomez-turriaga, Wouter Everaerts, Mohamed Shelan, Antonio Conde-Moreno, Fernando López Campos, Alexandros Papachristofilou, Matthias Guckenberger, Marta Scorsetti, Almudena Zapatero, Ana-Elena Villafranca turre, Clara Eito, Felipe Couñago, Paolo Muto, Wim Duthoy, Nicolas Mach, Valérie Fonteyne, Daniel Moon, Kristian Thon, Carole Mercier, Vérane Achard, Karin Stellamans, Els Goetghebeur, Dries Reynders, Thomas Zilli
Summary
Background Various locoregional treatments exist for PET-CT-detected pelvic nodal oligorecurrences in patients with Lanc prostate cancer. We aimed to assess whether elective nodal radiotherapy (ENRT) to the pelvis would be superior to metastasis-directed therapy (MDT).
Pub
Ma htt
S1
Methods PEACE V-STORM is a phase 2, open-label, randomised, controlled trial conducted in 21 hospitals in Australia, Belgium, Italy, Norway, Spain, and Switzerland. Eligible participants were aged 18 years or older, with WHO performance status 0-1 and a histologically confirmed initial diagnosis of adenocarcinoma of the prostate, with
D
a PET-detected pelvic nodal oligorecurrence (up to five nodes) following radical local treatment. Patients were randomly assigned (1:1) to MDT or ENRT. Randomisation was done online by minimisation with randomisation factor 0•80 and was stratified by type of PET tracer (choline vs prostate-specific membrane antigen) and type of MDT used (salvage lymph node dissection vs stereotactic body radiotherapy or simultaneous integrated boost). Participants and researchers were not masked to treatment assignment. Patients in the MDT group had salvage lymph node dissection or stereotactic body radiotherapy (30 Gy in three fractions every other day), with 6 months of androgen
in the ENDT aroun received a 45 Gy dose in 25 tractions to the pelvis in the pelvis in favor of more aggressive treatment.

OK, I see that the study was either treatment specifically to the metastasis in the nodes with 3 sessions of SBRT - the therapy that Dr Scholtz claims is better than full salvage therapy…OR…25 sessions of IMRT to the pelvic region and nodes, which is the treatment I just completed at Sloan…
My question was: how can you have even more radiation since you’ve already HAD salvage therapy?; but I think it’s because you only got it to the prostate BED initially and now the radiation will be directed to the pelvic lymph NODES and surrounding area…I think!!
Again, I would do this more comprehensive treatment (25 sessions with ADT) than whack a mole with SBRT. It just makes more sense to me although others may disagree.
Phil