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Recurrence in pelvic lymph node
Prostate Cancer | Last Active: 18 hours ago | Replies (26)Comment receiving replies
Hi Guys, I am the wife of Joe, who has biochemical recurrence after 7 years of initial treatment: RP and prostate bed radiation: 7 weeks I think.
OK, so now PSA is detectable at 0.149 (no ADT after initial treatment.
My question: must make a choice here:
1)Kaiser, our provider, wants to radiate the pelvic bed, whether or not PSMA PET, shows any positivity.
2) But, Dr. Scholz, our second opinion go-to: says that's crazy, just do spot radiation as the PSA rises, and you'll be fine -- actually go for a cure. Radiation is the only way to try for a cure in either case.
My concern: salvage radiation is most affective when started at very low PSA: 0.2 TO 0,5 at the very highest and that's a stretch. I think I've read every study by now. BUT PSMA PET most likely will be negative at these early levels. Urologists are unanimous that you start salvage radiation anyway. Most likely PSMAPET is not able to pick up micrometastasis.
So, here's my dilemma, which road does Joe take? I'm inclined to go for broke and radiate the pelvic bed (it's been 7 yrs since the prostate), if we keep waiting around to hopefully find all the lesions and radiate them, we could be missing lots of microscopic metastasis.
Replies to "@heavyphil Hi Guys, I am the wife of Joe, who has biochemical recurrence after 7 years..."
@barblouise
@heavyphil really hit the high point on this one.
You say he had seven weeks of radiation after the prostatectomy. That’s radiation to the prostate bed, Which is considered the lifetime radiation that could be done to that area.
I’m also with Kaiser and had the prostate bed radiated 12 years ago, It worked for 2 1/2 years, but then the cancer came back. In my case, it was because I have BRCA2, which sort of prevents my cancer from being stopped. They have zapped a metastasis on my spine that occurred eight years after the radiation. They know I cannot have my prostate bed radiated again.
You need to contact your doctor at Kaiser and find out about the previous seven weeks of radiation. Was it done at a different facility. Are they unaware that the prostate bed was already radiated. If that is true, then what Scholz Says is really your only option.
You do need a PSMA pet scan, but it may be too early to find anything with your PSA so low. That is what Scholz says to do. Do the PET scan find the metastasis and zap it/them with SBRT radiation.
It seems you really only have one choice if radiation really was done in the past.
While chemo, and Pluvicto are options with advanced cases you need to have multiple metastasis that are visible before they would consider it.
@barblouise Other considerations:
(1) If PSMA PET shows nothing, will they consider using and older PET scan - Axumin (F18-Fluciclovine) or C11 Choline? Typically PSMA PET sensitivity far exceeds Axumin or C11 Choline PET CTs. However, about 15% of prostate cancers do not express PSMA (or very little PSMA). (This is referred to as being PSMA-negative or PSMA-naive.) So PSMA PET scans won’t even see them even though you know something is wrong due to the rising PSA. (Mayo Clinic sometimes uses the older C11 Choline PET scan for this purpose.)
(2) Dr. Kwon (of Mayo Clinic) indicates that only 1/3 of men who have recurrence following prostatectomy have recurrence only in the prostate bed, and that they should not get salvage radiation there unless they’re absolutely certain of the location of recurrence. He says to first confirm where the recurrence is. (See Dr. Kwon’s presentation about recurrence: https://youtu.be/Q2joD360_pI)
(3) Is your husband’s prostate cancer still hormone sensitive?
There are other considerations once those are known.
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@barblouise if Joe already had prostate bed radiation after his prostatectomy I don’t think he can have full pelvic radiation again. However, he can have his pelvic lymph nodes radiated since they did not target them previously.
I agree with all your points about spot treating with SBRT and also the management of micro metastases and possibly letting them spread even further. It is a real dilemma for sure!!
It does seem however, that at this point, he is going to need some form of ADT because let’s face it : His cancer has come back after surgery and radiation so you would have to think it’s pretty strong, right?
I think you need more than just two opinions on this, and although it might be a hassle, in the long run it will give you the best chance for making the best possible decision.
Phil