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Recurrence in pelvic lymph node
I'm meeting with my radiologist this week, and would appreciate your suggestions about questions I should ask. After a prostatectomy five years ago (Gleason 8), this is my second recurrence. First recurrence was biochemical two years ago followed by a six month Lupron Depot shot and 36 rounds of radiation to the prostate bed. Now almost 5 years from diagnosis with PSA rising to 1.2, a PSMA showed a lesion in a pelvic lymph node. We are going to discuss spot radiation plus another 3-6 months of Lupron. What questions should I ask?
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@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.
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3 Reactions@barblouise This was radiation to the full pelvic region. A recent study concluded that there is a lower incidence of metastatic disease with this approach compared to spot radiation to a single lymph node. I previously had full radiation for an earlier recurrence in the prostate bed.
@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:
(3) Is your husband’s prostate cancer still hormone sensitive?
There are other considerations once those are known.
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1 ReactionWell...
He has had SRT...
If his medical team is recommending WPLN, then my experience says that is a feasible course of action.
You and your husband face decisions:
When to treat, with what, for his long?
You could go with WPLN only and now.
You could image now with PSMA. Statistically it has a 1/3 chance of locating recurrence. So, depending on your insurance and with the support of your medical team, roll the dice and see what happens.
I say depending on insurance because some are mired in old and cheaper ways and may require the old CT and MRI first before approving a PSMA. Others may approve the PSMA but if it comes back negative may have restrictions on a 2nd one. There is also the financial toxicity aspect, deductibles, co-pays, catastrophic cap..,
So, as part of the decision making process you may want to talk with your insurance.
There is data that supports SBRT as a way of delaying the need for systemic therapy. That requires something for the radiologist to aim at, thus the scan.
So, if you image now and it comes back positive, SBRT is in play. If it is negative, well, WPLN is still an option.
You may also want to discuss combining short term systemic therapy with radiation. What is short term, depends on his clinical data, GS, GG, PSADT....low to intermediate risk may point to six months. Again, a discussion with his medical team. I understand the time from his SRT to this activity may indicate a lower risk but the clinical data will determine that.
Why discuss systemic therapy? Well, even if the scan shows site(s) of activity there may be micro metastatic PCa too small to be detected. There s some data that points to a longer progression free survival when adding short term systemic therapy. Of course, SBRT only can avoid the dreaded side effects of systemic therapy. My experience with ADT has been annoying but didn't change what I did, only how I felt doing things.
Another thing to discuss with his medical team is the risk versus benefit of letting his PSA rise to say .5 where the statistical probability of locating activity doubles to 2/3. For my medical team and I we are comfortable letting my PSA rise to .5 then imaging.
So, you have choices but I am not sure you have the clinical data to make a fully informed decision, imaging being a key data piece.
What's the "right" decision? Who knows. That's a discussion for you and your husband then the medical team.
Now, what would I do? As I said, we are comfortable with the risk-benefit tradeoff of letting the PSA rise to .5, image and then decide.
Kevin
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2 Reactions@kujhawk1978
WPLN is not listed in any abbreviation I’ve ever seen. What do you mean by it? Wait for something on the pet scan to appear?
@jeffmarc
Whole pelvic Lymph Node...
It's what I did in 2017 as part of triplet therapy..
My radiologist treated the entire pelvic lymph node system with boosts to the sites identified in the C11 Choline scan and wider margins around them.
I'm not smart enough to explain how she determined the treatment plan, trusted that she knew what she was doing. She showed me the software planning program on her computer, it was better than Star Wars
The rational was given the likelihood of micro metastatic PCa, radiate them all.
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3 Reactions@kujhawk1978 Sounds a lot like current SRT: kill everything!
Phil
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1 Reaction@heavyphil
Phil
High risk PCa generally necessitates aggressive treatment decisions.
In military parlance we call it "fire for effect...!"
Kevin
@barblouise, good questions to ask and wow, you got some great, well-informed responses from the guys.
What are your next steps?
@kujhawk1978 100% !!!!!! I'm G9 and I'm out to kick its butt...