Pelvic radiation as part of SRT

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goodlife
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Date Joined May 2009
Total Posts : 2692
   Posted 3/1/2011 7:44 PM (GMT -6)   
In a recent Snuffy Myers video, he made the statement that he would advise pelvic radiation because the lymph nodes are the most logical place for the PC cells to migrate to.

I agree with his statements. However, the radiologist I talked to did not agree, and was not willing to include the pelvic lymph nodes as part of the IMRT treatment.

I am curious of all the guys here who have had SRT what their experience was with having the pelvic area included, and maybe why or why not. Particularly with a Gleason 9 and PNI, I am considering this to be a very logical inclusion in my treatment.
Goodlife
 
Age 58, PSA 4.47 Biopsy - 2/12 cores , Gleason 4 + 5 = 9
Da Vinci, Cleveland Clinic  4/14/09   Nerves spared, but carved up a little.
0/23 lymph nodes involved  pT3a NO MX
Catheter and 2 stints in ureters for 2 weeks .
Neg Margins, bladder neck negative
Living the Good Life, cancer free  6 week PSA  <.03
3 month PSA <.01 (different lab)
5 month PSA <.03 (undetectable)
6 Month PSA <.01
1 pad a day, no progress on ED.  Trimix injection
No pads, 1/1/10,  9 month PSA < .01
1 year psa (364 days) .01
15 month PSA <.01

John T
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Date Joined Nov 2008
Total Posts : 4269
   Posted 3/1/2011 8:06 PM (GMT -6)   
Goodlife,
It depends on if your pre sats indicate lymphnode PC. A high psa or a high PAP along with a G9 would be highly suspicious of lymphnode involvement. The only way to know with any degree of certainty is the Combidex MRI.
With a psa of 40 I was going to have my pelvic nodes radiated, but they came up clean on the Combidex.
With your lower psa and 0 of 23 nodes clear I think that unless you had seminal vessicle invasion your lymphnodes are probably clear. Seminal vessicle invasion follows a different path, and those nodes are not easily sampled during surgery. Also your psa has not risen in 15 months; I think if the lymphnodes were involved you would have seen a rise in 15 months.
The bottom line is that that without Combidex there is no way to be certain about lymphnode involvement and you can only make an educated guess.
JohnT
65 years old, rising psa for 10 years from 4 to 40; 12 biopsies and MRIS all negative. Oct 2009 DXed with G6 <5%. Color Doppler biopsy found 2.5 cm G4+3. Combidex clear. Seeds and IMRT, no side affects and psa .1 at 1.5 years.

Purgatory
Elite Member


Date Joined Oct 2008
Total Posts : 25393
   Posted 3/1/2011 8:22 PM (GMT -6)   
goodlife,

in my srt, i had prostate bed only, not pelvic. now that my srt has failed so fast, makes me wonder if the doctor made the wrong call or guess with me. probably know way to ever know that answer.

david
Age: 58, 56 dx, PSA: 7/07 5.8, 10/08 16.3
3rd Biopsy: 9/08 7 of 7 Positive, 40-90%, Gleason 4+3
open RP: 11/08, on catheters for 101 days
Path Rpt: Gleason 3+4, pT2c, 42g, 20% cancer, 1 pos marg
Incont & ED: None
Post Surgery PSA: 2/09 .05,5/09 .1, 6/09 .11. 8/09 .16
Post SRT PSA: 1/10 .12, 4/8 .04, 8/6 .06 11/10 Not taking it
Latest: 6 Corr Surgeries to Bladder Neck, SP Catheter since 10/1/9, SRT 39 Sess/72 gy ended 11/09, 21 Catheters, Ileal Conduit Surgery 9/23/10

Tony Crispino
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Date Joined Dec 2006
Total Posts : 8128
   Posted 3/1/2011 8:34 PM (GMT -6)   
Goodlife,
The way I heard it is that it makes no difference if there is evidence of lymph node involvement detected. It is my understanding that Dr. Myers is correct in that when there is evidence of extension beyond the prostate that it can manifest in the lymph nodes and not be detected for years. Evidence shows both biochemical improvement and survival benefit for stage 3 and 4 men.

Talk to another RO. Ask if they are familiar with WPRT with a focus on pelvic lymph nodes, let them know that the radiation centers at Harvard and Stanford, and now more, have published information on their findings. Imaging scans, while unable to detect the cancerous lymph nodes, can still help mapping the pelvic lymphatic system. This is a procedure that I did back in 2007 post prostatectomy. Dr. Myers himself had a lymphenadectomy, or a surgical removal of pelvic nodes.

This was a vital part of my follow up care after surgery. Evidence that my disease was becoming systemic was blaring from the post op pathology. I removed myself from inclusion in an early chemo study because they would not allow me that opportunity to hit the nodes. At that time I only had early evidence and Dr. Myers book. To date I am doing well and the SE's are nonexistent.

Tony
Advanced Prostate Cancer at age 44 (I am 48 now)
pT3b,N0,Mx (original PSA was 19.8) EPE, PM, SVI. Gleason 4+3=7

Treatments:
Da Vinci Surgery ~ 2/16/2007
Adjuvant Radiation Therapy ~ IMRT Completed 8/07
Adjuvant Hormone Therapy ~ 28 months on Casodex and Lupron.
Undetectable PSA.

Blog: www.caringbridge.org/visit/tonycrispino

don826
Veteran Member


Date Joined May 2008
Total Posts : 1010
   Posted 3/1/2011 8:45 PM (GMT -6)   
GL,
 
My radiation was primary not salvage but it included "pelvic" radiation due to suspicious illiac node detected on a CT scan. I have had no lasting effects from the radiation. Tony's advice to seek counsel from another Ro is good advice.
 
Best to you.
Don

Carlos
Regular Member


Date Joined Nov 2009
Total Posts : 486
   Posted 3/1/2011 8:46 PM (GMT -6)   
goodlife, 
 
Dr. Myers interest in lymph nodes may be based on recent findings by Dr. Stephen Bravo.  He uses Feraheme (off label) as a substitute for combidex to help identify lymph node involvment in PCa patients.  Old school says 90% of mets are in the bones however Dr. Myers thinks that may not be the case.
 
My radiologist did not recommend full pelvic SRT.  He says I can come back and catch the nodes later if necessary.
 
Carlos
Dx 2/2008, age 71, PSA 9.1, G8,T1c. daVinci surgery 5/2008, G8(5+3), pT2c. LFPF, good QOL. PSA <0.1 for 2 yrs. PSA rose to .2 at 30 months, SRT 12/2010.

goodlife
Veteran Member


Date Joined May 2009
Total Posts : 2692
   Posted 3/1/2011 8:47 PM (GMT -6)   
Thanks John. I know i am very early in my "delayed adjuvaent", or "early SRT" tx plan, but if I am going to do it, I want to do it right.

Obviously, we have no proof of PC in the prostate bed either but we are taking an educated guess. What Snuffy said made so much sense. Isn't it just another educated guess that if cells have migrated, that they would end up in the nodes ?

David, i am hoping to not look back and say should we have ? Not sure I can convince the rad guy, but I intend tom try.

This really is great site to be able to just ask dumb questions.
Goodlife
 
Age 58, PSA 4.47 Biopsy - 2/12 cores , Gleason 4 + 5 = 9
Da Vinci, Cleveland Clinic  4/14/09   Nerves spared, but carved up a little.
0/23 lymph nodes involved  pT3a NO MX
Catheter and 2 stints in ureters for 2 weeks .
Neg Margins, bladder neck negative
Living the Good Life, cancer free  6 week PSA  <.03
3 month PSA <.01 (different lab)
5 month PSA <.03 (undetectable)
6 Month PSA <.01
1 pad a day, no progress on ED.  Trimix injection
No pads, 1/1/10,  9 month PSA < .01
1 year psa (364 days) .01
15 month PSA <.01

Ed C. (Old67)
Veteran Member


Date Joined Jan 2009
Total Posts : 2461
   Posted 3/1/2011 9:35 PM (GMT -6)   
Goodlife,
Do you plan to do SRT even before you have evidence that you have BCR? My case is similar to yours (low pre-op PSA, only 2 nodes involved, Gleason 8) and have had undetectable PSA for 2 years. I'm interested inwhat you have to say.
Age: 67 at Dx on 12/30/08 PSA 3.8
2 cores out of 12 were positive Gleason (4+4)
Davinci surgery 2/9/09 Gleason 4+4 EPE,
Margins clear, nerve bundles removed
Prostate weighed 57 grams 10-20% involved
all PSA tests since (2, 5, 8, 11, 15, 18, 21 months) undetectable
Latest PSA test (2 years) <.008 ?

60Michael
Veteran Member


Date Joined Jan 2009
Total Posts : 2243
   Posted 3/1/2011 9:41 PM (GMT -6)   
Goodlife,
I found your question to be quite helpful as were the responses. The only dumb question is the one not asked.
Michael

dkob131
Regular Member


Date Joined Apr 2008
Total Posts : 364
   Posted 3/1/2011 9:48 PM (GMT -6)   
Goodlife:  I had "full pelvic" radiation along with the prostate bed.  I looked at it as my last chance for a cure so I was willing to go wide in the prostate area.  Obviously my Rad Doc. was the one who made the decision but he did ask my opinion, I said lets go as wide as possible.
 
So far so good, also I had my last lupron shot yesterday.  My total amount of time on Lupron will be 24 months.
 
David

Purgatory
Elite Member


Date Joined Oct 2008
Total Posts : 25393
   Posted 3/1/2011 10:28 PM (GMT -6)   
Carlos,

From all my local radiation experts, I have come to believe in the old school thinking you mentioned about going straight to the bones, as there are just too many cases where that is what happens, i.e. the hips, top of femur, etc, but the doctors I talked to all agreed that PNI can be a significant factor after surgery. I know that many surgeons, including the great Walsh disagree ,including my own surgeon about PNI, but the radiation and medical oncologist I have seen, feel that cancer cells can easily escape the prostate bed and end up just about anywhere, as the result of extensive PNI. Another one of those things thats hard for the experts to prove or disprove, you have to go back to what is happening with a particular patient in their exact situation.

David in SC
 
PS  I agree with Michael, the only dumb question(s) are the ones you don't ask, but should.  It's all an evolving learning process for all of us here.

compiler
Veteran Member


Date Joined Nov 2009
Total Posts : 7270
   Posted 3/1/2011 11:14 PM (GMT -6)   
Nothing close to a dumb question here.
 
My RO said prostate bed only in my situation.
 
I guess I'm just going to go with what he says.
 
Mel
PSA-- 3/08--2.90; 8/09--4.01; 11/09--4.19 (PSAf: 24%), PCA3 =75 .
Biopsy 11/30/09. Gleason 4+3. Stage: T1C. Current Age: 64
Surgery: Dr. Menon @Ford Hospital, 1/26/10.
Pathology Report: G 4+3. Nodes: Clear. PNI: yes. SVI: No. EPE: yes. Pos. Margin: Yes-- focal-- 1 spot .5mm. 100% continent by 3/10. ED- in progress. PSA on 3/10/10-: 0.01. PSA on 6/21/10--0.02. 9/21/10--0.06; 1/4/11-0.13 CRAP!

goodlife
Veteran Member


Date Joined May 2009
Total Posts : 2692
   Posted 3/2/2011 12:14 AM (GMT -6)   
Ed,

I didn't do "adjuvent" after surgery because of continence issues.

As I watch my PSA slowly rise, ( very slowly ), I am more convinced that my PC is still smoldering. I am hopeful that because of the slower doubling time and delayed onset, that there is still a good chance that it is still in the prostate bed, or maybe as far as the lymph nodes.

I have set .05 as my line in the sand. Again, this is kind of a delayed adjuvent step, but I am fairly certain that it is still growing and will result in BCR soon. I am taking a proactive stance and giving it a shot of radiation before it finds a home in a bone.

Will keep you informed.
Goodlife
 
Age 58, PSA 4.47 Biopsy - 2/12 cores , Gleason 4 + 5 = 9
Da Vinci, Cleveland Clinic  4/14/09   Nerves spared, but carved up a little.
0/23 lymph nodes involved  pT3a NO MX
Catheter and 2 stints in ureters for 2 weeks .
Neg Margins, bladder neck negative
Living the Good Life, cancer free  6 week PSA  <.03
3 month PSA <.01 (different lab)
5 month PSA <.03 (undetectable)
6 Month PSA <.01
1 pad a day, no progress on ED.  Trimix injection
No pads, 1/1/10,  9 month PSA < .01
1 year psa (364 days) .01
15 month PSA <.01

howard l
Regular Member


Date Joined Aug 2010
Total Posts : 152
   Posted 3/2/2011 11:35 AM (GMT -6)   
 
I had a total of 39 treatments 72y.
 
The first 32 were centered to my pelvis and pelvic lympnodes. The remaining were to the prostate bed.
So far so good 5 months post radiation my PSA has droped from 1.5 to .2
DX age 58
PSA 5.4
Gleason 5+4 = 9
City of Hope Clinical Trial (punch protocol). 6 sessions textore every 3 weeks + lupron
PSA .1
RP Oct 2009. Seminal Invasion positive margins. Lymphnods clear.
1 month PSA post op undetectable.
4 month PSA undetectable.
7 month PSA .5
Bone scan and CT scan negative. Prosticint scan mild activity in prostate bed.
EBRT May 2010. 39 sessions 70gy. On number 37.

Fairwind
Veteran Member


Date Joined Jul 2010
Total Posts : 3892
   Posted 3/2/2011 12:16 PM (GMT -6)   
My experience is virtually identical to Howard's...40 treatments, 72Gy, the last 5 or 6 focused on the prostate bed and referred to as "boost" by the technicians who were operating the machine..

My R-doc told me this..."I can't guarantee you your cancer won't come back..But I WILL guarantee you it won't come back in your pelvic area..." He bet me a Steak Dinner, my choice of restaurants..

My next crossroads, do I stay on the ADT for 2 years like he wants me to...
Age 68.
PSA age 55: 3.5, DRE normal.
age 58: 4.5
61: 5.2
64: 7.5, DRE "Abnormal"
65: 8.5, " normal", biopsy, 12 core, negative...
66 9.0 "normal", 2ed biopsy, negative, BPH, Proscar
67 4.5 DRE "normal"
68 7.0 3rd biopsy positive, 4 out of 12, G-6,7, 9
RALP Sept 3 2010, pos margin, one pos vesicle nodes neg. Post Op PSA 0.9 SRT, HT. 2-15-'11 PSA 0.0
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