What's the Big Deal with Radiating Lymph Nodes

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Kark60
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Date Joined Jun 2008
Total Posts : 91
   Posted 5/12/2011 4:13 PM (GMT -6)   
I recently completed SRT and, because I had negative surgical margins with BCR, the RO included the pelvic lymph nodes in the radiation field.

I also know including the nodes seems a bit controversial. My question... why not radiate the nodes just to be "safe"?

Any thoughts??
Diagnosed at 47 (currently 50). Pre-surgery PSA: 13.7 Pre-surgery Gleason: 4+3=7. CT Scan, Bone Scan, PET Scan: Clear. LRP 5/28/08. Left nerve bundle removed. POST-SURGERY: Gleason: 4+3=7; 10% of prostate all quadrants involved; EPE left base & apex; extensive PNI present. Bladder neck, lymphvasular space, seminal vesicles, 17 examined lymph nodes, and all surgical margins FREE of tumor. T3a. Four-week post-surgical PSA = 0.1; Seven-week = .01; 10/08 – 4/10 PSA= 0.0; 4/10=0.1; 5/10 & 8/10 = 0.1; 9/10=.15; Prostiscint = negative; 12/10=0.3. 12/15/10 began 70.2 grays SRT and finished 2/10/11. Post-SRT PSA 5/10/11 = <0.1.

Geebra
Regular Member


Date Joined May 2009
Total Posts : 476
   Posted 5/12/2011 4:38 PM (GMT -6)   
There are side effects of radiating a wider field. Colitis being the more common one. I had pelvic radiation done and it was not too bad.
Father died from poorly differentiated PCa @ 78 - normal PSA and DRE
5 biopsies over 4 years negative while PSA going from 3.8 to 28
Dx Nov 2007, age 46, PSA 29, Gleason 4+4=8
Decided to participate in clinical trial at Duke - 6 rounds of chemo (Taxotere + Avastin)
PSA prior to treatment 1/8/2008 is 33.90, bounced on 1/31/2008 to 38.20, and down at the end of the treatment (4/24/2008) to 20.60
RRP at Duke (Dr. Moul) on 6/16/2008, Gleason downgraded 4+3=7, T3a N0MX, focal extraprostatic extension, two small positive margins
PSA undetectable for 8 months, then 2/6/2009 0.10, 4/26/2009 0.17, 5/22/2009 0.20, 6/11/2009 0.27
ADT (ongoing, duration TBD): Lupron started 6/22/2009
Salvage IMRT to prostate bed and pelvis - 72gy over 40 treatments finished 10/21/2009
PSA 6/25/2009 0.1, T=516, 7/23/2009 <0.05, T<10, 10/21/2009 <0.05, T<10

Fairwind
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Date Joined Jul 2010
Total Posts : 3631
   Posted 5/12/2011 4:39 PM (GMT -6)   
I'm not aware of any controversy..I just finished SRT which included a broad pelvic field. I'm sure MANY lymph nodes were in that field..An interesting side-bar, at the end of my 40 treatments, the last 6 were called "Boost" where they focused the beam tightly on my prostate bed instead of the larger area that received the first 34 treatments..
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

reachout
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Date Joined May 2009
Total Posts : 725
   Posted 5/12/2011 4:40 PM (GMT -6)   
So, do we not need those lymph nodes, or are there consequences to not having them?
Age: 66
PSA: 7 tests over 2 years bounced around from 2.6 to 5.6
Biopsy 8 of 12 positive, Gleason 3+4, T2a
DaVinci August 2009, pathology Gleason 4+3, neg margins, T2c
Continent right away, ED
Viagra, Cialis did't work, Trimix works well
Post-surgery PSA:
3, month: undetectable <.1; 6 month: undetectable <.014 (ultrasensitive); 9, 12, 15 month: undetectable <.1; 18 month detectable .05

Fairwind
Veteran Member


Date Joined Jul 2010
Total Posts : 3631
   Posted 5/12/2011 4:53 PM (GMT -6)   
I believe the nodes survive but with diminished function...RO's get paid very well to avoid damaging healthy tissue too much...

goodlife
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Date Joined May 2009
Total Posts : 2691
   Posted 5/12/2011 5:19 PM (GMT -6)   
Snuffy Myers believes all SRT should include pelvic area. He says that it is the first place PC will spread.

My first visits with RO found him relyctant to do it. If/ when I do SRT, I will insist on the wide field SRT.

reachout
Veteran Member


Date Joined May 2009
Total Posts : 725
   Posted 5/12/2011 5:27 PM (GMT -6)   
goodlife, I don't think I would ever agree to radiation in places where my RO was reluctant to do it. I'd find a new RO who wasn't reluctant.
Age: 66
PSA: 7 tests over 2 years bounced around from 2.6 to 5.6
Biopsy 8 of 12 positive, Gleason 3+4, T2a
DaVinci August 2009, pathology Gleason 4+3, neg margins, T2c
Continent right away, ED
Viagra, Cialis did't work, Trimix works well
Post-surgery PSA:
3, month: undetectable <.1; 6 month: undetectable <.014 (ultrasensitive); 9, 12, 15 month: undetectable <.1; 18 month detectable .05

Tony Crispino
Veteran Member


Date Joined Dec 2006
Total Posts : 8128
   Posted 5/12/2011 6:20 PM (GMT -6)   
Kark,
It was REALLY controversial when I agreed to the protocol. Today, I think it's only controversial when you meet an RO that isn't current. In the last two years we have seen many studies disprove the theory that if it's in the nodes it won't help treating with local therapies. To the contrary we have are learning that surgeons should remove as many as safely possible in men who showed intermediate and high risk characteristics during the biopsy. Same goes with the radiation protocols. The next debate on the horizon is whether it's better to do it surgically or with radiation. Some theories I've read say surgical removal will have the lesser lymph node related issues because the surgeon can resection critical pathways. Additionally irradiating a wider area can have other repercussions. Others say it is still safe to do so with radiation.

@ Fairwind,
I do remember that my first 28 sessions were WPRT. The final ten were directed at the prostate bed.

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

goodlife
Veteran Member


Date Joined May 2009
Total Posts : 2691
   Posted 5/12/2011 6:21 PM (GMT -6)   
Reach,

In the end, does it make any difference ? My lymph nodes are going to get radiated.

Actually i have a little insurance issue. So i kind of have to "force" my RO to do it my way.

If i am going to have radiation, i am not goig to go half way.
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

reachout
Veteran Member


Date Joined May 2009
Total Posts : 725
   Posted 5/12/2011 6:53 PM (GMT -6)   
Goodlife, I'm not questioning your decision to have the lymph nodes radiated. My point is, if the RO is hesitant to do so, maybe it's because he's not experienced or has had bad results laying out the area to be radiated, and is afraid of SEs. So I thought it might be better to find an RO who has confidence he can define the field to be radiated including lymph nodes.

I understand your insurance issues but you could at least ask your RO specifically as to why he would not prefer to do it. If it's an insurance issue or he doesn't think it's necessary that's one thing, and you could press the issue. But if he admits he's not good at that specific procedure I would run and find another guy regardless of insurance.

Purgatory
Elite Member


Date Joined Oct 2008
Total Posts : 25364
   Posted 5/12/2011 7:10 PM (GMT -6)   
Goodlife, can I safely assume you have never had full radiation before? To do all that you think you should do, how many gys of radiation are you talking about? Once you get past 70 gys total, you can quickly cross the line into the danger zone. I had 72 this time, and my RO had considered extending it to 78. The 72 did so much damage to me, I can't even imagine if she had gone ahead with the extra 6 gys.

david in sc
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 margin
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, 2/11 1.24, 4/11 3.81
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 9/10

compiler
Veteran Member


Date Joined Nov 2009
Total Posts : 7197
   Posted 5/12/2011 7:58 PM (GMT -6)   
My RO said he would only radiate the prostate bed. I relied on his expertise.
 
He also said 68.4 total Gy. in 38 sessions.
 
When I suggested maybe one more session, he said no because even one additional session can have a huge difference regarding SE.
 
I think some of you are playing doctor, telling the RO what to do!
 
Mel

goodlife
Veteran Member


Date Joined May 2009
Total Posts : 2691
   Posted 5/12/2011 8:04 PM (GMT -6)   
David,

My RO says 66 to 68. Wide field radiation is fairly common, and the technique is well established.

By spreading the radiation over a wider area, I may actually get less in any particular area.

I will consult with Cleveland Clinic radiation guys before I make final determination.

Goodlife
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

Tony Crispino
Veteran Member


Date Joined Dec 2006
Total Posts : 8128
   Posted 5/12/2011 8:15 PM (GMT -6)   
Mel,
Each case is different. Every doctor will, or at least should, start from that plane. But using a line from my captain ~ 50% of all doctors are below the acceptance of knowledge that they should be at. I for one would always stand by your decision to rely on what you were told. I think it's incumbent on the medical community to make sure THEY are sure of what they tell patients. There are reasons to still be in the 2006 mode that told me when I did it that what I did was aggressive. I think 2011 has made a difference in this area and now most I talk to now say it was appropriate (little credit to me because I was relying the expertise). You should re-ask these questions to your RO with each weekly visit you should be having.

Our friend Mr. zufus is right ~ question everything...even if it means over and over...

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

compiler
Veteran Member


Date Joined Nov 2009
Total Posts : 7197
   Posted 5/12/2011 8:21 PM (GMT -6)   
I might also add that I can only HOPE my RO is very competent.
 
He was quite personable and seemed competent and confident.
 
I saw him twice for consultations well before I needed SRT (but it was also apparent that my PSA was rising and SRT was in my future).
 
I knew for a fact that my surgeon, Dr. Menon, was one of the best. I could not really find a good way to determine how good the RO was. So, I relied on my gut instincts and word of mouth. I DID KNOW that the machinery is state of the art.
 
Mel

goodlife
Veteran Member


Date Joined May 2009
Total Posts : 2691
   Posted 5/12/2011 8:39 PM (GMT -6)   
MeL,

I do appreciate what you are saying, but to date, I am not convinced that all the fine doctors I have consulted and had involved in my case truly have all the right answers, and have given me the best advice for me. I am one patient out of a thousand to them. The one minute they spend scanning my chart while they stand outside the exam room door doesn't compare to the time I have spent going over my records, reading on the Internet, and investigating treatment options.

I know, I know, they have years of education and read journals. Most of them don't know about Snuffy Myers, Fred Lee, Dr. Scholz, etc. Doesn't mean they are really up to snuff on Gleason 9 patients. They usually give me some statement that translates to we don't really know.

This is my body, my PC, and my life. I had a good shot with the surgeon who bought me at least 2 years cancer free. If I had done what my first doctor said, I would not have been so lucky. Now I am looking at radiation most likely. One shot. So do I say "ok mr. Doctor, whatever you decide is what I will do.". Or, do I spend hours doing research and say to the doctor, I believe that wide field radiation makes the most sense for a Gleason 9."

I don't look at it as playing doctor, but rather being the person with the most vested interest in getting the best and most thorough treatment available. If I am wrong, then, I may die a few months early, but at least I know I did everything possible. If the doctor is wrong, well, I was a Gleason 9 anyway.

Sorry about the rant, but I really think we put way too much trust in the medical profession. They just can't take care of every patient they have the way they should.

Goodlife

compiler
Veteran Member


Date Joined Nov 2009
Total Posts : 7197
   Posted 5/12/2011 8:52 PM (GMT -6)   
Goodlife:
 
You may be right. It's hard to say.
 
I have relied on my reading, knowledge, and the doctors. Still, in retrospect, maybe all the wrong decisions were made. To wit:
 
After surgery, even with the bad pathology, I did not do Adjuvent Radiation on the advice of my Ford doctors. Given the SE, I certainly was most pleased not to argue with them.
 
When the PC came back, I did SRT but without ADT. Again, my expert at Umich (Dr. Hussein a top-notch doctor, said I should just do the SRT, no scans needed -- NOTHING else needed). We will see how that works out.
 
Based on my readings, it may be that the experts are starting to lean towards ART and if not then HT with the SRT (or just before it).
 
In fact, when I see Dr. Scholz, he may well advise that I do HT, regardless of my post-SRT PSA.
 
Goodlife, this disease does not seem to have a straighforward path regarding treatments!
 
Mel

Purgatory
Elite Member


Date Joined Oct 2008
Total Posts : 25364
   Posted 5/12/2011 9:04 PM (GMT -6)   
goodlife, 66-68 should be good and safe for your goals, sounds like a good plan
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 margin
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, 2/11 1.24, 4/11 3.81
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 9/10

Northfoot
Regular Member


Date Joined Mar 2011
Total Posts : 81
   Posted 5/12/2011 10:39 PM (GMT -6)   
Compiler,
My history is like yours. I had RP at Johns Hopkins. G9 with positive margins. My doctor, Misop Han, said wait until rise in psa before radiation. That went 2 and a half years. His paper, with others in June 2008 said HT added to SRT offered little to no additional benefit. So did the RO where I live. So I had SRT without hormones. I think of it as Dr. Han first said, in that you treat it sequentially. I hope that is right, but like all of us, only time will tell.
Bill

logoslidat
Veteran Member


Date Joined Sep 2009
Total Posts : 5655
   Posted 5/12/2011 11:37 PM (GMT -6)   
TC you really seem up on this lymph node thing , so I started googling to ck it out. I found one study that said for every lymph node dissected, your chance of BCR is decreased by 3% have you seen that one. I had a 4 1/2 hour prostectemy, few seconds for me, and wondered why, never asked doctor. When pathology came back I knew why, 27 lymph nodes dissected all clean, probably done by his staff, there were five in the operating room with him plus 2 anethesiologist. Hey Im not complaining the doc didn,t do it all, its a teaching hospital, knew that up front. When your flying 50% of the controllers are trainees doing live OJT, with someone like me responsible ready to step in. I know mets could have been released before surgery but.......
I was concerned about effect of lymphnodes loss in a negative way,re immune system ,dont know, will stick head in the sand on that one. I like the firewall tho, which is what my local urologist called it. Suffered all the SE's pratt drain in for a month, lymphoceles around for 3 mos before resolving itself. But worth it. Having said that, psa anxiety building, due in June, postponed till July, Chapel hill, than Big Apple for the month of June.
Diagnosed 8/14/09 psa 8.1 66,now 67
2cores 70%, rest 6-7 < 5%
gleason 3+ 3, up to 3+4 @ the dub
RPP U of Wash, Bruce Dalkin,
pathology 4+3, tertiary5, 2 foci
extensive pni, prostate confined,27 nodes removed -, svi - margins -
99%continent@ cath removal. 1% incont@gaspass,sneeze,cough 18 mos, squirt @ running. psa std test reported on paper as 0.0 as of 12/14/10 ed improving

English Alf
Veteran Member


Date Joined Oct 2009
Total Posts : 2211
   Posted 5/13/2011 2:32 AM (GMT -6)   
There are about 500 lymph nodes/glands in you body with clusters in the groin, armpits, neck, and abdomen. So removing a few from the pelvic region should not affect the total lymph system than much.

There is a fairly good article about lymph nodes/glands on wiki at:
en.wikipedia.org/wiki/Lymph_node

If you radiate a lymph node it helps by damaging any cancer that may be in it, but it also damages the lymph gland, however RT will not sever any of the lymph ducts, so any lymph fluid circulating in the area simply has to find an alternative route to the next nearest node/gland. If it doesn't then you get problems with swelling.
If you surgically remove a lymph node, then you can leave the severed lymph ducts open and the lymph fluid can leak all over the place. If you seal the lymph ducts then you can get problems with swelling.
Thus RT may result in fewer side effects.

Lymph nodes are part of the body's immune system and on the basis that cancer is a problem for the body the lymph nodes nearest to a cancer site are often the first place to which a cancer may spread. Hence prostate cancer can spread to the lymph nodes in the groin/pelvic region (and breast cancer can sprerad to the nodes in the armpits/chest)

Crucial to the use of RT on the lymph nodes is accurate scanning to locate and thus target them accurately (Accurate targetting is of course the key with all RT!)

Alf

Carlos
Regular Member


Date Joined Nov 2009
Total Posts : 486
   Posted 5/13/2011 11:17 AM (GMT -6)   
At least we have a current phase III clinical trial that may provide some answers.  Currently, the RTOG is conducting a phase III, 3-arm, study (RTOG 0534) to examine the potential benefit of adding 4~6 months of androgen ablation therapy to salvage RT and to address a potential role of treating pelvic lymph nodes. 
 
Carlos

Dx 2/2008, at age 71, PSA 9.1, G8, T1c
daVinci surgery 5/2008, G8(5+3), pT2c
BCR 2 1/2 yrs after surgery
IMRT, 68.4 Gy, 12/2010 - 2/2011
PSA 0.07 three months after IMRT

logoslidat
Veteran Member


Date Joined Sep 2009
Total Posts : 5655
   Posted 5/13/2011 5:32 PM (GMT -6)   
English Alf, I hear that, at least I did after shaking sand from ears, thanks
Diagnosed 8/14/09 psa 8.1 66,now 67
2cores 70%, rest 6-7 < 5%
gleason 3+ 3, up to 3+4 @ the dub
RPP U of Wash, Bruce Dalkin,
pathology 4+3, tertiary5, 2 foci
extensive pni, prostate confined,27 nodes removed -, svi - margins -
99%continent@ cath removal. 1% incont@gaspass,sneeze,cough 18 mos, squirt @ running. psa std test reported on paper as 0.0 as of 12/14/10 ed improving
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