You are right that I do not see any value in treating individual lymph nodes. But I do think there's value in treating the entire pelvic LN area. The reason is that lymph is a fluid, fortunately a slow moving one, so if cancer is present in the LNs you can see, it is undoubtedly present in those you can't see as well.
Surgically, what Kwon is proposing to you is called an "extended pelvic lymph node dissection" or ePLND. What they do at Mayo is they use a fluorescent dye to help find all the LNs. This is very difficult. Unlike blood vessels, which branch predictably, lymph vessels network haphazardly. They try to get 20+ LNs out of the area, but they can't know if they got them all. As you know the dangers are lymphocele or lymphedema.
Using radiation, they can target the whole area and possibly get more of them. But there are toxicity dangers as well. The problem is that the small bowel comes into that area and the radiation can get pretty high for some of it. Bowel (enteric) tissue often has a late response to radiation that may not show up for years. A lot depends on your individual anatomy and visceral fat. This should be decided by an RO after a very
careful look at your pelvic CT.
Neither surgery nor radiation will be useful if the cancer is already systemic because they provide local control only. But, so far, your evidence from the PET scans is that it is still locoregional.
There is no evidence that spot radiation of individual LNs is a good idea; it may accomplish nothing while raising toxicity risk. Accumulating evidence of doing that showed that within 5 years more mets popped up elsewhere in 85% of men who tried it. There is no evidence that it even slows it down. As you see from your own experience (which is typical) LN-only progression proceeds very slowly at first anyway, taking years for new detectable mets to appear.
I liken this to picking mushrooms from under an oak tree. The mushroom is only the visible portion of the fungus whose mycelium extends down to the roots of the tree and throughout the soil. You can pick as many mushrooms as you like, but they will just keep coming and will have no impact on the fungus's growth. To get rid of it, you have to treat the whole area systemically with a fungicide. You seem to have an opportunity now to get rid of it, but I don't think it serves any purpose to treat only what you can see.
Allen - not an MD
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