I guess I'm confused by the need for such an intrusive diagnostic procedure. First of all, lymphadenectomy is not very good at finding all the cancer in the lymph nodes, while it can cause some very serious side effects, like lymphocele and lymphedema:/pcnrv.blogspot.com/2017/01/were-still-not-very-good-at-finding.html
What is usually done instead is to use a mathematical formula or nomogram to predict the likelihood that the lymph nodes have been invaded by cancer and can be cured with RP+ePLND or RT+whole pelvic radiation. They use a different formula and cut-off depending on whether you will be having a prostatectomy or radiation. The cut-off is higher for radiation because radiation treats a margin outside of the prostate anyway, even with whole pelvic radiation.
A good nomogram for surgery is the one below with a cut-off of 7%. To use it, print it out (enlarged if possible). Use a straightedge to find the number of points (on top) associated with each risk factor. For example, you are Gleason grade group 3, so you get 55 points for that, stage T2 gets you 20 points, PSA of 22 gets you 45 points, etc. Add up all your points to come up with "Total points." Then on the bottom, find the "risk of lymph node involvement (LNI)" that corresponds to your total points. You will see that it is above 7% for you.www.europeanurology.com/cms/attachment/2090693045/2075851227
The "Roach formula," used to determine whether whole pelvic radiation is called for, is easier to calculate. It's based on a simple formula:
Probability of LNI = (2/3 x PSA) + (Gleason score - 6) x 10
If that is higher than 15%, whole pelvic radiation should be offered. So, for you it is (2/3x22)+(7-6)x10=14.7+10= 24.7%. Whole pelvic radiation would be appropriate for you based on this.
So, no matter which curative therapy (assuming distant metastases have been ruled out by a bone scan) you choose to pursue, your pelvic lymph nodes ought to be treated in addition to your prostate.
Having spared you an unnecessary invasive diagnostic procedure, your next decision is surgery or radiation. Your NCCN risk classification is "high risk" because your PSA exceeds 20. Based on that, aggressive radiation will probably have a better outcome for you. By "aggressive," I mean the combination of external beam radiation to the whole pelvis, coupled with a brachytherapy boost to the prostate, and adjuvant hormone therapy for 1-2 years with it. Radiation has the advantage that it treats the full area, while surgery would only treat the capsule plus any of the lymph nodes they manage to find and remove. With your high volume disease, there is a high likelihood that it has already spread outside of the capsule, and you would need adjuvant radiation anyway. Here's a nomogram (easy to fill out) that shows the probability that it is outside of the prostate:/www.mskcc.org/nomograms/prostate/pre-op
That means, too, that they would most likely NOT be able to spare your neurovascular bundles, leaving you with a high probability of impotence and incontinence.
There are increased risks of urinary side effects with aggressive radiation, but they are of a different kind - urinary retention. The whole pelvic radiation carries risk of irritating the bowels, especially if you lack visceral fat (this is one time where it's better to be fat). The relative performance of aggressive radiation in high risk men is discussed in this article:/pcnrv.blogspot.com/2017/02/for-very-high-risk-patients-ebrt-bt-is.html
To get this kind of therapy, you will have to seek out an expert in brachytherapy who has experience with this sort of thing. There are two kinds of brachytherapy, high-dose-rate (temporary implants) and low-dose-rate (seeds). Either is fine in the hands of expert practitioners.
Allen - not an MD
•PSA=7.3, prostate volume=55cc, 8/17 cores G6 5-35% involvement
•SBRT 9 yr onc. results
•SBRT 7 yr QOL results
•treated 10/2010 at age 57 at UCLA,PSA now: 0.1,no lasting urinary, rectal or sexual SEsmy PC blog
Post Edited (Tall Allen) : 5/22/2017 11:00:16 AM (GMT-6)