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Salvage radiotherapy or wait and see/cyberknife??

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User
Posted 02 Jul 2024 at 11:29

My husband had robotic prostatectomy at the beginning of April. Histology post op was Gleason 4+3 with spread to two lymph nodes on left of pelvis, positive margins. 

Not entirely unexpected but his first post surgery PSA is 0.175 so above the undetectable threshold of 0.125 (maybe this was 0.0175 and 0.0125, it was all verbally delivered so I’m not sure). Urologist is referring him to oncology/radiology to discuss options. The urologist said that these are either go for salvage RT to the pelvis now or wait until PSA rises to 0.5 and then have a PET scan to see where cancer is so it can be treated in a more targeted way (cyberknife). The risk is that by that point the cancer will have spread to more than three lymph nodes and so cyberknife is not an option and he will no longer be on a curative path. Hopefully we will get more info from the radiologist but has anyone had experience of waiting for a PET scan rather than going for salvage RT straight away? 

Edited by member 02 Jul 2024 at 12:43  | Reason: Not specified

User
Posted 02 Jul 2024 at 18:20

Hello Mary,

Sorry to hear that - not what you wished for after the op.

I would be inclined to ignore what the urologist said about the oncology, and see what the oncologist says. They will probably be wondering, is this all in the prostate bed (possible due to positive margin), or are there mets in further lymph nodes?

Do you know what PSA was just before prostatectomy, i.e. how much it had changed since diagnosis? If it had gone up, then another PSMA PET scan might be useful. If not, it might not.

Given the known lymph node involvement, they might target the prostate bed and all pelvic lymph nodes. I don't know if this is done as a salvage radiotherapy, but there is a radial radiotherapy treatment which includes pelvic lymph nodes, so I don't see why not.

Wishing you all the best.

User
Posted 02 Jul 2024 at 20:31
It sounds as though they removed the lymph nodes during surgery - this is standard practice.

Definitely talk to the oncologist - they know their stuff and are the people who deal with things when surgery didn't clear it all up.

I'm on HT and just had my 28th RT session for the same reasons - compared to the surgery it's a walk in the park. Hardest part is the 45 minute drive there and back, all for 5 minutes lying in the machine.

User
Posted 02 Jul 2024 at 20:58

Hi Mary. I followed a similar path to your husband. Gleason 4+3 & 4+4, T3b, PSA 36 on diagnosis. I didn't have the benefit of a PSMA PET scan prior to surgery but the surgeon was basing on the assumption it had spread and removed a total of 34 nodes. The histology showed one of them to be positive, along with a positive margin on the prostate plus a post op PSA of 0.28. I had a PSMA PET scan when the PSA had increased to around 0.47 (applying interpolation between readings). Nothing showed up on the scan but I understand it is not always good at picking out residual cancer in the prostate bed. The Onco said I could wait a bit and have another scan when the PSA had increased but he pointed out that was a risky strategy. I opted to go ahead with SRT to the prostate bed and the surrounding surgical area. I am assuming he was referring to the area where lymph nodes had been removed. The guesswork seems to have paid off so far. Nearly two years since SRT PSA remains undetectable. On reflection the radiation to the pelvic area may have been belt and braces with just one out of 34 nodes being cancerous. In your husbands case there may well be some residual cancer in the prostate bed but with two out of six nodes positive there is also a chance there is another positive node(s) in there somewhere. The initial PSMA scan successfully flagged up two nodes but if there is another positive node in there is it still going to be detectable after the session on Bical? That's Something to ask the Onco. I wish your husband the best of luck.

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User
Posted 02 Jul 2024 at 13:32

Mary, I had recurrence 3 years after surgery and was told salvage RT was the next step. At the time ( 7 years ago) there was lots of talk about having a PSMA pet scan before agreeing to SRT. My oncologist refused the PSMA scan even though I had private medical insurance. The onco said SRT was a very educated guess based on years of experience. 

I went ahead with the SRT without HT,they thought the HT would do more damage to a urethral stricture. The PSA dropped from 0.27 to 0.08 at three months and 0.04 at 6 months. The PSA then started to rise so I assume something was left in the prostate bed but clearly there was spread outside the prostate bed area.

When my PSA reached 1.8 I had a PSMA scan and it picked up cancer in a lymph node. Last year following another rise another scan picked up cancer in another lymph node. Those lymph nodes were treated with 2 courses of SABR treatment (5 per course). Following yet another rise I had another PSMA last week and get the results on Thursday. 

The treatment to no more than 3 lymph nodes is an NHS restriction. The private sector will do more but you would need very deep pockets or medical insurance.

The level of PSA or the rate of rise of rise can make a difference to treatment options.

We know from posts on here a PSMA pet scan can see something at 0.023 or nothing at 200.

Thanks Chris 

 

User
Posted 02 Jul 2024 at 18:20

Hello Mary,

Sorry to hear that - not what you wished for after the op.

I would be inclined to ignore what the urologist said about the oncology, and see what the oncologist says. They will probably be wondering, is this all in the prostate bed (possible due to positive margin), or are there mets in further lymph nodes?

Do you know what PSA was just before prostatectomy, i.e. how much it had changed since diagnosis? If it had gone up, then another PSMA PET scan might be useful. If not, it might not.

Given the known lymph node involvement, they might target the prostate bed and all pelvic lymph nodes. I don't know if this is done as a salvage radiotherapy, but there is a radial radiotherapy treatment which includes pelvic lymph nodes, so I don't see why not.

Wishing you all the best.

User
Posted 02 Jul 2024 at 19:00

Originally Posted by: Online Community Member

Hello Mary,

Sorry to hear that - not what you wished for after the op.

I would be inclined to ignore what the urologist said about the oncology, and see what the oncologist says. They will probably be wondering, is this all in the prostate bed (possible due to positive margin), or are there mets in further lymph nodes?

Do you know what PSA was just before prostatectomy, i.e. how much it had changed since diagnosis? If it had gone up, then another PSMA PET scan might be useful. If not, it might not.

Given the known lymph node involvement, they might target the prostate bed and all pelvic lymph nodes. I don't know if this is done as a salvage radiotherapy, but there is a radial radiotherapy treatment which includes pelvic lymph nodes, so I don't see why not.

Wishing you all the best.

He had a PSMA PET scan in January which showed the two cancerous lymph nodes. Histology post surgery in April was consistent with the PET scan.

His PSA was 19 in September last year when first tested and rose slightly after that to 21 but he was put on bicalutimide from December until mid March so I don’t think it rose after that. I think you’re right though - he needs a proper conversation with oncology. The surgeon’s view on available treatments other than surgery is not always right and cyberknife may not even be an option. 

I’m trying to be upbeat but feel a bit down about it all really, even though it’s not a surprise. I had hoped he might get a reprieve for a few months! 

Your message and Chris’s input are really useful, thank you. 

User
Posted 02 Jul 2024 at 20:31
It sounds as though they removed the lymph nodes during surgery - this is standard practice.

Definitely talk to the oncologist - they know their stuff and are the people who deal with things when surgery didn't clear it all up.

I'm on HT and just had my 28th RT session for the same reasons - compared to the surgery it's a walk in the park. Hardest part is the 45 minute drive there and back, all for 5 minutes lying in the machine.

User
Posted 02 Jul 2024 at 20:56

Originally Posted by: Online Community Member
It sounds as though they removed the lymph nodes during surgery - this is standard practice.
Definitely talk to the oncologist - they know their stuff and are the people who deal with things when surgery didn't clear it all up.
I'm on HT and just had my 28th RT session for the same reasons - compared to the surgery it's a walk in the park. Hardest part is the 45 minute drive there and back, all for 5 minutes lying in the machine.

This is really reassuring, thank you and best of luck with the rest of your treatment. 

User
Posted 02 Jul 2024 at 20:58

Hi Mary. I followed a similar path to your husband. Gleason 4+3 & 4+4, T3b, PSA 36 on diagnosis. I didn't have the benefit of a PSMA PET scan prior to surgery but the surgeon was basing on the assumption it had spread and removed a total of 34 nodes. The histology showed one of them to be positive, along with a positive margin on the prostate plus a post op PSA of 0.28. I had a PSMA PET scan when the PSA had increased to around 0.47 (applying interpolation between readings). Nothing showed up on the scan but I understand it is not always good at picking out residual cancer in the prostate bed. The Onco said I could wait a bit and have another scan when the PSA had increased but he pointed out that was a risky strategy. I opted to go ahead with SRT to the prostate bed and the surrounding surgical area. I am assuming he was referring to the area where lymph nodes had been removed. The guesswork seems to have paid off so far. Nearly two years since SRT PSA remains undetectable. On reflection the radiation to the pelvic area may have been belt and braces with just one out of 34 nodes being cancerous. In your husbands case there may well be some residual cancer in the prostate bed but with two out of six nodes positive there is also a chance there is another positive node(s) in there somewhere. The initial PSMA scan successfully flagged up two nodes but if there is another positive node in there is it still going to be detectable after the session on Bical? That's Something to ask the Onco. I wish your husband the best of luck.

User
Posted 03 Jul 2024 at 23:48

Originally Posted by: Online Community Member

Hi Mary. I followed a similar path to your husband. Gleason 4+3 & 4+4, T3b, PSA 36 on diagnosis. I didn't have the benefit of a PSMA PET scan prior to surgery but the surgeon was basing on the assumption it had spread and removed a total of 34 nodes. The histology showed one of them to be positive, along with a positive margin on the prostate plus a post op PSA of 0.28. I had a PSMA PET scan when the PSA had increased to around 0.47 (applying interpolation between readings). Nothing showed up on the scan but I understand it is not always good at picking out residual cancer in the prostate bed. The Onco said I could wait a bit and have another scan when the PSA had increased but he pointed out that was a risky strategy. I opted to go ahead with SRT to the prostate bed and the surrounding surgical area. I am assuming he was referring to the area where lymph nodes had been removed. The guesswork seems to have paid off so far. Nearly two years since SRT PSA remains undetectable. On reflection the radiation to the pelvic area may have been belt and braces with just one out of 34 nodes being cancerous. In your husbands case there may well be some residual cancer in the prostate bed but with two out of six nodes positive there is also a chance there is another positive node(s) in there somewhere. The initial PSMA scan successfully flagged up two nodes but if there is another positive node in there is it still going to be detectable after the session on Bical? That's Something to ask the Onco. I wish your husband the best of luck.

Hi Chris, Thanks this is so helpful and particularly as your diagnosis is similar. I’m not sure if the bicalutimide would stop cancer in lymph nodes being detectable - in my husband’s case anyway, as the two cancerous nodes shown on the PET scan were still cancerous on removal three months later. The surgeon had expected the hormones to shrink them and leave scar tissue. A string of six nodes were taken and the other four were clear, but you are right that there could be another dodgy one somewhere. Or cancer cells in the prostate bed. Or both. The urologist said it was hard to say - guess work basically - but he seemed more concerned about lymph nodes. It will be interesting to see what the radiologist has to say about options. I agree that waiting and seeing is potentially risky - it wouldn’t be my preference. 

Thanks for your good wishes, all the best to you too and it’s great that your outcome has been positive. Positive stories are invaluable!

User
Posted 03 Jul 2024 at 23:53

Originally Posted by: Online Community Member

Mary, I had recurrence 3 years after surgery and was told salvage RT was the next step. At the time ( 7 years ago) there was lots of talk about having a PSMA pet scan before agreeing to SRT. My oncologist refused the PSMA scan even though I had private medical insurance. The onco said SRT was a very educated guess based on years of experience. 

I went ahead with the SRT without HT,they thought the HT would do more damage to a urethral stricture. The PSA dropped from 0.27 to 0.08 at three months and 0.04 at 6 months. The PSA then started to rise so I assume something was left in the prostate bed but clearly there was spread outside the prostate bed area.

When my PSA reached 1.8 I had a PSMA scan and it picked up cancer in a lymph node. Last year following another rise another scan picked up cancer in another lymph node. Those lymph nodes were treated with 2 courses of SABR treatment (5 per course). Following yet another rise I had another PSMA last week and get the results on Thursday. 

The treatment to no more than 3 lymph nodes is an NHS restriction. The private sector will do more but you would need very deep pockets or medical insurance.

The level of PSA or the rate of rise of rise can make a difference to treatment options.

We know from posts on here a PSMA pet scan can see something at 0.023 or nothing at 200.

Thanks Chris 

 

 

Best of luck for your PET scan results Chris. 

 
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