Question on lymph node treatment

Although I had surgery and radiation, my lymph nodes were left untouched at surgery due to lack of evidence of spread, and when I asked my RO if he was going to also radiate them he said no, because even if they were diseased he wouldn't get enough radiation to them with the IMRT to do much good.

So I asked my urologist the other day, if scans show that the cancer has spread to a few nearby lymph nodes, I understand they might be surgically removed or radiated with SRBT.

I realize this oligometastatic whack a mole treatment is controversial and not curative. But my question is about what he said about why he would not recommend it. He said removing the lymph nodes can have bad side effects like anemia. So, can loss of just two or three lymph nodes make someone anemic? Those of you who have had lymph nodes removed, how have you done without them?

JNF said...
Removing pelvic lymph nodes is tricky. How do you really know which ones to remove and many are very difficult to find.

A very common side effect is lymphadema ...

Thanks, that helps. As to which ones to remove, the idea would be that a sensitive PET scans lights up the ones affected and if it just a few they could be treated. But those SEs are a concern, combined of course with the problem that others will also light up soon enough. Funny thing, though, my urologist mentioned SEs with lymp node removal, and blood sugar SEs if he had put me on the metformin that I asked for but he refused, but he seemed perfectly fine with giving me Lupron if and when I needed it. No SE issues there LOL

Reachout-

I hope your RO isn't correct about the nodes!

My SRT included my nodes and from what I found out radiating the regional nodes can be successful.

Also, if your regional nodes have PCa, you are not necessarily oligometastatic.

Bobby Mac

Reachout,

Due to my original high risk dx my pelvic nodes were included in the IMRT portion of my radiation treatment. It didn't cause me any abnormal side effects.

Since your nodes haven't been radiated, you still have those options with IMRT and/or SBRT. I would be inclined to get another radiation assessment before I made any decisions.

I had a confirmed positive pelvic lymph node at initial diagnosis. My surgeon removed several nodes during my RP, and I've never had a problem related to them being gone. It certainly can cause lymphedema, and has for many, but for all of those folks there are ones like me who had no problem. Unfortunately, like everything with this disease you just never know. Maybe you'll have the SEs, maybe you won't.

As far as radiating the pelvic lymph nodes, since I had the confirmed positive node, my doctors strongly recommended whole pelvis radiation to hit any nodes that could also be positive but unknown. In addition, with my request following the advice from Tall Allen regarding findings about broadening the area historically treated, my RO agreed to treat nodes even outside of the typical area. In my discussion with my RO, he told me that the radiation was certainly strong enough to kill any cancer in the nodes that were treated.

I got 82 Gy to the prostate bed. I don't know why he said what he did, but I had no evidence of lymph node involvement. So he probably thought that it wasn't worth giving me a lower dose to the lymph nodes and risking damage. In retrospect I wish he would've done it

If you are going after all the lymph nodes IMRT is what is used to cover the broader area. If you are targeting lymph nodes or small areas IMRT can be used, but SBRT is often used to reduce the number of fractions by increasing the dose for each fraction. You wouldn't do this for the broad coverage for all the nodes.

So you have to decide. Do you only radiate the ones positively identified and then keep doing that in the future as others show positive? That is the whack-a-mole syndrome and would probably use SBRT. Or do you radiate all of them to clean up what doesn't yet show on a scan, but is very likely there? That would use the IMRT method.

reachout said...
Those of you who have had lymph nodes removed, how have you done without them?

I had three lymph nodes radiated with CyberKnife - no side effects. The PSA value went down by 50%. I guess there are still mets left, but I just wanted to get rid of the ones I saw with imaging, hoping it may extend survival.

I know of a patient who had an extended lymph node dissection. Several affected lymph nodes were found so the surgeons recommended pelvic radiation after the operation. The RO recommended adjuvant ADT for that. The patient refused since no ADT was the reason why he did the eLND in the first place. However, he now has side effects from surgery and radiation and his PSA is rising slowly.

George

Tall Allen said...
You certainly can have salvage radiation to the entire lymph node field. One HW member, Bob, had exactly that done. His doctor (Dattoli) used many very small doses to achieve a much higher total dose. Unfortunately in his case, it had already spread to bone. I don't know if that is better than conventional IMRT fractionation (1.8 Gy) to a total dose of 50-55 Gy, or SBRT to a total dose of 25 Gy in 5 fractions. All seem to have low acute toxicity.

To be more precise, my RO didn't say he couldn't radiate the lymph node field, he said he didn't think he could deliver enough radiation to the entire field to make much of a difference, while keeping toxicities low. Keep in mind that at the time I had no evidence of lymph node involvement. Had there been such evidence, he may have upped the toxicity risk. Although, looking back, I wish he had been more aggressive, I think he and I made the right call with the info we had at the time. And this guy was no slouch, he was the head of radiation oncology at one of the most recognizable national hospitals.

Tall Allen said...

So it behooves the patient to treat the entire (extended) area. Here's an article suggesting that it is an effective approach wen any cancerous LNs have been detected...

Interesting. But I also note that the article says "None of these studies reported the toxicity of the salvage treatment, but with improved external beam radiation techniques and scrupulous image guidance, toxicity has been improving." I am not sure what "has been improving means," but I suspect that with the technology available five years ago when I had SRT the concern about toxicity of wide field radiation was more significant than it might be today. At least at all but the most dedicated centers.

Tall Allen said...
As for "whack-a-mole," there is no evidence that it makes a significant difference. There has been only one pilot trial ever that had a control group, which you can read about here:

/pcnrv.blogspot.com/2017/12/metastasis-directed-therapy-for.html

Why would you risk playing whack-a-mole when there is no evidence of benefit, and it might preclude further treatment?

Fair question. I don't understand why it would preclude further treatment, since the only further treatment I can think of is ADT, and that is not precluded, just delayed. But as far as benefit, yes, no benefit at the 80% confidence level, but maybe I am willing to roll the dice betting that there really is a benefit ("Median ADT-free survival was 8 months longer in the MDT group") it's just that the N was not high enough for statistical significance.

But your point is well taken. I note from the paper that "We recently saw that there is a clinical trial at Johns Hopkins to detect and treat oligometastases using the more accurate PSMA PET scan. While outcomes may be improved with a more accurate scan, it will undoubtedly eliminate many patients from the oligometastatic pool of patients."

I applied for that trial but was told that I am too early. But I may re apply if I reach psa of 1.0

Tall Allen said...
I never heard of anemia from PLN treatment -- a good RO will scrupulously limit dose to bones.

That's good to know. That was a comment from my urologist, who is not a RO.

As another Radboud veteran, I agree (of course, to do otherwise would be foolhardy) with the Tall One. As per signature, IMRT to diagnosed lymph nodes seems to have done nothing, or possibly delayed further developments.

I just noted this important comment by Dr Strum on the paper that TA linked, concerning whack a mole:

"I have 34 years experience with ADT and IAD (intermittent androgen deprivation) and in the context of PSA recurrence (PSAR) I cam convinced that a number of men will go into complete remission (CR) and be able to have years of no treatment without recurrent PC. In our patients that received ADT using 3 drugs (called ADT3), and in whom ADT was used in men with PSAR, the time off ADT or IAD (intermittent androgen deprivation) exceeded a median time of 5 years. And in men receiving ADT2 using an LHRH-A + an anti-androgen the median time off was 24 months. So I am not sure that the goal of men NOT needing to go on ADT is such an important goal, especially if the assessment of nodal disease might be inaccurate due to the limitations of choline PET/CT."

That's the first time I've heard of the possibility of a complete remission possibility with ADT, or a median of as long as 5 years off intermittent ADT. Seems that all I've read is that ADT fails within 1 or 2 years then you try something else but in another couple of years you are screwed. My own urologist, for example, would only commit to my probably surviving at least 5 years with ADT.

I do wish there was more of a clear consensus as to what the prognosis is for ADT. Maybe there is and I haven't found it. Knowing that would make an ADT decision much easier for those of us facing that possibility.

Also, I don't recall much discussion of ADT vs age. There is a huge difference in a 50 year old contemplating a life on ADT with all its side effects, vs a 70 year old. The 50 year old has to trade off the potential for another 30 or 40 years of survivability, against side effects. The 70 year old only has a 10 or 20 year horizon, which he may survive anyway whether on ADT or not.

JNF said...
Each man is different and there just aren't hard and fast rules that a given treatment will always achieve or fail to achieve the same result in all men.

Yes I understand. Given that ADT has been in use for 65 years, though, you would think there would be lots of studies out there that characterized its effectiveness for different gleasons, ages, etc.

Reachout, did I understand this correctly: your uro only commits that you will survive for only 5 years on ADT?then what? I am in the same boat and don’t know what the heck should I do. I heard it takes 8 years to Mets and may be another 5 on other things. The median is 13 years. Why is he only committing to 5 years?