New Member, a Scot living in France, appreciates our English, such as it is.

I just want to introduce myself and say that I have found the information on this forum immensely helpful. I am a 61yr old Scot living in France, recently diagnosed:

PSA: 22

Biopsy: 25 of 35 positive.

Gleason 4+3

Grade T2c (minimum)

I had bone and CT scan last week

Abdomino Pelvic scan due next week

Lymphanadectomy scheduled 1st June.

I am really pleased there are so many guys on here willing to share their experiences. It helps me a lot. Particularly living in France where though I speak reasonable french, my medical/technical french is not so good. My Urologist, luckily, speaks good english.

Thanks again for sharing your experiences.

Gave your thread a title. It contains a mild joke. Let me know if it is a poor match for your sense of humor and I will adjust it. -- PeterDisAbelard

Post Edited By Moderator (PeterDisAbelard.) : 5/22/2017 7:59:10 AM (GMT-6)

John said...
Lymphanadectomy scheduled 1st June.

Is this a prostate surgery together with a lymphadenectomy?

George

John,

please get a second opinion or better yet, a new urologist immediately. A lymph node dissection is a full operation and not necessary before treating the prostate.

The result of the lymph node dissection is either the tumor has spread, i.e. they found affected lymph nodes, or not. With a PSA of 22 and a Gleaseon 4+3 it is likely that there are affected lymph nodes.

In case of no affected lymph nodes they will recommend to remove the prostate. Otherwise they will tell you the cancer is so advanced removing the prostate is not worthwhile. They will then recommend palliative hormone therapy and expect you to continue to live for about five years.

However, removing the prostate – and thus most of the cancer - is beneficial in any case. See e.g. this study:
Survival benefit of radical prostatectomy in lymph node-positive patients with prostate cancer

So the usual therapy is to both remove the prostate and do a lymph node dissection in one operation. Then you will know if there are affected lymph nodes and can try to fight these after the operation, e.g. with radiation.

George

Thanks for your concern and for the timely advice. I will certainly investigate further. I think from what I have heard from others that have been treated here, that Gemlin is correct and that the PLND is often performed as part of the diagnostic procedure.

I'll keep you informed

John

Hello John ! just a friendly welcome from another PCa brother !! David

George,

You seem a bit fixated on surgery as opposed to radiation. I found a study that talks about Sentinel Lymph Node Dissection (removal and examination of a few most-likely nodes) to try to identify patients who require additional pelvic radiation and longer periods of ADT as an adjuct to anticipated external beam radiation.

/www.ncbi.nlm.nih.gov/pubmed/28068243

You are right that extended Pelvic Lymph Node Dissection (ePLND) is generally done intraoperatively (during radical prostatectomy) because it is something of a major operation for a purely diagnostic procedure, but examination of a limited number of nodes is sometimes done prior to radiation therapy to identify patients who will need more aggressive treatments.

Bonjour John,
Je suis Canadian and many, many generations ago, my ancestors came from England/Scotland/Ireland.

Welcome to the group, but sorry you had to join. I've never read of anyone having a lymphadectomy before RP or primary RT. The European guidelines George gave you are a good reference.

I wish you the best with the upcoming scan.

Hi Johninfrance,

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.

Yes, I've read it, and I even referenced it in the article about detection. What you may have overlooked were the two previous words "Radioisotope-guided SLND." They were trying out an experimental detection technique using Indium 111 ProstaScint (Capromab Pendetide), a PSMA ligand, along with a 3D-gamma ray detector (SPECT) to find the unique lymph node drainage pattern for each patient intra-operatively. It seemed to work very well, at least better than standard, but this was a clinical trial, and it is not in widespread use anywhere else.

Even using Indocyanine Green to find pelvic lymph nodes is not a widespread technique, and is of questionable accuracy. Most urologists just remove whatever they can visually find according to where they expect the nodes to be. But everyone has a unique anatomy and drainage pattern, and nodes in fat pads are almost impossible to locate. While the radioactive tracer guidance techniques are clearly superior (and Combidex may be even better), we really don't know what their true sensitivity is -- how many positive LNs are missed by any of the techniques? It now seems that the historic pelvic treatment area (ePLND or WPRT) is not wide enough. Treating the pelvic LN area is still controversial. There is a big RCT in the works, but results are years away.

Well George, I have never seen anyone post a picture before, but I've heard they're worth a thousand words, and that one certainly speaks for itself! Not for the queasy.
Oh and least I forget, a warm welcome John. I hope your scans are very positive (meaning negative for mets) and you can avoid what is in that image George posted!
Beth

Hello again, sorry I have been absent from here for a while. I took a short vacation with my daughter and granddaughter.

Thanks for all of the information, which I am finding very interesting.

I took day from our vacation to drive back for the abdomeno-pelvic scan. Good news! No anomalies found.

I am visiting the hospital today and hope to have a talk with my urologist about the whole lymph node thing. If nothing else, just so that I can understand better what is going on.

I will keep you informed of progress and thank you all again for your messages of welcome and for taking the time to keep me informed.

John said...
He believes that a prostatectomy will not cure me

So he will do no prostatectomy but a lymph node dissection to find out how many lymph nodes are affected?

I think the text you cited relates to a lymph node dissection during a prostatectomy.

George

Gemlin,

I see no reason not to combine prostate surgery and lymph node dissection now. I expect after the scans and the LND the recommendation of the doctor will be hormone therapy.

George