I have a question concerning upcoming IGRT therapy.
My situation is briefly this. Age 65, 5' 11' 190 lbs, fairly active with 4-5 mile walks two or three times weekly plus light weight lifting two or three times per week. Non-smoker and gave up alcohol recently. I was diagnosed with prostate cancer in July 2009. PSA at the time was 11.3, DRE indicated a hard node, and biopsy of six cores showed Gleason 9 (four core samples 4, the other two 5). Stage is T2c and CAT, Bone and MRI scans did not discover any spread of the cancer beyond the prostate. I had a 4 month Lupron injection in August, followed by seed implant (palladium 103) surgery in mid-November. No lingering problems from surgery and I am about to undergo 25 sessions of IGRT radiation therapy. PSA one month after seed implant surgery was 0.57 but I am told that the number is not very meaningful at this time because of Lupron blockage.
In discussing the upcoming therapy sessions with the radiation oncologist who is supervising this stage of my treatment I inquired if there would be any point in targeting the lymph nodes as well as the prostate. He replied that the research on the benefits of this was not conclusive and that while I might consider it he did not generally recommend targeting the lymph nodes because of possible complications. I need to make a decision on this within a week or so and would appreciate any informed comments that would help my decision making process.
I believe that radiating the lymph nodes could result in lymphedema (swelling of extremities caused by fluid buildup) as a complication. I don't know much more than that, though.
A textbook I found via Google books, "Image-Guided Radiation Therapy of Prostate Cancer by Richard K. Valicenti, Adam P. Dicker, David A. Jaffray that says irradiating lymph nodes without knowing their status (in other words, prophylactic radiation) is controversial. The argument against it is just as I thought--"Physicians who do not favor prophylactic pelvic radiation in patients with prostate cancer tend to support their position by making the nihilistic argument that once the nodes are involved, regional therapy is of no benefit."
But the authors of the textbook do not agree. They go on at length, far too long to quote here directly, but in bullet form, they say:
* Regionally-spread prostate cancer is more common than some think.
* Lymph node involvement in high risk cases is underestimated nomograms indicate (i.e. more than 38% and perhaps as high as 65%.)
* A growing body of literature indicates a benefit to such pelvic lymph node radiation for patients at substantial risk of regional spread.
* There are nomograms and atlases to aid the practitioner in designing treatment fields.
* It is possible with image guided IMRT (IGRT) to target lymph nodes while largely sparing bladder, bowel, and penile structures.
The authors say there is no consensus on the matter, but it is a topic of current research by RTOG (Radiation Therapy Oncology Group, a national multi-center group funded by the National Cancer Institute).
So, I'm not sure where that leaves you. A second opinion, perhaps?
I'm interested, as always, in what lay expert az4peaks has to say about this matter.
The only imaging scan that can identify Lymphnode involvement with any degree of accurracy is the Combidex MRI, which is oly available in Holland. It is very useful in that it has a 96% accurracy in identifying any lymphnode involvement. It does have some false positives and there are ways to confirm these false positives.
If Lymphnodes are found positive they can be individually targeted with less damage than having the entire lymphatic system radiated.
If you need more information I would be more than happy to provide it.
The best Oncologists, Strum, Myers, and Scholz send their patients to Holland. The Dattoli Center has recently begun to recommend the Combidex to their high risk patients.
I had the scan last Feb. and it came up clear and I was able to avoid having my lymphnodes radiated. Other patients I have talke to have had lymphnode PC identified for targeted radiation.
psa at diagnosis 40 in nov-08
gleason 6 and 7
Treatment choice seeds and IMRT
Hi Sancarlos, - At one time, radiating Lymph nodes in high risk PCa patients was routinely done. However, after several professional Papers found NO demonstrable benefit, to justify the substantial morbidity risk involved, it generally fell from favor as a potentially beneficial procedure.
With that background, Replicants preceding Post pretty well sums up where its revived and continuing evaluation stands at the present time. - John@newPCa.org (aka) az4peaks
As we can see, those tested had at least one high risk factor, either PSA > 10, Gleason > 6 or Stage T3. My reading of the results is that approximately 20% of those tested had indications of positive (PS) lymph nodes.
That percentage is fairly high and leans me toward irradiation of the pelvic lymph nodes since I would suspect that with a Gleason 9 the percentage risk would be even higher than 20% in my case. However, I don't know what all of the "substantial" morbidity factors are. The radiation oncologist who is supervising my IGRT therapy mentioned the risk of a colon obstruction that might require surgery 6-8 years out. That does not sound so bad to me since unless my PS is cured with a Gleason 9 I could well be dead long before that.
So my question now is, what are some of the morbidity factors involved in irradiation of the pelvic lymph nodes, other than the one already mentioned.