lymph node involvement advise

BERTB

I'm halfway through radiation treatments,22 down 22 to go for a total of 79.2 gys. just to the prostate and surrounding vesicles. Originally, I thought I was also getting radiation to the surrounding lymph nodes. The rad. onc. indicated in my case (gleason 9/10) there is only a 7% chance of lymph node involvement and doesn't want to subject to the side effects of addition treatment. She mentioned if I want to treat the pelvic area, now is the time to do it. Does anyone have thoughts in this area. Should I now have radiation to the pelvic area or continue what the rad onc. suggest. From what I've been reading, you only have one chance at radiation and you can't go back. I'm a newbe here trying to understand all this in a short amount of time. Thanks so much for this site.
Additonal data:
age 61
dx April 2011
PSA = 5.4
Stage: T1c
CT & bone scan clear
MRI clear
treatment: radiation and H/T Lupron/Casadox.
thanks again.

VascodaGama

Your doctor is the best to consult and clarify your doubts
BertB

One concern in your case is the Gleason score of 9-10 that it is the highest in aggressivity and probable risk for recurrence.
T1c patients have high profile for localized/contained cancer, and that may have been the judgement done by the radiologist (she) who decided on the protocol and dose planning. 80 Greys in 44 sections is common and a “modern” way in radiotherapy. The dosage is voluminous but the time of tissue exposure to radiation is short (many fractions) which will lead to lessen damage of surrounding organs. Being the prostate and SV the only targets (no lymph nodes), the areas to be irradiated are smaller therefore, risks and side effects (gastrointestinal and genitourinary toxicity) can be minimized.

Radiation on top of radiation is not a good thing and may be risky, but directional (spotted) radiation is done to areas not receiving the initial full dose, but still within the isodose areas. Your radiologist is the best to answer your question and concerns.

In ASTRO’s Journal there are several articles on studies which reinforce their guidelines for radiotherapy. At their site’s search engine I typed this sentence “imrt for lymph nodes in prostate cancer treatment”, and got many articles that may be of interest to you.
http://www.redjournal.org/search/quick

One of the articles dated Nov2010, may help you in understanding the protocol but you have to purchase the full text. It is related to radiation protocols in Intermediate and High Risk cases, and it addresses the controversy whether or not irradiating the lymph nodes, gives better results;

The title is this;
“Pelvic Nodal Radiotherapy in Patients With Unfavorable Intermediate and High-Risk Prostate Cancer: Evidence, Rationale, and Future Directions”

The abstract writes this;

“Over the past 15 years, there have been three major advances in the use of external beam radiotherapy in the management of men with clinically localized prostate cancer. They include: (1) image guided (IG) three-dimensional conformal/intensity modulated radiotherapy; (2) radiation dose escalation; and (3) androgen deprivation therapy. To date only the last of these three advances have been shown to improve overall survival. The presence of occult pelvic nodal involvement could explain the failure of increased conformality and dose escalation to prolong survival, because the men who appear to be at the greatest risk of death from clinically localized prostate cancer are those who are likely to have lymph node metastases.”

In my view this could be exactly your case. The improvement provided by the hormonal portion in the treatment may be addressing (attacking) any metastatic occult cancer at the lymph nodes.
The only minus is that HT is palliative not curative, whether radiation can be curative.

Hope the above helps in your decisions.

I wish you a continuous good treatment.

VGama

BERTB

VascodaGama said:

Your doctor is the best to consult and clarify your doubts
BertB

One concern in your case is the Gleason score of 9-10 that it is the highest in aggressivity and probable risk for recurrence.
T1c patients have high profile for localized/contained cancer, and that may have been the judgement done by the radiologist (she) who decided on the protocol and dose planning. 80 Greys in 44 sections is common and a “modern” way in radiotherapy. The dosage is voluminous but the time of tissue exposure to radiation is short (many fractions) which will lead to lessen damage of surrounding organs. Being the prostate and SV the only targets (no lymph nodes), the areas to be irradiated are smaller therefore, risks and side effects (gastrointestinal and genitourinary toxicity) can be minimized.

Radiation on top of radiation is not a good thing and may be risky, but directional (spotted) radiation is done to areas not receiving the initial full dose, but still within the isodose areas. Your radiologist is the best to answer your question and concerns.

In ASTRO’s Journal there are several articles on studies which reinforce their guidelines for radiotherapy. At their site’s search engine I typed this sentence “imrt for lymph nodes in prostate cancer treatment”, and got many articles that may be of interest to you.
http://www.redjournal.org/search/quick

One of the articles dated Nov2010, may help you in understanding the protocol but you have to purchase the full text. It is related to radiation protocols in Intermediate and High Risk cases, and it addresses the controversy whether or not irradiating the lymph nodes, gives better results;

The title is this;
“Pelvic Nodal Radiotherapy in Patients With Unfavorable Intermediate and High-Risk Prostate Cancer: Evidence, Rationale, and Future Directions”

The abstract writes this;

“Over the past 15 years, there have been three major advances in the use of external beam radiotherapy in the management of men with clinically localized prostate cancer. They include: (1) image guided (IG) three-dimensional conformal/intensity modulated radiotherapy; (2) radiation dose escalation; and (3) androgen deprivation therapy. To date only the last of these three advances have been shown to improve overall survival. The presence of occult pelvic nodal involvement could explain the failure of increased conformality and dose escalation to prolong survival, because the men who appear to be at the greatest risk of death from clinically localized prostate cancer are those who are likely to have lymph node metastases.”

In my view this could be exactly your case. The improvement provided by the hormonal portion in the treatment may be addressing (attacking) any metastatic occult cancer at the lymph nodes.
The only minus is that HT is palliative not curative, whether radiation can be curative.

Hope the above helps in your decisions.

I wish you a continuous good treatment.

VGama

VGama
Thank you Sir!!!

robert1

One Chance
Dear BERTB:

You are absolutely right that there will be one chance to get this right the first time. The odds are good that your nodes are clear, but this is of such importance that I would almost certainly get a second opinion from another world class Radiation Oncologist.

Best wishes,

robert1