PC spread to para-aortic lymph node-where to go for 2nd opinion-Pa.

The oncologist is recommending the standard of care, there is nothing wrong with that. I personally do not always follow the standard of care and would try to get a surgery and lymph-node dissection of the affected lymph node just to try to improve the situation. However, if there is an affected lymph node, there are usually more which are not detected yet. Therefore hormone therapy will be part of your therapy.

I cannot recommend a doctor in PA for a second opinion.

G53

I think it is currently not that important whether the Gleason score is 4+3 or 4+4. The lymph node in the para-aortic area is outside the pelvis and thus it means M1. Doctors say this stage cannot be cured.

Idealy one would a get a second opinion on the CT and this doctor would say: "I do not see an affected lymph node there". There are interobserver differences! It would change everything and the doctor will claim after his surgery: you are cured now.

G53

I agree that it is important to get confirmation of the involvement of the para-aortic lymph node because this will determine, to a major extent, possible treatment(s). 

My earlier comment about radiation may have been naive, but the fact of the matter is that the cancer originated in the prostate. Did the biopsy suggest possible escape routes for metastasis?

With respect to your other question, Fox Chase claims to have expertise in prostate cancer. Certainly worth looking into that facility. 

https://www.foxchase.org/clinical-care/conditions/prostate-cancer

Further away, but Memorial Sloan Kettering in NYC is world-class: 

https://www.mskcc.org/cancer-care/types/prostate

S.

Welcome to the board. I think you are doing well in trying to obtain second opinions from due experts.

I do not know if you have already started ADT as suggested by your local oncologist but if you have done so, this will not disturb other treatments that may be recommended by other doctors at your newer facilities. The only minor effect is that ADT masks the PSA making this unreliable for judging cure or progression after involvement of a radical (surgery or radiation). ADT and chemo are in fact common therapies when the case is thought to be metastatic (not localized).

To that extent, I do understand your oncologist logic in recommending ADT because the paraaortic lymph nodes are just at the border of what one considers a “localized” case. In other words it is usually imagined as a lymph node belonging to the area classified as “far metastases”, to which cases radicals are not the prime therapy. The traditional lymph nodes judged localized are the ones at the iliac, inguinal and femoral areas.
However, I wonder why is the oncologist so sure that the lymph node identified by the CT scan is in fact affected by cancer. It could be a lymphedema case due to infection.

The Gleason rate 4 (prime number in the score 7) is usually aggressive and turns the intermediate case into high risk for metastases. This finding could lead to believe that other lymph nodes are also affected but were not detected in the CT. I would like to know what is described in the biopsy’s pathologist report. Can you share the contents here?

Treatments are chosen according to the clinical stage judged by the oncologist. He will provide it based on the results of the biopsy (number and location of positive cores), the result of a DRE and image studies. The best is a PET PSMA exam or at least a multi parametric MRI to locate the bandit.
I hope the second opinions provides with more information on his case so that you get a better a due clinical stage to advance with a definite treatment instead of a palliative approach.

Here are links that may help you understand the matters of PCa;

http://www.ccjm.org/index.php?id=105745&tx_ttnews[tt_news]=365457&cHash=b0ba623513502d3944c80bc1935e0958

Best wishes and luck.

VGama

S,

Thanks for sharing the details. I am sorry to say that the situation seams not good. According to the data, they got 5 positive cores out of 12, mostly in the left lobe. The base (just under the bladder) is affected all around. The apex seems free of trouble. The suspicious lymph node was also checked by the pathologist and found with PCa.

The above together with the Gleason score 4+3 sets your husband's case in the high risk group and the positive lymph node confirms metastatic disease. If all these are verified in your second opinion, radical approaches could be recommended but their meaning would be for lowering the burden of the cancer, debulking its bigger tumor (the whole gland). ADT and chemo would be preferred to try holding the bandit from advancing further.

In any case, the affected lymph node probably has been whole dissected for analysis freeing the condition of metastasis, if other lymph nodes are found to be negative. You could try checking the issue with a whole body PET 68Ga-PSMA exam that would be more precise in identifying PCa in other lymph nodes and soft tissues. Your oncologist response to your inquire regarding this exam got its logic because most patients do the PET with the intent of defining a treatment protocol. Rarely the exam is used as a screening tool. It is expensive (2 to 3K $) and not covered by most insurances. Other PET exams exist but they are not specific to PCa. They cover several cancers confusing the diagnosis and its results.

I would recommend you to discuss the matter in your next consultations. You can request for a doctor that would give you the referral for the test. Prepare a List of Question for your meetings and take notes (or record) of what doctors tell you. Here are ideas:

http://www.cancer.net/patient/All+About+Cancer/Newly+Diagnosed/Questions+to+Ask+the+Doctor

http://www.mayoclinic.org/diseases-conditions/prostate-cancer/basics/preparing-for-your-appointment/con-20029597

Survivors in this forum are not doctors but can help you understanding the matters based on their experiences. Just inquire and provide details for us to opinion.

Best wishes in this difficult journey.

VG

and incorpore questions like

If you get a second opinion, this doctor has to accept the fact that there is a positive lymphnode. In this case his recommendation will be about the same as your urologist provided.

I do not understand when the biopsy of the lymph node was done. If it was detected using the CT, it was detected after the prostate biopsy. Usually nobody will make a CT scan before the biopsy since you do not know yet if there is any cancer at all. So a second biopsy just to get tissue from this lymph node was required. Has that been done? I do not think so.

I recommend to make the PSMA PET/CT just to make sure that you get the right treatment done. It will show most of the metastases, if there are any, and the cancer in the prostate. It will clarify if this lymph node was properly diagnosed. It is an investment but you try to extend your life.

G53

Thanks for clarifying the presence of cancer in the lymph node. This makes the whole situation much more serious, but you already knew that. 

I have read that a fairly recent trial has shown that early taxotere (docetaxel) may be helpful when there is metastasis. But I am by no means saying that this would be advantageous for your husband. I am just suggesting to bring this up with the expert people that you are going to see.