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Old 12-28-2010, 01:48 PM   #1
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after RP, cancer in lymph nodes 4+5

A good friend had a radical prostatectomy in early December after a PSA of 10
and a biopsy revealing malignant cells in both lobes. The urologist removed a string of eleven lymph nodes during the procedure. One of the nodes had malignant cells and a Gleason rating of 4+5 was assigned. He has started hormone therapy. A bone scan is scheduled for mid-January and external beam radiation is scheduled for early March. He has been told in the past that his colitis condition may prevent radiation treatment or may result in a colostomy.

My friend can go anywhere for treatment. He is currently being treated at a lesser known regional cancer center with no proton facility and no particular reputation in molecular imaging. Certain cancer centers have proton therapy facilities and others have strong reputations in molecular imaging. Molecular imaging can aid in the detection of metastatized cancer, reducing the volume that proton therapy, for example, would need to target.

What is the best course for my friend? Should he seek treatment from a major center with proton facilities and leadership in fields like molecular imaging? Is proton therapy recommended after the prostate is removed? Does proton therapy off an opportunity to avoid irradiation of the colon that could impact his colitis condition? How is it determined whether salvage proton therapy is appropriate?

Thank you for any ideas!

 
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Old 12-28-2010, 11:33 PM   #2
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Re: after RP, cancer in lymph nodes 4+5

Kennard, can you please tell me if your friend has been having colitis flare ups lately? How bad is his colitis? I'm asking because my partner, Irv, has a history of ulcerative colitis but hasn't had an attack in several years. However, he has been having some trouble with his bowels over the past week and is unsure whether it is from his colitis or from the surgery. He just got back to work and I hope he isn't putting too much strain on his sytem too soon. He's a painter.

He had his RP on November 9th. His Gleason is 3+4 and he had extracapsular extension, a unifocal positive margin and seminal vesicle involvement. His staging is T3b and Adjuvant Radiation is the recommendation. He has his radiation oncology consultation on January 5th but we don't know yet if his colitis will be a problem.

That's why I'd really appreciate your reply telling me the severity of your friend's colitis. Does he have regular flare-ups? How is he now? etc.

Thank you.
Rhonda

 
Old 12-29-2010, 02:28 AM   #3
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Re: after RP, cancer in lymph nodes 4+5

Hi Ken,

The very first thing your friend should do is to consult an oncologist specialized in prostate cancer treatment. You say he is willing to travel anywhere so, go and shop for the best.

All types of radiation to the pelvic area will affect colitis because of its proximity to the rectum. A radiotherapists specialized in the treatment of prostate cancer could give you detailed information on the typical planned targets (studies) that would lessen complications with the colitis and at the same time assure the highest dose and best irradiation of the areas of possible metastases. Radiation technique and the equipment delivering the Gys are also important to be discussed as it varies in regards to their side effects. Surely you would not expect a non-bias answer to all forms of RT from a center caring for proton therapy alone.
If your friend’s case has been classified as Systemic, ADT may be the best treatment to control the cancer, independently of the radiation therapy.

PET scan (molecular imaging) is good to locate metastases but at the pelvic area it can raise false positives, particularly at the lymph nodes. A combination of PET with CT improves the findings.

There is a site called “Brotherhood of the Balloon” at protonbob with descriptive cases of pa-tients that have undergone proton therapy, where, probably you may find cases of guys with similar conditions of your friend.

I wish you get the best advice. Have a good New Year.
Baptista

 
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Old 12-29-2010, 01:39 PM   #4
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Re: after RP, cancer in lymph nodes 4+5

Batista,

Thank you for your comments. I will let you know what my friend decides on for radiotheraphy.

Allan

 
Old 12-30-2010, 10:32 AM   #5
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Re: after RP, cancer in lymph nodes 4+5

....Just feeling a little embarrassed and want to apologize for my self centredness here. Of course I'm so focussed on Irv but I have to stop myself and realize that we are all here for the same reason and similar concerns. Kennard, I'm so sorry for turning your concerns back onto Irv. You brought up an issue that related to a concern that I've been focused on for awhile without any answer but, clearly, I should have restrained myself and posted a new thread. Please accept my apology. Happy New Year to all here on this forum as well. We should all experience good news and good health in 2011.

 
Old 12-30-2010, 12:07 PM   #6
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Re: after RP, cancer in lymph nodes 4+5

Please don't apologize; it is I who should be apologizing for taking so long to get back to you about the impact of colitis on the treatment decision. I was awaiting further feedback from my friend and his advisors. One of those advisors spoke with colleagues at a major comprehensive cancer center this morning and he reported:

"I talked to one of the prostate specialists here this morning, and though I would pass along his suggestions, especially with respect to the colitis.

"He suggested that the most important consideration would be whether the colitis is active right now. When he has had patients come to him for treatment that have a history of ulcerative colitis, he gets them worked up (colonoscopy) to see if it is active. If it is inactive, then he proceeds as if the patient did not have colitis (as far as how much dose and how large a volume to treat). If it is active, then that would probably affect what he would decide to treat (or whether he would treat). He was actually not convinced (told him Gleason score and nodal status) that radiation was absolutely necessary after surgery and hormonal therapy. Your physicians obviously have more information, so I would take that with a grain of salt (if you trust the doctors there, they have the full story). However, he was extremely emphatic about being worked up for current status of the colitis."

I hope that this helps.

I will follow up with you.

Good luck to your friend, Irv.

 
Old 12-30-2010, 12:18 PM   #7
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Re: after RP, cancer in lymph nodes 4+5

Please do not apologize. I owe you the apology for the delay in responding. I was awaiting a response from one of my friend's advisors. The response came in this morning. This advisor, a Professor in a related field, spoke with two radiology oncologists at his hospital, a major comprehensive cancer center in the U.S. He passed on the following:

"I talked to one of the prostate specialists here this morning, and thought I would pass along his suggestions, especially with respect to the colitis.

"He suggested that the most important consideration would be whether the colitis is active right now. When he has had patients come to him for treatment that have a history of ulcerative colitis, he gets them worked up (colonoscopy) to see if it is active. If it is inactive, then he proceeds as if the patient did not have colitis (as far as how much dose and how large a volume to treat). If it is active, then that would probably affect what he would decide to treat (or whether he would treat). He was actually not convinced (told him Gleason score and nodal status) that radiation was absolutely necessary after surgery and hormonal therapy. Your physicians obviously have more information, so I would take that with a grain of salt (if you trust the doctors there, they have the full story). However, he was extremely emphatic about being worked up for current status of the colitis."

I will follow up with you.

Good luck to Irv.

Allan

 
Old 02-02-2011, 01:43 PM   #8
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Re: after RP, cancer in lymph nodes 4+5

Hi kennard,

I've seen earlier responses and won't go over those points again, but there are a few more points for your friend to consider, especially about proton radiation. I'll respond in green to your first post on your thread.


Quote:
Originally Posted by kennard View Post
A good friend had a radical prostatectomy in early December after a PSA of 10
and a biopsy revealing malignant cells in both lobes. The urologist removed a string of eleven lymph nodes during the procedure. One of the nodes had malignant cells and a Gleason rating of 4+5 was assigned. He has started hormone therapy. A bone scan is scheduled for mid-January and external beam radiation is scheduled for early March. He has been told in the past that his colitis condition may prevent radiation treatment or may result in a colostomy.

...What is the best course for my friend? Should he seek treatment from a major center with proton facilities and leadership in fields like molecular imaging? Is proton therapy recommended after the prostate is removed? Does proton therapy off an opportunity to avoid irradiation of the colon that could impact his colitis condition? How is it determined whether salvage proton therapy is appropriate?

Thank you for any ideas!
A key supposed advantage of proton therapy is its supposed capability to target a cancer precisely with little radiation to surrounding areas. In fire arms terms, it is supposed to be like a sniper rifle with a scope. On the other hand, when there is no longer a precise target to hit since the prostate has been removed, the radiation strategy is usually to blanket an area of likely spread of the cancer beyond the old prostate area (the prostate bed). Ultra precision is actually a disadvantage in executing that strategy, it seems to me.

There is another disadvantage to proton beam therapy, though it is a theoretical concern. Proton beams get diverted a bit when they go through materials of different densities. The concern is that that throws off the aim. By this time we should have known whether that theoretical concern translated into a real treatment concern for patients. Unfortunately, after repeatedly publishing their success rates for several years, the Loma Linda facility - the most experienced by far - ceased publishing new success statistics. That has many of us concerned. It's in sharp contrast to continued publication of impressive results for seeds and combos with IMRT and/or hormonal blockade, and also fairly impressive results for IMRT.

I've read that proton facilities often couple with IMRT radiation when spread beyond the prostate is suspected. IMRT, and even, arguably, the older 3D conformal beam therapy, make better shotguns when there is not a specific target, as I understand it.

Advanced imaging makes sense to me. In addition to the normally targeted area, the imaging might detect one or two stray metastases that are more distant. Those could be hit with spot radiation, perhaps including proton beam. There is a new imaging capability in Florida that appears to be superior to the excellent Combidex imaging that was formerly available in the Netherlands.

That's my two cents. I hope it helps.

Take care,

Jim

 
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