Lymph nodes removal

agt · New User Joined: 04 Nov 2009 Posts: 5 Location: Australia

Hi,

My father had seen two urologist to help him make an inform decision regarding his treatment.
They both suggested robotic laparoscopy, one with lymph nodes removal, the other one dont want to remove the lymph nodes.

Do you have any thoughts on what are the advantages/disadvantages of lymph nodes removal?
The urologist that doesnt want to remove the lymph said that there would be no point/benefit of removing the lymph nodes.

I think by removing the nodes could prevent it from getting a recurrent from the cancer, but is there any side effect with the lymph removed??

Thank you for your help.
_________________
My dad, 72y.o Gleason 4+3; still deciding on treatment.

johnT · Senior User Joined: 27 Apr 2009 Posts: 173

What was your dad's PSA? Lymphnodes are removed during surgery to see if the cancer has spread and not for any treatment reason. If his psa is high, indicating lymphnode involvement a Combidex MRI can identify it better than surgery, but it's only done in Holland,
I must really question the recommendation that a 72 year old man undergo surgery; radiation is usually recommended for anyone over 70. I would definately get another opinion.
JohnT
_________________
psa at diagnosis 40 in nov-08
gleason 6 and 7
Treatment choice seeds and IMRT

agt · New User Joined: 04 Nov 2009 Posts: 5 Location: Australia

Hi JohnT,

Thank you for the reply.
His psa in sept 09 is 19.1 ug/L. ( I am not sure how to convert this to the measurement that most people here use but his normal range shouldnt be more that 4ug/L i think).

He has been taking Proscar (Finasteride) since 2004 for BPH, then in 2006 replaced (by his -other- urologist) with Avodart (Dutasteride) 0.5mg/L.
One of the urologist mentioned that dutasteride could masked the PSA so its become lower that it supposed to be.

He has been given the option of radiotherapy, but thinking that there wont be anything beyond that, with surgery it seems that there will be another treatment (radiotherapy, etc) that we can do, in the case of re occurant.
Considering that the surgery would only be a keyhole, he seems to be more willing to do this, rather that radiotherapy.
But again, he has to see a consultant physician before he has the green light to go for surgery.
Well he is still not 100% sure.

Back to the lymph node topic, if there is no Combidex MRI (i still have to ask the doctors here), would there be more beneficial if it be removed?
_________________
My dad, 72y.o Gleason 4+3; still deciding on treatment.

johnT · Senior User Joined: 27 Apr 2009 Posts: 173

I would have a serious talk with his doctors. A psa of 19 is high and if he is on Adovart or Proscar his psa would be normally in the 30's. This is indicative of lympnode involvement. Removal of the lymphnodes in surgery would be done to confirm that. Then he would be radiated anyway.
You need a 2nd opinion from a specialist in prostate cancer, hopefully an oncologist that could futher evaluate your father. A recommendation for surgery on a high PSA 72 year old doesn't make a lot of sense.
JohnT
_________________
psa at diagnosis 40 in nov-08
gleason 6 and 7
Treatment choice seeds and IMRT

srtimmons · Posted: Fri Nov 06, 2009 9:04 pm Post subject: lymph nodes

I think lymph nodes normally should be removed and checked during a radical prostatectomy.

First of all, the body has plenty of lymph nodes, so a few missing will not make a difference. Second, a common spread from the prostate is to the adjacent lymph nodes. Thus, if removed, they can be checked for cancer spread. This is the best was to see if the disease has enterd the lymphatic system.

I can't understand why a surgeon would not remove the ones nearby and have a pathologist look at them. What I have learned is that there is a wide range of beliefs and treatments offered by the medical community.

My advice is to take an aggressive path. Leave nothing to chance.
_________________
Age 58
Dx 6/15/2009; PSA 7.1; 7/12 cores positive; Gleason 6 (3+3) and 7 (3+4); PNI observed. Bone Scan and CT scan negative. Robotic RP 7/20/2009

Path report 8/11/2009 - clean margins, negative lymph nodes, negative seminal vesicles, Gleason 3+4, Stage T2c; 15% of prostate involved; NoMx.

Post-RRP PSA: 9/09: .006

johnT · Senior User Joined: 27 Apr 2009 Posts: 173

Removal of lymphnodes is not that simple. There are permanent complications that can arise, such as swelling and weakness in the removal area. The lymphatic system is also complex and PC can start in any lymphnode, not just the ones in the pelvic area, although that is the most common area. If there is seminal vessel involvement there is usually lymph node involvement that starts in lymphnodes that are normally not sampled during surgery.
Pathologists often miss PC in removed lymph nodes because it may be microscopic.
Only if lymphnode involvement is suspected, usually by a very high psa, should nodes be removed for sampling. Nodes can also be biopsied with a needle biopsy, but the best method is the Combidex MRI using nano iron oxide particles.
JT
_________________
psa at diagnosis 40 in nov-08
gleason 6 and 7
Treatment choice seeds and IMRT

agt · New User Joined: 04 Nov 2009 Posts: 5 Location: Australia

Thank you for the replies.

Dear johnT:
He already has his second opinion, perhaps I could ask him a third opinion from a radiation oncologist?
Both of the urologist have also suggested radiotherapy besides surgery, but it was my father who wasnt very keen on the idea of the radiotherapy.
Therefore they both still also willing to do the laparoscopy (robotic or conventional, but not the open surgery) but with condition that he would be seen by a consultant physician before proceeding.

In your opinion, what would be the normal/good maximum age to have the surgery? Sorry to ask a lot of question to you, but when you said that he is too old to have surgery, should we only considering the age, or also the condition of each person?

Dear srtimmons:
We have the same thinking, that why would leave a lymph nodes behind if there is apossibilities of spreading in there?
On Monday, i will check this one with the surgeon that wouldnt remove this.
However, we have learnt as johnT said that removing lymph nodes would also have its own risk.
But it maybe an advantage if they are able to check under microscope(?) for any microscopic residual...?

Still not too sure...

Please let me know if you have more information on this.

I havent post information about his CT and MRI, they both are clear.
_________________
My dad, 72y.o Gleason 4+3; still deciding on treatment.

johnT · Senior User Joined: 27 Apr 2009 Posts: 173

Patrick Walsh, the most noted prostate surgeon in the US, says that 70 should be the cut off for surgery. Most doctors agree with this as the healing problems and complications are much greater in anyone over 70.
Older patients tolorate radiation much better than surgery.
JT
_________________
psa at diagnosis 40 in nov-08
gleason 6 and 7
Treatment choice seeds and IMRT

Jean222 · Senior User Joined: 14 Dec 2008 Posts: 249

Hi Agt,

In your second post, you state that the surgery will 'only be a keyhole'.

Please do not let that phrase persuade your father to have surgery.

The size if the incision isn't the factor here, as they blow up your abdomen with gas and cut away.

There is just as much cutting inside, as there is with open surgery.

It's still a very major operation, difficult to recover from and has very serious side effects for the patient.

If your father has ANY other medical issues, it should not be done after the age of 70.

Even if he is in perfect health, it's probably not a great idea to have a major operation as the recovery can be very difficult and there are a lot of risks.

Please remember, it's not the size of the outside incision but what they've done to his inside that counts.

Radiation is probably his best treatment choice, as John has pointed out.

Best wishes,

Jean

Replicant · Moderator Joined: 01 Nov 2006 Posts: 741

I agree with Jean. It's still major surgery. Don't let "keyhole" fool you. You get several such holes, and one of mine is a good deal bigger than a keyhole, I assure you. And like Jean said, all the cutting is still done on the inside. Sometimes the surgery isn't as easy as we hope, as we see from a posting today by Joel's wife. Like Joel, I was in the operating room for about 8 hours, and the next several days were rough. Some men have terrible problems with incontinence afterwards, even if things seem to go well.

Radiation treatments are very easy in comparison. There are still possible side effects from radiation, but usually not that bad. The most common, a creeping erectile dysfunction that builds up over years after the end of radiation, may not be of much concern to him. Serious incontinence problems are now rare after external beam radiation as a primary treatment.

As far as cancer control goes, in young men surgery has a long term edge in success, but that doesn't hold true for older men.

As JohnT noted, Walsh (a surgeon!) advocates radiation for older patients.

If I were 72, knowing what I do now from personal experience with both radiation and surgery, I would go for radiation, and if the cancer were not controlled then, go for hormone therapy (ADT) and hope for a remission long enough to live out a normal life span. But that's just me.

I would go ahead with consults with a radiation oncologist and a medical oncologist, besides the uro and personal physician, and not jump right into surgery.
_________________
Replicant

Dx Feb 2006, PSA 9 @age 43
RRP Apr 2006 - Gleason 3+4, T2c, NXMX, pos margins
PSA 5/06 <0.1, 8/06 0.2, 12/06 0.6, 1/07 0.7.
Salvage radiation (IMRT) total dose 70.2 Gy, Jan-Mar 2007@ age 44
PSA 6/07 0.1, 9/07 (and thereafter) <0.1
http://pcabefore50.blogspot.com

agt · New User Joined: 04 Nov 2009 Posts: 5 Location: Australia

Thank you very much for all of the inputs.

I will suggest him to see radiation oncologist before deciding on the treatment.

Apologize if the topic has been deviated from lymph nodes into the option of the treatment, but do appreciate your kind help.

He is also going to meet PCa Support Group in the coming week. Hope that the others experience would also helps him make the decision.

I will keep you all posted.

Please feel free to add any other suggestion...

Take care!
_________________
My dad, 72y.o Gleason 4+3; still deciding on treatment.

Jean222 · Senior User Joined: 14 Dec 2008 Posts: 249

Hi Agt,

With a PSA of 19, it's very probable that the nodes are positive, ie that the cancer has already moved out of the prostate bed.
Another reason to choose radiation, in my opinion.

Removing the nodes will *not* prevent the cancer returning and yes, there can be major effects from the removal of the nodes.

The only reason for node removal is to check to see if the cancer has spread.

It is not curative in any way and cannot prevent a recurrence.

I think a PSA higher than 10, is a sign that the cancer is spread but someone else might confirm it for you.

Best wishes,

Jean

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