Nikhilesh i am not entirely convinced by your suggestion of RT + Hormones.
Having read all your provided links at depth, following are my conclusions:
The first link you provided: http://www.ncbi.nlm.nih.gov/pubmed/11489709
(Not sure whether you ve read it yourself)
1. This is not for patients who have already had Prostatectomy. All what they did was stage patients with Pelvic Lymphadenectomy and then give either androgen blockade or RT + Androgen blockade.
The prostate gland was untouched, where as in this patient, the surgeon has done a RP.
2. Majority (60%) of pts had orchiectomy , few had LHRH agonists & few diethylstiboestrol or Megestrol acetate,
the latter hormones are not standard initial hormones. Clearly i feel the andorgen arm only was given inferior treatment.
Links 2 and 3 are good articles and the EORTC guidelines are definitely worth reading.
Link 4 is consensus guidelines of the Australian and New Zealand Radiation Oncology Genito-Urinary Group which deals with high risk patients defined as positive surgical margins, seminal vesicle invasion and/or extracapsular extension who have a high risk of residual local disease.
I think so far from the discussion and what Nilesh intends to do is " HOW DO IT "
We still have nt answered the " Need to do it "
I think this patient will have the side-effects of Surgery and Radiotherapy with probably no meaningful benefit.
Hence i remained unconvinced and would be interested if there were any further articles fitting in with Nileshs description of a patient
who should have had Radical Prostatectomy And positive pelvic nodes.
I would be the devils advocate here to recommend hormone treatment alone as i do not think you can deliver sufficient tumoricidal dose to the pelvis to achieve cure.
Even if you were able to do so with IMRT, he is at a high risk of systemic disease. As per the AJCC 2010 staging this is stage IV disease with N1 disease. For Nilesh, it may be too late as he may have released the bullet and its gonna be difficult to refrain this patient from having radiotherapy once when you ve told him we can do it at the time of your initial consultation. But you can certainly ask for a Bone scan
I believe he is a non-secretor as with just PSA=6 , he has got such a horrible advanced disease.
Another query which Nilesh has is timing from surgery.
The best article which Nikhilesh sent us (link 1) mentions patients should start RT within 3 months of Pelvic lympadenectomy.
Could not find any other good evidence about the timing.
Nilesh what is the post op PSA ?
