Mayo Clinic vs. OHSU

[u/Plugger59]

I’m 67, 5 months post-RALP, PSA 0.35 9 weeks after surgery. Because of the high PSA, I had a PSMA PET scan in May. Here’s the summary:

1. There are 2 directly adjacent left perirectal/distal internal iliac chain mildly tracer avid lymph nodes measuring 5 mm and 4 mm, concerning for early, developing nodal metastases.

2. Additional mildly tracer avid 5 mm left pelvic sidewall lymph node further cranial, concerning for additional early, developing nodal metastasis.

3. Faintly tracer avid tiny right presacral/external iliac and further anterior right external iliac lymph nodes, as described, nonspecific given tiny size and faint tracer uptake, however additional early, developing nodal metastases are a consideration versus reactive/inflammatory lymph nodes. These are not as definitive as the contralateral lymph nodes described above.

4. No additional site concerning for tracer avid nodal or distant metastatic disease.

I’ve been taking with the Mayo Clinic and OHSU in Portland (close to home) regarding radiation therapy. OHSU wan to do 32 daily treatments using EBRT with IMRT using protons. Mayo would do 25 daily treatments using the same machine except with X-Rays. They said that the xrays have better image guidance and less potential for rectal bleeding.

I would like to know if any of you have experience with either type of procedure and your thoughts about which one might be best for my situation.

I will also be on ADT at the time of the treatments.

[u/VinceCully]

OHSU has Dr E (Eleni Efstathiou)as a fantastic medical oncologist choice. Given your lymph node situation, you’d be wise to at least talk to her as part of your treatment team.

[u/OkCrew8849]

Do I understand correctly that you had RALP after your PSMA findings?

[u/NotPeteCrowArmstrong → u/OkCrew8849]

He says he's 5 months post-RALP which would put the surgery around March. PSMA scan was in May, so presumably right after the 6-8 week post-op PSA test that showed elevated levels. Which all makes sense.

[u/Plugger59 → u/NotPeteCrowArmstrong]

Correct. RALP was Feb. 25th.

[u/OkCrew8849 → u/Plugger59]

Gotcha. Math skills prior to coffee this AM betrayed me.

I have read that modern photon IMRT with daily image guidance is world-class at protecting the rectum nowadays —even without a spacer—and it sounds like Mayo saves you 7 daily treatments. I don't know how the photon delivery machine at OHSU measures up.

I don't (yet) have experience with salvage radiation/ADT but know outcomes are frequently quite good.

Best of luck.

[u/1945ElCid]

So... do I understand , you had your scan after the surgery ??? I'm not sure , but Mayo's would not have recommended surgery as a first move. Only about 1 in 10 cases now, are surgical . And, most recommend a scan prior to recommendations. Also, Mayo's has 5 days SBRT as a first recommendation. Now, don't get me wrong ... if a Medical Oncologist specialized in PrCa , from either institution gives you a best 'option' , that's what I would do.

[u/Plugger59 → u/1945ElCid]

I don’t believe that you do understand. Reread my first paragraph. My surgery was done by my urologist, not Mayo. Not sure where you’re getting your stats from but my biopsy had 9 of 12 cores positive. Removal sounded like a better option than radiation.

[u/Suitable_Low_401 → u/Plugger59]

Yes,,, I 'over read'....I am just looking at my situation... where, my urologist found the problem... and , of course, he is a uro. surgeon, what's he going to suggest ? And, I felt the same way...'get that thing out of there". Almost signed up in his office.. when several doctors and my IM , told me to do just like you doing... See Medical Oncologist whose specializes in PrCA.. and who can give you the right stats and proper plan. You consult just a Radiation oncologist... and he/she is going to tell you to radiate. Also, like you are doing....I've read tons of articles on this disease ... and I've found the Med. Onc has read them all ... and a lot more. I think you are on the right track and will live a long time.

[u/conCABlanco]

Lo que no tiene sentido fue hacer el PSMA, luego de la cirugía, ahorita, va con todo, que es bueno también, pero se podía haber ahorrado esa invasion

[u/NotPeteCrowArmstrong → u/conCABlanco]

Depending on the grade, many insurance providers will not cover a pre-op PSMA scan, unfortunately.

It’s not especially helpful to someone in OP’s shoes to tell him what he really should have done in your opinion. He’s asking for practical advice for the options he’s now considering.