Hi, all.  We met our local uro today.  He is so cool. He was very open
and information-gathering.  He said he thought it was appropriate we
were going at it very aggressively ("full court press") and that it
looked like our onc knew what she was doing.  He is fine with treating
Steve and helping with ED issues.  He says there's two trains of
thought on the maintaining function, but he's fine with VitV (do mail
programs kick out emails with that word?), that the shots are not an
option during chemo, that we can try a VED if we want, half of people
like it okay and half don't.    He lent us a video, although Steve has
already seen one from Tom B, I haven't yet.  Since we are more
interested in preserving potential function than trying to have
intercourse, we're going to try it as an exercise device at least.
Also a colonoscopy today showed nothing, one tiny polyp, dr will call
after path report.  No concerns at this point.  Anyway, that's our
update.  A good local uro.

I asked him about RT with pos lymph nodes with my standard argument
that we'd be asking for a bunch more SEs without probable benefit.  He
said he would question that, with known pos nodes, but that we should
consult with Grado and that he thought Grado would recommend it.  I
said, "Yes, because that's what Grado does," and he nodded but didn't
say anything.

I realize we need to consult with Grado, and am eager to do so, but
really I would like more information about why this would be a good
idea.  Or not.

I can find studies of RT with and without ADT, but my question is the
opposite of that.  Are there any studies of ADT with and without
radiation?  That is my question, really.  Will RT add any advantage to
ADT+chemo? Also, I only found one thing about identifying nodal
involvement and targeting it, rather than doing a blanket dose of
radiation basically from the navel to the knees (exaggerating only
slightly).

I can find a lot of information on clinically localized cancer and RT,
but once we got the path report it trumped the "clinically localized"
staging.  And not much on salvage RT w/pos lymph nodes.  This had a lot
of stuff but I don't know how useful it was after all
http://tinyurl.com/ldhds.

Some various quotes that indicate to me that there is no positive
indications for this (remember, his prostate is gone) or else indicate
RT after PSA has started rising but before it reaches .02:

...
The optimal management of patients with lymph node-positive prostate
cancer remains controversial. The role of pelvic irradiation in
patients at high risk for nodal involvement continues to be debated.
Studies of prostate irradiation with and without inclusion of the
pelvic lymph nodes show poor outcomes for node-positive patients,
supporting the concept that many of these patients have systemic
disease at presentation. Although no randomized trial has examined the
role of pelvic irradiation in pathologically node-positive patients,
available data fail to reveal any significant benefit of this approach
over prostate-alone irradiation. More promising therapeutic approaches
involve the combination of local therapy and sustained hormonal
therapy. Series comparing prophylactic irradiation of the pelvis and
prostate to irradiation of the prostate alone have shown no clear
benefit of pelvic irradiation. Pelvic irradiation may play a role in
the treatment of early-stage or occult nodal disease, although this has
yet to be examined. Until prospective, randomized trials demonstrate
the efficacy of pelvic irradiation in the management of prostate
cancer, its use cannot be routinely recommended.
....
In patients with locally advanced prostate cancer, RT-PCR/hK2 (to
detect lymph node pos)  is strongly associated with prostate cancer
progression, failure following salvage radiation therapy, development
of clinically evident metastases, and prostate cancer-specific
mortality after surgery.
...
http://theoncologist.alphamedpress.org/cgi/reprint/6/2/183  (A grand
rounds)

This one indicates to me that salvage RT should wait for PSADT, which I
assume would happen after ADT:
Salvage radiotherapy is an effective method for achieving PSA response
and improving progression-free survival in post-RP patients with a
rising PSA,[28,29] but is most useful in select patient populations.
Two large retrospective studies found that patients with Gleason score
8-10, preradiotherapy PSA < 2.0 ng/mL, negative surgical margins, PSA
doubling time </= 10 months, and seminal vesicle invasion independently
predicted disease progression.[30,31] Nevertheless, early salvage
radiotherapy (ie, upon detection of PSA </= 2.0 ng/mL) enabled patients
with Gleason 8-10 and positive surgical margins to achieve a 4-year
progression-free probability of 81% when the PSA doubling time was > 10
months and a 37% probability when the PSA doubling time was </= 10
months.[31] Thus, even for patients with other adverse features,
patients with PSA doubling time > 10 months can show durable responses
to early salvage radiotherapy, whereas those with PSA doubling time </=
10 months are more likely to show poorer response and should therefore
be considered for more aggressive therapy.