Imaging for metastatic PCa

[Cancersucks]

Any opinions on best radiologic diagnostic tool to use for metastatic PCa?  What are most of you getting?  Onc here uses FDG PET/CT scan.  CT scan says diffuse osteoslerosis but that can be healing bone, as well as, bone destruction.  

[Hidden]

The key is establishing a baseline to judge future scans and changes. Yes, it picks up fractures, arthritis, previous mends and new bone growth...... But, I am sure that your Oncologist discussed the findings from the Radiologist noting explanations that are "lit up" for something that could be other than mets. With the baseline, one can readily see new areas and growth of initial discovery. To me, most important is the intensity of the "lit" areas. Type that I had .... Nuclear Bone Scan of the entire body with CT Scan of the abdomen.

Question? How many scans have you have and over what period. For example, from February 2003 thru August 2010, I had twenty scans and was able to follow from initial discovery to diminishment to replacement with new bone growth.

Unlike skeletal scintigraphy, which depicts bone metabolism, PET-CT with specific radiopharmaceuticals depicts tumor metabolism all over the body, including in bone. It is a type of molecular imaging.

The visualization of glucose metabolism by positron-emission tomography with 18F-fluorodeoxyglucose, coupled with a simultaneously obtained CT (18F-FDG-PET-CT), is now a standard diagnostic technique in oncology. In patients with lung cancer or malignant melanoma, for example, PET-CT with FDG has replaced other techniques for the detection of bone metastases as these are highly metabolically active tumor types, metastases can be detected with high sensitivity and specificity. Because of the high tumor contrast, metastases in other organ systems or in the soft tissues can be detected as well. 18F-FDG-PET-CT can thus be used for complete staging of these tumor types, among others.

Your Oncologist is the person who can best explain best practices and new discoveries in the field of radiology. Ask away to your pro. In my opinion, experienced Oncologists and Radiologists can tell the difference between destruction and healing; especially with baseline scans.

Keep kicking the bastard,

Gourd Dancer

PS. I have zero medical training, so it is important to ask those who do.

[Neal-Snyder in reply to Hidden]

Well, G.D., you've obviously educated yourself impressively. 

I've learned that radiologists can't necessarily tell the difference between a spinal tumor & degenerative disc disease. What may tip them toward choosing the former is the knowledge that you have PC. Over time, they may agree that some spots are degenerative & not bone mets.

[Hidden in reply to Neal-Snyder]

Thank you NS. I spent a lot of time reading, viewing my scans all the while receiving explanations to my questions. Interesting that several years into my Advanced Prostate Cancer journey I went to a small town hospital for a kidney stone attack. One of the tests performed was an IVP x-ray of the kidneys with nuclear tracers to see what was going on and the reason for the obvious blockage. All worked out in the end.

However, three days after I got home I received a telephone call from the Radiologist informing me that he saw something that he did not like on the film and that I should seek further medical help. I asked if he was talking about the mets at L2 and T3 and he replied that he yes. Surprised that I knew about the two hot spots. In other words, not knowing that I had Prostate Cancer, he was able to ascertain that I had areas of concern that indicated that I had Advanced Prostate Cancer through the IVP x-rays of the organs of the Geniturological area. In other words two areas of my spine were lit up in the background when they should not have been and the spots appeared to be more that arthritis.

Diagnostic tools in the hands of a medical professional are great and even some old, standby techniques still get the job done.

GD

[Neal-Snyder in reply to Hidden]

My best friend's dad was diagnosed because of his dentist's analysis of a dental x-ray. The dad was quite old, & was on his way to dying of other causes, so there was no reason to give him something new to complain about. But the diagnosis convinced my friend to start seeing a urologist, which worked out well for him.

[pjoshea13 in reply to Hidden]

My uderstanding is that PCa cells prefer fatty acids over glucose for energy, particularly palmitic acid.

Dr. Myers once fielded a question on PCa & sugar in his vblog, by saying good luck trying to get an insurance company to pay for a PET scan.  Meaning a radio-labeled glucose PET scan - the only option at that point.

One problem is, to the extent that there is glucose uptake, this doesn't change when cells become cancerous.  Uptake levels would increase in cells that are dividing quickly, but its not possible to distinguish between BPH & PCa.

For metastatic PCa, the issue is that, since cells largely do not favor glucose over palmitic acid, FDG uptake is insufficient for a clear image.  Consequently, there has much interest in using radio-labeled choline.

In the latest paper that I could find in PubMed - March 17 - [1]:

"In most cancer types, 2-[18F]-fluoro-2-deoxy-d-glucose (18F-FDG)-PET is an accurate method for detecting bone metastases."

"As a bone-specific tracer, there is accumulating evidence to support the use of sodium 18F-fluoride (18F-NaF) PET-CT in the diagnosis of skeletal metastases in breast and prostate cancer, although relatively little data are available to support its use for assessment of treatment response."

"In prostate cancer, 11C-choline and 18F-choline PET-CT have better specificities than 18F-NaF-PET-CT, but equivalent sensitivities in the detection of bone metastases."

Going back to 1998 [2]:

"Prostate cancer is difficult to visualize using current techniques."

"... has revealed that the tumor, in general, is characterized by an increased uptake of choline into the cell to meet increased synthesis of phosphatidylcholine, an important cell membrane phospholipid."

"Imaging of prostate cancer and its local metastasis was difficult when 18F-FDG was used because, within the pelvis, the areas of high uptake were concealed by the overwhelmingly abundant radioactivity in urine (in ureters and bladder). By contrast, it was easy when 11C-choline was used because the urinary activity was negligible and tumor uptake was marked. The radioactivity concentration of 11C-choline in prostate cancer and metastatic sites was at an SUV {standardized uptake value} of more than three in most cases. The SUV of 18F-FDG was considerably lower than that of 11C-choline."

-Patrick

[1]  ncbi.nlm.nih.gov/pubmed/269...

[2]  ncbi.nlm.nih.gov/pubmed/962...

[Spitzz]

I've heard good things about "choline-c-11-pet-scan" 

"DO YOUR OWN RESEARCH"

mayoclinic.org/tests-proced...

and 

phxmi.com/newsletter-august...

Choline-C11 was a major topic at the PCRI conference in LA Sept. 15

BEST OF LUCK - Spitzz

[BrentW]

My PSA has been as high as 343, rising from 17 in just six months, but my doc tells me that I do not look like a person with cancer issues.  I had a PET/CT scan in 2010, but it revealed nothing.  My doc tells me that it is probably pointless for me to have further scans right now, that I must have multiple micro-deposits that would not be detectable, scans not being able to find anything smaller than 5 mm across.  Even if we did, he says it would not change my treatment.  I don't know where I am going with this, other than to say that I find the whole matter of scans quite dispiriting. 

[Hidden in reply to BrentW]

BW

If there were undetectable micro-metastasis six years ago, how do you know that they have not grown or attached themselves from the blood stream into bone or organ? Second question, would the treatment change by a Urologist as opposed to a Geniturological Oncologist?  

My purpose is not to worry you, but call a spade a spade if need be. In my opinion, your situation bears close monitoring to give you options down the road if need be.

Keep kicking the bastard,

GD

PS. My Stage 4 had zero symptoms and I certainly did not feel nor look like a man with Advanced Prostate Cancer twelve years ago.

[dave100 in reply to BrentW]

Second opinion would be MY next step.

[Hidden in reply to BrentW]

re "my doc tells me that I do not look like a person with cancer issues".

What does a person with cancer issues look like?

1. High PSA (check)

2. did he do a DRE?

3. did he do a biopsy?

What does he expect to see? Mushrooms growing out of your ears?

Or do you mean that the scans are all clear?

He says he would not change your treatment. What's that?

Sounds a little behind the times to me.

Is he helping you pick out your casket at least? You don't say.

[Break60 in reply to BrentW]

BW

What a strange comment from your doctor! With PSA that high it would seem that mets would be visible with the latest Pet CT scan technology. At a minimum I would think you'd be on systemic treatment.

Bob

[Hidden]

My onc recently had me have an F18-NaF Pet/CT Bone Scan. This test uses Sodium Fluoride as the contrast. He told me that this test is 45% more effective in locating distant mets.

He told that it is a fairly new test. And , yes mets in T1 & T2.

Joe

[Cancersucks]

Three scans in year since diagnosis.  First scan showed innumerable hypermetabolic lymph nodes and innumerable areas demonstrating FDG uptake and innumerable FDG avid foci throughout skeleton.  Second scan in July was much better but last scan in January, after chemo, was worse than second scan, still showing diffuse bony sclerosis and at 11 tumors through spine and left hip and femur.

[Joe32963]

Dr. Pomper at JH has developed a contrast agent to detect the vascular system established by PCa cells. I was part of a trial and the scan was able to detect cells not picked up by any other scan. It helped direct my radiation therapy. Was a Gleason 9. Had 4 Psa post radical prostatectomy. Off all drigs and PSA is undectectsble. So far so good.

[Hidden in reply to Joe32963]

I wonder if people try to cauterize blood vessels that feed tumors? Maybe HIFU cannot be that well focused. Maybe get some antenna chemical that is tuned to an unused frequency and attach it to a tracer chemical and broadcast on that frequency. .. (right)

[Break60]

I'm waiting for my PSA to rise to around 2.0 to get the axumin scan in order to be assured of better accuracy. Next PSA test is Monday. Last two monthly readings in Feb and Mar were 1.1 and 1.3.