Metastasis Prostate gland to Pelvic Lymph/abdominal nodes ? To early to stage ID for me? Why?

[depotdoug]

I'm confused about why I can't get a NCCN type Advanced prostate cancer status or staging from my Med Onc yet.

Fact(s): 68Ga-PSMA-11 PET/SCAN 08/01/2019 Reveals parotid max SUV32.1,mediastinal blood pool max SUV 2.0, liver max SUV 8.9.

Fact: posterior mid to apical aspect of prostate(atrophied) PSMA avid region SUV 11.7 with 1.2cm x1.2cm x 1.8cm

Fact: PSMA avid lymph nodes, right common iliac, periaortic, & infrarenal retroperitoneal lymph node chains. largest 1.4x0.7. (SUV 8.4) Low level avid activity in mediastinal and hilar lymph nodes representing "reactive lymphadenopathy". Ok, I have no idea what this means in staging.

Fact: abnormal PSMA area in my posterior right fourth rib with SUV 1.6. Maybe representative of an old post traumatic injury than metastatic.

PSMA radiology Impression:::

1. Recurrent disease within the posterior mid to apical aspect of the prostate.

2. Pelvic lymphadenopathy.

3. Mild activity in posterior right fourth rib probably representative of an old mild injury.

My prostate treatment sequencing is: a) 2005 42 IMRT rad treatment zaps. b) 2008-2012 ADHT Lupron/Casodex combo. c) 2019 Recurrence PCa post biochemical ADT treatment

My question stated in Title above is: Am I too early to stage my advanced prostate/Lymph node cancer. Like the National Comprehensive Cancer Network charts provide??

Doug

[Tall_Allen]

Possibly because he doesn't want to officially restage you based on an experimental scan? But what difference does it make in your treatment? You seem to eligible for docetaxel or abiraterone - is your staging affecting what your insurance will cover?

[Lupronzytiga in reply to Tall_Allen]

GA-68 PSMA PET MR may recieve FDA approval next year.

In my opinion, this scan may be the best scan available for metastatic prostate cancer.

I am not a Dr., this is just my opinion.

[depotdoug in reply to Lupronzytiga]

That is a PSMA Magnetic Resonance Imaging / PET Scan? If it is I can't have that type performed on my body, I think. I've got an ICD/Pacemaker 2nd one implanted Jan2019.

I've been told MRI's can fry my RA(right atrial) RV-(right ventricle leads) and damage my ICD/pacemaker.

But I'm not a doctor either.

[Lupronzytiga in reply to depotdoug]

I believe there are issues with pacemakers.

I believe some of the newer ones are MRI compatible

[depotdoug in reply to Lupronzytiga]

Yes, I wish and asked to receive a MRI compliant device, but I got what my insurance would pay for. Besides the total system needs to be MRI compliant or forgiving. That means both RV and RA spiral wire leads going down my arteries then stuck adhered to my Right Atrium and Left Ventricle heart muscles. Its a big complicated procedure to remove and replace a pacemaker or defibrillator lead(wire) that still works. Plus its invasive and dangerous to achieve unless you(me) has an experienced EP doc.

So I've given up on that adventure.

[Tall_Allen in reply to depotdoug]

There are only a handful of PET/MRIs in the US.

[timotur]

*This is just my opinion.* If all your mets were in the prostate bed below the common illiac artery split, and not in bone (M0) you would still be pT3b. It appears this is the case since the uptake at the rib of SUV 1.6 is below the usual cutoff of about 3.5, so that is probably negative. It could be your MO is researching this or consulting others to make sure. Even so, some literature has suggested a positive PSMA scan is only about 63% positive predictive, meaning it's a false-positive about 37% of the time. So most likely you are stage 3 (*IMO*).

[depotdoug in reply to timotur]

Thxs. I assumed but should not do that yet, about my Pelvic lymph node ‘avid’ regions. Like I mentioned in the post details to Tall_Allen my 1st Lupron injection is doing its thing. As planned. And 6 weeks out # 2 Lupron injection will do the same.

I asked my PCP doctor last Thursday and he said about the same thing, probably nothing definitive to quantify yet.

My next TBD 68Ga-PSMA-11 PET/ scan is around mid February.

[timotur in reply to depotdoug]

Ok DD, you may want to take another PSMA scan before your PSA falls below 1.4 ng/ml....

jnm.snmjournals.org/content...

[depotdoug]

Thxs Tall_Allen...Staging doesn’t affect my treatment yet, not one bit. I’m just 6.5 weeks into 1st 3 months Lupron Depot injection.

* 1 week ago my new(est) PSA lab was down to 2.9ng/mL from 8.566 Sept 10th. Same for T-level labs 10.9ng/dL down from 294. Yes Lupron chemicals in my blood stream is doing it’s thing, downward.

Really though Tall_Allen I presumed everyone with Ad PCa was staged, especially when metastasis ID’d. Point is I’m trying to follow my disease and treatment flow on the NCCN Guidelines documents. That’s a whole lot of medical oncology information to comprehend, for a laymen.

>>> Bottom line should I press my MO for a ‘staging’ or status tag before my next appointment Dec10th or just wait till 10Dec?

12/10 is my next Lupron Depot injection. Insurance is not even in the picture for staging for ‘docetaxel’ and or abiraterone yet. My PCP doctor last week read my PSMA PET radiology report and tried to assure me that it was or may not be positively clear for distant metastasis, yet.

Can a 3rd time recurrence PCa male be too early, even with Lymph node ‘avid lit’ metastasis, to definitively pinpoint staging levels?

Doug

[Tall_Allen in reply to depotdoug]

My question was about restaging, not staging. My question is - what decision depends on restaging?

[depotdoug in reply to Tall_Allen]

Guess since I’m just entering‘advanced prostate cancer status I’m looking for a NCCN status level. I’m probably totally confused; but my ONC RN did tell me 2 weeks ago that it’s too early to Start xtandi, or higher powerful meds. Like I’ve said I’m trying to anticipate-my next med treatment attack plan n

[Tall_Allen in reply to depotdoug]

There is no such thing as “planning “ for this. You can only deal with what you’ve got when you’ve got it. You are only causing yourself needless anxiety.

[depotdoug in reply to Tall_Allen]

You absolutely nailed this issue of mine. I just re-looked at the NCCN(National Comprehensive Cancer Network) Guidelines V4.2019 and 1) I've been directly at the Clinical Practice Guidelines in Oncology, Yeh the Oncologist's tools all 166 .pdf pages. No wonder I can not decipher a whole lot of useful information. pg 2 has 32+ doctors listed as contributors. Plus the NCCN Guidelines are a statement of treatment approaches to are disease.

If I was not a retired electronics engineering communications specialist, I probably would not have even pondered self-analyzing such an extensive research medical doc.

Enough said. You can surely get a stiff neck or sore back studying this information for no positive reason at all.

I'll keep exercising my body keeping my anxiety levels in check; for how long? We shall see.

DepotDoug

[depotdoug]

Late breaking news: I received letter today from my local MO saying he wants me to due 1. annual CT scan abdomen/ pelvis w/contrast and 2. Nuclear medicine total body bone scan Dec 5th. Fact is my local MO does not know I’m being treated, monitors by and Indianapolis Cancer center MO, yet.

Should I do the 2 scans Dec 5th??

Not sure what they would show or not show. 2 MO’s which one to use or use both?

Doug

[MateoBeach]

My suggestion would be to obtain a CD with the full scan data of the Ga-PSMA-11 scan you had, and take it to (or have it sent to) the radiation oncologist who did your original primary IMRT series in 2005. They will have your treatment simulation scans and can fuse it with the prior images to clearly assess the location of the current situation including the pelvic lymph nodes and apical recurrence in the prostate. Some combination of stereotactic body RT (SBRT) and/or right pelvic hemispheric RT could possibly provide effective treatment for you at this juncture. (Disclosure: I am going through similar treatment for pelvic lymph nodes identified on Ga-PSMA PET/CT at this time.)

[depotdoug in reply to MateoBeach]

Thanks I'm very interested in getting my 68Ga-PSMA-11 scan CD or digital image file. Looks like its time to call my Radiology Imaging lab P.O.C.'s.

[GP24]

Doug,

I was in a similar situation. After the biopsy my URO ordered a bone scan. I thought: crap, I'll have a PSMA PET/CT instead. It showed several lymph node mets and every doctor I met insisted on ADT. The guidelines recommend, if a patient presents with mets, too late for surgery or radiation, treat with ADT only. However, the guidelines expect that these mets were detected with CT and bone scan and not with the much more sensitive PSMA PET/CT. Therefore I would recommend to get the CT/bone scan without presenting the PSMA PET/CT results first and then to read the guidelines based on the results of the CT/bone scan.

It may well be that the CT and bone scan do not detect any mets. Your MO will tell you: the cancer did not spread and I now recommend surgery or radiation. This will probably cure you.

My alternative off-guideline recommendation is to get radiation according to the latest results of the STAMPEDE trial: esmo.org/Press-Office/Press...

You can also ask the RO to extend this radiation to the pelvis to treat any mets which are unvisible yet and also do a boost to the visible mets on the PSMA PET/CT. All this while continuing ADT for six months following the radiation, because you are high-risk. All this should destroy most of your tumor burden and put you in a better situation.