Bone marrow involvement

[Rexwaterbury]

How do you know if your bone Mets are involving your marrow, and what treatments can be done about it?

Thanks in advance.

[Hidden]

Prostate cancer in your bone marrow will respond or not respond to treatment the same way as other prostate cancer in your body.

The way you know for sure is to biospy the bone marrow. What do your blood counts look like now?

[Rexwaterbury in reply to Hidden]

Platelets 86,000. Hg 9.5. WBC 3.0. I have had anemia since chemo last year. I have always had a low wbc. The low platelets are a new finding.

I am scheduled for lu/ac in Heidelberg on Thursday (3rd cycle). Doc plans to increase the ac225.

[Hidden in reply to Rexwaterbury]

Thrombocytopenia and anemia are classic signs of bone marrow invasion. You can get an infusion if they get too low. Wishing you the best with treatment.

[Tall_Allen]

You can see it on a scan. Depressed cellular output across all blood factors.

[Shanti1 in reply to Tall_Allen]

Hi TA,

Will bone marrow invasion show up like any mets do on an axumin or PSMA scan as localised lesions, or will it show as a more diffuse pattern, or both?

My husband consistently has WBC between 2.5-3.5, and RBC, hgb, htc just under normal. They were low prior to diagnosis and continue low now, although he has been off ADT for almost 2 years and jogs daily. His iron profile (ferritin, TIBC, UIBC, %SAT) and B12 are normal. He never had chemo. ADT and Zytiga were the only treatments. He had mets to lymph, lung, and sacrum. His PSA is now 0.89 and we will reinitiate therapy at 1. As his PSA has gone up, WBC and RBC inicies have gone down, so I wonder about bone marrow involvement, however, platelets are normal and have not changed over time. Are the steady, mid-range platelets enough to discount any major bone marrow involvement?

Thank you!

[Tall_Allen in reply to Shanti1]

I'm not a radiologist, sorry - suggest you ask him and his oncologist.

[LearnAll]

Bone marrow biopsy is confirmatory.

If all three cell lines (Red cells, White cells and Thrombocytes) are low ,it raises suspicion of bone marrow invasion.

Mere decline in thrombocytes alone is not enough...because isolated thrombocytopenia is

most of the time drug induced. Some drugs such as losartan, nattokinase etc can lower thombocytes.

[Rexwaterbury in reply to LearnAll]

So if my other parameters (Hg and wbc) are low but still at baseline without significant change, does that decrease the likelihood there is marrow involvement? And does it matter? If I’m getting lu177 and ac225 for bone mets, does it matter if the marrow is involved?

[LearnAll]

As you already know that chemo can reduce all three blood cell lines for few months and mostly they tend to recover as times goes by.

Some people have lower baseline and new reading should be compared with lower baseline of the person.

In fact, if your platelet count is on low side of normal range it often is good sign (if only platelets are low) because that brings your PLR (platelet Lymphocyte ratio) lower.

In my opinion, Lu177 /ac225 can be done to eradicate bone mets even if there is some bone marrow invasion. Mets are the cause of bone marrow invasion..if mets are dried up, invasion stops. However, your treating specialist can only provide definitive opinion.

[NurseRatched]

I find this all so confusing: If a person has bone mets, isn’t there an assumption of bone marrow involvement? Perhaps one of you can explain this in a way that makes sense to me. Tia.

[LearnAll in reply to NurseRatched]

Having bone mets does not mean that the man has bone marrow invasion...it may or may not be so.

To understand this, you will have to take a look at anatomy of a bone...There is an outer membrane called, periosteum...after that we have hard shell like layer, called cortical bone...and then, the innermost part of bone which is soft and spongy area and houses bone marrow.

In mild cases of bone mets, the mets just sits on the periosteum and can not penetrate further...On scans they can still shine as bone mets and generally they cause minimal or no pain.

After that, if bone mets start getting more severe ,they start corroding the outer hard layer, called Cortical bone...which is usually hard to penetrate...as long as mets are not able to go deeper than cortical layer...there is no bone marrow invasion.

Third stage is when mets are successful in reaching deeper into medullary part which has spongy, trabeculor soft area....once mets reach inside this part, the true bone marrow invasion has started. The intensity of pain increases with this deeper penetration. Also, you will start seeing changes in your blood cell count as the marrow becomes less able to produce enough of each blood cell lines.

Please note that mets are basically a bunch of prostate cancer cells collected together with some fibrous tissue etc.

[Rexwaterbury in reply to LearnAll]

Well that’s what I don’t understand in my case. First of all I’ve only had bone mets for a year or so, and only recently more widespread. None of the mets were very large on Psma scan, and all intensely avid. And I’ve since had 2 cycles of lu177 and Ac 225. And I don’t think I have any bone pain. Muscle and joint pain yes, but no bone pain that keeps me up at night or requires analgesics. So how could I have suspected bone marrow infiltration?

[AlanLawrenson in reply to LearnAll]

Thank you for your clear explanation of the progression of mets to the point it invades the bone marrow. Sadly, I lost my 79 year old brother to PCa in January. His blood chemistry certainly went haywire over his last two months when bone marrow invasion was accelerating. They withdrew all treatment for him other than palliative care at that time.

I had arrange for him to have compassionate access to Veyonda (Noxopharm ASX: NOX) which has done very well in the small DAART1 trial which saw efficacy with 50% of these late stage PCa patients. Sadly, his oncology team wouldn't not approve this course of action, even though I had provided them full trial results. Very disappointing.

DAART2 has been postponed to next year due to COVID. Interesting that Veyonda also kills the COVID 19 virus. An application is into the FDA to progress this as an IND trial.

[LearnAll]

Muscle and joint pains are not caused by bone mets....more often they are side effects of Lupron like drugs.

I guess they are suspecting bone marrow infiltration based on your low numbers of all three blood cell lines. And that is logical because not addressing bone marrow infiltration can cause more problems. In any case, your current treatment needs to be completed.

Once treatment works and after wards if your blood cell numbers improve significantly ..that will constitute an indirect evidence that it was in fact ,bone marrow infiltration.

[immunity1]

A late reply. Interested to know how your Lu/Ac treatment is going. I am also having more Lu. Typically thrombocytopaenia is a result of Lu treatment (M Hofman results).

[Rexwaterbury in reply to immunity1]

I had a mixed result. Worked well on my lymph node mets, not on my bone mets. So after 3 cycles it is a failure.

[immunity1]

Sorry to hear of that result Rex. From my experience, none of my soft tissue lesions had disappeared at the time of my 4th cycle but 5/6 had disappeared a year later - as predicted by the group administering it. I had no bone mets at that time. So hopefully there will be regression of your PC lesions,over time or at least a stop in expansion. Cheers, R