Lu-177 continue or not ?

[bjornbar]

Hi all

Want some good advice for Lu-177 continue or not ?:

I been for 3 x Lutetium 177 with the normal German protocol, infusion every 4 weeks, even if the threatment been in Finland, and also on my own cost.

Radiographic scans been made:

PET-PSMA CT two weeks before first Lu-177

Spect the day after each infusion

PET-PSMA CT two weeks after third Lu-177

I am on Xtandi, started just two weeks before first infusion, and since then.

The PSA response is:

Day of start of Xtandi 163

Just before first infusion 123

Two weeks after first Lu-177 70

Just before second infusion 136

Two weeks after second Lu-177 100

Just before third infusion 211

Two weeks after third Lu-177 224 (a few days ago)

As you all see I got a PSA response on the first two, but not a general downsloping curve.

After the third, the curve is creeping upward all the time.

The PSA is also rather well corresponding to my amount of bone pain, lower back mostly. Need Oxicodone to sleep and sometimes also at daytime.

The Alk Phosphate is just slightly going upwards, today 6.8 Ukat/L, for US units something like 400 UI/L

Side effects of Lu-177 not much beside the bone pain which is severely limiting my fysical activity.

But it is not a side effect, but an effect of my disease I suppose.

Thoughts on continue Lu-177 or not ? Xofigo is an option to choose.

Taxanes is no option anymore.

Waiting for answer on FoundationOne Liquid CDx, but this dont give a solution for all.

[Tall_Allen]

Ask for an FDG pet scan. Further use of Psma targeted therapy can sometimes increase progression.

[Tall_Allen in reply to Tall_Allen]

Read this:

prostatecancer.news/2019/12...

[tango65]

If you did not have Provenge you could discuss about this treatment along with Xofigo.

When I had the treatment in Munich they advised me to measure the PSA 5 weeks after treatment. If you have many bone metastases you may consider to have a tandem treatment with Ac 225 PSMA and Lu 177 PSMA, particularly if there is bone marrow infiltration. I believe Bad Berka nad Heidelberg do this type of treatment.

[GP24]

The normal German protocol is an infusion every 8 weeks. After two infusions (at 16 weeks past the first infusion) you should get a PSMA PET/CT to see if the metastases are reduced.

If the PSA value rises, this is not a good sign. As Allan wrote, you can get an FDG pet scan to see if there is tumor which has no PSMA expression and therefore cannot be treated with Lu177 infusions. This can cause the rise in the PSA value.

If Lu177 does not work any more, you can try Ac225 instead. This does cause side effects, it damages the salivary glands.

[Fairwind]

I had 6 infusions of Lu-177 as part of the now closed "Vision" trial..They were 6 weeks apart. The first 3 infusions produced a dramatic lowering of my PSA. The last infusion I received was in December, 2019 with my PSA already trending upwards..So while the Lu-177 worked spectacularly at first, the effect was short lived..My lowest PSA during treatment was 185 in Oct-Nov 2019. It was 3800 a month ago..I had a PSA test today but I don't have the results back yet..

[Hidden in reply to Fairwind]

You posted a while back about Cyclophosphamide. Were you able to get it prescribed and try it?

[Patrick-Turner]

I agree with Tall Allen that an FDG PET scan be done to see if some of your Pca will not respond to Lu177.

I am having a second series of Lu177 now, because first 4 shots in first half of last year did work well with Psa moving down to 0.32 in 12 months since I began first 4 shots.

I had FDG PET scan before starting second series of Lu177, plus PsMa Ga68 PET CT scan.

The FDG scan was negative which means all my Pca that is now only in my bones according to PsM scan is all likely to to be killed with more Lu177.

After last Nov 2019 when Psa went to nadir of 0.32, Psa rose x 100 to 30 before I began more shots last 24July, and Psa is going down again about 10 now. Next and 6th is 2 October, and I am on Xtandi, and will be on Veyonda for 10days because it is thought that these drugs make my Pca express more PsMa and thus attract more Lu177 to to tumors in my bones, so Lu177 is more effective.

But it does seem all my Pca will respond to Lu177. If I had some Pca that didn't respond, there's maybe only PARP inhibitors or chemo for those tumors which don't respond to Lu177.

When I began Lu177 in Nov 2018, Psa hardly moved after 2 shots, only 25 to 17, and Psa only really went low after 4 shots.

Here in Australia where I am getting Lu177, the infusions are 8 weeks apart, not 4 weeks apart which you say is German protocol. The timing may suit a lower dose of Lu177. Dose size affects outcomes.

Yesterday I cycled 100.0km around my city of Canberra, and today I feel just great.

I have no aches or pains due to Pca. So I feel than Lu177 is working, but if I had mets that didn't respond it would be a very different situation. The medical provider here in Australia has a 70 % success rate, IOW, Psa is reduced as it was for me quite a bit between first Lu177 and beyond the last of 4 shots. Mean time for Psa to stay low after Lu177 is about 18months. Just as many get that as those who don't get that. The 70% non success indicates quite a few men won't respond to Lu177, but 70% will, and there's just as many men who get less than 18 months Psa reduction as those who get more than 18 months Psa reduction; some get a month of time, some get 5 years. Like so many things injected into a man to kill Pca, it can only do what it will do, and only for a limited time. Once the radioactivity of Lu177 fades down fast because half life is only a week, there will be Pca that was not all killed in many tumors, so Pca continues to grow. Pca in bones is harder to kill because of nature of blood vessels needed to get Lu77 to Pca sites, and this is an imperfect mechanism of conveying a drug to bone mets.

I may complete this series of Lu177 shots, and if Psa goes low, and follow up PsMa scans show a good result after 2 shots, docs may not give me more, and just wait unto Psa rises again for a third round. I can't have too many shots of Lu177. There is a point where toxicity has to be considered.

So I might last another year, maybe 2, but after that nobody knows yet.

Patrick Turner.

[NecessarilySo]

In my case I recently took Lupron with Xtandi in June 2020 after a 4 year vacation from treatment. I had previously taken Lupron thrice, and my PSA was 35 before recent treatment. After a month in July, 2020 PSA dropped to 7.7. In August, 2020 it had dropped to 0.8, and last check early September 2020 it had fallen to 0.3. In comparing to your case, where PSA did not fall, (as much) I have to conclude that your PC is hormone insensitive or castration resistant. So I looked at the Xofigo site and it seems to be a radioactive injection that has small half-life. It appears you should go to active cancer sites and slow them down, either with radiation or other means. I have had some success with nonmedical approaches including lycopenes, heat, and magnets, (mostly in addition to the Lupron.) However, I have no idea about mcrpc if they would be effective. Scheduled for another Lupron injection tomorrow. Alk Phos 106 in May 2020 and in Sept. 2020, normal.

[bjornbar]

Thanks Allen, Tango , GP24, Fairwind och Patrick for valuable answers.

The Lu-177 series is decided to be exited now by my doctor at the site performing this.

The continuation is suggested to be Xofigo, and this view is shared by my swedish "own" oncologist , so it will be covered by health-care and performed in my home town. No more travelling ! The last is not a small thing, as travelleling and staying at hotels felt more and more adding tension, as I got quite some back and pelvis pain. Also cost-wise great.

Radio treatment for bone pain is scheduled for day after tomorrow and the Xofigo start in one week, 6x with 4 weeks apart. Xtandi stops now.

Last blood data: Psa 324, is 40 % up from last reading 3 weeks ago, Hb just at 100 which is slightly down, Alk Phosphate slightly down from last high value, othervise all is within normal range.

Would love be out biking as Patrick, but is definitely not within my capability as for now.