Mixed results after two more Lu177 treatments

[andrew61]

On Monday I had a Pylarify PSMA scan after two Lu177 treatments in Munich. The results are mixed. The lymph node metastases are now much smaller but the C1 metastasis is bigger and there are now other new bone metastases. Super disappointing.

This week I'll be seeking advice as to whether or not to go ahead with the planned additional Lu177 treatments or if I'm going to have to swap to something else. Doesn't seem much point in shrinking the lymph nodes while the bones run wild.

Photo shows the Lu177 infuser they use in Munich.

[Tall_Allen]

Suggest an NaF PET scan.

[Brysonal in reply to Tall_Allen]

Could you expand here please in terms of why this scan in this situation? Getting assessed for Lu-177 and this is on the list of tests/scans for this week and wasn’t sure why tbh.

[Tall_Allen in reply to Brysonal]

Not all prostate cancer cells express PSMA or a lot of it (called "non-avid"). For men who have most of their metastases in their bones, Na F(18) PET can detect cancer in places that PSMA PET scans can't. For men in whom much of their prostate cancer shows up on a NaF(18) PET but is not very PSMA-avid, Xofigo may be a better choice than Lu177PSMA617.

It is also possible for some men who don't have a lot of bone metastases to nevertheless have many metastases that are not PSMA-avid (called "discordant"). This may occur later in progression. In them, an FDG PET scan may show much cancer that would not be treated by Lu177PSMA617:

prostatecancer.news/2019/12...

[Hidden in reply to Tall_Allen]

Does non-PSMA expressive cancer produce PSA in the same amount as PSMA-expressive cancer? so that if the PSMA scan showed no reading, yet there was substantial PSA, you could assume it was non-PSMA expressive?

[Tall_Allen in reply to Hidden]

PSA and PSMA are completely unrelated proteins.

[Brysonal in reply to Tall_Allen]

Thank you. Interesting to know. I wonder why no FDG PET scan planned. Having PSMA PET scan tomorrow / NAF ( 18) today and MpMRI to look at the prostate specifically but no FDG PET scan on the plan.

[Tall_Allen in reply to Brysonal]

Prostate cancer becomes less PSMA-avid and more FDG-avid as it progresses.

[Javelin18 in reply to Tall_Allen]

I’ve been trying to find the research that shows PSMA avidity change over time or in relation to treatment. You’re a rich source of references. Do you have a reference for that?

[Tall_Allen in reply to Javelin18]

Yes, I've read that often. It is less in the prostate, more in metastases, and less in later metastases. I'm sure you can find the studies.

[Javelin18 in reply to Tall_Allen]

Thanks, I’m just starting my search. The introduction for this paper implies that it has information relating PSMA avidity to cancer stage.

ncbi.nlm.nih.gov/pmc/articl...

I haven’t read the paper yet.

[Brysonal in reply to Tall_Allen]

Does that mean Lu-177 needs to be timed earlier rather than later therefore ..in the PSMA avid stage?

[Tall_Allen in reply to Brysonal]

The best timing is when PSMA is maximally avid.

[GP24]

You could ask the doctors in Munich to add Ac225 to the Lu177. This works better against bone mets.

[andrew61 in reply to GP24]

I think that might be one option - with the salivary gland damage as a downside.

[GP24 in reply to andrew61]

What I meant is a mix of Lu177/Ac225 in one cycle (=Tandem). This does not damage the salivary glands as much as a pure Ac225 cycle. Here is an image of an exceptional responder to this mix. As you can see his salivary glands are working still.

Exceptional response to Lu177/Ac225 mix.

[andrew61 in reply to GP24]

Thanks. I will follow this up.

[GP24 in reply to GP24]

I want to point out that this patient responded so well that his case was presented at a recent conference. That's where I got the slide from. This is not the usual response. However, adding some Ac225 works better against bone mets than Lu177 alone. This combination is offered by a few clinics only and it is difficult to source Ac225 currently. So the PSMA therapy is usually done with Lu177 only.

[lewicki in reply to GP24]

I had both at the University of Heidelberg. I do have dry mouth and it is much better.PSA <0.04. No ADT now for 13 months.

I am at the decision time to go back on ADT.

I understand AC-225 is hard to get. July 2020 only available every other month.

[GP24 in reply to lewicki]

I take Bicalutamide 50 mg after a Lu177 cycle to stretch the time until new mets appear. This drug causes fewer side effects than Lupron and at a PSA value of 0.04 I think it will work sufficiently well.

[lewicki in reply to GP24]

Thanks. Is there an issue of Bicalutamide can turn negative. Just watch PSA for continuance?I had 4 MBq Actinium -225 and 4 GBq Lutetium -177 four times at the University of Heidelberg. I had Lymph-node, bone, visceral ( liver or lung) metastatic castrate resistant prostate cancer.

[Hidden]

Hang in there ! Andrew61….I too am from 61.. I pray that you get better !

[Alexey25]

Dear Andrew 61,Unfortunately it very much reminds my case. I had two Lu177 treatments in Bonn( they were practically the only clinic ready to accept me without prior Docetaxel chemo). Initially I had lymph nodes and liver metastases. After two Lu177 treatments Ga68 PET PSMA CT detected zero positive development while my PSA kept going up. Following my oncologist's strong advise urgently switched to chemo( it also was practically useless in my case while a have got a bouquet of heavy side effects but it is a different story).Conclusion is very simple - the Lu177 treatment is very expensive( especially with the intermediate "assistance" of booking health and similar companies) but surely it is not a magic silver bullet. It could be effective against lymph nodes( I personally spoke with some person who's lymph nodes just disappeared after the first Lu177 but the treatment was not effective against his bone metastases. His lymph nodes actually returned one year later), but practically not effective against bones metastases and absolutely not effective against liver metastases ( it was the reason for Munich to reject me).

Hope you will find the best treatment to help you.

Alexey

[GP24 in reply to Alexey25]

I am sorry to read that. My understanding is that the liver does express some PSMA too and therefore Lu177 does not work well to attach to PCa mets within the liver.

I heard that you can radiate liver mets with SBRT.

[Alexey25 in reply to GP24]

Thanks for your comment. Unfortunately liver metastases are practically not treatable separately in case of so called systematic disease ( I have also lymph nodes and bone) as actually all my body is full of cancer cells. The lymph nodes have been treated twice with a Cyber knife without any impressive results but surely with some heavy radiation impact. In case of some single bone metastasis the Cyber knife was very effective even after only one treatment.

[j-o-h-n]

Damn..... decisions..... May you make the right one(s).....

Good Luck, Good Health and Good Humor.

j-o-h-n Thursday 11/18/2021 10:10 PM EST

[andrew61 in reply to j-o-h-n]

Thanks j-o-h-n !

[djm21m]

Sorry to hear your bone mets not responding yet. I'm curious what is the Cost per Treatment in Munich ? What is Cost of 2 nights in Hospital ? Did you go to TUM (Tech Univ Munchen) ? Hope you can get some response with Ac225 if you choose to do that.

[andrew61 in reply to djm21m]

They charge EU 12,000 upfront but each time I’ve had an EU 3,000 credit back a few weeks later.