Opinions on my husband’s Pylarify scan results? Is additional radiation possible?

[SuppWife]

1/15/2022 UPDATE:

Results of my husband's Pylarify scan:

CLINICAL HISTORY: 68 years-old Male with RESTAGING PROSTATE CA.

* PSA level: 0.30 NG/ML (7/13/2021)

(NOTE: at time of scan PSA between 10 and 12)

* Prostate cancer biopsy: Radical prostatectomy 4/17/2018, prostate adenocarcinoma diagnosis, Gleason score 5+4 = 9 (grade group 5), extraprostatic extension with invasion of bladder neck, symmetrical, and left vas deferens. Margins extensively involved by tumor.

* Gleason score: 5+4 = 9.

* Prior treatment: Radical prostatectomy, 4/2018. ADT. Proton beam radiation therapy to pelvic floor 9/2020.

* Current prostate cancer medication: eligard.

FINDINGS:

* Liver background activity = 3.5 / 6.3 mean/max SUV

* Blood pool activity (descending thoracic aorta) = 1.6 / 2.6 mean/max SUV

* Parotid gland activity = 4.5 / 21 mean/max SUV

HEAD/NECK:

Brain: Normal activity within the brain. Bilateral basal ganglia calcifications

Salivary glands: Normal..

Nasopharynx, oropharynx and hypopharynx: Normal.

Adenopathy: No pathologically enlarged or radiotracer avid lymph nodes

CHEST:

Heart: Normal physiologic activity is present within the myocardium.

Lungs: Normal.

Adenopathy: No evidence of pathologically enlarged or radiotracer avid lymphadenopathy within the mediastinum, hila, supraclavicular or axillary regions

ABDOMEN/PELVIS:

Liver: Geographic fatty infiltration of the right liver is noted. No suspicious observation is seen.

Gallbladder: The gallbladder surgically absent.

Spleen: Normal attenuation and activity.

Pancreas: Normal attenuation and activity.

GI tract: Stomach, small bowel and colon appear normal.

Kidneys: Normal physiologic radiotracer activity and excretion of the kidneys.

Bladder: Bladder appears normal with excreted radiotracer

Prostate gland/bed: Surgically absent without abnormal uptake, max regional uptake 2.6.

Seminal vesicles: Surgically absent without abnormal uptake.

Adenopathy:

Regional lymph nodes:

* No significant lymphadenopathy

Distant lymph nodes: Approximately 8 retroperitoneal lymph nodes are identified with increased radiotracer uptake and three representative nodes as follows:

* Left periaortic lymph node measuring 1.5 x 1.2 cm with max regional SUV of 36.9 (CT image 177)

* Small aortocaval cluster measuring 1.1 cm with max regional SUV of 20.5 (CT image 183).

* Left common iliac lymph node measuring 1 cm with max regional SUV of 24.3 (CT image 196)

OSSEOUS STRUCTURES: Normal marrow uptake. Mild asymmetric pectus excavatum is noted with sternal implant. Multilevel degenerative changes of the spine are noted without abnormal uptake.

SOFT TISSUES: Scattered soft tissue tissue densities are noted consistent with injection sites. Diastases of the abdominal recti muscles are noted with small umbilical hernia containing fat.

IMPRESSION:

1. Distant retroperitoneal and left common iliac lymph nodes demonstrating increased tracer uptake concerning for metastatic disease.

2. No abnormal uptake within the prostate bed or regional lymph nodes.

END of REPORT

Dr. Sartor said darolutamide and test PSA monthly. Said radiation usually not done with more than five positive lymph nodes. Possibly good candidate for LU-177 later.

Anyone have any thoughts?

Is additional radiation to these lymph nodes possible or too close to other organs? Is it worth a consult with an RO?

It’s gratifying to know the proton beam salvage radiation to his prostate bed was apparently successful.

Thanks for any opinions or advice as I try to advocate for my husband.

[Hidden]

Note he said "usually." If it were me, and I could radiate them, I would want it simply because radiation will work in the short run to specific areas. But some of these are higher up I think and certainly would be worth talking to an RO. The other thing you run into is insurance coverage. Although insurance will pay for palliative radiation to distant bone metastases, I'm not sure that includes lymph nodes. Sometimes these doctors have to get a little creative to get the insurance company to pay. The only thing I base this on is my personal experiences and talking to other prostate cancer patients.

[SuppWife in reply to Hidden]

Thank you for your reply! I hadn't thought of the insurance aspect. He's covered by traditional Medicare and a supplement. I think we'd like to explore it with an RO, just in case.

[rscic in reply to Hidden]

I agree with an RO (Radiation Oncologist) consult WITH an MO (Medical Oncologist) being involved (consulted) as well.

[Tall_Allen]

It couldn't hurt to get a second opinion from an RO. Last year, they expanded the pelvic treatment area for lymph nodes to include those identified. It is borderline with that many in that place and radiation can be dicey that high up. Nubeqa is useful in any case.

[SuppWife in reply to Tall_Allen]

Thank you for your reply. Dr. Sartor said he'd be a likely good candidate for Lu-177 and he was pleased there was nothing showing up in bone and liver. If we found a good RO who thought treatment of this area was reasonable do you know if that would that affect his future access to Lu-177? We wouldn't do anything without talking to Sartor first, but wondering if that would exclude him from that treatment in the future.

[Tall_Allen in reply to SuppWife]

No, it would not exclude him. There were no exclusions for previous salvage RT in the VISION trial.

[tango65]

I was in a similar situation in 2016, with several lymph nodes mets in the pelvis and the retroperitoneum up to the renal arteries. I started ADT and I went to Germany and got treated with Lu 177 PSMA. One treatment made all the mets PSMA negative. I continue in ADT and 5 PSMA PET/CTs done after the treatment in Germany have been negative. I am having a new one next month.

[SuppWife in reply to tango65]

That's great! You've only had one Lu-177 treatment?

[tango65 in reply to SuppWife]

Yes, that is correct. It seems Lu 177 PSMA has better results when done early and in castration sensitive cancer. GP24 is other member of the forum who have had the same results with Lu 177 PSMA when treating node metastases when the cancer is castration sensitive.

[tango65 in reply to SuppWife]

There is clinical trial combining SBRT and Lu 177 PSMA for castration sensitive PC. Perhaps, he may qualify:

clinicaltrials.gov/ct2/show...

I f interested contact:

Contact: Michael Zelefsky, MD 212-639-6802 [e-mail]

or Michael Morris MD, [e-mail]

[SuppWife in reply to tango65]

The words castration resistant have been mentioned by Dr. Sartor. His PSA started rising pretty rapidly around September of this year while on Orgovyx then Eligard. If he responds to Nubeqa and his PSA goes down would he still be considered castration sensitive?

[Justfor_ in reply to SuppWife]

If your numbers are correct (not a typo) and his PSA rose from 0.3 to 10 within six months while on ADT, i.e. PSADT 30-35 days, you have to deal with a very aggressive disease. Fight it with whatever you can lay your hands at, (Lu177 included) and monitor effectiveness by bi-monthly (if not weekly) PSA tests.

[SuppWife in reply to Justfor_]

Yes, I'm afraid it is not a typo. That's why I'm thinking about radiation to the LNs. He'll be getting PSA measured this week. Hoping the Nubeqa is helping. Thank you for your reply.

[tango65 in reply to SuppWife]

No if the PSA goes up when the testosterone is below 50 the cancer is castration resistant. The Lu 177 will work. It has been shown to prolong life in mCRPC patients with very advanced disease. He sbould start Nubeqa and look for Lu 177 treatment in clinical trials here or paid treatment with Lu 177 abroad. Nubeqa will control the cancer for a while, so there is time to look for Lu 177 PSMA treatment.

[tango65 in reply to SuppWife]

This is a list of clinical trials with Lu 177 PSMA in the USA:clinicaltrials.gov/ct2/resu...

[SuppWife in reply to tango65]

Thank you for your replies. Started the Nubeqa and staying in touch with Dr. Sartor. He will get blood work this Thursday. Hoping PSA will be heading down. 🙏🏻

[CurrentSEO in reply to tango65]

Hi Tango65,

- How in advance you started ADT prior to your Lu?

- Are you staying on ADT continually since your Lu treatment in 2016?

- Do you take any second line hormone (Abi, Enza...) treatments besides standard ADT?

- Did you have any treatment to primary?

Thank you!

[Spyder54]

Yes, was good to see that Proton Beam was effective!On the Retroperitoneal Lymph Nodes, there is a Dr Donaway having success with Nano Knife. Can be done without injury to surrounding tissue. Eventually may become a 5th Standard for Prostetechtomy.

Watch his videos vitals.com/doctors/Dr_Rober...

[SuppWife in reply to Spyder54]

Thank you! I will check him out. I appreciate it!

[Spyder54 in reply to SuppWife]

youtu.be/hAjgZEu5xpI(Not working as expected?)

[SuppWife in reply to Spyder54]

Just got a chance to watch. Really interesting!

[SuppWife in reply to Spyder54]

I’m so grateful to you for sharing this with me. I try to stay updated at HU but sometimes life gets busy and PCa situation gets briefly stabilized and I visit less often. I’ve missed discussion of Nano Knife till now. I’m doing lots of googling. Gonna reach out to Dr. Donoway’s practice with my husband’s stats and scan results to see what he says. Maybe a trip to Germany? Thank you again 👍

[SuppWife in reply to Spyder54]

Hello, Spyder54,

we've just heard from Dr. Donoway and he said he is not currently offering this treatment but referred us to Dr. Gary Onik who he says is doing a clinical trial. Do you have any information about Dr. Onik? Thanks in advance.

[treedown in reply to SuppWife]

We have patients of Dr Onik on the forum. Addicted2cycling is one.

[SuppWife in reply to treedown]

Thank you!

[MateoBeach]

He can also get Provenge treatments now that he meets criteria for castrate resistant metastatic. That is a worthwhile adjunct. Consult the best RO you can find. If he finds he can treat all the nodes with acceptable risk, that should be #1. Lu-PSMA treatments should be the backup as many only get very limited improvements. About 1/3 do very well with it though, especially to LN only disease. So that should be #2.

[SuppWife in reply to MateoBeach]

Thank you! I appreciate your input. When we asked Dr. Sartor about Provenge for my husband he said it wasn’t indicated. At that time his PSA was rapidly rising and it was PRE-Pylarify scan. The assumption has always been my husband is metastatic because of his PSA. It was 34 at DX and 17 after Rp. But so far no visible mets in bone or liver. Docs always seem surprised. Maybe we should ask Dr. Sartor about Provenge again, post scan? He’s been taking Nubeqa since the scan and is getting PSA tested today. 🙏🏻