Inconclusive lesion of rib

[Della71]

Hi,

I have been actively reading here and other than a basic question about Drs. in my area have not posted. It is likely that I shouldn't be posting in the feed regarding advanced pca, if so please inform me of where best to ask my question.

My husband who is 62 yrs old was diagnosed finally (after questionable treatment and biopsies for several years) in December 2021. He was Gleason 4+4 down graded to 4+3 after prostatectomy in February. Pathology did note cribriform glands present. Stage 3tb as there is seminal vesicle invasion but no other concerns in the post op pathology.

He had 2 opinions regarding treatment prior to surgery. 1st urologist suggested "the kitchen sink" the Dr. he chose wants to take things one step at a time as to avoid overtreating.

Our biggest concern is that the staging bone scan and ct showed a solitary suspicious mixed lesion in a rib. Was reviewed by 3 radiologists, 2 urologists and a radiation oncologist who all just said they are not overly concerned but cannot rule out mets. We wanted a psma pet but insurance turned it down. Both Drs. felt it was ok to wait until his 1st post op psa (will be done in about 10 days) as it's the best determination of metastatic disease. If psa still detectable Dr. wants an Axium scan and did not mention psma. My question being is this the right scan and will it determine micro mets vs. oligometastatic disease if in fact the rib lesion is cancer? Waiting since early January to determine whether or not there is distant mets is extremely difficult and we just want to be certain that we have a clear picture of his actual stage. The cribriform and sv invasion are of huge concern as to greater likelihood of distant mets.

Thank you all, I am learning so much, Your knowledge is valuable and appreciated.

[GP24]

A PSMA PET/CT is more sensitive than an Axium scan. However, the Axium scan will be payed by your insurance. A solitary suspicious lesion could be a false positive. I would just observe this. If it increases in size it will be cancer and you can radiate it with SBRT then.

[Justfor_]

How many PSA labs do you have post RP? I am reluctant to believe that he had RP last February and stil no PSA.

[Della71 in reply to Justfor_]

He had RP on 2/21/22 and first psa will be in about 10 days at 12 weeks post op.

[Justfor_ in reply to Della71]

This 3 months post op PSA is only a fishy way to lessen the burden of docs who will have to spend 10 min, a tel. call or an e-mail to explain-discuss the results with their patient. Depending on the pre-surgery PSA, 4-6 weeks, are more than enough to shed light to the post op scenery. Anyway, you have already been stalled during two months, you can wait for 10 days more.

What you must make absolutely certain though, is that your husband will get an ultrasensitive test, that is, 3 or min 2 significant digits after the decimal separator (point). From the level of care that you have presented here, I will not be surprised if he will get a standard test instead, i.e. a single decimal digit after the decimal point.

[Della71 in reply to Justfor_]

I'm not quite sure what you mean by level of care. The lab that processes the psa is independent of with the cancer center my husband goes to. They are both major providers in our area. I am now understanding that 1st psa 90 days post op is not unusual or negligent.

[Justfor_ in reply to Della71]

You wrote and I quote:

"... (after questionable treatment and biopsies for several years)...."

And now you are worrying whether he has bone metastasis or not!

Anyway, I have no intention to dispute on that with you. If you are satisfied with the care you have got, who am I to disagree. I only wished to be helpful. It seems I am not, no problem with that. Wishing you a PSA <0.02, I bow out.

[Tall_Allen]

It's sometimes hard to tell when there are solitary small rib lesions on a bone scan/CT if it is cancer. Actually, a much more sensitive PET scan for the purpose is NaF(18). It is not usually covered by Medicare/insurance, although it is far less expensive than PSMA PET scans.

If he still has measurable PSA 3 months after surgery, he will qualify for a PSMA PET scan.

[Della71 in reply to Tall_Allen]

Thank you, I now have a better understanding of the reason for waiting 3 months post op for his psa. May I ask your opinion on ogliometastatic disease or a single met? Is it uncommon or is there a greater likelihood that there are micro mets? Safe to assume that if the lesion is cancer not only SBRT would be the treatment but ADT would be indicated? And can you offer any additional info about the cribriform gland. Is that something we should be additionally concerned about as far as risk? I appreciate all the information you are able to provide as this is all new to us and we have had two relatively different opinions with regard to treatment.

[Tall_Allen in reply to Della71]

For every bone met you can see, there have to be thousands too small to be seen with any technology. It's OK to zap the met, if it is a met, but systemic therapy is necessary too. No one yet knows if zapping metastases is helpful, but if safe, why not?

You have to wait 3 months for PSA to clear from the blood - it goes way up because of the surgery.

I don't understand your question about cribriform glands - that was in the prostate, which was removed. There is no further action to be done about it.

[Della71 in reply to Tall_Allen]

Thank you. My concern about the cribriform glands being present is not knowing if the fact that they existed places him at higher risk as Gleason 8,9, 10 does.

[Tall_Allen in reply to Della71]

That's in the past, as the Gleason score is.

[Scottybear]

Sounds like me! G9 with on small possible rib met.... and it got blasted with Sabre radiation while doing prostate. Be safe and not sorry was the plan. All the best