Hello!
This is my first post to this forum, which I am following from some time ago, since I have some doubts about next steps of treatment of my advanced PC and would appreciate very much your help, in order to take best grounded decisions.
My basic history on this matter is:
• 2016: 58 years. PSA 4.86. Estrone very high (89 pg/mL). Estradiol low (9 pg/mL). DHT very low (0.21 ng/mL). SHBG normal (46 ng/mL). Free testosterone very low (3.2 pg/mL). Started hypocaloric vegan diet, including also some typical supplements for prostate health.
• 2016 to 2018: PSA goes down from 4.86 to 4.61. Estrone very high and up (89 to 169 pg/ML). Estradiol continues low (9 to 11 pg/mL). DHT up, but continues low (0.21 to 0.34 ng/mL). SHBG up, until very high value (97 ng/mL). Free testosterone increases to normal (20 pg/mL).
• 2018: PCA-3 test. Score 23.
• 2018 to 2020: PSA increases from 4.61 to 6.28.
• 2020 to 2021: PSA increases from 6.28 to 8.97.
• 2021-Nov: MRI: PIRADS 5 with extravascular extension.
• 2022-Jan: Biopsy: PC confirmed.
• 2022-March: PET-TAC-Choline: No evidence of either local lymph nodes extension or metastasis. There are small slightly hypercapting foci in both pulmonary hilums, subcarinal and retrocaval pretracheal region, which in the fusion images seem to correspond to small subcentimeter adenopathies, probably reactive/residual in nature. Also, millimetric nodular images in the lingula and LII, with non-specific characteristics at present.
• 2022-March: Da Vinci Radical Prostatectomy, including 11 lymph nodes.
• 2022-April: Pathological analysis:
o 1 - Prostate: adenocarcinoma of the prostate, Gleason index 7 (4+3), tertiary pattern minority 5 (<5%). Prognostic group 3. Bilateral affectation, both compartments, from low levels, up to glandular high levels. High tumor volume. Focal presence of cribriform glands. Perineural invasion. No signs of lymph vascular invasion. Capsular invasion with extensive extra prostatic extension, mainly at the level of the posterior compartment of the prostatic lobe left, in middle levels. Tumor-ink contact in several focuses. Seminal and base vesicles: free. pT3a; PN+; LVi-; R1 (multifocal).
o 2 - Right lymphadenectomy: metastasis at one of three isolated lymph nodes (1+/3). No signs of capsular invasion.
o 3 - Left lymphadenectomy: metastasis at one of six isolated lymph nodes (1+/6). No signs of capsular invasion.
o 4 - Periprostatic fat: metastatic infiltration of prostatic adenocarcinoma in two isolated lymph nodes, (2+/2). pN1.
• 2022-April-June: Persistent PSA after RP:
o 26/04/2022 0.55
o 04/05/2022 0.46
o 11/05/2022 0.50
o 19/05/2022 0.49
o 26/05/2022 0.51
o 03/06/2022 0.49
• 2022-April: Estrone very high (99 pg/mL). Estradiol a bit high (29 pg/mL). DHT low (0.37 ng/mL). SHBG very high (115 ng/mL). Free testosterone normal (11 pg/mL).
• 2022-May: Added a natural aromatase inhibition formula to my supplements, getting reduced estrone level, to a low value of 24 pg/mL, but increased estradiol level, to a high value of 36 pg/mL. DHT continued low (0.30 ng/mL). SHBG still higher than before (147 ng/mL). Free testosterone a bit lower (7 pg/mL). No variations on PSA, all the time around 0.50, as shown above. I have stopped for the moment using it, trying to use other alternative anti aromatase supplements, since this formula has genistein, which has been found proliferative at low serum contents in some in vivo essays, according to information found in this forum.
• 2022-May: Given the persistent PSA after RP, a private MO proposed to make a CT-PET-PSMA scan, in order to try to detect residual cancer locations. If it would not detect anything, he considered that no treatment (radiation or hormone therapy) should be initiated for the moment, just observing the evolution of PSA. In case of detecting any cancer location, possible appropriate treatment should be studied.
• 2022-May: By the other side, given the persistent PSA, my insurance MO has proposed to proceed, within 6 months after RP, with adjuvant EBRT, combined with ADT. He has proposed to make first imaging with CT + scintigraphy + MRI. I asked to him why not imaging with CT-PET-PSMA, since this would be more sensible to locate possible small cancer nodes with PSA = 0.50. He agreed that PSMA would be better than CT + scintigraphy, but said that PSMA was not covered by my insurance at this stage of the illness, so I should do it by private and, anyway, combine it with insurance covered MRI.
• 2022-June: I have next week an appointment with a private MO, to program in principle an immediate CT-PET-PSMA scan. I don’t know yet if it can be selected 68Ga or 18F types, or if only one of the two types is available.
• 2022-June: I have already programmed within a few days the MRI recommended to be combined with PSMA by my insurance MO.
At this stage, I have the following main doubts, about which I would appreciate very much your opinions:
1. Do you agree that any PSMA scan (68Ga or 18F) is better than CT + scintigraphy in my current condition, to try locating as small as possible cancer nodes?
2. If possible to choose between 68Ga and 18F types, which one would you recommend for my current condition?
3. About possible radiation or hormone therapy in the near future, I understand treatment/s and best variants would be affected by the results of the PSMA scan, but I am somewhat surprised by the different opinions provided a priori by my insurance and the private MO. I have checked recommendations of the NCCN guide for my condition (with affected lymph nodes, pN1) and it says:
At this time the Panel recommends that patients with lymph node metastases found at radical prostatectomy should be considered for immediate ADT (category 1} with or without EBRT (category 2B), but that observation is also an option for these patients. (Category 1: high-level evidence, uniform consensus on appropriateness. Category 2B: low-level evidence, not uniform consensus on appropriateness).
So, although observation would be an option, ADT is highly recommended (direct estrogen reduction only would not be an option), while EBRT seems to be more questionable, taking always also quality of life in consideration. I understand that possible radiation therapy application and type should be highly affected by PSMA scan results, as the private MO suggest.
Sorry for the long post. Best regards,
L.J.
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