Concerning PSMA. Lymph Nodes, Prostate and Bones involvement.

[Silentio]

Greetings all. My treatment for PCa began in 2008 in the EU with radiation and ADT (Decapeptyl) which I have taken on and off for the last 14 years with intermittent breaks. I consulted with Dr. Sartor at Tulane at the time and continue to seek his advice. Over the years my PSA has ranged from undetectable to 5.0. PSMA in Heidelberg in 2018 showed 'no suspicious lesions.' PSMA last month (June 2022) is more troubling with four areas of metabolically active sites including a 56mm para-aortic lymph node, prostate, and two sub-centimeter spots in the spine and pubic bone. Oddly, my PSA was last recorded at 1.90 in May. I have restarted the ADT (Decapeptyl). My RO is planning a new round of radiation in two months' time and my MO will start me on Enzalutamide in combination with the Decapeptyl.

I wondered if anyone has any thoughts on treatment options or experiences in advanced PCa. It would be greatly appreciated. Are there helpful links for more information on this site or elsewhere? I am concerned about the two-month delay in starting the radiation and the shorter wait (several weeks) for the Enzalutamide. What is to be done with an active site such as the 56mm para-aortic LN? Why would my PSA be 1.90 while the disease grows metastatically?

I realize there is no cure for Advanced PCa. But how do we slow this train down?

Thanks in advance.

[Tall_Allen]

Welcome, Silentio. It sounds like you are staying on top of your recurrence. The Decapeptyl will stop all progression for a long time, so you shouldn't worry about waiting for other medicines and treatments.

The proposed radiation is not curative. Whether treatment of metastases has any benefit is still unknown. But why not, as long as it is safe? Was the SUVmax in the prostate high enough (say, >10) to confirm recurrence there? There are many false positives with low uptake in the prostate because the PSMA radioindicator is excreted through the bladder and urethra. If it is true, some brachytherapy seeds may be all that is required, although the risk of retreatment may exceed the benefit.

I don't know why your PSA has stayed so low with those metastases. Perhaps, you are just finding them early before they have grown large enough to put out a lot of PSA. Response to hormonal therapy will be prognostic.

[Silentio in reply to Tall_Allen]

Hi Tall, thanks for the reply. It is very helpful. I will look into the SUVmax. Need to do my research! Fingers crossed the Decapep helps. Thanks. All the best, Silentio

[tango65]

Consult about getting a biopsy of the large para aortic lymph node if it is possible. They could do histological, IHC and genetic studies which could lead to therapies with specific drugs. It could also help to explain large mets with a relatively low PSA.

A mpMRI could help to determine if there is cancer in the prostate if there were doubts about the PSMA PET/CT diagnosis.

If I were in your situation I would start the ADT and the enza and then try to get treatment with Lu 177 PSMA abroad if financially possible or I would try to get into one of the clinical trials with Lu 177 PSMA for castration sensitive cancer:

clinicaltrials.gov/ct2/resu...

Lu 177 PSMA is a systemic treatment and it will treat the cancer everywhere.

[GP24]

Ask Dr. Sator if you can get into the PSMAddition trial. He offers this to his patients.

[Silentio]

many thanks GP24 and Tango. Those are really helpful.