Which MRI study to order: Slowly rising... - Advanced Prostate...

Advanced Prostate Cancer

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Which MRI study to order

LowT profile image
LowT
32 Replies

Slowly rising PSA after robotic prostatectomy 2016. Which is the most appropriate MRI study to oder?

Pelvis MRI or Prostate?

With and without contrast?

32 Replies
dadzone43 profile image
dadzone43

Neither is going to be specific. Is your PSA high enough for PET scan?

LowT profile image
LowT in reply to dadzone43

No.

Tall_Allen profile image
Tall_Allen

multi-parametric MRI, not just an MRI.

tango65 profile image
tango65

I f you a had a prostatectomy and have a rising, request a PSMA PET/CT instead of a MRI. It will identify cancer in the whole body and it may be useful to guide therapy.

London441 profile image
London441 in reply to tango65

He says his PSA is not high enough for PSMA PET to be of diagnostic value.

tango65 profile image
tango65 in reply to London441

What is the PSA value?

London441 profile image
London441

Good question, he said only it wasn’t high enough. LowT what is it?

LowT profile image
LowT

0.081

LowT profile image
LowT

My question is which study is most appropriate as the prostate has been removed. Should the study be a pelvis MRI. And with and without contrast. That is usual for prostate MRI But the prostate is no longer there. Are they looking for lymph nodes, etc.

At surgery there were many enlarged lymph nodes (2-5cm diameter). Total of 24 removed. All were negative. None of them showed up on scans prior to surgery.

RMontana profile image
RMontana

Here is a good bar graph that shows PSA vs PSMA PET sensitivity (finding PCa);

PSA vs PSMA PET sensitivity
RMontana profile image
RMontana

This is another bar graph that shows PSA vs PSMA PET sensitivity for different MET (metastasis) scenarios

PSMA PET vs PSA at time of test with different MET conditions
LowT profile image
LowT in reply to RMontana

note it says < 0.2. Not < 0.02. Do you know of any studies reporting on <0.1?

RMontana profile image
RMontana in reply to LowT

No...that is the point...below 0.20 you are below 40%...but what if at 0.10 you are at 20-25%...is it worth the scan...if I were you I would get one just to make sure there is nothing there...this is what I did before I got sRT. I had to fight for the test as my OC did not want to have a 'baseline' scan that showed going into sRT I had no MET. But I wanted one and pushed to get a PSMA PET...now, I was on ADT at the time with very low PSA (less than 0.02 for sure). But at UCLA where I got the scan the Dr's told me one advantage to getting the scan, even with ultra low PSA, was to make sure there was no MET outside the prostate...my ADT could have been masking a tumor that was large enough to find, but was not putting off any PSA to locate it (it was not broadcasting its location).

I dont know with you; are you on ADT? If you are get a scan to have a baseline that shows no MET...even on ADT if you have a tumor larger than say 2-4mm it will show up! If you are not on ADT then you have ultra low PSA and your sensitivity (finding a PCa tumor) are lower than 40% at PSA levels of 0.20...in this case you have no choice but to wait...

...if I were you (and I may be headed there right now; am coming out of 21 months of ADT following RP and sRT), I would get a scan at 0.20...then get one every frigin year if I have to until I can find out where the PCa is located...early detection is absolutely crucial in any disease; its primordially critical with PCa...my two cents...

LowT profile image
LowT in reply to RMontana

No, never on ADT and want to avoid if possible as I’ve had low T in past and can’t deal with it My plan was to get PSMA PET CT when in Turkey next month as my low PSA it would not be covered here and as we had Turkey trip planned so I was in process of scheduling that. Cost is cheaper there.

Now with the MRI result the PSMA PET is being scheduled here.

RMontana profile image
RMontana in reply to LowT

OK...just FYI when I got my PSMA PET at UCLA it was Jan20...it had just been FDA approved and had no insurance coverage as it had no procedure codes yet...out of pocket for the scan was $3300...dont know what they would charge in Turkey and dont know what the out of pocket would be now at UCLA...if this sounds close to what you would pay then consider it...looking on line I see prices range from $750-1850...BUT the secret sauce in any scan and particularly in PSMA PET is the reading...what I am told the critical part of finding small MET is the skill of the Radiologist...the problem they are having now with PSMA PET is training the readers around the USA to read the scans...so consider that as well...

If you want to find out what the out of pocket cost at UCLA (the best in the USA and one of the best world wide), here is the contact email; wwpetctsched@mednet.ucla.edu. Their phone number is; 310-794-1005 / 800-825-2631.

Up to you...its only money, but man what you would not give to have spent an extra $2 grand to have found PCa early...but I understand...Rick

LowT profile image
LowT in reply to RMontana

yes, my thinking as well. Dr Kwon at Mayo spoke highly in his recent lecture of specific Dr in Turkey as well as overall care. My plan, since already we were traveling there, was to schedule it, which I was in the process of doing when I got MRI results.

This along with other issues have resulted in cancellation of that trip

Other issues also dealing with is persistent elevated LH & FSH levels at 3x high normal limits, even though my T is now 5-700 range. Also elevated Prolactins which is reported to promote angiogenesis so not good with neoplasms. That has been brought down with Cabergoline but had to stop due to visual SEs.

As you can see my case is somewhat complex.

LowT profile image
LowT in reply to LowT

A lesson I’ve learned is that no two prostate cancers are alike and everything has a context!!

RMontana profile image
RMontana

Here is a good article on PSMA PET and its effectiveness (sensitivity and specificity) for different PSA levels at time of test...note that at PSA less than 0.02 ng/ml you have a 1/3d chance at finding MET!!! Vegas has far worse odds!!! So manage your case actively and dont wait if you think you need a test...get one, get one each year...do what you think you need to do for your health. Dont wait for your Dr; he may delay and take too long to call for a scan...let us know what happens...Rick

210717 ART PSMA PET Effectiveness Post Treatment

There is an almost linear increase of PET-positive result with rising PSA level: Patients with PSA ≤ 0.2 ng/ml had a detection rate of 33.3%, patients with PSA 0.21 ≤ 0.5 ng/ml a rate of 41.2% and patients with PSA 0.51 ≤ 1.0 ng/ml a rate of 69.2%.

Median PSA before PET/CT in pts. with pathological findings (n = 92) was 1.90 ng/ml and without (n = 37) 0.30 ng/ml.

PSA level at time of PET/CT was the only factor associated with PET-positivity.

In pts. with a PSA ≤ 0.2 ng/ml, the detection rate of any lesion was 33.3%, with a PSA of 0.21–0.5 ng/ml 41.2% and with a PSA of 0.51–1.0 ng/ml 69.2%, respectively.

Regarding the anatomic distribution of lesions, 42.2% and 14.7% of pts. with relapse or persistence had pelvic lymph node and distant metastases.

In pts. at initial diagnosis the detection rate of pelvic lymph nodes and distant metastases was 20% and 10%. 

68Ga-PSMA PET/CT had a high detection rate of PCa recurrence outside the prostatic fossa in pts. being considered for salvage RT (22.4% PET-positive pelvic lymph nodes and 4.1% distant metastases).

Compared to CT, PSMA PET/CT had a significantly higher sensitivity in diagnosing rates of local recurrence/primary tumour (10.1% vs. 38%), lymph nodes (15.5% vs. 38.8%) and distant metastases (5.4% vs. 14.0%).

This resulted in a modification of RT treatment in 56.6% of pts.

The detection of PCa is strongly associated with PSA level at time of 68Ga-PSMA PET/CT. PSMA PET/CT differentiates between local, regional and distant metastatic disease with implications for disease management. PSMA PET/CT allows for tumour detection in post-prostatectomy pts. with PSA ≤ 0.5 ng/ml considered for salvage RT.

ro-journal.biomedcentral.co...

LowT profile image
LowT

here’s the report. uPSA was 0.08. FINDINGS:  Status post prostatectomy..  There is a new small enhancing nodule in the left superior prostatectomy bed in the region of the left seminal vesicle.  This measures approximately 0.9 x 0.4 cm (image 17, series 6 and image 49, series 9).). There are no enlarged or morphologically abnormal lymph nodes. The urinary bladder is unremarkable. No suspicious osseous abnormalities are identified. Stable small postoperative fluid collection in the left external iliac region. «

PSMA PET CT been orderef

LowT profile image
LowT in reply to LowT

Which type of PSMA PET would be most appropriere?

RMontana profile image
RMontana in reply to LowT

Dont know if they have other than Ga68 PSMA PET right now...they are working on other isotopes to be able to get more scanning capacity, but right now that is it...other than the half life limit of distance that this isotope places between the production of the isotope and the scan platform there is nothing wrong with Ga68 that I know of...its the standard of care for this Tech at present...its what I got Jan20. TNX

LowT profile image
LowT in reply to RMontana

The FDA approval is a little bit broader for PSMA-PET imaging. Fluciclovine F 18 is only approved for recurrent disease, whereas PSMA is also approved for initial staging

LowT profile image
LowT

»appropriate»

LowT profile image
LowT

ive read Gs better for bone and F better for soft tissue. ??

LowT profile image
LowT

Have to remember some cancers are not PSMA avid!!

LowT profile image
LowT

if mine is maybe lesion can be treated directly avoiding RT and ADT as I already have lymph edema from the extensive lymph node removal.

lcfcpolo profile image
lcfcpolo in reply to LowT

Hi. Out of interest. Which hospital and Dr. in Turkey was recommended please? Good luck with your scan.

LowT profile image
LowT

as I understand it most will not order PSMA PET CT with PSAs < 0.4 or higher. So definitely on the front edge.

RMontana profile image
RMontana

1st of 3 ART on uPSA Ultra Low PSA;

Pro PSA versus ultrasensitive uPSA fluctuations over time in the first year from radical prostatectomy

A classical definition for ultrasensitive PSA (uPSA) relapse is 3 rising uPSA values after nadir [10]; recurrence seldom occurs in patients with uPSA <0.04 ng/ml, 3 years after RP

The 1-year after surgery BCR rate was 34.9 % using uPSA value > 0.02 ng/ml, while 38.6 % using 3 rising uPSA values after nadir; at the same time, no subject had an imaging-confirmed metastatic disease.

The uPSA values sequentially increased in 43.4/ 69.8/ 83.1/ 89.0 % patients, at 3/6/9/12 months after RARP, respectively.

Several trials showed that adjuvant RT after RP decreases BCR risk and provides survival benefit for high-risk patients [21–23].

uPSA >0.03 ng/ml emerged as good relapse predictor, while the above correlation between was marginal [25].

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

RMontana profile image
RMontana

2d ART on uPSA Ultra Low PSA; look at the BOLD extract from the ART...provocative!

PSA Ultra-sensitive PSA Following Prostatectomy Reliably Identifies Patients Requiring Post-Op Radiotherapy

Using first postoperative PSA cutoff ≥0.2 ng/mL has only 46% sensitivity to detect failures. If the relapse cutoff is lowered to first postoperative uPSA ≥0.03, sensitivity substantially increased to 70% (Table 4).May 1, 2016

Any post-op PSA ≥0.03 captured all failures missed by first post-op value (100% sensitivity) with accuracy (96% specificity).

Defining failure at uPSA ≥0.03 yielded a median lead-time advantage of 18 months (mean 24 months) over the conventional PSA ≥0.2 definition.

uPSA ≥0.03 is an independent factor, identifies BCR more accurately than any traditional risk factors, and confers a significant lead-time advantage.

Biochemical failure precedes distant metastasis by about eight years

A meta-analysis quantified the success of salvage RT to decrease by 2.5% with every 0.1 PSA increment [10].

Benign uPSA patterns occurred in the range from 0.01 to 0.02 ng/mL, sometimes persisting over several repeated PSA draws.

Once the threshold was increased to uPSA ≥0.03, nearly all patients (98%) eventually relapsed (Figure 1).

Specifically, initial and continual monitoring with uPSA out to at least 5 years and at intervals not longer than 6 months between tests so that eventual failures can be identified earlier and postop RT can be initiated with a greater likelihood of success.

Use of the conventional assay and cutoff (PSA ≥0.2 ng/mL) is flawed.

data showed that about half 50% of relapses missed by conventional PSA relapse criteria would be anticipated with uPSA.

The majority of our patients had uPSA failures within the first three years (82%) but a substantial number (18%) relapsed much later and therefore a closer PSA surveillance probably should extend to a minimum of 5 years.

ART (adjuvant)is better than delayed SRT (salvage), ADT (androgen deprivation) alone, or neither.

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

RMontana profile image
RMontana

3d ART on uPSA Ultra Low PSA;

Usefulness of ultra-sensitive prostate-specific antigen following radical prostatectomy

After a median follow-up period of 52.2 months, the biochemical "failure-free" rate in the PSA nadir <0.008 and ≥0.008 ng/ml groups was 94.3 and 58.8%, respectively,

Thompson et al (11) reported that adjuvant radiotherapy following RP for stage pT3N0M0 prostate cancer significantly reduces the risk of metastasis and increases survival

however, the improvements in clinical progression-free survival were not maintained.

Late adverse effects (any type of any grade) were more frequent in the postoperative irradiation compared to the wait-and-see group.

In addition to potential problems with the reagents and measurement methods, there exists the possibility of ‘noise’ created by residual benign prostate tissue during measurement, or the production of PSA by the periurethral glands or other organs.

there are three trends in ultra-sensitive PSA;

a) the temporary elevation type group, PSA levels increased temporarily, followed by a subsequent decrease to <0.008 ng/ml

b) the consecutive elevation type group (PSA≥0.05 ng/ml) and

c) the peaking out type group (0.008≤PSA<0.05 ng/ml)

The consecutive elevation type group, transited to <0.05 ng/ml

Cases with the pathological factors ≥pT3 and EPE are mainly following the transition of the consecutive elevation type group.

The European Association of Urology guidelines state that patients with a PSA level of 0.1–0.2 ng/ml following RP do not exhibit either clinical or biochemical disease progression.

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

Papillon2 profile image
Papillon2 in reply to RMontana

Art 1. 👍 Art 2. 👍 Art 3. 👍

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