Second Recurrence. Second PET F18-PSMA

[anpun]

History: 54 years old now.

February 2017: Prostatectomy (Da Vinci). Gleason 4+3. T2N1MO (1 lymphatic node of 28). December 2019: psa:0.21 ng/ml.

PET/PSMA GA68 show the prostate bed and one lymph node were illuminated.

28 session of radiation was given (august 2020) to the prostate area (61 Gy) and the dose increased (63 Gy) to the PSMA uptake area. To the pelvic area (50 Gy) and 62 Gy to the uptake area.

ADT 6 moths.(Casodex+Decapeptyl)

16/09/2020: psa: 0.02 ng/ml (T=21 ng/dl).

04/01/2021: psa:0.02 ng/ml.(T=456).

05/07/2021:Today psa: 0.16 ng/ml (T=508).

11/01/2022: psa: 0.51 ng/ml (T=385)

February 2022: PET F18-PSMA: Conclusion: showing no signs morpho-metabolic effects of locoregional or distant tumor recurrence.

July 2022: PET F18-PSMA (PSA=1.20), where it concludes:

"PET/CT 18F-PSMA shows multiple subcentimeter and hypercaptant lymph node images retroperitoneal lesions at the para-aortic level described suggestive of infiltration of prostatic origin. (M1)"

The medical team advises me 6 months of ADT (Casodex+Decapeptyl) and irradiate the area.

What do you think? Can it be curative or is it unlikely? I understand that at least if radiation works it can give me more time to start ADT for life.

Thanks

[GP24]

No, it is not curative. There are mets present smaller than those a PSMA PET/CT can detect. These will continue to grow and be visible in less than a year.

Therefore I recommend this radiation in combination with (intermittent) ADT. Then it will take longer for new mets to appear.

[MateoBeach]

Had a very similar situation this year. You can read my previous posts, “Why I Choose an Unproven Treatment” and follow up posts.What I would do (and did do), given that 2/3 of patients will have another recurrence within two years after nodal SBRT at other sites. Yes, these are progressions of micro-metastases. If they are able to target the para aortic / retro peritoneal sites now seen on latest PET with SBRT, I would have them do so.

If you want to explore the possibility of attempting to treat the unseen remaining sites with molecular targeting using Lu-PSMA-J591 (not Pylarify), then you can contact GenesisCare AU / Theranostics in Perth Australia and have a virtual consult with Dr. Nat Lenzo. You can PM me for contact information if you would like. I had these treatments in May this year. No guarantees of course, but initial results seem good and remain hopeful. Paul

[Tall_Allen]

I don't understand why you have been put on such limited term ADT after radiation. I think that is the cause of your recurrence; the short use of ADT only selected for the most resistant cancer cells. With nodal involvement, it should have been 2-3 years, as in this clinical trial ( which also uses Erleada):

clinicaltrials.gov/ct2/show...

I also don't know if they expanded the pelvic treatment area. The expansion was published at about the same time you got salvage radiation, so they may not have known:

prostatecancer.news/2021/05...

It seems like you have this one last chance at a cure. This time, insist on 3 years of ADT. If you're in the UK, you should be able to get Decapeptyl+abiraterone, as in this STAMPEDE trial:

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

[HopingForTheBest1]

Genetic testing could identify viable treatment options.

[London441]

If you radiate, your medical team want to give you 6 months of casodex again, or did you ask for this?

[anpun]

Proposed by the medical team. Why?.Thank you

[GP24]

There is a study by Shipley which used Bicalutamide after salvage radiation. Bicalutamide has fewer side effects than Lupron, so I think this may be the reason the medical team recommended Bicalutamide (Casodex).