Confused on next step

[compiler]

OK, Cliff Notes Version:

dx in 2009. Failed surgery/SRT. Have done GREAT using Casodex 2 weeks then Lupron + Casodex (50 mg/day), usually 9-12 months. Numerous HT vacations. 3 times scans found a very few ext. lymph node hot spots. Each time did a 3-month Lupron shot + Casodex + SBRT one month after starting Lupron. OK, fast forward to now. PSA rising. Did Pylarify-PSMA scan today. My dilemma:

1) Suppose I get similar scan findings. I keep reading that other drugs work better (Xtandi/Zytiga/other ones I can't remember, possibly along with Lupron?). Nevertheless, do I stick with JUST what's worked (Lupron/Casodex)? That's what I'm leaning towards with the other drugs ready if I don't get the usual response.

2) Suppose scan findings show more widespread spots, rendering SBRT moot. Same question: what to do.

3) Due to a spinal injury, I am not in the best of health (but not terrible either). Do I add chemo? If so, in both cases above, or just #2.

I will be discussing all this with Dr. Lam next month but I'd like to garner your opinions.

Mel

[tango65]

There are many possible treatments if the PET/CT finds progression of the cancer. Please post the results of the PET/CT when they are available.

[compiler in reply to tango65]

Tango & Shooter:

Here are the scan results. I sure hope I'm reading this correctly. I am assuming "physiological" uptakes are not significant. This was also mentioned in my 2018 scan and seemed to not mean anything. It looks again like Oligometastatic disease?-- 2 nodes. I am hopeful these two can be handled via SBRT. Note: I was expecting pylarify scan but it looks like it was again Ga-68. Not thrilled about that, but it's done. I would appreciate any feedback on these results:

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PSMA PET TUMOR CLINICAL

INDICATION: Biochemically recurrent prostate cancer

Initial therapy: Radical prostatectomy

Recent therapy: Salvage RT + ADT

Most recent PSA values(ng/mL):

PSA: 2.0 Date: 9/8/2022

PRIOR PET/CT: 10/17/2018

CORRELATIVE ANATOMIC IMAGING: None

PROCEDURE:

Radiotracer: 68Ga-PSMA

Injected dose (mCi): 5.5

Intravenous injection site: left forearm

About sixty minutes following tracer administration, sequential

non-contrast-enhanced CT and PET imaging were performed from the vertex

of the skull to the mid thigh. Oral contrast (900 mL of 1% w/v barium

sulfate) was administered in divided doses 90, 60 and 5 min prior to

imaging.

FINDINGS:

Overall PET and CT image quality and inter-modality registration are

satisfactory.

Mediastinal blood pool SUVavg: 1.4

Hepatic parenchyma SUVavg: 7.2

Physiological radiotracer uptake in salivary glands, lacrimal glands,

liver, spleen, duodenum, proximal small bowel, kidneys, and urinary

activity.

A. Prostate bed:

PSMA-RADS: 1A. Status post prostatectomy. No abnormal PSMA radiotracer

uptake is noted in the prostate bed.

B. Pelvic lymph nodes (N+ disease):

Key lesion: present

Side: midline

Location: common iliac

Size (maximum in cm): not measurable

Size (perpendicular in cm): not measurable

SUV max: 4.2

PSMA-RADS: 3A

Total number of positive pelvic lymph node lesions: 1

Additional Locations: none

Screen shot(s): yes

Comment (pelvic lymph nodes): Mild persistent low level PSMA uptake

within an aortic bifurcation lymph node, which was previously larger

with more tracer uptake in 2018 (SUV max 4.2, previously 9.6); this

lymph node has been previously irradiated. Prior left common iliac lymph

node has resolved.

C. Soft tissue involvement (M+ disease):

Key lesion: present

Side: left

Location:retroperitoneal

Size (maximum in cm): 0.5

Size (perpendicular in cm): 0.9

SUV max: 53

PSMA-RADS: 5

Total number of positive soft tissue lesions: 2

Other Location: retroperitoneal

Screen shot(s): yes

Comment (soft tissue): Although the previously described multifocal left

para-aortic lymph nodes have resolved following radiation, there are 2

new nonenlarged lymph nodes with intensely increased PSMA expression,

one in the left periaortic region at the level of L2-L3 disc space, SUV

max 44.0, and another anterior to the distal aorta, SUV max 12.3.

D. Bone involvement (M+ disease):

PSMA-RADS: 1A. The osseous PSMA radiotracer uptake is physiologic and

unremarkable.

E. Incidental findings:

Kyphotic curvature of the thoracic spine. Small amount of pericardial

fluid. Status post cholecystectomy. Bilateral renal calcifications

likely represent nonobstructing calculi with the largest measuring up to

0.4 cm in the right and 0.5 cm on the left. Atrophic left kidney.

Fat-containing inguinal hernias.

INTERPRETATION:

1. Two new nodal metastases with intense PSMA expression in the lower

retroperitoneum/para-aortic region, as described in the report body.

Screen shots sent to the PACS.

2. Although uptake at prior irradiated lower retroperitoneal/pelvic

lymph nodes has largely resolved, there is low-level persistent PSMA

expression within an aortic bifurcation lymph node, which is

indeterminate for a residual site of nodal metastatic disease.

Screenshot of this lesion was also sent to PACS.

3. No definite findings of distant metastatic disease.

-----------------------------------------------

Note: The findings are rated as benign/likely benign (PSMA-RADS-1/-2),

equivocal (PSMA-RADS-3), or likely cancer/definitively cancer

(PSMA-RADS-4/-5), as described in the PSMA-RADS classification schema

version 1.0 (Rowe SP, Pienta KJ, Pomper MG, Gorin MA. PSMA-RADS Version

1.0: A Step Towards Standardizing the Interpretation and Reporting of

PSMA-targeted PET Imaging Studies. Eur Urol. 2018;73:485-487)

-----------------------------------------------

[tango65 in reply to compiler]

You could consider ADT plus new anti androgens, for example abiraterone, or try to get Lu 177 PSMA treatment in a clinical trial given the very good PSMA expression of the mets.

You could qualify for one these trials:

clinicaltrials.gov/ct2/resu...

These are systemic treatment which will treat what you see and other areas with smaller size which do not appear in the PET/CT.

To me, direct therapy of the mets gets complicated . One of the previous irradiated metastasis continues to be PSMA positive and I doubt they will irradiated that met again. Consult with your RO.

If I were in your situation I will try to get Lu 177 PSMA treatment, a systemic treatment. I did that in 2016 when I was diagnosed with pelvic and retroperitoneal metastases and 1 treatment of Lu 177 PSMA took care of all the mets according to 5 PSMA PET/CTs done after this treatment.

Lu 177 PSMA treatment is available abroad if financially possible, Germany Austria, Australia, India, Israel etc.

[compiler in reply to tango65]

Tango:

I don't read it that way. It says "largely resolved." Not much uptake. I suspect worth watching. (Indolent?). I'll see what RO and Dr. Lam say.

Mel

[meowlicious99 in reply to compiler]

what about the operating word 'although' in the 'largely resolved' sentence @compiler

I read it same as tango65 that you now have systemic disease, unfortunately.

Please keep us posted about the outcome of your Dr consult. Sending you good vibes.

[tango65 in reply to compiler]

Well, that node has a SUV of 4.2 when the blood pool SUV is 1.4 and the liver SUV is 7.4. I think the report means that they are not sure this a residual lesion of a previous treated metastasis and in consequence this lesion could be active cancer (local recurrence?). The RO will know what to do. Please keep us informed,

I wish the best of luck with your treatment.

[Shooter1]

What a decision to make. In you case I would probably stick with what has worked and milk it for all it's worth. I've never had a decision like that to make. Never had an HT vacation and each time PSA climbed new bone mets have been found.... Doing well though. 5 1/2 years in and now out of SOC treatments, but trying BAT ( so far it doesn't look good) and hoping for another extension on my lease of life. Best of luck to you on your journey.

[compiler in reply to Shooter1]

Good luck Shooter. Hoping you get a pleasant surprise with BAT!

[MateoBeach]

With this progression to retroperitoneal sites I would go for Lu177 treatments as promptly as possible, either Pluvicto if you meet criteria, or abroad.

You could discuss further SBRT with your RO as you are still borderline oligometastatic. But you are approaching the futility of whack-a-mole as we call it. Note that sometimes adequately irradiated nodes can take two years to completely disappear from scans, so residual doesn’t prove treatment failure.

I would definitely stop using Casodex. It often fails and starts feeding the PC after some period of effectiveness. May be better to start a new round of ADT simultaneously with SBRT without Casodex if you have been off of it. And enzalutamide May be better to prepare for Lu Pluvicto treatments.

[compiler in reply to MateoBeach]

Thanks for the feedback. Unfortunately, I am unable to travel much due to a spinal injury. I will see what Dr. Jackson, the RO at Umich, says. I will also see what Dr. Lam thinks. I am still leaning towards the Lupron/Casadex combo since it has always worked so well (drops my PSA to undetectable and T well below 50 with crappy but tolerable SEs). I am hoping that the new node locations are accesible via SBRT. Hoping they have not been previously radiated.

Mel

[compiler]

Well, I looked at my previous (2018) scan as I am concerned that the area has already been radiated. It may have been.:

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Oligo metastatic disease with PSMA expression in distal

retroperitoneal and left common iliac lymph nodes, consistent with

recurrent prostate cancer.

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Very similar to current description but perhaps "distal" seperates it?