1st PSMA pet scan results; help with meaning?

[Keeper70]

My husband just received the report but won’t be seeing the MO until Thursday. Can someone explain these findings?

1. tracer avid multi focal prostate nodules with extensive involvement of the right aspect of the prostate with extra prostatic extension consistent with prostate cancer.

2. 2 tracer avid normal size right internal and right external iliac nodes consistent with nodal metastatic disease.

Any help understanding this would be greatly appreciated

His psa was .2 at time, btw his psa at Dx was 4.1, he’s stage 4 Gleason 9

Thanks to all

[GP24]

There is cancer in the prostate as you already know. It has grown a bit outside already. Then there are two affected lymph nodes which are no immediate threat.

Why don't you get the prostate radiated including the lymph nodes in the pelvis?

[Keeper70 in reply to GP24]

So….. that may be a next step? our MO will review report with us in a couple days. Do you think that the PSMA detected something new? Seems like FDG pets indicated similar node involvement but we thought chemo fixed that 3 years ago. His psadt is a concern as Elligard and Casodex are his current line of treatment

Thank you!

[GP24 in reply to Keeper70]

I would have done this step shortly after diagnosis. But you can still do this. My suggestion is to make an appointment with a radiation oncologist and discuss radiation with him. Your MO will not radiate you. Combining radiation with hormone therapy is usually very effective.

[Keeper70 in reply to GP24]

thank you so much, we will , sounds like our winter in Arizona may be a bit different this year ☹️ Does anyone know a good center near Mesa?

[Keeper70 in reply to GP24]

Thank you again for your suggestions. My thoughts are if MO switches him to Abi or Enzalutamide, could he wait a few months before getting radiation? Or is it wiser to deal with it now? What kind, I”ve read about brachia? We don’t have a radiologist oncologist at this time. and we don’t know much Thanks!

[GP24 in reply to Keeper70]

I would suggest a standard IMRT radiation because you will want to include the two iliac nodes in the radiation field. Brachytherapy is directed to the prostate and not to the lymph nodes. The radiation oncologist will make a recommendation based on the PSMA PET/CT and the radiation systems he has available. Maybe you can arrange a video consult with the hospital you prefer for the radiation. You cannot just walk up to the hospital and expect to be radiated the following week. Yes, you can wait for a few months. But be aware that your husband has a disease which intends to kill him.

[Keeper70 in reply to GP24]

Ouch!’ That last line of your reply really stung, I think I’ll sign off here for a while

Hope everyone stays healthy and happy.

[Tall_Allen]

The scan detected cancer in the prostate and in his nearby pelvic lymph nodes, which tells you he is castration resistant. Consider Xtandi or Zytiga next.

[Keeper70 in reply to Tall_Allen]

thanks TA, kind of what we thought but his psa is still quite low at .22, he has never had high PSA as he was DX at 4.1 it’s so crazy trying to figure all this out! Do appreciate so very much all your responses

[GP24 in reply to Keeper70]

I think it is likely that a PSMA PET/CT in 2019 would have shown more mets. These did shrink during chemo and ADT and now you can detect only two mets with the PSMA PET/CT. In this case your husband would not be castration-resistant now. Adding Xtandi or Zytiga will help though.

[Keeper70 in reply to GP24]

Thank you GP24.. if you would , please elaborate why you think that adding Enz or Abi would be of benefit now or just stay on ADT and Casodex until PSA gets a bit higher? He will be tested monthly for the rest of the year and while we are in AZ , he will get his Eligard shot there.. thank you, and best to all that are dealing with this b*tard of a disease....

[GP24 in reply to Keeper70]

Enza and Abi are more effective than Casodex. Therefore replacing Casodex with either Enza or Abi+Pred. will control the cancer for a longer time as recent trials have demonstrated.

However, destroying tumor cells with radiation is beneficial and I recommend to add that to the hormone therapy.

[Teacherdude72 in reply to Tall_Allen]

Why not Nubeqa?

[Tall_Allen in reply to Teacherdude72]

He was metastatic when he had chemo, so he is metastatic and castration resistant - only Zytiga and Xtandi are approved for that.

[Keeper70 in reply to Tall_Allen]

I follow you TA and I always appreciate you citing studies and providing links to clinical trials, etc. There’s so much to this disease and so much more to learn from all of these contributors on this forum! Based on my husband’s PSM A pet and pelvic lymph nodes involved, Besides adding Zytiga or XTANDI , As someone else suggested is radiation a good option in addition to ADT? And if so , what kind? Thanks in advance for any replies

[Tall_Allen in reply to Keeper70]

When he had chemo, he was polymetastatic, right? If so, there's been proven to be no oncological value to radiation of the prostate.

There may be some value in preventing urinary problems later, but that has to be weighed against the side effects of radiation.

[Keeper70 in reply to Tall_Allen]

thank you TA.. not sure if he is oligo or poly.... was never listed anywhere but he had 3 bone mets and 2 lymph nodes... none of which showed up after his 5 rounds of chemo and started ADT with Lupron......... when he switched to Eligard, he was still psa undetectable until May this year when he was prescribed the Casodex.... our MO is not a prostate specialist.........maybe time to find a prostate specific MO and RO.....what you do think/ MN is a great resource for U of MN medical and Mayo.. but we are several hours out of town......

[Tall_Allen in reply to Keeper70]

Charles Ryan at UofMN is also CEO of the PCF - if he's taking new patients, he's great! Also Emmanuel Antonarakis. I don't know any prostate oncologist who has a great reputation at Mayo.

If he only had 3 distant metastases, debulking the prostate (with whole pelvic radiation) may still be helpful.

prostatecancer.news/2018/09...

[Keeper70 in reply to Tall_Allen]

Thank you TA... will check them out! Maybe a better option going forward....

[Seasid in reply to Tall_Allen]

Preventing urinary problems is a big deal. I am doing the SBRT of my prostate as it is very difficult to control the cancer inside the prostate without radiation. I have no regrets although I am polymetastatic.

The second reason for radiating my prostate is that I don't have any visible mets on the 68ga PSMA PET scan. Therefore we hope that I could continue on Firmagon injections alone. That would mean less side effects.

It looks that the cancer in the prostate is castrate resistant while the bone mets are still hormone sensitive.

Therefore killing the castrate resistant prostate cancer in the prostate gland is a good thing.

I actually wanted to kill all the visible mets with SBRT MRI Linac but the PSMA PET scan didn't show any mets.

[Tall_Allen in reply to Seasid]

Only being oligometastatic on a bone scan/CT counts. If you have no metastases on a bone scan/CT, you are technically considered to be non-metastatic (stage M0) for purposes of whether its advisable to do debulking with radiation. That is true whether or not metastases show up on a PET scan.

Prophylactic radiation of the prostate has to be made on a case-by-case basis. Often, hormone therapy will shrink the prostate enough so that one can pee well without radiation.

[Seasid in reply to Tall_Allen]

I agree with you. But I realized that the radiation is the most effective in killing the cancer in the prostate.

One member here had 25 chemotherapy treatments and still his SUV max value was above 80 on the PSMA PET scan.

4 years ago my RO and MO agreed with each other that I will contact again RO.

I did that and the 68ga PSMA PET scan was performed and professor Emmett didn't see any mets only castrate resistant prostate cancer with SUV max value of 14 in my prostate.

Therefore I made a decision that even if the radiation therapy will not extend my life it has a potential to make my life more carefree without nightmares about the cancer spreading locally to the rectum or / and urinary bladder etc.

Maybe I made a mistake?

I really didn't want to go to chemotherapy or Abiraterone plus Prednisone or Enzalutamide at this stage when Degarelix injections alone can manage the cancer in my bones.

I also had the FDG PET scan just to see that I dont have any mets, neither PSMA positive nor PSMA negative mets.

[Tall_Allen in reply to Seasid]

The point is that irradiation of the prostate DOES extend life if there are 0-3 metastases on a bone scan/ct.,which is what you had.

[Seasid in reply to Tall_Allen]

Good point. Thanks

[Keeper70]

thank you, waiting to see what MO says on Thursday... you maybe right on!! It would suck to have to do radiation in AZ though

[tango65]

How many metastases did he have in the previous scans? How do the previous scans compare with this scan?

[Keeper70 in reply to tango65]

Hi Tango.... this was last fdg pet was in June '22...Impression: No evidence for FDG avid residual or metastatic disease.. so in 4 months they found mets, but not in bones... kind of disappointing none the less.... PSMA more accurate and sensitive,, may have been there all along as far as we know? .. thanks for the reply

[tango65 in reply to Keeper70]

You said he had metastatic cancer, what were the results of the studies showing he was metastatic?

[Keeper70 in reply to tango65]

Original diagnosis showed Mets in his right acetabulum , left hip and a small spot in spine; chemo seemed to resolve that, mo said 2 lymph nodes not a big concern,and since 2019 ,pets 2x year show no new hot spots

[tango65 in reply to Keeper70]

If I am understanding correctly he had only 3 bone metastases at diagnosis. The cancer was oligometastatic castration sensitive. The Stampede study showed that oligometastatic CSPC had a survival advantage if the primary tumor was irradiated.

The situation now is different, but he continues to be oligo metastatic .

It may not be the SOC, but I thinik you could consider to consult with a radiation oncologist and discuss about doing radiation to the primary tumor and the whole pelvis and ADT plus abiraterone.

The radiation may not prolong life at this time but it may help to reduce local complications in the future when the cancer becomes difficult to control. Cancer in the pelvic limph nodes and cancer in the prostate may growth and cause complications withe the urinary track and even with the rectum.

[Hidden]

wow! That is a lot to digest. I appreciate the information and will need to address this with our MO

She never advised us to consult any RO

As Docetaxel was 1st line

His 6 cycles were reduced to 5 and then just Lupron till Elligard subbed in 2021

Clear scans until PSA started increasing yet still very low, Casodex added May”22

Fdg pet clean, PSMA not so much? Thank you for offering some enlightening info!

[RMontana]

Try this LINK...also click on my icon and there are other articles I reference...good luck...TNX

youtu.be/uKvizpoiMlU(Not working as expected?)

[Keeper70 in reply to RMontana]

thank you for sharing that video! He does fit into one of those scenarios discussed! So much to think about

[mjtct61]

How would one know they are castrate resistant with a PSA of .2? I thought the PSMA PET scans werent that accurate until PSA reaches 2?

[Keeper70 in reply to mjtct61]

that’s a great question. I’ve heard various opinions but most were .2 or above. My husband was switched to PSMA from FDG by our request, MO was out of town but did order it, will get to discuss findings and treatment options with her on Thursday

[Seasid]

You could do what tango65 recommend and continue with ADT only.