PSMA scan results just arrived but interpreting them is difficult and no Onc telmed available until next week. Orgovyx failed two months ago

[SViking]

Any idea what this means or suggestions?

Study Result

Impression

1. Previous prostatectomy with no F-18 PSMA evidence of local recurrence or

2. Two F-18 PSMA avid presumed bone metastases, one in the right posterior third rib and the other in the left anterior T4 vertebral body.

3. No other F-18 PSMA evidence of metastatic disease noted.

Narrative

HISTORY: Prostate carcinoma, status post previous prostatectomy and proton beam therapy; currently on androgen deprivation therapy with rising PSA

FULL RESULT: Prior exam: 1/27/2020 (F-18 fluciclovine scan)

TECHNIQUE: Following intravenous injection of 10.2 mCi of F-18 PYL PSMA and a 89 minute uptake period, multi-bed station 3-D PET and low resolution axial CT image acquisition was performed in a dedicated PET/CT scanner to include the skull vertex to the proximal thighs. Multiplanar PET and CT reconstructions were performed. The CT images were utilized for attenuation correction and localization purposes. CT images were fused with the corresponding PET images.

FINDINGS:

NORMAL PHYSIOLOGIC FINDINGS: There is normal uptake in the urinary tract, liver, spleen, salivary glands, lacrimal glands, and mediastinal blood pool. There is also normal patchy uptake in bowel loops.

ONCOLOGIC AND POTENTIALLY ONCOLOGIC FINDINGS: Previous prostatectomy. No F-18 PSMA activity is noted within the surgical bed or adjacent soft tissues.

There is a focus of intensely F-18 PSMA activity in the posterior medial right third rib with SUVmax of 12.1 although no associated bone lesion is seen on CT (image #174).

New focus of mild F-18 PSMA activity is noted in the left side of the anterior T4 vertebral body with SUVmax of 3.2 also not associated with bone lesion seen on CT (image #182). There is a sclerotic lesion in the right posterior body and right lateral mass of L3 without increased F-18 PSMA activity. No other abnormal bone lesion is seen on the PET or CT portion of the exam.

No pulmonary nodule or pleural effusion is identified although there is mild scarring/atelectasis in both posterior lung bases.

NONONCOLOGIC FINDINGS: There is a right-sided superior vena cava.

There is persistent moderate coronary artery calcification.

Trace pericardial effusion identified.

Single punctate calcification again noted in the liver.

Small left renal cysts and left ureteral stent are also noted without evidence of hydronephrosis.

Mucous retention cyst is newly identified within the medial inferior left maxillary sinus. There is mild bilateral mastoiditis. There is evidence of previous posterior lumbar spine surgery at L4-5.

Reference values:

Mediastinal blood pool activity: SUVmax = 1.5

Component Results There is no component information for this result.

[Tall_Allen]

2 bone metastases. What questions do you have?

[SViking in reply to Tall_Allen]

thanks. But how to proceed from here? Second generation ADT or radiation like photon or proton? I’m just thinking about if they’re going to do radiation will it pass through my lung?

[Tall_Allen in reply to SViking]

I'm confused. Are you on Orgovyx now? You should be. Whether you want to play whack-a-mole with your metastases is of lesser importance. A good RO can advise you about whether it is safe to do so.

[SViking in reply to Tall_Allen]

yes, I am currently on Orgovyx for the last 13 months. PSA started to climb three months ago.

[SViking in reply to Tall_Allen]

What is the downside to playing whack-a-mole? I thought it was better to get rid of the lesions because they weaken the bones.

[Seasid in reply to SViking]

Plus you are also getting rid of the CRPC.

[Tall_Allen in reply to Seasid]

Thanks for explaining. The only downsides of playing whack-a-mole is if you forgo ADT or if you put radiation in places where it is unsafe. So, you are detecting new metastases on a bone scan while you've been using Orgovyx- that shows that castration resistance is beginning. So, I agree with you that it is time to add abiraterone or enzalutamide. If there is bone pain, consider Xofigo too.

Monthly Xgeva or Zometa can prevent fractures. Good idea to get a baseline DEXA scan.

[Seasid in reply to Tall_Allen]

Good advice. Thanks

[SViking in reply to Tall_Allen]

So far, no bone pain. I've previously been treated three times with SBRT at UCLA by Steinberg who really believes that whack-a-mole can go on indefinitely as long as I am ogliometastatic each time. But given the rib lesion this time I might check with Rossi for Proton to be sure my lung doesn't get radiated.

[Tall_Allen in reply to SViking]

Proton won't help if it is unsafe. Steinberg has no evidence of benefit.

[SViking in reply to Tall_Allen]

Dr. Rossi says he can treat the lesions with using SBRT Proton. Five fractions at each site.

[Tall_Allen in reply to SViking]

Did he alert you to any risks?

[SViking in reply to Tall_Allen]

Not yet. I have time to think this over as to what’s worse for my bones? Proton radiation? Or allowing the tumors to weaken my bones further?

[Tall_Allen in reply to SViking]

Monthly Xgeva or Zometa (+ Celebrex) will prevent weakening of bones.

Specifically ask for dose to organs in the mediastinum.

[SViking in reply to Tall_Allen]

thanks again. Dorf put me on 90 day shots of Xgeva a year ago. At that time we did a bone density scan and another one yesterday. Results coming up this afternoon.

[Seasid in reply to SViking]

Just do SBRT to your mets if it is safe to do and you don't have too many big mets and if you don't have other global therapies to control the CRPC in the bone met/s.Otherwise if you have bone pain you could combine Xofigo with chemotherapy.

Micromets did not kill anybody.

You need your MO and RO working very closely as a team. Listen to them and ask for second opinion (maybe from Dana Farber cancer institute) and make an informed desission.

[Seasid in reply to Seasid]

If you didn't have chemotherapy yet you could maybe discuss that with you oncologist before Abiraterone or even local radiation. Chemotherapy can be very effective for bone mets.

[Tall_Allen in reply to Seasid]

Many patients (and doctors, who should know better!) erroneously believe that. Radiation does nothing to reverse the genomic changes that causes CRPC. What one is doing, as far as anyone knows, is "treating PSA."

This may change your thinking:

prostatecancer.news/2020/07...

[Seasid in reply to Tall_Allen]

Thanks, we are all thinking about that.

[Ahk1]

”PET scan revealed two lesions in my seminal vesicles “. 10 years later they found this? Normally the seminars gets removed at the time of the RP. Just wondering why they didn’t take them out.

[SViking]

I’ve heard that in 2010 it was not standard practice to remove seminal vesicles

[NecessarilySo]

I have been in a similar condition, used Orgavyx for a few months, but reverted to Lupron. For awhile I used Xtandi secondary but stopped due to hypertension/cardio concerns. My PSA has been stable for the past two years at <0.1. Per your bio your PSA rose from .008 to .04 recently, causing your concern. I don't get PSA results beyond first decimal point, so imo you might be too anxious about PSA rise.; two readings 0.2 or more indicate recurrence. Your PSA rise suggests possible crmpc but I would watch for several readings before jumping to conclusions., I self treat rib lesion and vertebrate lesion with extra-hot one-minute-showers and they seem to be fading, spine pain gone for past two months. (106 degrees kills cancer cells.) Scans never detected them, so radiolosit missed them I suppose. I just suspect them and feel pain from them. Scan reads are not 100% I gather. PSA can flluctuate also for various reasons, such as physical stimulation of mets. What is your T, testosterone level? Mine is 3.

[dhccpa in reply to NecessarilySo]

Hot showers kill Mets?

[Gl448 in reply to dhccpa]

Someone posted a couple of months ago that hot water does kill prostate cancer. Was it you NecessarilySo?

I so wanted to call out the guy on spreading quack science, but I googled it and found some stuff at cancer.gov about hyperthermia treatments for some cancers. Immersion in special hot water tanks at 113° is one of the FDA approved methods. Another method is temps as low 106° are used to flush inside the peritoneal cavity to treat cancer.

I’m dubious that a hot shower at home actually shrinks bone Mets, but the ribs are close to the skin and if the water is hot enough and applied long enough and often enough it might actually work, so if he thinks it’s helping it probably can’t hurt. Edit: (From cancer.gov:  Treatment with hyperthermia requires special equipment and expertise and is not widely available. It is also not clear if it helps people live longer.)

I doubt hot showers work, but hyperthermia is FDA approved.

Edit: I misread about him having scans showing the Mets actually exist he says they don’t show in scans but he feels them (?).

Either way, I might have to use the hot tub at the gym more often. Can’t hurt. 😆

cancer.gov/about-cancer/tre...

[dhccpa in reply to Gl448]

I've been doing hot water all over combined with a cold finish. This is in my shower/tub so I don't know how hot/cold. I've been doing this religiously since 8/2021. Cheap and easy, but I have no idea if it's working. New scans next week, first since Sept. 2021. This should be a good test of the theory.

[NecessarilySo in reply to Gl448]

Probably me. I suspect I've rid myself of a dozen or more lymph node mets, and several skull mets, over the past five years. Click on my name for past posts.

[SViking in reply to NecessarilySo]

Thanks. My PSA is clearly rising confirming castrate resistant. Interesting idea about hot showers though.

PSA results

[Gl448 in reply to SViking]

From cancer.gov: Treatment with hyperthermia requires special equipment and expertise and is not widely available. It is also not clear if it helps people live longer.

I doubt hot showers work, but hyperthermia is FDA approved..

cancer.gov/about-cancer/tre...

[Seasid in reply to SViking]

Your PSA doubling time is about 1 month. If it continues this way the best would be for you to consider chemotherapy. If you start Abiraterone plus Prednisone or Enzalutamide than you would probably miss the opportunity to have chemotherapy. Chemotherapy is the most effective when the cancer is growing quickly. The beauty of the chemo is that it really kills cancer. You should consider everything with your oncologist.

I had early docytaxel chemotherapy and I am very happy with the results until now.

4 years later i developed CRPC in my prostate according to the PSMA PET scan and just recently finished with the SBRT of my prostate with MRI Linac.

My PSA dropped from 1.4 to 0.67 2 weeks after radiation. These results are not important too much. In 3 months I will test the PSA again.

The PSMA PET/CT scan was performed at PSA 1.25 and i didn't have any visible bone mets or any other mets on the PSMA PET scan nor on the accompanying investigational CT with contrast injection.

I believe that it was a good decision to radiate my prostate cancer as the cancer was in 95% of my prostate with the SUV max value of 14.

Now the hopes are that I could further continue with Degarelix injections alone.

I really don't want to start chemo/ Enzalutamide if it is not absolutely necessary.

We will see what will happen.

My initial idea was to radiate my visible mets. That was my reason for contacting the RO.

4 years ago my MO and RO agreed that I will contact RO when my PSA will start to rise. It went from 0.2 to 1.5 in a little bit more than a year.

Therefore we concluded after the PSMA PET/ CT scan that the cancer in my prostate is now CRPC and that I should make a decision what to do.

I really wanted to get rid of the CRPC cancer from my prostate with SBRT with MRI Linac as soon as possible before the local spreading to my rectum or bladder etc.

My problem was that some people here had 25 chemotherapies and still the cancer was present in their prostate with SUV max value of above 80 on the PSMA PET scan without a single metastasis after all that chemotherapies.

I realized that the SBRT is the best option to get rid of the CRPC from my prostate. If I need, i could add later something else, but now I am staying with Degarelix only at least for 3 months.

[SViking in reply to Seasid]

I heard they are coming out with an adjusted dose Pluvicto for low volume disease like mine. Anyone else know something?

[Seasid in reply to SViking]

It is very toxic and ineffective to get Lutetium PSMA infusions for low volume cancer. Plus it is not recommended if your life expectancy is more than 8 years.

[SViking in reply to Seasid]

Toxic even with lowered doses for low volume disease?

[Seasid in reply to SViking]

I am not a doctor but my understanding is that it is not effective either in low or high dose and it is toxic in a low volume prostate cancer.

In PeterMac they won't give you Lutetium PSMA therapy if you have a low volume cancer.

Why don't you contact Professor Hofman with a short email? He will be more than happy to reply to you.

I am not a doctor and i don't know anything (i don't have a proper information) about your desease.

You just keep this in your mind before jumping into Lutetium PSMA therapy.

[MateoBeach]

This came out this morning. Repeat SBRT to oligo metastatic sites does confer additional benefits.

practiceupdate.com/C/145664...