PSMA - how is this?

[Thunderball1]

Click link for animated video:

ibb.co/vP7p8XH

My recent PSMA is shown with 4 images in order. Right-click image, open in new tab to zoom in. What do you see? Does this look bad news to you or of serious concern? Would you suggest RP, radiation, or AS?

My urologist seems to have taken this PSMA scan to supersede all my previous tests as the reason to suggest I have RP (as he said: "if it was me...") and that I see his urologist colleague who does robotic RP (as he is older and does not know that technique, only open RP). Uro2 staged me as pT2c (why the "p"?? error?) but seems based on biopsy/MRI/PSMA not DRE. Anterior TZ tumors are not even palpable, right?

First uro was uncommunicative, pushy and only recommended his TP biopsy. Did not even do DRE. I changed uros.

Second uro: did his suggested TP biopsy. He did DRE but didn't say what he felt. I have asked him to report that result.

Scans seem to be increasingly recognised and PSMA even more so for clinical considerations prognosis. Many articles seem to be out there considering how staging will in future be affected by PMSA so the old-fashioned past methods of DRE only may change in future.

Some of you on my recent post here said I am NOT a candidate for RP but for AS and you suggested I am LOW risk. Why? But you have not examined me fingerwise or otherwise so on what basis do you suggest it? More details below.

I certainly do not want the side effects of RP and currently am thinking of a plan to pursue repurposed drugs (Metformin, Atorvastatin, etc) and AS. I will maybe meet uro's colleague for another opinion but I imagine he will simply suggest RP.

PSMA (7/23)

Report:

PET/CT 18F PSMA

237 MBq F-18 PSR. 140 mL Omnipaque 350

Group 1 carcinoma prostate.

Tumour:

Multiple foci of intermediate PSMA avidity tumour within the prostate

gland.

No seminal vesicle involvement.

Nodes:

No PSMA avid pelvic or paraaortic lymph nodes.

Metastases:

No PSMA avid skeletal or other metastases.

CONCLUSION:

T2 N0 M0 prostate carcinoma

According to PSMA report, no metastases. Good. But what do these lit up areas mean?

PSA:

Two PSA tests in the last week (8/23) were 6 and 7 (7 when done 2 months ago) so I think 6-7 is my PSA although it changes by at least 0.5 every test (??).

MRI (5/23)

Second MRI done (following MRI 6 months ago (PIRADS3). Now suggesting one PIRADS4 right anterior TZ that has increased on scan from 6 to 12 mm in 6 months, and PIRADS3 left TZ 12mm and stable from 6 months ago. Thus bilateral via scan.

Report:

PI-RADS 4 lesion right anterior transitional zone towards the apex. High risk.

PI-RADS 3 lesion left anterior transitional zone towards the apex. Intermediate risk.

BIOPSY (6/23):

TP biopsy targeted right anterior area with 15% involvement of "combined length of tissue") (8 of 12 cores involvement); nothing in right template (11 cores); and less than 5% of "combined length of tissue" in left template area (2 of 10 cores involvement).

---

Please consider these sample images from PSMA and if you have experience with PSMA, sensitivity, specificity, and all that, what do you think this scan shows? I find "experts" these days are overwhelmed by scans that light up. They make the cover of Nature and Science. For example, with brain imaging, what do they really mean? For the brain vs. mind question, not a lot. With PCa??

How bad does my scan look?

According to uro my risk stratification is: T2c, INTERMEDIATE, FAVOURIBLE RISK.

According to MRI Report, the two lesions are: INTERMEDIATE and HIGH RISK.

Nowhere is "LOW" risk ever mentioned by these "qualified experts".

Thanks for your relevant thoughts.

[Tall_Allen]

In the US, PSMA PET scans are not used for low risk PCa because they have no meaning.

[Thunderball1 in reply to Tall_Allen]

My doctor classified my NCCN risk stratification as intermediate favourable, not low . Perhaps you know better? If so, explain.

I found this informative. Perhaps you will too. Maybe.

See from 26min 27 sec - 26:27.

According to this expert from Mayo Clinic, like you, I think he would think I am LOW not intermediate avidity (as per my PSMA report) and so less risk for mets. He would say I have merely some green "blush" as he calls it - "less hot than liver and more hot than blood but far less than parotid glands" - hence LOW avidity.

But you didn't see this before you said I was low risk PCa. Why?

Video should start automatically at the relevant time spot:

youtu.be/JoJomACA5UM?t=1586(Not working as expected?)

And here is my PSMA scan, animated, in case you have familiarity with such visualisation:

ibb.co/vP7p8XH

Have you seen many PSMA scans? If so what do you see and how does it look? Take time. Let's not shoot from the hip.

[Tall_Allen in reply to Thunderball1]

I don't shoot from the hip. You are definitely low risk. I've explained the mistake your doctor made in staging. If you didn't follow, there's nothing more I can tell you. PSMA PET scans are meaningless for your risk stratum. Only Active Surveillance is appropriate for you.

[NotDFL]

I think that you should consider SBRT.

[Thunderball1]

I found this helpful to understand how their colour coding relates to grade (starts around 13 min mark, see esp. 20:36 on). The green shade is low avidity/activity but Report says intermediate??

youtu.be/JoJomACA5UM?t=788(Not working as expected?)

[Thunderball1]

Here is an animated video of the full set of slices in the PSMA PET CT.

3 mm slices.

The green shade is low avidity/activity according to the YouTube seminar, but my Report says intermediate avidity??

ibb.co/vP7p8XH

[RCOG2000]

I had similar diagnostic features in 2000 at age 53 elected treatment with brachytherapy and external beam radiation. Remission for 18 years with minimal urinary and sexual side effects .

[RMontana]

OK...in my view it looks like you are in good shape...the PSMA PET confirms there is no MET (metastasis) and that your PCa (cancer) has not spread; you have a contained tumor at this point! That is great; you goal now is to fine tune what treatment you need, at the latest point you can obtain it, so as to destroy the clone cells before they spread outside the gland! The sooner you act, the less evasive treatment you may need, the better, faster, fuller recovery you will have...that is the short and narrow...

If I were you I would move sooner than later and see if focal treatment is an option; treating the tumor only. You may not need a RP if the tumor is small enough; get some medical opinions on treating the tumor and see if that makes sense...one type of focal therapy could be external beam radiation! Others can include seeding (Brachytherapy). If you treat focally then PSA will guide your next step as you will know if the PCa has been successfully treated or not.

If focal therapy wont work then you must decide between RP and RT...if the tumor is contained and small enough RT may be as effective as RP...if its not contained then in my opinion a RP had some advantages as a skilled surgeon can see what is going on inside during the surgery and the recommendations for follow on treatment can be better supported with your pathology report. I think I shared this but here are the pros and cons of both RP vs RT....

healthunlocked.com/active-s...

For your PSA doubling time, it looks like yours is doubling every 14-15 months, which is good...but your PSA is already too high. Here is a podcast on that subject...for me the size of the tumor, its growth rate and the total PSA are significant and additional AS may not be prudent...if it were me.

healthunlocked.com/active-s...

I had a TZ tumor and NO ONE felt it...I had two URO's and neither one did...you did the right thing and got a pMRI (parametric MRI)...get those as often as needed to track this tumor and make sure it does not approach and extend beyond the prostate. A PIRAD 3 is neutral; a score of 4 starts to lean towards need of treatment; mine was a PIRAD 5 and had by that point escaped my gland; dont let this happen.

You still need genomic scoring of your PCa cell type...I dont see this. For me GS is not enough; I would want to know how aggressive the cell type was. Decypher for me is the best method to do this, although there are many more...here is a good link. If you have a low GS and a low Genomic score, then you could push the AS farther, wait longer to act and follow the tumor growth via pMRI...but sooner or later you will need to treat this...

healthunlocked.com/active-s...

...otherwise, here is the best mapping of testing I have seen; take a look at this and see if this may help you calibrate your decision on treatment...push and ask for these tests. I asked but was blown off...if your insurance can pay for these why not have them...but you need some type of testing, beyond GS (gleason), to make the best decision.

healthunlocked.com/active-s...

In the end what terrifies men about PCa? Erectile Dysfunction (ED)...yes, before I get slammed, death as well, BUT that is not what is bugging you, or was me, at the onset...if your disease is contained your desperate to survive this cursed visitor 'intact,' with you ED minimized...so from that standpoint I can tell you not to worry. There are options for you in the event your treatment takes erectile function away from you; there is hope, life and function beyond that point. Dont fret too much about that. The big thing is the sooner you act, the more treatment options you have, with less evasive outcomes! From the ED standpoint I can share more, but for now dont worry about that...take this journey one entrance ramp at a time...your in a good place and can make really good decisions going forward....do what your doing, seek alternate medical advise and get as much testing as you can to make good decisions...BUT what ever you do, GET this thing before it gets outside your prostate...Rick

[j-o-h-n in reply to RMontana]

To RMontana.......... you're a wicked sob.... but thank goodness you play for our team.....(kudos to you),,,,

Good Luck, Good Health and Good Humor.

j-o-h-n Sunday 08/06/2023 4:33 PM DST

[Thunderball1 in reply to RMontana]

Great, thanks...lots to digest here.

What about using the metabolic approach and repurposed drugs... metformin especially and Atvorastatin for example have been shown to help. Would you support that and AS?

[Thunderball1 in reply to RMontana]

PSADT is more. I mean it goes up OR down by 0.5 or so every time even if twice on same day!! Very unreliable test here. So I round up and average several. Compared to a year ago my PSADT using the calculator is 3.4 yrs.

[RMontana]

…those are viable options. You would have to decide which regime to follow. I should use PSA doubling time as a guide to effectiveness. But I still feel that you were missing genomics testing. If you could get this done and have a low genomics score this would help support continued active surveillance since you have a low Gleason score. I have talked about this in my review of your situation.

That’s what I would do. But you have to decide for yourself how to proceed. Make sure you have your bases covered and have good metabolic baseline testing to know where you were starting from. Good luck and let us know what happens. Rick.