FDG+/PSMA- lesions

[MyDad76]

My dad has metastatic CRPC. Xtandi failed, but at the moment he is still on it as we evaluate possible treatment options.

Today we received also results of PSMA PET CT - it it stated, that there are discrepancies (loss of PSMA expression) with at least 4 bone mets when compared to findings of FDG (FDG + / PSMA - bone mets). Most of my dad's mets are in lypmh nodes and now bladder wall - all lymph node mets and bladder have sufficient PSMA expression.

Does this mean that LU-177 is not a good choice for my dad? I guess adding AC-225 to the mix would not make any change in terms of efficacy, as AC-225 also works only on mets expressing PSMA? What is considered a low expression for mets - SUV less than 10?

To get a second opinion on the readings, do you have any suggestions to whom I could turn to? I was thinking of Heidelberg in Germany?

If LU-177 is not a viable option and my dad does not want to peruse chemo, is palliative treatment all that is left? My dad is 81 years old, he does not have co-morbidities and is not experiencing pain, is still doing quite well all things considered.

[Tall_Allen]

Read this:

prostatecancer.news/2019/12...

Without docetaxel first, he will not be able to get Pluvicto in the US, except on a clinical trial.

Docetaxel is his best bet for improving his QOL and extending life. It's too bad that his irrational fears are getting in his way.

[MyDad76 in reply to Tall_Allen]

Pluvicto is not even available in our country, so I would take him anyhow to Germany or Austria and pay out of pocket.

For peace of mind I will send his scan reports for evaluation to one of the clinics in Germany.

As for chemo - perhaps a talk will change his mind, but I will not push and let him decide.

[john205]

Regarding Pluvicto (Lu-177), my oncologist told me that it is available in the US, but for some people it may require referral to another facility depending on where you are. Regarding Xtandi, did he fail treatment from the outset, or did iti initially work, then begin to fail. I have been on Xtandi for almost 3 years and it is now beginning to fail, but slowly, with slow rise in PSA. I recently added Talzenna, a PARP inhibitor that can be used with Xtandi. I don't yet know if I am responding or not. Another alternative is olaparib, also a PARP, inhibitor that can be used by itself. Either of those requires the presence of BRCA, or other relevant mutation in the biopsy, so that info is important. I agree with Tall Allen. There should have been a course of chemotherapy, like docetaxel, before considering any of those alternatives.

For me, my plan is to continue the Xtandi and Talzenna (if it's working) unless my PSA rises dramatically (not happening yet) and is only rising slowly, until my next set of scans is done by the end of this year to see if there is radiographic progression. My next step may be Lu-177. I can do that because I have already jumped through all the other required hoops. Hope that helps.

[Thedawg]

I’m 64 and in pretty good physical condition. I felt I was able to tolerate chemo pretty well. I continued my gym schedule and a modified work schedule. I took nausea medicine about twice a week. That being said, in hind sight, according to my doctor at md Anderson, chemo may or may not have helped my cancer. Radiation and hormone therapy most definitely helped. I’m still on hormone therapy today.

[V10fanatic]

I recently found out that I am PSMA/FDG discordant as well. I'm starting Taxotere this week, but if that doesn't work I expect to move on to Xofigo next. Has your Medical Oncologist brought up Xofigo for the bone mets?