PSMA PET Looks Good But PSA Rising

[FaithOverFear104]

Hello, I am hoping someone can help us understand what we might be missing prior to meeting with MO this week.

My husband was diagnosed with metastatic prostate cancer with mets to pelvic lymph node and a few spots in bones in early January 2022 at 56 years old. He was successfully treated with Triplet Therapy and has been off all meds on ADT vacation since February 2023 (full history in bio).

He still has his prostate. His PSA has been going up since August 2023. The last two checks, it was over 6. His MO did not seem concerned about those numbers because he is otherwise healthy and his first PSMA PET in November showed a possible recurrence, but contained to his prostate. No mets anywhere. However, since there was such a big jump between two recent PSA checks, another PSMA PET was ordered - and, as far as we can tell, it still looks pretty good (??) - even better than the November scan.

Just wondering how his PSA could be going up to the degree that it has, when his PSMA PET looks relatively okay as far as we can tell? I will post the most recent scan report below. Is there something we should be asking the MO about? Why would PSA be going up but PSMA PET looks the way it does?

Thank you in advance for any input and guidance.

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February 12, 2024. Submitted body PSMA (F-18 piflufolastat) PET/CT performed originally February 2, 2024

CLINICAL STATEMENT: Prostate CA. EOD

TECHNICAL DETAILS PER OUTSIDE REPORT: Reviewed

FIELD OF VIEW: SKULL VERTEX to the upper thighs The standardized uptake values (SUV) are normalized to patient body weight and indicate the highest activity concentration (SUVmax) in a given disease site.

COMPARISON: PSMA (Ga-68 PSMA) PET/CT November14, 2023 ; different PSMA radiopharmaceutical, therefore SUV comparisons are not meaningful and therefore not reported

CORRELATION: None

FINDINGS:

HEAD/NECK: no suspicious findings

LUNGS: Unchanged right upper lobe calcified granuloma.

PLEURA/PERICARDIUM: No abnormal uptake.

THORACIC NODES: No abnormal uptake.

HEPATOBILIARY: No abnormal uptake.

SPLEEN: No abnormal uptake.

PANCREAS: No abnormal uptake.

ADRENAL GLANDS: No abnormal uptake.

KIDNEYS/URETERS/

BLADDER: Excreted tracer and physiological uptake limit PET evaluation

ABDOMINOPELVIC NODES: No abnormal uptake.

BOWEL/PERITONEUM/

MESENTERY: diverticulosis coli

PELVIC ORGANS:

Prior PSMA tracer avid lesion involving the right andposterior midline subregions of the prostate diminished in extent, scintigraphically; residual small ill-defined patch, image 270 series 12, SUV 5.4.

BONES/SOFT TISSUES:

No suspicious bone lesions

Few scattered subcentimeter sclerotic PET-negative bone lesions unchanged, probably benign

OTHER FINDINGS: None.

IMPRESSION: Non-MSKCC PSMA (F-18 piflufolastat) PET-CT February 2, 2024 submitted for MSK interpretation,

Since prior MSKCC (Ga-68) PSMA PET/CT,

1. PSMA tracer avid prostate gland disease, probably diminished in extent scintigraphically.

2. No PSMA tracer avid metastases evident elsewhere. Additional findings as above

FINAL REPORT

[God_Loves_Me]

here is good article urotoday.com/conference-hig...

[NanoMRI]

As you asked for any input. After my RP and salvage RT failed to get all my cancer, six years ago, at usPSA 0.10, I had both Ga68 PSMA and perceived better Ferrotran nanoparticle MRI. The Ga68 was clear, as anticipated, while the nanoMRI identified suspicious lymph nodes. I went for salvage pelvic lymph node surgery which confirmed cancer in my common illiac and paraaortic nodes. Hope this helps. All the best!

[Tall_Allen]

"... and a few spots in bones in early January 2022 ..."

Exactly how many is "a few"? I assume it was on a bone scan/CT?

[FaithOverFear104 in reply to Tall_Allen]

Sorry, TA - I think we haven't been entirely sure about the exact number because of the multiple notes on his baseline reports from Jan 2022 (NM Bone Scan whole body and CT Abdomen, Chest Pelvis) because of the multiple references to "possibly degenerative, benign, etc.". (two in spine and one rib?? And lymph node). In any case, here are those reports. All subsequent scans showed resolution of mets and even at one point in early 2023, "no suspicious findings in prostate". The PSMA PET I am asking about in original post is his second one. First was in early November. Wondering if we should be asking for different testing to understand why PSA is going up given that it looks like not much is going on in PSMA PET (if we are interpreting it correctly) Thank you for your help:

NM BONE SCAN 1.13.22 FINDINGS:

SKULL: Slightly heterogeneous uptake in the skull, nonspecific.

SPINE: Multifocal uptake in spine, corresponding to slightly sclerotic lesions on CT, for example in T9 and L3. Focal uptake in the cervical spine, possibly degenerative. Focal uptake laterally along L4 and T12 possibly degenerative.

RIBS, SCAPULAE,

CLAVICLES, STERNUM: Focal uptake in left posterior ninth rib, corresponding to slightly sclerotic lesion on CT. Focal uptake in the sternal body, corresponding to a slightly sclerotic changes on CT. Mild uptake in the lateral right rib, corresponding to healed fracture on CT.

Focal uptake in the right third and left seventh costochondral junction with no correlating finding on CT, probably benign/degenerative.

PELVIS: Uptake in the right ischium and left iliac crest, corresponding to slightly sclerotic lesions on CT.

EXTREMITIES: No abnormal uptake

SOFT TISSUES: Physiologic uptake

KIDNEYS/BLADDER: Both kidneys are visualized. Excreted activity is present in the urinary bladder.

IMPRESSION: Findings consistent with osseous metastasis.

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CT ABDOMEN, CHEST PELVIS done on same day:

FINDINGS:

LUNGS/AIRWAYS: Coarse calcification in the right upper lobe measuring 0.9 cm. Subcentimeter lower pole nodule measures 0.3 cm and in left upper lobe anterior measures 0.2 cm

PLEURA/PERICARDIUM: No effusion.

MEDIASTINUM/THORACIC NODES: No adenopathy.

HEPATOBILIARY: Unremarkable.

SPLEEN: Unremarkable.

PANCREAS: Unremarkable.

ADRENAL GLANDS: Unremarkable.

KIDNEYS: Unremarkable.

ABDOMINOPELVIC

NODES: There is pelvic adenopathy. Right obturator/external iliac node measures 4.3 x 3.2 cm, right internal iliac suspected node measures 0.9 cm and node/nodule in the right ischial anal fat measures 0.7 cm.

PELVIC ORGANS: Prominent prostate with increase vascularity on the right; should be correlated with submitted MRI December 24, 2021.

Suspect left pararectal node measuring 1.1 cm versus contrast filled diverticulum.

PERITONEUM/ MESENTERY/BOWEL: Colonic diverticulosis. No ascites. No bowel obstruction

BONES/SOFT TISSUES: Scattered sclerotic osseous lesions including in the pelvis and spine at L3, and T9. Correlate with same day bone scan

OTHER: Fat-containing left inguinal hernia.

Atherosclerotic changes

IMPRESSION:

1. Scattered nonspecific subcentimeter pulmonary nodules.

2. Abnormal prostate which should be correlated withsubmitted MRI

3. Right pelvic adenopathy. Left pararectal node versus contrast-filled diverticulum.

4. Suspect bony metastases. Correlate with same day bone scan.

[Tall_Allen in reply to FaithOverFear104]

The exact number on a bone scan at the time of diagnosis matters because if there are 3 or less, radiation to the prostate may still be beneficial:

prostatecancer.news/2018/09...

Ignoring the ones that may be attributable to benign/degenerative causes, there are these with correlative CT findings:

SPINE: T9 and L3.

RIBS, STERNUM: left posterior ninth rib, sternal body

PELVIS: right ischium and left iliac crest

So I count 6 bone metastases, which is too many. It is a biomarker that tells you if debulking is likely to have any benefit. It doesn't matter what did or did not show up after therapy or on a PSMA PET scan.

[FaithOverFear104 in reply to Tall_Allen]

Thank you so much for clarifying that for us. Wish his MO would have from the beginning. But anyway....Wondering if is there other imaging or testing we should ask his MO for to try to get to the bottom of the PSA rise?

[Tall_Allen in reply to FaithOverFear104]

There's a lot more metastases than one can see with any kind of imaging. Even the best PET/CT scan can't see any tumors less than about 5 mm in length. With PSA rising, you have to assume some occult tumors are active and treat accordingly.

[FaithOverFear104 in reply to Tall_Allen]

Thank you so much. I appreciate your input very much.

[j-o-h-n in reply to FaithOverFear104]

He's an Ace.......

Good Luck, Good Health and Good Humor.

j-o-h-n

[FaithOverFear104 in reply to j-o-h-n]

Definitely!!!!