My SO was diagnosed last year with stage 4 Prostate cancer. Although his PSA never went extremely high (8.0) his Gleason scores were two 8's and a 9. The cancer when diagnosed consumed his complete prostate and was found in the vertebras of his neck, shoulder and shoulder socket plus his pelvis and numerous lymph nodes; plus a spot on his lung. At first androgen suppressant and 3 radiation treatments to his neck plus Apalutamide seemed to begin to tap down the cancer with his PSA level reaching a low of 0.31. However, before a year later, his PSA began to rise. Another PSMA Scan. was preformed with good and bad news.
1. The Good News:
many lymph nodes which were involved seemed to be cleared of disease
the vertebrae in his neck and shoulder bone and shoulder socket disease appeared gone
the left side of his prostate appeared cleared but still present in the right side
2. The Bad News:
Metastatic cancer in his mid to lower back had hugely increased. Cancer appeared in about every other vertebrae
His lungs showed inflammation with PSMA.
He opted out of taking chemo as one of his biopsies (108 page report from Germany) revealed the normal protocol of taxotere would not be effective against his cancer.
We made an appointment to see a well known doctor in Austria who has been treating stage 4 prostate cancer for over 10 years with Ligand therapy.
He has now had 2 nuclear Ligand treatments but still often has severe bone pain (he was diagnosed
with stress fractures in his T12 and T9 just prior to his first Ligand treatment in Austria.
He is due for his 2nd bone hardening treatment tomorrow plus bloodwork. His PSA has lowered some (0.38 now) from it's high. He is still slightly anemic (but has always been slightly anemic) and his hemoglobin is still slightly low (11.2). Lymphocytes are low and Neutrophils are just slightly high otherwise his labs are in the normal range.
Should I be questioning whether the cancer is in his bone marrow which would require a ACC225 ligand treatment? what type of a test will answer this question? Any help or pertinent information would be appreciated.
Written by
chuigk
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There are cancers which don't respond well or at all to Lu 177 PSMA treatment.
Perhaps they may respond to Ac 225 PSMA treatment. The problem with Ac 225 PSMA ligand is the destructive effects on the salivary gland unless the ligand J 591 is used. It may be possible to get this ligand with Ac 225 outside a clinical trial in Australia.
There are several trials with J591 and Ac 225 in the USA
You could discuss doing tandem therapy , a mixture of Lu 177 PSMA and Ac 225 PSMA unless a PSMA PET/CT show diffuse infiltration of the bone marrow. in this circumstance Ac 225 may be the most appropriate ligands to use.
Thanks for your response. His PSMA Scan in early Jan. of 2024 did not mention or apparently show diffuse infiltration of the bone marrow. I was of the opinion that it would require a bone marrow biopsy to determine bone marrow infiltration. His treatments have been in Austria where they also do ACC225 treatments. I am emailing his Austrian doctor today for what tests would show bone marrow disease.
Although he has/had? stress fractures in his T12 and T9 due to the cancer, should he still be having frequent bone pain flare ups?
Lozenges and chewing gum will not protect the salivary glands when using small molecule ligands such as Lu 177 PSMA 617 or Lu 177 PSMA IT . The problem persists if the same ligands are used with Ac 225. I know that in Europe they are fond of the lozenges (they gave me a lot of them when I had Lu 177 PSMA treatment in 2016).
You could also consider to discuss treatment with Provenge ( a vaccine shown to prolong life) and with Xofigo (Ra 223). This treatment could help to control the bone pain and also to prolong life.
As TA said fractures can take a long time to heal. I had a pathological stress fracture in my manubrium which could not be set, of course and surgery to repair it was not recommended. After several months it did heal and I could cough without intense pain. If the fractures are in your spine there is little you can do to prevent motion which cause the pain when the two separate parts move differently. I though my fracture might never heal because the two pieces moved separately every time I coughed or made certain other moves. But it did heal after a long time so at least my body still has the ability to heal bones.
Bone metastases permanently make bones brittle and subject to fracture. Hopefully, the bone strengthening agents will prevent further fractures. But fractures can take a long time to heal.
Ac225 is quite toxic, especially to salivary glands. I know they are experimenting with 50/50 mixtures with Lu177 to dilute side effects.
Thanks! Will advise as to what I find out. His Dr. In Austria already has him taking special lozenges for his salivary glands. I'm adding chewing gum to his protocol to help.
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PSMA PET Looks Good But PSA Rising 
mcrpc , stage iv with aggressive treatments
PSMA scan results 
Prostate Cancer 
