This is for my son's father (and my best friend). His biopsy showed prostate cancer, Gleason Score 7 (3+4), Grade 2, cancer found in all 12 cores. Yesterday he went in for a PSMA PET Scan and the results were delivered to his online account this morning. His Dr is closed for the holiday weekend so we won't have any info from him as far as interpreting these results and a possible treatment plan. Some of the results are obvious in meaning, but we're wondering if these results mean that the prostate can be removed and this is potentially curable? It looks like the cancer is in the prostate and some surrounding lymph nodes, but I'm not positive. Thank you in advance for any help or comments, here is the information we received:
Impression
1. Asymmetric focal right posterior prostate gland uptake consistent with given history of prostate cancer.
2. Small radiotracer-avid right posterior pelvic/internal iliac node compatible with metastasis.
3. Focal right pelvic sidewall uptake, suspicious for small nodal metastasis, versus misregistered ureteral activity.
4. Focal uptake along the left pelvic sidewall and left external iliac region may represent ureteral activity, versus small nodal metastases.
5. No convincing macroscopic radiotracer-avid distant metastatic disease.
TECHNIQUE: Patient was given 6.6 mCi Illuccix (Ga-68 gozetotide/PSMA-11) radiopharmaceutical intravenously. Injection to scan time was approximately 57 minutes. Then, CT and PET imaging was performed from occiput to mid thighs. Reformats and fusion
imaging performed with attenuation correction from CT images.
FINDINGS:
Head/Neck:
No abnormal uptake.
Physiologic distribution of tracer is seen in the salivary and lacrimal glands.
Chest:
No abnormal focal lung uptake.
No abnormal axillary, periclavicular, mediastinal, or hilar nodal uptake.
Abdomen/Pelvis:
At least mild prostatomegaly.
Asymmetric focal right posterior prostate gland uptake SUVmax 12.3, consistent with given history of neoplasia.
Probable small radiotracer-avid right pelvic sidewall node SUVmax 10.3, versus misregistered ureteral activity.
Small radiotracer-avid right posterior pelvic/internal iliac node SUVmax 5.6 measuring approximately 4 x 4 mm (image 337).
Focal uptake along the left pelvic sidewall SUVmax 3.8 may represent ureteral activity, versus small node.
Focal uptake left external iliac region SUVmax 10.3 (image 320), may represent ureteral activity, versus small node.
No abnormal liver uptake.
Physiologic distribution of radiotracer is seen in the liver, spleen, pancreas, ganglia, bowel, kidneys and urinary tract.
Skeleton:
No abnormal uptake.
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Autumn911
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hi! No bone metastasis which is good, he seems oligometastatic, so there are not many metastasis and they can try a curative approach from what I understand. But his doc will surely explain him all the options.
A possible treatment plan would be radiation of the prostate and the pelvis to radiate the lymph nodes. After that hormone therapy for a while. Should result in a very long survival.
It is incorrect to state: " but we're wondering if these results mean that the prostate can be removed and this is potentially curable?" A prostatectomy is not the only way to cure prostate cancer. Radiation may be curative, as it was with me.
There may be some cancer in the pelvic lymph nodes, but that is not at all certain. The uncertainty comes from the kind of PSMA PET tracer they used (Ga-68-PSMA-11). It is excreted from the kidneys, which is why the report repeatedly mentions the ureters. A new radiotracer, Posluma, is not as likely to give false positives. He should discuss re-doing the PET scan with Posluma.
There was a CT. It says,"measuring approximately 4 x 4 mm (image 337)." That had to be from a CT. The problem was the radiotracer used, not that it lacked a CT.
A PSMA PET/CT is more sensitive than a CT. If the met does not show up on the CT it does not mean there is no met. Stefano Fanti discussed this in a presentation. It is wrong to accept only those mets which are also visible on the CT.
You misunderstand. A CT is absolutely necessary at time of PSMA PET.
During the study the radiologist will overlay the PSMA PETT over the CT.
Without it a radiologist could not identify the location and position of the tracer.
A CT will be able to show where the ureters are, if the tracer shows to be at the ureter position, a good radiologist will properly determine whether is tracer being removed, or a lymph node ir bone met.
PSMA PET can show PSMA expression even if there is no correlation on imaging with CT or MRI. However, when SUVmax is low, and there are no imaging correlates, it is assumed that it is a false positive, especially if it is in an area known to give a false-positive with the Ga-68-PSMA radiotracer, like the ureters or the outer perimeter of the prostate. It is much more definitive to get a Posluma PET/CT that has a lower false-positive rate around the prostate.
Prof. Fanti mentioned: As part of the Q&A at APCCC 2024, respondents were asked “In the majority of patients with clinically high-risk localized or locally advanced prostate cancer and one PSMA PET positive bone lesions, without a correlate on the CT component of the initial PSMA PET, what do you recommend as the next investigation?” Dr. Fanti was shocked that the most common answer (55%) was correlate with conventional imaging (ie. MRI, x-rays, or bone scintigraphy)
He also discussed false positives but concludes: "CT confirmation is not useful or necessary"
I put your report into AI for a simple summary - here's what came back
Prostate Cancer Location: The scan shows a significant focus of cancer in the right back part of the prostate gland.
Lymph Node Metastasis: There is a small lymph node in the right pelvis that appears to have cancer.
Suspicious Area: There's an area in the right pelvis that might be a small lymph node with cancer or possibly just a misregistered ureter (part of the urinary system).
Additional Suspicious Areas: On the left side of the pelvis, there are areas that might also be small lymph nodes with cancer or ureteral activity.
No Distant Metastasis: There is no evidence of cancer spread to distant parts of the body.
Interpretation:
The cancer is primarily in the prostate and has likely spread to some nearby lymph nodes.
Curability and Treatment: It is often possible to treat prostate cancer effectively, especially when it has not spread to distant parts of the body. The doctor will consider several factors, including the spread to lymph nodes, to decide on the best treatment plan. Options might include surgery to remove the prostate, radiation therapy, and/or hormone therapy.
It is important to wait for the doctor’s interpretation for a definitive treatment plan.
I'm with TA. - check out Radiation first before you (as some put it) extract the "mothership"
A well thought out Radiation plan can deal with both Prostate and Pelvic Lymph nodes. In the meantime get onto some ADT to put a lid on the cancer growth.
I'm into my Radiation / ADT treatment plan with some Brachy Boost to be done in August. So far I feel fine and pretty positive.
Always get both sides of the PC treatment story. Surgery is only one side.
(corrected regarding Posluma). With my imaging experiences with this beast, I learned to seek second radiology opinions and concurrence of the two opinions – or I ask the radiologists to strive to come to agreement. And, I make sure my doc’s will truly use the results in making their recommendations. Also, I leaned this is especially important in the US as PSMA’s were not approved for use in US until December 2020, so practical experiences are limited.
To your question of curable – this discussion can be an endless loop. I think your statement is correct as can be radiated can replace “can be removed”. Whether surgery or radiation is used for primary treatment, curability depends on all the cancer being within the treatment field, which is not yet possible to determine with 100% accuracy. My cancer was not confined to my prostate gland and post my RP, my remaining cancer was not all within the salvage radiation field.
If I could have a do-over, I would again have surgery but with extended pelvic lymph node dissection (ePLND) using the frozen pathology section method. As Justfor stated, availability of this procedure is limited in the US. I traveled abroad for my salvage ePLND over six years ago. I am only aware of the Mayo clinic offering this procedure in US.
As for whether your docs used the correct tracer, this can be another endless loop discussion. I have had two Ga 68 PSMA PETs and just today had my second Pylarify. My first Ga 68, done in Europe in 2018, was clear, while the ‘better’ Ferrotran nanoparticle MRI identified five suspicious pelvic lymph nodes; confirmed by salvage ePLND. In my experience Pylarify has not proven to be any 'better' than Ga 68. I have not had Posluma - not familiar with it.
Although there now seems be some ‘debate’ as to usefulness of mpMRI, I continue to have mpMRI imaging for comparison with my PSMA PET.
Hope this helps. All the best for your best friend!
appreciate the correction - I have edited. Looks like Posluma has been out a year or so - perhaps worthy of inquiry even though it does seem to come with common claims and disclaimers.
Additional comment: Found this interesting statement - "Those are important aspects of the trial in basically showing that we can identify patients who perhaps are not staged based on our conventional imaging as a localized prostate cancer, which basically outperforms the conventional imaging that is currently used, whether that be bone scan CT or MRI scan, which is largely what's used in the US. In addition to the findings in LIGHTHOUSE....".
I note no mention of Ga 68 nor Pylarify and no clarification of type of MRI - such as multiparametric MRI or Ferrotran nanoparticle MRI (latter not available in US).
I think this adds to my comment the discussion of best imaging methods is an endless loop. Interesting that advertising for Pylarify is embedded in this Posluma 'review' -
Wow, thank you so much everyone for your input. This has given me so much information to go on when helping him figure out the best path forward. Right now we've only been working with the urologist, so my next step will be to make an appointment at the best cancer treatment center we have here. We'll request a second opinion on all of the data and images and request a second PET scan using Posluma to get a more accurate reading of lymph nodes involved. I'll post again when we receive a treatment plan and run it by you guys before we agree to it. Thank you again for your help, it really means a lot.
friendly comment, radiologist do imaging and oncologist do radiation and drugs - that's what they 'want to do'. Yes, a bit of support for urologist whose profession and surgical skills I am most grateful for. Just yesterday consulted with oncologist also certified in hematology - the combo I like. Handling my Pylarify and blood biopsy. All the best to all of us fighting this beast.
I used my AI, perplexity with Claude 3.0 on academic mode. Here is the summary and solutions.Based on the provided PSMA PET scan results, here is a summary of the findings and potential treatment options for prostate cancer with a Gleason score of 7 (3+4), Grade 2, and cancer found in all 12 biopsy cores:
PET Scan Summary
The PSMA PET scan shows:
Asymmetric uptake in the right posterior prostate gland consistent with the known prostate cancer diagnosis.
A small radiotracer-avid lymph node in the right posterior pelvis/internal iliac region, compatible with metastasis.
Suspicious uptake in the right pelvic sidewall and left pelvic sidewall/external iliac region that could represent either additional small nodal metastases or ureteral activity.
No convincing evidence of distant metastatic disease outside the pelvis.
Treatment Options
For prostate cancer with a Gleason score of 7 and lymph node involvement, treatment options may include:
Surgery (radical prostatectomy) to remove the prostate and nearby lymph nodes
External beam radiation therapy to the prostate and pelvic lymph nodes, often combined with hormone therapy
Hormone therapy alone or in combination with other treatments
Chemotherapy, such as with docetaxel, in some cases
The optimal treatment approach depends on factors such as the extent of cancer spread, overall health, and patient preferences. Studies suggest that intensifying treatment with a combination of surgery or radiation plus systemic therapy may improve outcomes for node-positive prostate cancer, although more research is needed.
Close monitoring with additional scans and discussions with the oncology team will help determine the most appropriate course of action. Cure may still be possible if the cancer is limited to the prostate and nearby lymph nodes. However, the lymph node involvement does increase the risk of recurrence compared to cancer confined to the prostate.
In summary, the PET findings are consistent with high-risk prostate cancer with pelvic lymph node spread. A multidisciplinary team should review the case to recommend an individualized treatment plan, likely involving a combination of local therapy (surgery or radiation) and systemic treatment (hormone therapy +/- chemotherapy). While cure is still potentially achievable, close follow-up will be important to monitor treatment response.
Summary of PSMA PET Findings
The PSMA PET scan shows:
Asymmetric focal uptake in the right posterior prostate gland, consistent with the known prostate cancer
A small radiotracer-avid right posterior pelvic/internal iliac lymph node measuring 4x4 mm, compatible with a lymph node metastasis
Additional focal uptake in the right pelvic sidewall and left external iliac region that could represent either additional small lymph node metastases or misregistered ureteral activity
No convincing evidence of macroscopic distant metastatic disease
These findings indicate the prostate cancer is likely stage III (T1-4 N1 M0) or possibly stage IVA (T1-4 N0-1 M1a) if the additional pelvic uptake represents definite lymph node metastases. The lack of distant metastases is a good prognostic sign.
Proposed Next Steps
Discuss the PSMA PET results with the patient, explaining that the cancer appears to be confined to the prostate and nearby pelvic lymph nodes, without any spread to bones or other organs.
Recommend a multidisciplinary evaluation by medical oncology and radiation oncology to discuss the optimal treatment approach, which will likely include:
Androgen deprivation therapy (ADT)
Radiation therapy to the prostate and pelvic lymph nodes
Consideration of chemotherapy in addition to ADT and radiation, given the lymph node involvement
If not already done, send the prostate biopsy tissue for genomic testing to further characterize the biology and aggressiveness of the cancer. This can provide additional prognostic information.
Engage the patient in shared decision-making regarding his treatment preferences and goals, weighing the potential benefits, risks and quality of life impacts of the different treatment options.
Develop a comprehensive treatment plan that addresses both the cancer and the patient's overall health, with close follow-up and
It sounds a little like mine from 4 years ago, only I had it after removing the prostate, then finding the PSA rising. I have been on ADT therapy for 4 years with no growth in the lymph node mets, and have kept working full time. I think the prognosis is pretty good. I wish you the best
Don't be so quick to consider 'prostate removal' as the only or best option. It is the most invasive option, the option most likely to lead to impaired QOL -- quality of life. It is also what urologists do. It's how they make a living.
and don't other docsc make their living doing their thing? I remain most grateful I worked through all the anti-urologist/surgery talk when I chose RP nearly nine years ago. And it certainly is true radiation and ADT lead to impaired QOL for too many men.
Congrats on your excellent results. I stand by what I said. I chose an option other than RP surgery and I am doing fine. Actually, after TURP surgery for BPH ten years prior, I was considered a poor candidate for RP. So RP isn't a good option for other reasons too, besides invasiveness and QOL concerns.
I wish to note I do not bash RT as so many bash RP. I was considered a poor candidate for RT - based on mpMRI findings adequate margins were not achievable.
I realized the great benefit in the full removal of the primary tumor and the ability to so quickly and accurately test to <0.010. My post RP nadir was 0.050 and we immediately knew my cancer had gotten out - sparing me the deliberations of proclaiming when recurrence 'begins'; of course with spread it is actually not recurrence.
Would you please update your friend's bio (age? location? meds? treatment center(s)?Doctor(s) name(s)? PSA numbers, and etc.). This info is voluntary but it helps him and you and helps us too.
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