Introduction and asking for help interpreting latest scan results and thoughts on future treatment plan please.

[APCFighter]

Long time reader but first time posting..

I have just received my latest PSMA PET-CT scan results and would like some help interpreting the results and gain your thoughts about situation and treatment plan.

My overall history:

After slowly rising PSA scores to a relatively low peak of 6.1 at 59 years old, biopsy was completed in 12/2019. Had non-nerve sparing RALP with pelvic lymph nodes bilateral 02/2020. Pathology found Advanced Stage - 4, 90% ductal variant prostate cancer with Non-focal, margins involved, multifocal, and extraprostatic extension. Gleason score = 7 (4+3).

PSA scored remained higher than expected and subsequent PSMA scan in 05/2020 showed metastasis as regional and rectal distant lymph nodes cancerous

Received 35 Radiation treatments ending 12/2020 along with 6 monthly HRT shots ending 1/2021. NED until August 2023 then PSA started rising slowly wtih PSA increased from 0.113 on 2/27/2024 to 0.224 on 5/28/2024.

Had a PSMA PET-CT scan on 12/6/2023 that was completely clear. I had another PSMA PET-CT scan on 7/5/24 which shows:

1a.) A bio-chemical recurrence with a 4 mm left para-aortic node with subtle tracer uptake (SUV max 3.0) which has increased in size (previously 2 mm) and is newly tracer avid from prior exam (previously SUV max 2.1).

1b.) Additionally, in the left mesorectal region, there is a focus of subtle tracer uptake without definite CT correlate (SUV max 2.5).

2.) There is also a single tracer avid punctate sclerotic focus within the medial right iliac wing showing the beginnings of bone metastasis.

Current recommended treatment plan is Lupron shots, either Abiraterone acetate along with Prednisone or Enzalutamide. Also have a consultation with the radiation oncologist scheduled for next week.

Thoughts and opinion on treatment plan very much appreciated?

[DLimey]

what was your psa ahead of the psma?

We are in mets finding stage. Another psma in 2 weeks.

Similar pathology. Ductal after RP showed 50% with intraductal spread from 4/21, salvage imrt + 6 mo lupron 4/22, undetectable 8/23, but psa at .23 at 2/24 follow up. Psma in April was negative. Last PSA was .5 in May.

Your recommended treatment is same his RO suggested would be likely once mets are found. We are hoping for an MO consult soon.

[APCFighter in reply to DLimey]

I think you are asking what my PSA was when I had my first scan. On 5/12/2020 ( 3 months after prostatectomy ) PSA = 1.608. Then was 0.110 on 7/1/2020. My Surgical Oncologist felt it should be NED (No Evidence of Disease) at that time. Scan confirmed Stage 4 metastatic cancer so I started Radiation.

PSA & Scan History:

04/05/2019 6.012 ng/mL

11/27/2019 5.589 ng/mL

12/23/2019 Biopsy (Gleason=4+5=9)

02/18/2020 Prostatectomy (Gleason 4+3 =7)

05/12/2020 1.608 ng/mL

05/28/2020 PSMA CT/PET Scan

07/01/2020 0.110 ng/mL

10/8/2020 Radiation started

11/25/2020 Radiation completed

01/11/2021 < 0.008 ng/mL

02/26/2021 < 0.008 ng/mL

07/12/2021 < 0.008 ng/mL

11/16/2021 < 0.008 ng/mL

01/10/2022 < 0.008 ng/mL

07/07/2022 0.012 ng/mL

10/03/2022 < 0.008 ng/mL

02/08/2023 < 0.008 ng/mL

08/10/2023 0.022 ng/mL

11/06/2023 0.036 ng/mL

12/06/2023 Completely clear PSMA scan

02/27/2024 0.113 ng/mL

05/28/2024 0.224 ng/mL

07/05/2024 PSMA CT/PET Scan now showing Bone and Lymph node Mets

[DLimey in reply to APCFighter]

Thanks. So you don’t have a PSA right before the 7/5 imaging? CT/PET is not same as PSMA scan? Asking because he had PSMA at .25-ish before Imrt and again at .33-ish and both have been negative, yet your imaging picked up mets. We want to make sure he’s getting the right imaging and read ductal and intraductal both can be sneaky. Partially why we want the MO consult as his RO doesn’t seem to know much about ductal.

[APCFighter in reply to DLimey]

Apologies - I've meant CT-PET PSMA scans throughout.

Additionally, I mistakenly forgot to list an additional PSMA scan on 12/6/2023. This scan was driven by the increase from the last undetectable PSA when my PSA tests measured 0.022 then 0.036.

Thankfully this scan came out completely clear with "No evidence of PSMA avid malignancy - so that was a relief.

Relative to your question, my last PSA score before the latest July scan was taken 5/28 and was 0.224.

I have 90% ductal and I've found that it is rare. Its rarity causing very little knowledge/understanding that I've been able to find. My MO doesn't know know much about the ductal variant. I have read that ductal can be more aggressive and doesn't typically cause as large of a PSA score.

Thanks for sharing I'd love to hear more about your story going forward. I'm very interested in learning more about the ductal variant. See the attached website:

ncbi.nlm.nih.gov/pmc/articl...

[DLimey in reply to APCFighter]

I’ve been researching the ductal variant since this latest recurrence, after looking back at his 2021 pathology reports trying to figure out what made hubs cancer so fast to fail localized treatments. This variant isn’t slow to grow. He too is currently at a 3 month doubling time. Latest psas: Feb .23, Mar .31, Apr .42 May .50

His surgeon shared he had a “very aggressive” cancer, but we didn’t discuss what made it aggressive. RO was so positive it was curable, so this recurrence to metastatic was a shock.

Pre-RP his PSA had jumped from I think he said 2.9 to 5.6 in 15 months from 2019 to 2020, Then in 5 months to RP it jumped to 8.3.

[Tall_Allen]

Although your PSA is still low, your PSADT is very rapid. You might want to discuss the EMBARK and PRESTO protocols with your MO.

prostatecancer.news/2023/05...

prostatecancer.news/2022/09...

[APCFighter in reply to Tall_Allen]

Agreed doubling time is very bothersome. Thanks for the links - I'm always looking for good info..

[Retireddoc]

Sorry to hear about your situation.

After pelvic radiation they usually cannot do any additional radiation treatment to your rectal region. However, they can likely target the para aortic and iliac wing bone met with SBRT.

Some MOs may also consider triple therapy with ADT, Darolutamide and Docetaxel. You have oligo metastatic disease and aggressive early treatment may be helpful.

[janebob99]

I agree that your doubling is recently very short, ~ 3 months. You may want to consider doing aggressive triple therapy treatment now.

[Shamrock46]

So sorry you're facing the uptakes and doubling. The only thing I can add, having read the other replies, is that your choice of Abiraterone/Enzalutamide should depend on your cardiac health. My husband was also offered both after his 1st recurrence and chose the Enzalutamide because he had cardiac issues that would have been impacted by the Abiraterone, probably landing him in the hospital for further treatment. After researching both drugs I presented my concerns to both the MO and cardiologist, who asked what choice my husband had. He did have one and chose the Enzalutamide. Both have side effects and my husband was prone to experience many of them but we felt it had fewer than the Abi. Sometimes you have to go with your gut but there are no good choices in this mess. You just try to balance being helped with the cancer vs. the side effects and your tolerance for them. There's always another weighted option in the wings with yet another decision. Good luck in your deliberations!

[RoseDoc]

There are a few options. Talk to you oncologist for their advice. Triple therapy has been mentioned and may be the best option. Interventional radiologist can ablate the lymph nodes.

Bottom line, I would suggest that the earlier you are with aggressive treatment, the better.

[Seasid]

Sorry, what is your treatment now?

[Seasid]

Could you please watch this video?

urotoday.com/video-lectures...

Where are you now? In which hospital? Could you consult a centre of excellence?

I would not over react in your situation before I consult someone trustworthy and competent.

[APCFighter in reply to Seasid]

Thanks for the video. Indiana's University Hospital Simon Cancer Center. I've recently been to the Mayo Clinic in Jacksonville, Florida. The MO there agrees with IU Health is saying and doing.

[APCFighter]

An update of my situation. I've started getting a Lupron shot every 3 months. I began taking Enzalutamide (160Mg daily) and the RO is doing all of the prep needed for giving me stereotactic body radiotherapy (SBRT).

[Cp014]

I too have an intra ductal component seen in one of my samples.

My psa never above 6.25. Fact went down to 4.25 after that. So I put off biopsy. Then went back up to 5.25.

During that time period I had ct scan due to major constipation. (A sign of advanced pcm), which showed three adenopathy possible in my lung nymph nodes.

The MO was not too concerned since all blod tests and scans were negative.

I immediately had biopsy. Which noted the IDCPC component and also scored another sample as an aggressive cancer w score of 9.

Folks put this IDCPC on the readings for a reason . The drs should know more about it! Ecspecially the ones treating us.

I just noting another example of IDCP here for whatever it’s worth.

Hopefully folks find a way to treat this better.

[APCFighter in reply to Cp014]

Hi Cp014 - I have "ductal" which is not the same as intraductal as I understand it.

Please see this attachment:

science.org/doi/10.1126/sci...

[Cp014]

Yes you are correct. Sorry about that.

[APCFighter in reply to Cp014]

No worries - I do not fully understand the difference exactly. Nevertheless, good luck with your journey and I agree that you always need to specific when describing your PC.

[Cp014 in reply to Cp014]

Thankyou for the info, link.