Continuing on my patient-directed path of precision medicine investigation, scheduling second opinion of this imaging finding, an appropriate liver MRI and lesion biopsy. Note, it is possible this lesion is not prostate cancer, it may be something else of concern, maybe benign.
Wish to share I remain most grateful that since my diagnosis nearly ten years ago, that I am a strong self-advocate and not dismissive of very frequent uPSA testing, liquid blood biopsy testing and imaging at 0.03X. Oddly, this is fascinating but I sure could do without this fascination
From Pylarify imaging report:
COMPARISON:
Ga 68 PSMA PET-CT 06/30/2022 (clear findings)
FINDINGS
Abdomen and Pelvis: Status post prostatectomy. There is a new 2.3 x 2 cm hypodense lesion inhepatic segment 8 (series 3, image 107). No uptake over background liver activity is seen with maximum SUV 6 (background liver uptake maximum SUV 9). A 2.5 cm left adrenal nodule with attenuation of 4 Hounsfield units is consistent with an adrenal adenoma and stable. Sigmoid colonic diverticulosis is present.
Bones/joints: No abnormal foci of uptake.
IMPRESSION:
A new 2.3 cm hypodense lesion in hepatic segment 8. Mild PSMA uptake is lower than surrounding background liver activity. Findings are concerning for metastatic disease of uncertain origin.
Consider further evaluation with MRI liver protocol with and without contrast and consideration of tissue sampling to assess for malignancy.
From GUARDANT360 liquid blood biopsy: (note last year’s result “Not Detected”.
Q. Which cancer metastasis could lower that PSMA uptake in the liver and why do they believe that it is a malignancy?
A. PSMA (Prostate-Specific Membrane Antigen) PET-CT is a highly sensitive imaging modality for detecting prostate cancer metastases, as PSMA is often overexpressed in prostate cancer cells. However, other types of cancer and non-cancerous conditions can also show some PSMA uptake, and certain factors can result in lower PSMA uptake.
### Reasons for Lower PSMA Uptake in Liver Metastasis:
1. **Tumor Differentiation**: Poorly differentiated or more aggressive forms of prostate cancer may exhibit lower PSMA expression, leading to reduced uptake. The cancer cells might lose PSMA expression as they become more aggressive, which can result in a lower signal on PSMA PET-CT.
2. **Non-Prostate Cancers**: Some non-prostate cancers can metastasize to the liver and show variable PSMA uptake, often lower than that seen in prostate cancer. Examples include:
- **Liver metastases from colorectal cancer**: These can occasionally show mild PSMA uptake, but generally, it’s much lower than prostate cancer.
- **Neuroendocrine tumors**: These can sometimes metastasize to the liver and show mild uptake.
3. **Benign Liver Lesions**: Some benign liver conditions (e.g., hemangiomas or focal nodular hyperplasia) might show mild PSMA uptake. However, the imaging characteristics and clinical context often help differentiate these from malignant lesions.
### Why Malignancy is Suspected:
1. **New Lesion**: The lesion is new, which raises concern, especially in a patient with a history of prostate cancer.
2. **Hypodensity on CT**: The lesion is hypodense (appearing darker) on the CT scan. This characteristic can be seen in metastases, which often appear hypodense due to their different composition compared to normal liver tissue.
3. **Size and Appearance**: A lesion of 2.3 cm in size, with the described imaging features, might be considered suspicious for malignancy. Malignant lesions often present as new, hypodense lesions in the liver.
4. **Lower PSMA Uptake**: While high PSMA uptake is typical of prostate cancer metastasis, mild or lower uptake does not rule out malignancy, especially if the lesion is new and concerning in appearance.
### Further Evaluation:
The recommendation for an MRI with contrast and potential biopsy indicates that while the lesion's appearance raises suspicion, the imaging alone is not definitive. MRI can provide more detailed information on the lesion's nature, and a biopsy can confirm whether it's malignant and determine its origin.
In summary, while the lesion shows lower PSMA uptake, its characteristics and the context of your medical history lead to suspicion of malignancy, warranting further investigation.
Talk about a curveball and a great example of self-advocacy.
I am sure that it is fascinating and nerve-racking in the same breath. While it's easy to go with the standardly accepted marker of .1 is "undetectable", these findings confirm what Dr. Nicholas Mitsiades (UC Davis) shared at a Sacramento men's support group meeting.
Dr. Mitsiades quietly listened as the men shared their journey's and chimed in at the end of the meeting giving a few words of wisdom. It was along the lines of - psa numbers alone do not define your disease state after treatment. Through their study and research (UC Davis) they were finding metastasis well below the .1 threshold that has mutated and does not express elevated levels of psa. He shared that the cancer you were diagnosed 5 - 10 years ago could be very different than the current disease you're battling. Dr. Mitsiades kindly warned against only promoting success by your journey of favorable levels of psa.
While the jury is out to WTH you uncovered with your diligence, I wish you all the best to kicking a$$ on what has reared its ugly head!
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