If you are diagnosed with prostate cancer and get a bone scan, this will often reveal a few bone metastases. Then your MO will give you the verdict: lifelong ADT. Usually you will not get radiation or surgery of the prostate because the tumor has already spread.
However, there is a study by Dr. Thomas Hope from UCSF now. He and his coauthors looked at patients who got both a bone scan and a PSMA scan. As it turned out, in 57% of the cases metastases detected with an initial bone scan were false positives because they did not show up on the PSMA scan. This changes if the bone scan was done when there was a recurrence or the patient had CRPC. Then bone scan and PSMA scan had about the same results. jnm.snmjournals.org/content...
Therefore, if you are initially diagnosed with bone mets on a bone scan, check this result with a PSMA scan. Often the bone mets will turn out to be false positives and you can get your prostate radiated plus a short course of ADT. If the PSMA scan detects lymph node mets, you can get your pelvis radiated too.
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If you are initially diagnosed with a bone scan, it is likely time to find a new physician. Bone scan and CT are not appropriate for defining spread. If potential spread is an issue, PSMA PET is considered by most to be the appropriate test.
I disagree. Bone scan/CT should be the first imaging for all unfavorable risk patients, followed by a PSMA PET/CT if the bone scan was negative. The debulking decision has to be based on a bone scan/CT.
Unfortunately, all too often, urologists will stop with a negative CT and bone scan. It would seem that this approach would result in significantly greater cost for those with negative scans.
It is the only way to know if debulking is worthwhile, so it has to be done. Cost of a bone scan/CT is low and is always covered by insurance if indicated.
Are you referring to debulking LN dissection at primary treatment? With reduced sensitivity with CT/bone scan, if a positive initial imaging, the full extent of disease might be missed with more sensitive PET/CT?
Until there is a similar trial done with a PET scan, we have to use a bone scan to see if it is worthwhile for a patient. It is not important to know the full extent of metastases (which we will never know), only to know what makes a clinical difference in a given therapy.
That makes good sense, but we will face the same limits considering the available evidence from clinical trials with the introduction of new imaging technology, AI interpretation of imaging and pathology as well as new biomarkers.
In the study I presented, Hope discusses the STAMPEDE M1 RT trial. He writes: "These results bring into question how to define patients with low-volume disease using PSMA PET in light of the STAMPEDE M1 RT data. If one were to apply our initial staging data to the M1 RT trial, 56% of patients with low-volume disease based on bone scanning had localized disease by PSMA PET. Therefore, there is a greater likelihood that the overall survival benefit seen in the trial is not driven by preventing further development of metastatic disease but rather by providing definitive RT to nonmetastatic disease that was incorrectly classified as M1 by bone scanning."
The biggest problems with Hope's data are that they are retrospective and uses community-based radiologists of uneven quality. OTOH, the STAMPEDE trial was prospective and used a top radiologist to review all the patients. I would trust STAMPEDE over Hope's conjectures.
I've had at least three distant Mets in hip socket and vertebrae on every single scan from August 2018 through 1/3/2024: Cats, nuclear bone scans, MRIs, and 5 PET scans (1 PET Bone Scan and 4 Axumins).
However, I had my first PSMA scan on 7/17/2024. It showed no uptake anywhere outside the prostate (SUV was 25 in the prostate).
My PSA was 1.92 at time of PSMA, up from .5 nadir in 4/2021. I've been on Lupron (only) since 11/2018.
Meeting with RO Wednesday to discuss, but my MO was surprised by the lack of distant uptake, and the high SUV in the prostate.
bone scan was clean and them my PetScan showed low volume on the pelvic and in Lymph nodes . 28 rounds of IMRT and ADT for two years 🤮after four months PSA .011
First BCR scan I received was a Bone Scan. Was told 2 mets on ribs. I asked what ribs? Response was 9 and 10 left side. My smart ass response was, "could it be the fractures that healed 32 years ago"? CT and PSMA confirmed poorly healed bone fractures!!
Similar experience. Had a bone scan and the urologist reported that I had mets on rib 3 and 8 left side, I told him that was a coincidence since I had a bone scan 8 years prior for 2 broken ribs from playing hockey. He pulled up the old bone scan and they were identical. Had a PSMA PET scan one year ago and the analysis was a single met on only the left 8th rib. Very confusing.
yea I am confused. I just got a bone scan 8/13. Have psma pet scan 8/16. I insisted once I realized I was having a bone scan and not the psma pet.
Hoping we all, my drs, which I am currently recruiting, scheduled appointments already will have enough to start making most informed decisions regarding treatment.
FYI I dropped my oncologist. She would never even talk about my prostrate or my symptoms. She get upset with me when I try to talk about anything beyond my lungs. Lung dr same way. He sent me to her. I dropped them both. They not do anything or even discuss my prostrate cancer. Really?
Until we do a lung biopsy.
So I Found urologist at Utsw and MO at md Anderson. Which I already planned to do. No way I leave my hands in those other two!
My uro in Austin requested the bone scan. I had to request him to also request the psma. I would have thought he do that initially knowing I have the masses in my lungs or nodes? So yes confusing.
On this subject, I recently received a clean PSMA in July. Went over the images with MO and there was no uptake at all the places you might think and I scored 0 on the scan. Had a little rise in my PSA from .55 to .77 and the doctor is asking me to take a nuclear bone scan. Seems over the top to me. I do have a prostate and yes i am taking TRT, or was, that may be affecting the PSA. Maybe maybe not. But what is the usefulness of a bone scan at a sub 1.0 PSA level? I am just not looking forward to all the "this might be..." "this is worrisome for..." I know I will get with a bone scan, since it is very sensitive but not specific. And I have all the usual broken bones and inflammation of somebody that has been around for almost 70 years. Would cancelling it be ok?
The MO should not check the PSMA PET/CT, there will be a report by the RO where you got the PSMA PET/CT. He is trained to analyse PSMA PET/CTs. I would not get a bone scan, a PSMA PET/CT is the better imaging method.
Thanks for that information. I did get a report from the expert at the PSMA. They also have all the slice of the body photos available on the portal to the MO that can be zoomed in on and he didn't see any uptake at all in the lymphs or anywhere for that matter. Basically my RO retired and he set me up with an MO for the monitoring. So now I am going to ask him to cancel it and if things change and get worse, get another PSMA in about six months or if PSA lowers, or stays stable, just monitor it.
IMPRESSION:
1. No PSMA avid focus to suggest local or metastatic metabolically active disease.
2. miPSMA score: 0
Reference: Based on published literature, the imaging score for PSMA agents is as follows:
miPSMA Expression Score
Score Reported PSMA expression Uptake
0 No Below blood pool
1 Low Equal to or above blood pool and lower than liver*
2 Intermediate Equal to or above liver* and lower than parotid gland
3 High Equal to or above parotid gland
* For PSMA ligands with liver-dominant excretion (e.g., 18F-PSMA1007) spleen is recommended as reference organ instead of liver.
I read that you should have a PSA value above 10.0 ng/ml for a bone scan. Maybe it can be a bit lower with the newest devices. I would repeat the PSMA PET/CT when the PSA value gets above 2.0. I had to wait until it got over 3.0 to detect mets.
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