Bone mets on the move...how much trouble am I in?

[SViking]

Here is the latest PSMA scan results. Looks like tumors continue rising up the spine to the base of my skull. as of six weeks ago--probably worse by now. Currently on Xtandi half dose and Orgovyx but PSA continues to rise. What the heck are my options? Kishan at UCLA says too much SBRT over last five years to try anymore. (5 times now) Also completed Eclipse Trial last year and Provenge to no avail. PSA now up to 6.7 and going up a point every month.

PET/CT TUMOR IMAGING OUTSIDE FILM REVIEW

DATE: 9/26/2024

DATE OF OUTSIDE PET/CT: 8/19/2024

DATE OF INTERPRETATION: 9/27/2024

PROCEDURE: DICOM files of an outside PET/CT were uploaded to

PACS and reviewed on a multimodality viewing station.

Quality of outside studies cannot be assured, nor technical factors

controlled. Quality control can only be exercised on a locally performed

study.

CORRELATION: None

COMPARISON: PSMA PET/CT dated 3/5/2024

CLINICAL HISTORY: 72-year-old male with history of oligometastatic

prostate cancer status post multimodal therapy. Between PSMA PET/

CTs on 3/5/2024 and 8/19/2024, he was started on enzalutamide and

received interval SBRT to L rib, R femoral head, and R iliac on

5/15/2024.

ONCOLOGIC FINDINGS:

History of metastatic castrate resistant prostate cancer status post

prostatectomy and radiation therapy with:

1. More than 10 new skeletal lesions with mostly intermediate to high

PSMA activity. For example:

* C4 vertebral body without clear CT correlate, SUV max 11.6 (4-117)

* Left scapular spine with underlying sclerosis, SUV max 15.7 (4-151)

* Right clavicle with underlying sclerosis, SUV max 10.4 (4-152)

* Right transverse process of T6 with underlying sclerosis, SUV max

8.4 (4-203)

* Base of skull lesions with low PSMA activity including at the clivus

with underlying sclerosis, SUV max 3.9 (4-77).

1. Right retrocrural lymph node with low PSMA activity, SUV max 2.4

(4-277).

2. Mild bilateral gynecomastia. Left breast gynecomastia is associated

with low PSMA activity, SUV max 3.1 (4-222).

3. Previously treated areas of bony metastases remain without

associated PSMA activity, including the right femoral neck.

ADDITIONAL FINDINGS:

PET:

Physiologic 68Ga-PSMA-11 uptake is noted in the lacrimal and salivary

glands, nasopharynx, vocal cords, gastrointestinal tract (especially

duodenum), spleen, liver, both kidneys, ureters and the urinary bladder,

and testes.

For SUV reference:

SUVmean/max parotid/salivary gland 13.6/18.7 (4-93)

SUVmean/max right hepatic lobe 4.8/5.8 (4-262)

SUVmean/max descending thoracic aorta (level carina) 2.3/2.5 (4-199)

PSMA-expression score*:

High (3): "e SUV parotid/salivary glands

Intermediate (2): "e SUV liver

Low (1): "e SUV blood pool

CT:

HEAD AND NECK:

Atrophic thyroid.

CHEST:

Lungs: Unchanged bilateral lower lobes reticular scarring and

atelectasis.

Lymph nodes and Mediastinum: Ovoid calcified lesions in the anterior

mediastinum, stable.

Pleura: Left upper lobe calcified pleural plaque, unchanged.

Cardiovascular: Mild to moderate atherosclerotic calcifications of the

thoracic aorta and coronary arteries.

ABDOMEN/PELVIS:

Liver: Stable punctate calcification in the caudate likely represents a

prior granulomatous disease.

Gallbladder and bile ducts: Unremarkable.

Spleen, pancreas, adrenals: Stable punctate calcification in the spleen

likely represent prior granulomatous disease. Unchanged mild

prominence of the main pancreatic duct.

Kidneys and ureters: Atrophy of left kidney. Stable left renal lesions,

previously characterized as simple appearing renal cysts. Mild left

pelvocaliectasis without frank hydronephrosis.

Bowel: Scattered colonic diverticula.

Bladder and reproductive organs: As above.

Lymph nodes: Unremarkable.

Peritoneum: Unremarkable.

Vessels: Mild to moderate atherosclerosis.

Abdominal wall: Postsurgical changes in the anterior abdominal wall.

Status post bilateral inguinal hernia repair.

MUSCULOSKELETAL:

As above.

Multilevel degenerative changes of the thoracolumbar spine.

PET-CT body scan image import Date of Exam: 8/19/2024 Page 3 of 3 •

Chronic rib fractures involving the right posterior fifth and sixth ribs.

Retention sutures in the left proximal humerus.

Stable L5 spinous process hardware in place.

IMPRESSION:

1. History of metastatic prostate cancer with interval development of

numerous (>10) PSMA avid osseous metastases, some with underlying

sclerosis, consistent with progression of disease.

[Tall_Allen]

Xofigo combos and/or docetaxel:

prostatecancer.news/2021/02...

[SViking in reply to Tall_Allen]

Thanks TA. Awhile back I asked Tanya about Xofigo and she just said it was not for me. Maybe that's because of bone marrow damage from previous radiation and that my hemoglobin never recovered--still at 10.7

What about BAT?

[Tall_Allen in reply to SViking]

Have your metastases been painful?

[SViking in reply to Tall_Allen]

actually no pain at all. I get various body aches and pains from the meds but nothing from tumors. Obviously when the beast is at the base of the skull that is somewhat alarming. Is there a danger of cancer moving into my brain?

[SeosamhM in reply to SViking]

Hey, SV. In my opinion (see my bio for relevance): While there is likely some statistical occurrence of PCa metastasis to the brain, simply having our cancer proximal to the brain (e.g., mine has been at C2 and in/on skull) does not mean it is "closer" in a biochemical sense. You and I have shared history of skeletal/bony mets, which means that the cancer cells that spread are likely to spread to bone (again, it's all statistics, isn't it?).

But I agree that it isn't a good look for your bones, brother! It is unfortunate that your doc thinks that you've gone to the radiation well too much and is ruling out Xofigo. Your apparently permanent low blood values are similar to mine and my SBRT count is up to 3. I've been told that treatment for my next recurrence is likely going to be a Xofigo combo.

Is it simply an age-based risk evaluation - you are 72 and I am 57? I am a bit confused - it seems like the obvious next treatment in line for us (I think you've had Pluvicto, as well).

Good luck - I'll be following! Since your treatment box is getting smaller, I'm glad you are thinking outside of it, i.e., BAT. I know that I'm going to try my best to try every relevant treatment before this thing drives me under - I'm shooting for the moniker Data Point Joe!

Regards, Joe M.

[SViking in reply to SeosamhM]

I guess what the most is bone fractures and so forth. I lift heavy weights and wrestle, which makes me feel really good but I’m wondering now if that makes it easier for fractures to occur. I don’t have any osteoporosis but it’s my understanding that the cancer makes the bones weak that spot or even sometimes builds back too strong, making them brittle. Currently on one shot of Xgeva every 90 days.

[SeosamhM in reply to SViking]

True, PCa bone mets can either weaken (sclerotic) or build (lytic) bone. The good news is that the increased fracture risk in a bone proper (not just the tumor) really depends on the size of the tumor relative to the cross sectional area of the bone that is being stressed, and how that bone is being stressed.

I work out regularly and, like you, hard. Well, you are a wrestler, so a workout fanatic. I'll say I work out "pretty hard". Here's the story:

One of the main reasons I found out I had mPCa is by fracturing the tumor in my C2 vertebral body on a roller coaster. I thought I had a nasty case of whiplash. It turns out that, while the tumor fractured and created ligament damage, my native healthy bone did not fracture.

Similarly, I had (have? - still shows a bit on PSMA PET) a large tumor in my lower left femur - through the wall and into marrow. But even at the tumor's largest it was small (<15%) relative to the cross section of the femur, and I've not had problems. However, I did not have radiation to that tumor because of the risk of radiation embrittlement - that happened in my L4 tumor and the vertebra has become a bit of a degenerative mess. I also had radiation to C2 which resulted in complete degradation of the vertebral body, but somehow my body replaced it with some sort of scar tissue/bone matrix that works.

Oh - and this is all without Xgeva. I took it initially but started having nasty side effects and convinced my docs with a DEXA scan that I didn't need it...yet. I'm keeping that in the toolbox, though.

It's a long way of saying that I think the benefits of weight lifting and exercise like wrestling outweigh the risks. You know yourself better than anyone - analyze the risks and adapt if you have to, but don't stop.

[SViking in reply to SeosamhM]

Thanks. I like your answer. Can you tell from my above PSMA scan how bad my tumors are? Keep in mind that that was from almost 2 months ago and had been moving quickly.

[SeosamhM in reply to SViking]

I will give you some "good news/bad news" armchair quarterbacking based on my experience.

First, the good news. In an otherwise healthy man, bony skeletal mets are not going to be the thing that kills us. If my cancer wants to slowly eat at my bones, I'm okay with that type of battle and - in the short term - I don't really care where bone mets occur as long as I can treat them. I fear soft tissue metastasis (including bone marrow) and neuroendocrine mutation. There is no indication of these in your scan.

The bad news is that you are definitely at a point where a treatment plans need to be made. Your cancer is obviously on the move. Your PSA is rising and the key takeaway in your shared scan is the "(m)ore than 10 new skeletal lesions with mostly intermediate to high PSMA activity".

Unsurprisingly, I agree with TA - on your remaining "traditional treatment menu" with Xofigo ruled out, docetaxel (or another taxane-based chemo) is your best conservative bet.

But it's your life. You've been at this grind for 13 years. I wouldn't say that BAT is necessarily off the table, just that it has definitive risks - we are literally baiting the beast. S**t could go seriously wrong and the "therapeutic response" is only at ~30% (see: ncbi.nlm.nih.gov/pmc/articl....

Docetaxel has a better response rate and less risk. And, yes, there is always a side-order of ADT along with that. 🙄

[SViking in reply to SeosamhM]

Thanks. Already back on Orgovyx and now switched from half dose of Xtandi to Nubeqa . Hoping for a better result without having to do chemo. Even at half dose of Xtandi the side effects were brutal for me and just being off for last three days is a tremendous relief.

[Tall_Allen in reply to SViking]

Metastases to soft tissue in the brain is very rare with PCa. BAT has been useful in keeping enzalutamide working longer in asymptomatic men (which is why I asked). But now that docetaxel has been proved to reverse enzalutamide resistance, there is no need to risk BAT.

[SViking in reply to Tall_Allen]

That's very interesting. How many docetaxel treatments are necessary to resensitise so Xtandi works again? And is ADT required during that treatment time?

[Tall_Allen in reply to SViking]

prostatecancer.news/2022/10...

[dhccpa]

You posted rather than answering TA directly, so he may not see it.

[NecessarilySo]

I suggest you read my bio. I had a growing metastasis on my spine, but have managed to eliminate it using heat and lycopene in addition to ADT. I don't understand your scan showing facial metastases, and also I don't understand why you have no pain. Anyway, you have nothing to lose and much to gain by simply reading my bio.

[SViking in reply to NecessarilySo]

if you’re referring to the two black dots on my face on the scan, I believe those are my eyeballs.

[NecessarilySo in reply to SViking]

No I was referring to the large black masses on your cheeks.

[ulfhbg in reply to NecessarilySo]

Hi !

Just a personal guess but couldn’t that be the salivary glands? These looks like areas in the face you put ice packs when your’e having treatment with Pluvicto (Lutetium 177).

Well, just guessing.

Best wishes - Ulf

[dk73]

my hubby is 8 years in: surgery, radiation, taxotere chemo, zytega, Xtandi, more chemo and then pluvicto. Eligard shots every 6 months and zometa every 3 months. Before starting pluvicto, his PSA 27 and bone Mets in spine, pelvic bone & left femur. After 4 rounds of pluvicto, PSA & ALP over 230 with 5 spots in skull, shoulders, ribs, more spine Mets, pelvic bones and both femurs. He is now on Jevtana chemo. PSA 32 and ALP back to normal range. He will be 72 in January

[SViking in reply to dk73]

That’s quite the fight. I’ve had Pluvicto too and it failed miserably. Even Provenge only gave me stable PSA for two months. What’s next if the chemo fails again?

[dk73 in reply to SViking]

Good question. He hasn’t been able to do chemo since Aug 30. He is battling radiation cystitis and has been in the hospital 4 times with severe bleeding and blood clots. Has been on a catheter the whole time. He developed clots to the lungs. They are going to put in a filter this weekend and get him off Eliquis and fingers crossed this will stop the madness! Chemo will resume two weeks after this new procedure. So even with best laid plans, there can be road blocks along the way🙁

[Seasid in reply to dk73]

Your husband likely developed pulmonary embolisms (PEs), which are blood clots that travel to the lungs, a common complication in advanced cancer, particularly in those undergoing treatments like chemotherapy. There are several reasons why this may be happening:

1. Cancer and blood clotting: Cancer increases the risk of blood clots (called a hypercoagulable state). Tumors can release substances that increase clotting, and advanced stages of cancer, especially metastatic prostate cancer, are associated with an elevated risk of venous thromboembolism (VTE), which includes deep vein thrombosis (DVT) and pulmonary embolism (PE).

2. Chemotherapy and reduced mobility: Chemotherapy drugs can damage blood vessel walls and reduce physical activity due to fatigue, both of which increase clot risk. Reduced mobility from being hospitalized and catheterized can also contribute to clot formation.

3. Radiation and surgery effects: Radiation, particularly to areas like the pelvis, can further increase the risk of clots due to damage to the blood vessels in the treated areas. Surgeries also elevate clotting risk due to changes in blood flow and healing processes.

The doctors are planning to insert an inferior vena cava (IVC) filter because blood-thinning medications like Eliquis (an anticoagulant) may no longer be suitable for him, possibly due to the risk of bleeding. He is dealing with radiation cystitis, which involves severe bleeding from the bladder due to previous radiation therapy. Continuing Eliquis could worsen the bleeding.

The IVC filter is a small device inserted into the large vein that returns blood from the legs to the heart (the inferior vena cava). It traps clots before they can reach the lungs, offering protection from pulmonary embolism without the need for anticoagulants, which are risky in his case due to the bleeding complications.

By placing the filter and discontinuing Eliquis, the doctors hope to prevent further clots from reaching the lungs while avoiding the serious bleeding risks associated with anticoagulant medications.

[dk73 in reply to Seasid]

He also had been immobile in the ER for 28 hrs while they tried to clear the clots from the bladder to get the urine flowing again. We were released at 10 pm and he woke me up at 4 am the next morning saying he couldn’t breathe. So back to ER. We’ve been to the ER 4 times since 9/12 and officially admitted twice. He’s been in again for a week now, filter placed, off Eliquis and we will hopefully be starting hyperbaric oxygen treatments soon. Chemo has been halted for now because the cystitis is the main focus. (This is his third go around with chemo since 2017)

[Seasid in reply to dk73]

It is difficult to have a plan, but still you should talk to his medical oncologist and ask him to try to recommend him some sort of plan how to go further. I am myself missing it now, but my maybe biggest mistake was that after the sbrt radiation of my prostate with the MRI linac when after six months my PSA dropped to 0.25 I didn't start bicalutamide, but I was waiting until my PSA raised above 2. I think it was a mistake.