Which scan is the most accurate in detecting Mets when PSA is rising? I know there have been many advances in the last few years. Thanks for any feedback you can share.
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The Choline PET scan at Mayo clinic is the most sensitive we have found
Not according to Dr Kwon
All I know is that after six rounds of Lutetium 177, the PSMA scan showed only a small amount of cancer and pelvic lymph nodes. We followed up at Mayo clinic with a Choline PET. It in lymph nodes his lymph chain that were blocking his right kidney. He had to have an immediate nephrostomy. Within a day of the nephrostomy, he had sepsis due to an infection in that blocked kidney. He had to go to the hospital for sepsis treatment. If it hadn’t been for that, choline PET, he wouldn’t be alive today.
As I share seven years ago I traveled to Europe for Ga68 PSMA PET CT and Ferrotran nanoparticle MRI for comparison. While the PSMA was clear the Ferrotran successfully identified multiple cancerous pelvic lymph nodes.
It is my understanding there is no #1, no absolute ranking. IMO if the goal is earliest possible detection we may have to try several different imaging methods to see which contrast agent 'works best' for our individualized cancer.
I had 3 PSMAs and none indicated any sign of the disease despite having a rising PSA. My doctor went back and tried an Axumin PET scan and that was the test that found the source: 3 affected lymph nodes adjacent to my trachea. I had the surgery in 2016, follow-up radiation in 2020. Now I'm on ADT hormone treatment.
What was your PSA at the time out of curiosity?
It was 12 before surgery, went to <0.1 afterwards, then started slowly climbing 2 years later, up to 5. After radiation, once again <0.1. After about 2 years started slowly climbing once again up to 8-11 range. First PSMA was when PSA was 4, I think. After the Axumin lit up near the trachea I had a biopsy which confirmed it to be from prostate. I’ve been on ADT for a year now, first Xtandi + Lipton, then Xtandi + Orgovyx. My PSA has been undetectable for the past 9 months.
It depends. Read this:
prostatecancer.news/2016/12...
Thanks for that. Do you think much has change in the scans over the last 8 years? Other than perhaps availability of them, like the Ga-68?
8 years? The most recent entry was this year.
I think folks tend to look at the original date atop your articles and think perhaps they've never been entirely updated.
Unfortunately, the software doesn't allow me to change that line.
TA, is there a Choline PET aside from the one at Mayo MN? I thought so, but may have just assumed it.
Mayo has a patent on the C-11 Choline PET and has invested a lot in the manufacturing equipment, which is why they encourage their PCa patients to have it.
Thanks
A very informative and helpful article TA. Thank you so much for sharing.
Given the reports form Dr Kwon's patients here and in previous posts of mets being detected at extremely low or even undetectable PSA, together with Dr Kwon's public reporting of these events, do you believe these reports are incorrect, misunderstood or other error in understanding/intepreting?
A friendly yet direct question. Do you think I am incorrect, in error or lying in my shares about Ferrotran nanoparticle MRI I had seven years ago next month at Radboud UMC, Nijmegen, Netherlands. That imaging identified five suspicious pelvic lymph nodes at uPSA 0.13, the smallest 3mm, largest 6mm. Did I not understand or did I misinterpret the urologist who performed my salvage ePLND, and the pathology report, that confirmed six cancerous nodes including paraaortic nodes.
I was not implying anyone was lying or incorrect, so please dont take offense. I am trying to fully understand these patient and dr reports re Dr Kwon of mets showing up for extremely low or undetectable PSA, via Dr Kwon's scan process, including his Choline PET as well as the PSMA PETS.
Thought I've read a couple of studies that said Ferrotran MRI for PC was actually better than 68ga PSMA PET and I think it dealt with LN's specifically? Perhaps the effectiveness of the scan depends on the organ involved and maybe even the chemistry of the patient?
My patient experience with lots of imaging, including the Ferrotran, two Ga68 and two Pyalrify PSMAs, one fluciclovine, is that yes 'success' depends on many factors. As others share, the key, especially at lower PSA levels and especially when objective is earlier possible detection, is to have several comparative methods which is not what insurance providers, many docs and even patients want to do.
And yes, I share my Ferrotran correctly identified pelvic lymph node mets whilst the concurrent done Ga68 was 'clear'.
Unusual events happen. They are not the norm, and ought not guide treatment.
thanks
Thanks TA—I for one truly appreciate your factual reporting and unwavering adherence to evidence-based clinical studies. ( I’m also interested to read posting by others in our community about their first-hand experiences. As my wife reminds me, each of us represents our own individual “statistic”As 39 year non-Hodgkins lymphoma and nine and a half year Gleason 8 prostate cancer survivor, her optimism has certainly helped my mental state. The challenge for each of us is to decide how much weight to give to the various anecdotal reports we read, and make decisions accordingly. The value accounts of individual experiences hold for me is that raise questions in my mind that I can research further and/or discuss with my medical or radiation oncologist, as appropriate.
Thank you again for your many valuable contributions to our community.
Remember that when a clinical trial has a sample of a thousand, it represents a thousand anecdotes. In your case, having both lymphoma and PCa, there are many considerations that are not represented by the experience of others.
Thanks again. I know this is especially true with respect to types/dosages and late term side effects of chemo and radiation administered 38 years ago. This seems to be largely uncharted territory when it comes to treating PCa. So my oncologists have chosen to follow recommended PCa SoC. Now, at 76, I consider myself extremely fortunate in life, all things considered
All things considered inadvertently became my mantra early on lol.
"You probably want to start with a PSMA scan..."
PSMA doesn't catch everything. There is a complimentary scan that catches what PSMA misses. I forget its name but Tall Allen knows what it is called.
It probably doesn't make sense to ever do either of these scans without the other.
FDG PET is what you are looking for --- it will identify metabolically active cancer cells regardless of PSMA+ or PSMA-
I wonder if anyone on this forum can attest to success with FDG when PSMA and all others were unsuccessful?
Certainly hope so -- if PSMA PET is negative (which is <20% of cases), FDG PET can help identify certain tumors, but the patient already likely knows they are metastatic, so if a PSMA targeted therapy is off the table, a med onc may go straight to a chemo recommendation
In an ideal world, men would get both FDG PET and PSMA PET, but in a world w/ the insurance industry as it is, many have to choose and gravitate to the PSMA PET
Is there a reference for PSMA PET being negative <20% of the time? This is not my understanding for lower PSA values. And is there a reference for how often FDG PETs help when PSMA is negative? In all my imaging efforts and experiences FDG has never been recommended to me as primary or alternative - this is in US and several European countries.
Come to Melbourne Australia to Peter Mac Callum cancer centre. The standard of care is PSMA plus fdg pet scan.
pluvicto-hcp.com/psma-posit...
You will see the ">80%" of men here, with references at the bottom (Hupe notably) -- y ou MAY see other sources as high as 95%, or lower, it is somewhat variable
But it is much more prevalent than any of the genetic alterations that is for sure
Thanks for link - the positives on FTG got my attention as it has not been recommend to me. However, maybe we see this differently. The link reads (at least to me) >80% of men are PSMA positive. For me this reads as PSMA avid, not as to success of PSMA PET - in other words not saying PSMA PETs are 'successful' >80% of the time.
My read on FDG is that its more precise usefulness is for CR patients, which I am not (yet anyways), as I have not (yet) gone to ADT therapy. A copy and paste - "Concurrent use of FDG-PET along with PSMA-PET has shown great promise in the evaluation of disease in CRPC patients".
Additionally, if known metastatic and PSMA-, FDA PET may or may not be of use -- if known high volume/high risk disease, your med onc may reach for chemo regardless, but others may want to assess how actively those PSMA- tumors are growing .. which is where the FDG PET would come in and perhaps help with the chemo now/chemo later decision/discussion
Yes. It would be great if both PET Scans were the normal course of treatment.
I can. I had 2 PSMA's that came back negative(with PSA at 1.5 & 4), so an FDG was suggested. It picked up 4 bone mets.
Great FDG imaging worked for you - I have imaging coming up and will look into FDG for comparison. Your bio shares you are "officially PSMA/FDG discordant" - at PSA values of 1.5 & 4 we certainly hope other methods work as well. Specifically, my ask was about FDG success when multiple other methods failed as I have not had success with multiple PSMA nor fluciclovine at different uPSA values; while another method did work at uPSA 0.13.
You are correct it is a best scan but PSMA pat scans can't pick up PSMA negative metastasis. That is the obvious downside.
OK I will bite. What is a “negative metastasis”?
Metastasis that isn't expressing PSA.
Thanks! Learned a new term.
PSMA.
Without PSMA expression, not PSMA avid, without PSMA avidity, PSMA negative etc.
You can't use PSMA pet scan in the above mentioned setting.
Usually the tumour stops being PSMA avid when it is crpc or after lots of PSMA infusions.
When you kill all the PSMA expressing cancer and the PSMA negative cancer repopulate the space.
when you say PSMA scan do you mean Ga68 PSMA PET scan
I had a PSMA and also an fdg pet scan before I decided to irradiate my prostate.I didn't have any visible mets on any scans. I said to the registra that I don't want to fry myself if I have any visible mets except what was visible on my prostate otherwise I would most likely just start Enzalutamide and would skip the radiation of my prostate. The temptation was too high not to radiate my prostate.
Does the choline scan show PSMA negative cancer?
A choline PET/CT scan can detect some cancers that are PSMA-negative, particularly in prostate cancer cases, but its effectiveness depends on the characteristics of the tumor. Here's how it works and what it means for PSMA-negative cancers:
Choline Scan Overview
Choline PET/CT imaging uses radiolabeled choline to detect tumors. Cancer cells often have increased choline metabolism, making this scan effective for cancers with high choline uptake.
It is commonly used for detecting recurrent or metastatic prostate cancer, especially when PSMA-PET scans are unavailable or when PSMA-negative tumors are suspected.
PSMA-Negative Cancer
Prostate-specific membrane antigen (PSMA) is highly expressed in most prostate cancers, making PSMA-PET a preferred imaging method. However, not all prostate cancers express PSMA (PSMA-negative tumors).
In PSMA-negative cases, choline PET/CT can serve as an alternative since it detects tumors based on metabolic activity rather than PSMA expression.
Key Considerations
1. Detection Sensitivity: Choline PET/CT has lower sensitivity than PSMA-PET, especially for detecting small lesions or those with low choline uptake.
2. Tumor Biology: Not all PSMA-negative cancers have high choline metabolism. Therefore, a choline scan might miss tumors without significant choline uptake.
3. Clinical Context: The choice between choline PET/CT and other imaging modalities depends on the clinical scenario, tumor characteristics, and availability of imaging technologies.
Conclusion
A choline PET/CT scan can detect some PSMA-negative cancers, but its effectiveness varies. It is less sensitive than PSMA-PET for prostate cancer but may still provide valuable information in specific cases. Always consult with an oncologist or nuclear medicine specialist to determine the most suitable imaging method based on the cancer's characteristics.
ChatGPT said
Thanks for posting the response. I think I’ll request each of the scans mentioned to see what’s available to me.
What is the best scan for detecting non PSMA avid cells. I've had 5 Axumin, but TA always mentions FDG. Let's clear this up.
Professor Hofman in Peter Mac Callum cancer Centre in Melbourne Australia is definitely using fdg pat scan. I am not sure if there is something better (ask ChatGPT).
tango65 recommend me fdg pet scan saying that it will pick up everything above 5 mm. That is why I decided.
If your PSMA SUV max is high and it correlates with the PSMA pet scan you could maybe even consider lutetium J591 infusion one cycle like Mateo recommends plus SBRT of your prostate with a high precision MRI Linac machine. I am not a radiation oncologist but that is what Mateo recommends. You could read his comments and posts. You could come to Perth Australia and do one cycle like he did. It is cheap. You could also do either in Melbourne Australia in a Peter Mac Callum cancer Centre the SBRT of your prostate with the high precision MRI Linac Electa Unity Swedish machine or here in Sydney Darlinghurst like I did.
Contact Mateo.
Mateo said that lutetium J591 could even bind to micromets and kill them. I am not a doctor but you could approach professor Hofman etc for this question. I could also recommend Sartor because you are located in the USA. Or maybe online consultation with Dana Farber radiation oncologist? Etc
You're absolutely right—consulting experts like Professor Michael Hofman or Dr. Oliver Sartor would be a great way to clarify the role of Lutetium-177 J591 in targeting micrometastases or non-PSMA avid cells. Here’s a bit more context on this treatment approach and your suggested options:
Lutetium-177 J591 Therapy
Mechanism: Lutetium-177 J591 targets the extracellular domain of prostate-specific membrane antigen (PSMA) but has shown the ability to bind even to micrometastatic disease. This is because J591, unlike some other PSMA-targeting agents, can potentially bind to PSMA expressed on micrometastatic or poorly differentiated cancer cells, including those with low PSMA expression.
Advantage: Radiolabeled J591 can deliver targeted radiation to cancer cells, effectively treating even small metastases that might not show up well on imaging.
Limitation: Its efficacy in non-PSMA avid tumors still depends on some level of PSMA expression. Non-PSMA avid cancers may require alternative targets or systemic therapies.
Consulting Experts
1. Professor Michael Hofman (Australia):
Renowned for his expertise in PSMA PET imaging and theranostics.
Could offer insights into whether J591 or other radioligand therapies are suitable in your case.
2. Dr. Oliver Sartor (USA):
Specializes in advanced prostate cancer therapies, including novel radiopharmaceuticals.
May provide guidance on integrating Lutetium J591 with other systemic therapies.
3. Dana-Farber Cancer Institute (USA):
Offers access to multidisciplinary teams and clinical trials for advanced prostate cancer.
Radiation oncologists here could provide second opinions on imaging and treatment strategies.
4. Online Consultations:
Platforms like Cleveland Clinic MyConsult or Mayo Clinic's Online Consultations allow virtual second opinions from top cancer specialists.
---
Practical Steps
1. Seek a Multidisciplinary Team Opinion: Connect with experts in nuclear medicine, radiation oncology, and medical oncology to evaluate your unique case.
2. Clinical Trials: Explore clinical trials for Lutetium-177 J591 or alternative radiopharmaceuticals targeting micrometastases.
3. Imaging and Biopsy Correlation: Ensure imaging findings align with biopsy results to better understand your tumor biology.
Given your proactive approach, consulting these specialists directly (either in-person or virtually) will provide clarity and help you explore cutting-edge treatments.
ChatGPT said
Just to make a disclosure that tango65 doesn't believe that lutetium J591 infusions are killing micromets. Its because of the results of some trial in New York. I have to dig this up. Maybe we know more now? tango65 said that before some time ago.
Did you see this?:
AusiBrysonal
3 days ago
I was on the J591 trial in Brisbane, Aust. The side effects knocked me for six. I had clotting in the bladder, platelets dropped to 15 and ended up in hospital for 2 weeks. There were 11 others here on the trial before me and some or many ended up in hospital. The Oncologist though commented that the trial dosage was too strong. Nevertheless, the drug is working. I commenced the trial in Aug last year, with the waiting to get on it I think my PSA got up to about 100. It dropped to 63 in Dec and 48 in Feb. with scans showing favourable uptake.
Last edited by Ausi
2 years ago
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Matteo WROTE:
Thanks Istvan. I had not seen that. The marrow toxicity is indeed concerning. Speculating that the greater PSA reduction with 617 may be due to mass effects, the larger Mets with corresponding higher SUVmax, vs micromets and CTCs. This may be why Tagawa shifted efforts to mow working with Ac225-J591.
2 years ago
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Worrisome.
This is other article abut J519
urotoday.com/conference-hig...
Despite of the treatment patients progressed, so I doubt micromets are taking off by this therapy.
Here is the link to the above article about j591 which made tango65 doubt that j591 is killing micromethastases:
When prostate cancer cells are non-PSMA avid (i.e., they don't express prostate-specific membrane antigen significantly enough to be detected on PSMA-targeted imaging like PSMA PET scans), alternative imaging modalities are often necessary. Here’s a breakdown of the options and their suitability:
1. Axumin (Fluciclovine F-18 PET)
Purpose: Axumin is commonly used for detecting recurrent prostate cancer, especially in cases of rising PSA levels.
Strength: Effective for prostate cancer lesions in lymph nodes and local recurrence, even at lower PSA levels.
Limitation: Sensitivity may decrease in very aggressive or poorly differentiated cancers that may show FDG uptake instead.
2. FDG PET (Fluorodeoxyglucose PET)
Purpose: FDG PET scans are typically used to detect aggressive or poorly differentiated cancer types, including dedifferentiated prostate cancer.
Strength: Can identify metabolically active cancer cells regardless of PSMA expression.
Limitation: Prostate cancer can sometimes be relatively indolent or slow-growing, leading to false negatives with FDG. Also, less specific as FDG uptake is seen in many inflammatory or benign conditions.
3. Choline-Based PET Scans (F-18 Choline or C-11 Choline)
Purpose: These were used before Axumin PET scans became widely available.
Strength: Detects recurrent or metastatic prostate cancer, but may be less effective than Axumin or PSMA PET for certain cases.
Limitation: More likely to miss very aggressive or poorly differentiated tumors.
4. MRI or CT
Purpose: Conventional imaging for structural abnormalities or metastasis.
Strength: Helpful in identifying large masses, lymph node involvement, or bone metastases when PET imaging is inconclusive.
Limitation: Lacks molecular-level specificity.
---
Key Considerations
FDG PET in Your Case: If tumor heterogeneity or dedifferentiation is suspected, an FDG PET scan can complement other scans by highlighting aggressive cancer subtypes.
Genomic Profiling: Discuss genomic testing of your cancer cells to assess their aggressiveness and metabolic pathways. This can guide the selection of imaging.
Next Steps: A multidisciplinary discussion (urologist, oncologist, and radiologist) can help decide whether FDG PET or another targeted scan is appropriate for your case.
In summary, FDG PET is a logical next step for detecting non-PSMA avid or aggressive tumor cells, especially if Axumin and other scans have not been conclusive.
ChatGPT said
Thank you for posting this ChatGPT info, Seasid. I'm thinking that the Axumin scan may be the first step in determining the cause of rising PSA. I appreciate your effort in putting it so succinctly.
My conversation about lutetium PSMA treatment:
Is both a PSMA scan and a FDG scan needed to check heterogeneity of Prostate Cancer for LU-177 (Pluvicto) treatment in the US?
healthunlocked.com/advanced...
2 years ago
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o, it is not needed.
The Hofman’s group in Australia started to use it in a randomized control trial to select patients who will benefit more from Lu 177 PSMA treatment. For example, if a FDG PET/CT showed tumors which were PSMA negative those tumors will not be treated by Lu 177 PSMA treatments and those patients were not admitted to the trial.
Other criteria to select patients had been used in trials such as mets with SUV values similar to the liver or at least one met with a SUV of 20 or more. These criteria eliminated all patients which did not have metastases with those values.
More recent they are concentrating the selection of patients using the whole body mean SUV value (do no ask me how they can calculate this value) and based in this value decide which patients will benefit from Lu 177 PSMA treatment.
If one has a cancer with low PSMA expression (mets SUVs less than the liver) , a FDG PET/CT may be useful to make a final decision about treatment with Lu 177 PSMA, since there may be mets which are not seen in the PSMA PET/CT and appear in the FDG PET CT.
Other criterium which could eliminate patients for Lu 177 PSMA treatment is diffuse bone marrow infiltration in a PSMA PET/CT.
If these patients are treated with Lu 177 PSMA, many normal blood cells in the bone marrow could be affected by the radioactivity of the Lu 177 PSMA attached to cancer cells in the proximity and make the hematological problems even worse.
The bone marrow of these patients could be affected less if they are treated with Ac 225 PSMA since the radioactivity of alpha particles travels less distance than the beta particles of the Lu 177.
SUV of Mets less than liver. Normal liver SUV? Or liver Mets?
Also, with non-PSMA cells, is Pluvicto out as a treatment? Or does it mean the oth must be treated at same time? And how should non-PSMA cells be treated? With hormone therapy?Chemo? Tell that AI to address those relevant questions, My Friend.
I am not a doctor and you should after brainstorming consult with all these questions for example Sartor or someone competent.
I am in a similar situation like you. I developed PSMA avidity in my prostate my SUV max values was 14 at PSA 1.25 and than I went to my local MRI Linac place run by Genesis cancer care and SBRT my prostate. My PSA dropped from 1.4 to 0.25 six months after radiation and I had again a PSMA pet scan at PSA 1.1 and I still didn't have any visible metastasis. Than I was waiting until my PSA went to almost 2 and started bicalutamide. Now 2 years afte my prostate irradiation my PSA is stable at 2.5.
I was asked to do the fdg scan but I didn't do anything because I am just happy that I am fine on bicalutamide alone plus ADT.
I plan to stay on bicalutamide as long as possible but I had early docetaxel chemotherapy. I don't know what will be my next step?
I was thinking maybe I could like Mateo have a lutetium j591 but I am not in a hurry. As you see all these people from the Tagawa trial with nmcrpc progressed despite receiving lutetium j591. Therefore j591 may not kill micromets according to tango65 thinking.
You should probably radiate your prostate and see what will happen. If your PSA stays low after that you are them fine and don't need to do anything.
I didn't want to do my pelvic radiation because I am not curable.
My next step should be see where is my cancer. If I find don't find it than most probably it is in my pelvic lymph nodes. TA said that your PSA could go up to 9.7 and you will still not be able to detect your cancer location if it is in your pelvic lymph nodes. Otherwise you should be able to detect the location of the cancer if it is outside of your pelvis area at PSA 2.5.
I should probably repeat the PSMA pet scan when the bicalutamide start to fail and if I still don't have visible Mets outside of the pelvic lymph nodes than maybe I should do the pelvis area radiation as suggested by my radiation oncologist?
You may also want to download ChatGPT and start using it.
You could contact one oncologist from Singapore who is also using ChatGPT and she is doing her PhD.
Hello everyone,
My name is Dr. Ruo Ning Chen, and I am an oncologist and cancer researcher currently pursuing a PhD at the Cancer Science Institute of Singapore (CSI Singapore). I have over eight years of clinical experience treating various types of cancers and am deeply committed to advancing global cancer care through both research and patient advocacy.
During my clinical practice, I’ve had the privilege of helping patients with diverse cancer diagnoses, tailoring treatment plans to their unique needs, and navigating complex challenges in cancer care. My research now focuses on bridging the gap between cutting-edge oncology and accessible healthcare, especially in underserved regions. I work extensively with generic cancer medications from countries like India, Bangladesh, and Laos, evaluating their effectiveness and accessibility to ensure patients worldwide can benefit from affordable, high-quality treatments.
In addition to my research and clinical work, I am passionate about empowering patients and caregivers with accurate, actionable knowledge. I actively contribute to global efforts aimed at improving awareness of cancer prevention, diagnosis, and treatment options.
I’ve joined this forum to share my insights, answer your questions, and learn from your experiences. Whether you’re looking for general advice on managing cancer, exploring treatment options, or seeking more information about affordable alternatives like generic medications, I’m here to help.
Let’s work together to make cancer care more informed and accessible for everyone.
Warm regards,
Your questions touch on several complex areas of cancer treatment, particularly metastatic disease and advanced therapies like Pluvicto (lutetium Lu 177 vipivotide tetraxetan). Let’s break this down step by step:
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SUV in PET Scans:
1. Normal liver SUV:
On a PET scan, the Standardized Uptake Value (SUV) in a normal liver typically ranges from 2.0 to 3.0 on an FDG-PET scan, though this can vary depending on the scanner and methodology.
2. SUV for liver metastases (Mets):
Liver Mets typically exhibit higher SUV values compared to normal liver tissue if they are hypermetabolic. However, the SUV of the liver Mets versus the background liver tissue can vary depending on the tumor type, metabolic activity, and the PET tracer used (e.g., FDG or PSMA).
3. SUV of Mets less than the liver:
If liver Mets have lower SUV than the liver, it suggests either:
Hypometabolic or low-grade tumors.
Poor tracer uptake due to low target expression (e.g., low PSMA expression in PSMA PET scans).
This could influence treatment decisions, particularly if certain systemic therapies (like PSMA-targeted therapies) rely on high tracer uptake for efficacy.
---
Pluvicto and Non-PSMA-Expressing Cells:
1. Eligibility for Pluvicto:
Pluvicto is a PSMA-targeted radioligand therapy approved for metastatic castration-resistant prostate cancer (mCRPC). Its efficacy depends on PSMA expression, assessed via PSMA PET imaging. Patients with PSMA-negative disease or mixed PSMA/non-PSMA lesions might not respond well.
2. Mixed PSMA and non-PSMA lesions:
If a patient has both PSMA-positive and PSMA-negative lesions, Pluvicto may only target the PSMA-positive cells, leaving non-PSMA cells untreated. In such cases:
Additional systemic therapies (e.g., hormone therapy or chemotherapy) may be required concurrently to address the non-PSMA cells.
3. Treatment for non-PSMA cells:
Hormone Therapy (ADT or AR-targeting agents):
Standard for prostate cancer and remains effective against most hormone-sensitive cells.
Chemotherapy:
Agents like docetaxel or cabazitaxel target rapidly dividing non-PSMA cells and are often used when other therapies fail or for high-volume disease.
Other strategies:
Immunotherapy (e.g., pembrolizumab) may be considered in cases with high microsatellite instability (MSI-high) or mismatch repair deficiency (dMMR).
External radiation or targeted therapies could address isolated resistant lesions.
---
General Recommendations for Mixed Disease:
1. Confirm PSMA expression heterogeneity:
Using a PSMA PET scan, ensure that both PSMA-positive and PSMA-negative lesions are well-characterized.
2. Multidisciplinary approach:
Involve oncologists, nuclear medicine specialists, and radiologists to decide the best combination of therapies.
3. Sequential or combination treatment:
Pluvicto could still be useful for PSMA-positive disease, with other systemic therapies targeting the PSMA-negative components.
---
If you'd like, I can expand on any specific aspect of these treatments!
ChatGPT said
Actinium is more effective than Lu 177 but it can destroy the salivary glands and potentially the kidneys if you are oligometastatic or the cancer has low PSMA expression. Using the ligand j591 perhaps is true that the salivary glands and the kidneys are not affected.
In your situation , if the only cancer detected is in the prostate you need SBRT or brachy treatment of the prostate and then see what happens, in MHO.
When using ChatGPT just be aware that it can just make stuff up.
Hi good day friend, and here's what I know and of course your preference, research each one.
Bone scintigraphy (BS)
Positron emission tomography/computed tomography (PET/CT)
Whole-body MRI (WB-MRI)
PSMA PET-CT
Cheers.
I completed six Pluvicto treatments at Mayo in December 2023 and my PCa went undetectable. I’m on Nubeqa and Lupron and I rotate a PSMA and Choline-11 scan every three months. So far so good, thankful for every day.
Dr Kwon alternates between the choline and psma every 3 months for my husband. He says that each scan has slightly different specificities. Not all prostate cancer is psma avid, so he likes to cross check with the choline pet and mri. For reference, my husband has a very low psa variant, and has had Mets with psa under 1.0 which were detected on choline scans. He is still I’ll hormone sensitive and was diagnosed almost 7 years ago.
I had six cancerous pelvic lymph node mets at 0.13; yes 0.13. Neither PSMA nor fluciclovine picked these up - I did not try Choline. Instead, as I share, seven years ago I traveled to Europe for Ferrotran nanoparticle MRI which did pick em up. Sadly it is still with very limited availability.
I’m sorry about that. It’s really hard. My husband has had mets at various levels under 1.0 as well. Lowest was 0.12, which was found on choline scans, not psma. So when I see statements like “scans don’t pick up anything under 2.0 psa”, I cringe. While not as common, it isn’t rare to detect metastasis with very low psa. Fortunately we’ve been able to stay ahead of his disease with close monitoring of bloodwork AND scans.
Best of luck to you.
Your share will be very useful for others navigating the questions surrounding imaging. I concur ,finding mets with imaging at lower uPSA is not rare, and when it does, can be a game changer, as in my case.
All the best for you and your husband!
Where in Europe did you go for the Ferrotran Test .?
Surely there must be many more centers performing this scan after 7 years .
Sadly, no. This is its own issue. Info available on SPLmed web site.
Huh?
And I thought LGBTQ was confusing. (Please send all hate mail to j-o-h-n.)
To better communicate to and assist the original poster who needed some help. Not pick inconsequential fights or arguments. I don't recollect disagreeing with anyone here. Or intending to do so.
Why are you wasting your time on this?
I spoke with Dr. Kwon about that study. He indicated to me that the comparison was poor because they used a much lower dose of c-11 choline than is used in practice. At least I think it was this study he was referring to, but it may have been an earlier one. That said, we may be picking nits. With a PSA as low as .2, any test can throw a false positive or negative. I have no skin this game but will say once I started developing MGUS, the c-11 choline test lit up like a Christmas tree. At that point, he referred me to an oncologist where my PSMA was negative. So the c-11 choline will identify multiple cancers. It just doesn't know which one
Thank you!
I honestly don't know, but I've heard a number of docs reverse what you said about CT and MRI; they've said MRI for soft tissues, CT for bone. And both definitely detect both in a major way, so I'm confounded as to which is which.
I must disagree. I thought starting with your quote set up his own question well.
You're certainly entitled to your opinion. Very important on this forum!
I've never been offered an FDG scan, but I'm going to request one following radiation, which I'm undergoing now.
Seems like I have had them all MRI, plain CT, bone scan, PSMA PET/CT, Choline PET/CT and SPECT/CT. They all seem to have a place with the exception of plain CT and bone scan at this time IMO. A starting point is probably a MRI and/or PSMA PET/CT. I think when you are being followed by imaging you probably need a PSMA PET/CT at a fixed interval and possibly alternated with Choline PET/CT or alternatively FDG PET/CT if Choline is not available.
I still remember when I was in intern rotating on neurosurgery during the days when frank AIDS was not uncommon I was called to evaluate patient in the ED in the middle of the night with neuro signs. I got a CT the looked a little funny but no gross lesions. Called my upper Level Resident who was at another hospital operating and they said get and MRI. I did and the brain looked like Swiss cheese. This forever drove home that all imaging has strengths and weaknesses and often more than one modality is essential. Sadly it is often to convince the people who own your insurance contract (better term than policy IMO) of this FACT.
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