I was lucky to be diagnosed shortly after Ga-PSMA PET Scans were available. The biggest challenge with treating PCa in my opinion is you don't know what you don't know due to the limits of imaging sensitivity and specificity, especially at low PSA levels, but at all levels there can exist extremely small tumors that imaging can't see.
Europe appears to be ahead of the USA for some reason in moving toward a complimentary imaging strategy. PSMA PET + superparamagnetic iron oxide nanoparticles (SPION) MRI (aka ferumoxytol) The SPION MRI scans appear to be able to pick up smaller lesions than PSMA PET in many cases which NanoMRI appears to be an anecdotal case of that.
I believe UCSF pioneered PSMA PET. Anyone know what centers are leading the charge for SPION MRI for PCa imaging in the USA? Any guesses on how many years off we are before FDA approval and thereby insurance approval?
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jazj
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Radboud U in the Netherlands pioneered Ferumoxtran-10 (Combidex) about 15 years ago. I believe they hold the patent. Mukesh Harisinghani at U of Mass used it in the US and Michael Milosevic used it in a trial in Toronto. There is a clinical trial in Europe. MD Anderson canceled their trial.
Another USPIO-MRI called Ferumoxytol (Feraheme) was tried by Sand Lake imaging in Florida. They stopped using it - IDK why.
Combidex can detect cancer in lymph nodes that is only 2 mm, as opposed to about 5 mm for PSMA PET/CT. It's not sensitive enough to detect microscopic cancer, so all pelvic lymph nodes still must be irradiated. It would be interesting to see a randomized trial of Combidex MRI against the Roach formula to see which gives better results.
Not to get off on a tangent but prior to confirmation of metastatic disease, I'm curious what your opinion is on just enduring the higher likelihood of significant side effects of Whole Pelvic RT (WPRT) as opposed to RT to only the prostate bed with or without ENRT to the lymph nodes? I would venture to guess Salvage treatment essentially is not curative in the majority of cases because cancer we couldn't see with imaging was not in the field of treatment.
The SPPORT trial proved that if PSA>.35, whole pelvic salvage irradiation is more likely to be curative. But 0.35 is not a hard cut-off --things like Decipher score, time at undetectable, Gleason score, T stage, margin status may provide useful info for decision-making.
I was about to reply regarding patients looking back on the treatment decisions, but I don't want to take this thread on a tangent. Will start a new thread.
jazj appreciate the shout-out for my actual experience. Seven years ago this week I was lucky to have found my way to Radboudumc, Nijmegen, Netherlands for the "Nano-MRI (Combidex)" (product name at that time) and Ga68 PSMA PET CT for comparison. That was nearly three years before FDA approved Ga68 for use in U.S. UCSF was one of the US trial centers but not so sure they should be referred to as pioneers, unless you mean one of the first on US soil.
The Nano-MRI (Combidex) identified five suspicious sites, ranging from 3mm to 6mm. Note the Ga68 did not identify any sites. Six total cancerous pelvic lymph nodes were confirmed by biopsy during salvage pelvic lymph node surgery. An interesting side-note I learnt was that Combidex originated in the U.S. in the 1990’s.
As to Europe being ahead in imaging for prostate cancer, yes, I think this is fair to say. In 2014 I was introduced to mpMRI in London, England. A very interesting book, published in 2012 by Drukkerij Efficient Nimegen is The Value of 3 Tesla Magnetic Resonance Imaging for the Detection and Aggressivenes Assessment of Prostate Cancer – From Theory to Practice. An autographed copy was given to me during my visit to Radboudumc.
I have no way to even guess how soon the FDA may approve SPION MRI but IMO history suggests later not sooner, especially for prostate cancer. I am saddened it is taking so long for Europe to approve Ferrotran nanoparticle MRI – again had mine in trial seven years ago.
Unfortunately or fortunately for us, the FDA's measured approvals are due to their primary concern with global climate change and the survival of the Delta Smelt.
This ASCO article published Jan 6 2025 just seems laughable. Are you kidding me? Who is this article intended for, doctors that have been living under a rock?
I wanted to also mention, imaging may be an area that AI may make a big difference in the future. Similar to the Artera AI test which uses microscopic images of tissue. If you can provide a large enough data set that includes imaging of tens if not hundreds of thousands of patients along with other diagnostic test data, the AI theoretically could make an "educated guess" with very high probability of where the cancer spots are that typically the imaging or the radiologist doesn't have the ability to clearly see.
Adding to what Tall Allen and NanoMRI have written:
I had a long talk with Dr. Prof. Barentsz during my infusion for this scan in 2014. The technology was invented in the US, but the company then messed up on their FDA application (including no radiologist involved in the submission). Barentsz was eventually able to purchase the technology, but only after overcoming many obstacles. My radiologist here, who trained with Zelensky at MSK, as soon as he saw my nanoMRI scan, immediately called Dr. Barentsz and asked to purchase licensing rights for the US. The answer was no, seems that, (somewhat like Mayo with their choline scan), they want to get as many patients as possible so as to pay for their investment. Anyway, Radboud is a nice town to visit--one of the three towns in the film "A Bridge too Far" with a small historic center and the rest rebuilt after WW II. I was there shortly after Mauritshuis in The Hague reopened after a multi-year restoration (Girl With One Pearl Earring, etc.) and I visited during the 24-hour interval between the infusion and the 3-T MRI.
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PSMA testing coming to South Florida...if you can get a decent urologist to prescribe it for you...
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How is PSMA PET scan being used in your experience?
