PSMA PET Suspicious for Mets - Questions

[FaithOverFear104]

Good morning - Pasted below is the report from the first PSMA PET scan my husband has had that has shown possible mets or anything other than activity in the prostate since he started Intermittent ADT about two years ago.

I am hoping for some guidance on what to expect/what to ask for in terms of further testing and/or possible treatment options based on this scan? Also, is it possible that what they are seeing in C-spine and pelvis could be something other than metastases?  If they are suspected mets, what testing would confirm that? And if confirmed, what treatment options might he consider? Is the only option other ADT treatment or is there something that can target the mets?

My bio should be current but to summarize, he was metastatic at diagnosis In January 2022. He had successful treatment with Triple Therapy. By late February 2023, it was primarily significant mental health side effects that led to his request to begin intermittent treatment. After his first PSA rise during his first break, his MO offered different treatments (Orgovyx, and I believe Casodex) and he opted for Enzalutamide/Xtandi. Due to his having had a grand mal seizure back in 2017, his MO put him on a half dose (two tablets rather than four). Since then, it has done the job of lowering his PSA significantly. Each time he has been given a break it has been coupled with scans showing no new activity as mentioned above, and other labs looking good. 

Also, I should note that other than what I mentioned above, my husband has had no other treatment (no radiation, etc.). And, he has not had any genetic testing since early 2022, when they tested blood and tissue from a lymph node biopsy. At the time, there were no actionable mutations. His new MO has said that if anything shows that can be biopsied, she will want to do that to see if anything has changed in that regard. 

I appreciate any guidance. We meet with the MO tomorrow morning. 

Thanks in advance. 

EXAM: GALLIUM-68 PSMA PET/CT CLINICAL HISTORY: Patient with prostate cancer. Gleason 4+4 [8] prostate cancer metastatic to bone and lymph nodes. PSA on February 01, 2025 was 11.13 ng/ml. 

TECHNIQUE: Radiopharmaceutical: 6.5 mCi Ga-68 PSMA intravenously Uptake time: Body:62Pelvis:96Field of view: Vertex of skull to upper thigh Oral Contrast: Not administered IV Contrast: Not administered  The CT protocol used for this PET/CT study is designed for attenuation correction and anatomic localization of PET abnormalities. This companion CT is not designed to produce, and cannot replace, state-of-the-art diagnostic CT scans with specific imaging protocols for different body parts and indications. The standardized uptake values (SUV) are normalized to patient body weight and indicate the highest activity concentration (SUVmax) in a given disease site.  

COMPARISON: September 20, 2024.  CORRELATION: None.  

FINDINGS: REFERENCE REGIONS: Parotid gland SUV mean: 15.Liver SUV mean: 5.8.Blood pool at aortic arch SUV mean: 1.5. 

HEAD/NECK: No abnormal uptake.  

CHEST/BREAST: No abnormal uptake. Bilateral gynecomastia. LUNGS: No abnormal uptake. Calcified granuloma right lung unchanged. 

PLEURA/PERICARDIUM: No abnormal uptake. 

MEDIASTINUM/THORACIC NODES: No abnormal uptake. Minimally avid nonenlarged right axillary node, SUV 1.9, image 104, probably reactive. Low-grade right perihilar uptake, possibly nodal, SUV 2.3, image 117, previously SUV 2.4. 

HEPATOBILIARY: No abnormal uptake.   

SPLEEN: No abnormal uptake. 

PANCREAS: No abnormal uptake. 

ADRENAL GLANDS: No abnormal uptake. 

KIDNEYS/URETERS/BLADDER: No abnormal uptake. 

ABDOMINOPELVIC NODES: No abnormal uptake. 

GI/PERITONEUM/MESENTERY: No abnormal uptake. 

PELVIC ORGANS: Discrete tracer uptake at the left prostate base inseparable from the seminal vesicle SUV 7.6, image 252, previously SUV 8.0Focal uptake at the right lateral base to mid prostate SUV 9.3, image 264, previously SUV 7.4.  Trace bilateral hydrocele. Left greater than right fat-containing inguinal hernias. 

BONES/SOFT TISSUES: Increased intensity of focal uptake at the left lateral C2 vertebral body SUV 10.8, previously SUV 3.5.Low-grade uptake at the C3 vertebral body SUV 3.6, new.No substantial change in rim sclerotic bilateral iliac bone lesions with below background uptake, SUV 1.0 on the left, image 227 and SUV 1.1 on the right, image 227Faintly sclerotic focus at the right inferior pubic ramus, image 269, SUV 1.2, image 269, new. 

OTHER FINDINGS: None. 

IMPRESSION:

1. Since PET/CT September 20, 2024, no substantial change in tracer uptake at the left prostate base and slightly increased intensity of tracer uptake at the right lateral base to mid prostate gland. Suspicious for viable tumor.

2. Increased intensity of tracer uptake at the C2 vertebral body and new low-grade uptake at the C3 vertebral and right inferior pubic ramus, suspicious for metastatic disease.

3. Unchanged few mixed lucent/sclerotic osseous lesions.  

[GP24]

A met at C2 was detected in the previous PET-CT and did increase in size/uptake. This are two bone mets . These can be radiated. Discuss the next therapy with your doctor.

[FaithOverFear104 in reply to GP24]

Thank you so much. Will do! I appreciate you taking the time.

[Tall_Allen]

Instead of taking an inadequate dose of Xtandi, consider switching to Nubeqa, which should not exacerbate his epilepsy.

There is no need to reconfirm his bone metastases- the high SUV is dispositive.

Consider Michael Morris' clinical trial of Xofigo+ lower-dose docetaxel:

clinicaltrials.gov/study/NC...

[FaithOverFear104 in reply to Tall_Allen]

Thank you, TA! We appreciate you very much. Will definitely discuss with MO tomorrow.

[j-o-h-n in reply to FaithOverFear104]

If you get to see Dr. Morris at MSKcc you've hit the jackpot....

Good Luck, Good Health and Good Humor.

j-o-h-n

[FaithOverFear104 in reply to j-o-h-n]

Oh I know it!! We tried to see if he could be the lead on my husband's case early on, but Dr. Morris didn't have room in his case load at the time. Unfortunately, I am not sure my husband will qualify for this study bc he is not castrate resistant. We are asking about it anyway though.

[j-o-h-n in reply to FaithOverFear104]

Too bad. Well I wish you both -

Good Luck, Good Health and Good Humor.

j-o-h-n

[FaithOverFear104 in reply to j-o-h-n]

Thank you!

[Shellhale]

Talk to the MO about radiation to the primary tumor since it's still showing activity. There is evidence now that radiating the primary increases overall survival. Also instead of him taking a half dose of Xtandi which is known to cause seizures, consider switching to nubeqa which does not cross the blood brain barrier. He will get more efficacy from the HT. SBRT may be an option to bone mets also. Wishing you both the best of luck as you navigate treatment options.

[FaithOverFear104 in reply to Shellhale]

Thank you so much for your reply. We have asked about radiating the primary tumor in the past and now about radiating the mets and every time have been told by the MO that radiation would not help. I am not sure if this is a Sloan Kettering thing or if it is somehow the MO not wanting to connect us with a Radiation Oncologist for some reason. I hate to think that - but we have never even been able to speak to an RO. I will try again to see if we could at least get a consult with one at MSK - otherwise maybe we will have to look elsewhere. It's very frustrating. He has been on Nubeqa in the past. I don't believe it was approved for monotherapy when he started Intermittent but we will look into it. Thank you again. Wishing all the best for you and your husband as well.

[dhccpa in reply to FaithOverFear104]

If you're at MSK you can't just make an appointment with an RO? Or you're hesitant to go around your MO? Just curious. I haven't yet gone to a major medical system except for second opinions.

[FaithOverFear104 in reply to dhccpa]

I guess we have always viewed his MO (there have been a few bc his original one left MSK about a year into our journey) as the quarterback - or the lead - on my husband's case. It isn't as much about stepping on toes as it is feeling like there should be some kind of coordinated effort if there are multiple lines of treatment from different doctors. I will keep pressing on it and will see if we can get anywhere. We would rather hear from an RO that radiation isn't an option (if that is indeed the case).

[dhccpa in reply to FaithOverFear104]

Were I live it seems to be necessary to seek out different opinions. Of course, you don't want conflicting treatments. But I've gotten the sense that if you get another doctor's opinion, sometimes (and it probably depends on the doctor) your original doctor actually likes knowing what other doctors think, even if they don't say that openly. I agree you have to be deicate in how you put things and do things. But you seem to have a good grasp of prostate cancer basics, at the very least, so carry on with your best judgement. I've often wondered if I went ot a large medical center and found myself with their one "prostate cancer expert," I'd be any happier. Hard to say for sure.

[FaithOverFear104 in reply to dhccpa]

Thank you. We will keep pressing on. If need be we will seek opinions within MSK and elsewhere just to be sure.

[Shellhale in reply to FaithOverFear104]

My husband is on monotherapy nubeqa. I would get a second opinion for sure. Not knowing the specifics for his case, not sure why they haven't recommended radiating the primary. I would ask your MO why he thinks it would not help? I would also push for a liquid biopsy (circulating tumor DNA test) if they haven't mentioned it already. Since my husband's PSA is rising again we plan on asking for more DNA sequencing. He has a PSMA scan scheduled 3/26. He won't do ADT so SBRT is the plan if anything lights up. Last PSMA all nodes were resolved. No bone mets.

[FaithOverFear104 in reply to Shellhale]

Thanks so much. May I ask how your husband is doing on Nubeqa monotherapy? How is he feeling and is he experiencing side effects? Also - where is he being treated? Sounds like your husband has a solid plan. We also asked about liquid biopsy and they shot that down as well. I don't get it, really.

[Shellhale in reply to FaithOverFear104]

He has done great with really no side effects on Nubeqa. He works out with weights 4x a week and we bike ride and stay pretty active. He is being treated at University of Colorado Anschutz Cancer center. It's NCI designated. Sometimes you have to push these doctors. I work with doctors, they get very busy, as long as you have a solid reason for wanting something they will usually honor your request. Be ready to state the reason for your request and why it is important to you.

[FaithOverFear104 in reply to Shellhale]

Thank you so much! I hear you. Yes we lived in Colorado for a long time. If we were still there, we'd be going to UofC too. Thanks again for all of your input.

[Shellhale in reply to FaithOverFear104]

No problem. We live in Woodland Park. So we started at Rocky Mountain cancer center. We switched because the MO wasn't very knowledgeable with PCa. He told me he had only done 1 liquid biopsy in 15 years. I knew we needed to switch after that. I should have known better. I actually used to work at Anschutz in the hospital so I knew that they had a high success rate being a research hospital. Good luck with everything and hope all goes very well!!

[FaithOverFear104 in reply to Shellhale]

We miss it there sometimes. We still have family in Northern Colo and friends all over so we get back when we can. It is tough bc being treated at one of the top cancer centers, I feel like we shouldn't question things but I don't get it. I asked about a liquid biopsy but they said they dont really do that. ugh. Anyway - we will keep seeking the best care and treatment. Thanks again for all of your input. Wishing all the best for you and your husband.

[Shellhale in reply to FaithOverFear104]

Don't ever feel bad about questioning things. I have never been offended when a patient questions me. Sometimes I learn something new. Explain to the Dr that it is known that during the evolution of this PCa that cells become resistant and PCa is very heterogenous and we want to be assured that we are not missing anything that can be targeted within the genomics of the tumor. Especially since oncology is evolving into more personalized medicine. So we would like to pursue a tumor DNA sequencing test please. Let me know how it goes. Keep us updated. 🙏

[FaithOverFear104 in reply to Shellhale]

Thank you again so much! Will do for sure!