From my understanding PSMA are very accurate in determining PCa spread, but it also it is also would be diagnostic in discovering PCa in the Prostate.
If other screening tools such as PSA, DRE, and perhaps MRI indicate suspicions for PCa, instead of using biopsy, why not employ PSMA to determine if a biopsy is even necessary?
If the PSMA indicate a PCa in the prostate, then proceed with a directed biopsy to determine the Gleason grade to determine if Active Surveillance is an option?
well, of course, that makes sense - however, the price will make the decision - not the necessity or common sense - the world we live in
no doubt, but are biopsies that inexpensive?
most of the procedures we receive - for this disease and other medical issues are expensive in this country and as recent events point out, the people who make the decisions about which procedure and what will be paid ... have a great deal of power. Are they using it with compassion and ethically? Maybe - maybe not
Yes, compared to PSMA PET scans!! No even close!!
Most if not all hospital protocols require a biopsy before approving an operation to remove human tissue.
Most urologists perform the biopsy and the prostatectomy.
My point wasn’t that a biopsy wasn’t necessary, but only if the PSMA was positive would it be necessary, because you need to determine the Gleason grade.
The Gleason Score was invented as an indirect indicator of the PCa progression and in particular it's probabilistic correlation to a metastasized disease. Now, that there is a means of a direct look into the latter, it is redundant. Rhetorical question: Which of the two will provide a more concrete indication for SVI? As to the internals of the prostate a mpMRI is way more specific than any biopsy. Hence, the combo of mpMRI and PSMA PET gives a more solid indication of the disease's progression. But, some will loose a part of their income, if you prefer the bare truth to the marketing hype.
I have a 3 + 4 Gleason biopsy but a negative psma pet Pirad 2 mri and low decipher
I think that a PSA would show cancer, but not give an indication of Gleason score.
PSA indicates a heightened risk of cancer...it does not indicate cancer.
Sorry, I meant PSMA scan
Professional privileges. Urologists will not surrender lucrative biopsies to radiologists and PSMA imagings.
Nice that TA is here to correct all the incorrect musings of many others here.
Like: "There is no PSADT bellow 0.1". Nice, really nice!
I have no idea re the value of measuring the doubling time below 0.1......perhaps you've read studies?
Calculus dates back to the ancient Phoenicians, Greeks and Arabs. No need for me to re-invent it.
@Justfor_ You seem to be often cynical. Biopsies reveal tumor cell types -- critical to treatment planning. PSMA PET/CT does not...
That wasn’t my question or point. I was speculating that perhaps the biopsy can be avoided is the PSMA scan was negative. If it is positive then a biopsy would absolutely need to be followed up to determine the Gleason grade.
No, you got that wrong. PSMA PET scans have only about 40% sensitivity for finding metastatic spread. It is not at all diagnostic for finding PCa in the prostate.
from what I have read it is very accurate as a diagnostic if the PSA is >1 Ng/ml in the prostate.
I am not talking about spread, but diagnostic for PCa in the prostate I have seen figures close to 90% accuracy
urologytimes.com/view/dr-re...
The link you provided is not about detection in the prostate.
No it doesn’t because it has never been approved for that. What I read from it is that it is very accurate if PSA values are >1, and I was simply suggesting why couldn’t it be used as a diagnostic, and if it is positive in the prostate bed then proceed with a biopsy to determine the grade, otherwise just continue on AS.
It was just a speculation, no tasting this is a protocol that should be followed.
It has never been used for that because it is not diagnostic. PSMA is a protein that appears on prostate cancer cells as it progresses, so it is ill-suited as an early screening tool.
That answers my question, thanks
I'm thoroughly confused now. What then are the strengths of the PSMA scan if not Mets or prostate?
With a rising PSA in 2020 I had a PSMA PET/CT performed that showed up NOTHING. Dr. was still concerned so ordered a 3TmpMRI for remaining half of prostate check. Indicated nothing other than some enlargement then next PSA dramatically lowered.
Had rapid rise in to 12ng/mL PSA late 2023. The PSMA PET/CT showed 3 spots in left remaining prostate lighting up with the rest was clear.
Had the most complete rendition of a prostate biopsy available with the prostate still within, the Saturation Transperineal 3Dimension Prostate MAPPING Biopsy that yielded 47 cores for sampling with 3 cores positive at 3+3. Currently on Watchful Waiting. Scans can be totally WRONG!!!
Thanks. I realize that scans can be wrong or incomplete without complementary imaging or biopsy. In fact, I've been trying to make my own docs aware of that since they all seem to regard the PSMA as next to infallible among scans (leaving biopsy aside).
Still, TA's specific comment on this post left me confused. Perhaps he was addressing the issue of initial confirmation of PCa, but that wasn't clear to me.
T_A wrote -- " ... It is not at all diagnostic for finding PCa in the prostate. "
Confusing - YES - since my most recent PSMA found the PCa in my remaining left half of prostate.
Initial finding (which is the OP's question) is different from salvage, and high false positive rate in the prostate.
Very interesting. Thanks for the example that nothing is perfect, even biopsies, though a saturated Tp biopsy like you had narrowed that window significantly.
Glad it was a low grad.
All the best.
Thanks 👍👍
The first TP-3D-PMB I had for the whole prostate yielded 100+ core samples for inspection. It provided clear borders for the GL 10 tumor in the right half so only that half required Cryoablation using enough probes to ablate the entire prostate.
PSMA PET scans have low sensitivity for finding metastases but high specificity. Because PSMA doesn't appear on the surface of prostate cancer until it has progressed, it is particularly ill-suited for early prostate cancer detection. It also has a high false positive rate in and around the prostate due to kidney excretion.
Thanks for the clarification. My first and only PSMA in July showed no abnormal uptake outside the prostate (contradicting earlier Axumin scans) but showed 24.7 SUV max in prostate, much higher than Axumins had shown (around 4.5-4.8,). I don't know if there is a normal uptake for prostate or if SUV max levels for PSMA are on the same scale as Axumin.
That's high enough to not be a false positive.
Totally agree 👍
Yes, I suspected that. In January, six months earlier, my latest Axumin showed about 4.7, roughly the same as the previous 3 going back to 1/2020. Am I correct that the PSMA uptake in prostate cannot be compared directly to Axumin uptake in prostate?
There's a lot of overlap.
incorrect 90% for a pet scan and around 92 or 3 for an MRI
Here's what I see:
mpMRI has sensitivity of 44% and specificity of 94%
PSMA PET has sensitivity of 49% and specificity of 95%
pubmed.ncbi.nlm.nih.gov/272...
What is your source?
When used together, a prostate MRI and a PSMA PET scan can be highly accurate at detecting prostate cancer, often providing better detection than either modality alone, with studies showing combined accuracy rates reaching around 90% for clinically significant cancers; however, the exact accuracy can vary depending on the individual case and the specific imaging technique used.
Your pubmed article is 9 years old and my source is my Prostate Oncologist. He has been doing exclusively this for about 30 years. When my MRI showed as being borderline and more likely to be benign causes, he felt that we should do a biopsy to be safe (makes sense). Then he said that if I was able to pay for or get a PSMA approved, that would be another great option for now. Nothing is 100% and we have a LOT more info than the PSMA (MRIs, free PSA, 4K, PSA trajectories, DREs, 2nd opinions, etc.). Of course PSMA is not full proof but it helps paint a picture and I believe you will be seeing it used more and more in the diagnostic phase as patients look for alternatives to biopsy; especially with people who can afford it.
Your prostate oncologist has not published. If he had legitimate findings he would publish. It is nonsense unless there is better data in a peer-reviewed journal.
Oh ok thanks...
Psma is expensive and not so good for your kidneys. And can miss some cancer cells.
A biopsy pretty much confirms or not that you have prostate cancer.
By definition, prostate cancer starts in your prostate.
Currently thou I believe noninvasive color ultrasound and certain scans are as reliable as invasive biopsies.
Biopsy was quick and only a minor discomfort it saved me more waiting time and additional copays before moving on to RP
Even normal prostate cells express PSMA-protein, that's why PSMA-scan can't tell if the cell is cancerous or not. However if PSMA-scan shows something outside of prostate then it's definitely a metastasis because, normally, prostate cells are not living outside of prostate.
That clarifies one point. But PSMA is not all that accurate for bone mets? I'm asking because of TA's comment above.
PSMA was how I found I had a bone mat in my hip socket in 2019. After three years of Lupron and abiraterone I had another PSMA…F18 last January. It showed that the bone met was gone and I am now considered in remission..
Excellent news
That's great! Had you had any other scans prior to the PSMA in 2019 that failed to find the met?
I had two PSMA Tests over 3 year period and neither of them showed PCa but Biopsy did...
How'd you get two PSMAs before biopsy? Did you pay out of pocket?
I had Biopsy's but since they so inaccurate, both times the Doc didn't think we would see anything and they were right both times. If a PSMA Test shows something then you know its bad and spreading!
Doc ordered both tests. 1st time I didn't have insurance and negotiated the price and down to $8,000, that 4 years ago. Second time USA MEDICARE picked up the tab.
murk if the PSMA show it is confined to the prostate bed that would not necessarily mean it is spreading unless it showed outside the prostate I believe.
A PSMA Test isn't good enough, accurate, nor can it guarantee that cancer has not metastasized (spread). It is only good for confirming that it has. This is why some Doc's, insurances or Countries with National Healthcare do not recommend, offer or pay for these tests. All just IMO 
Materials and methodsWe retrospectively evaluated toxicities and outcomes of patients with intraprostatic recurrence following primary radical radiotherapy for hormone-sensitive prostate-confined or locally advanced PC. Intraprostatic recurrent lesions were detected by 11C-/18F-choline-positron emission tomography/computed tomography (PET/CT) or 68Ga-prostate-specific membrane antigen (PSMA)-PET/CT after evidence of biochemical relapse (defined in accordance with the Phoenix criteria: PSA ≥ PSA nadir +2 ng/mL [12, 13]). All patients underwent subsequent 1.5 T multiparametric prostate magnetic resonance imaging (mpMRI) using T2-weighted (T2W), diffusion-weighted (DWI), and dynamic contrast-enhanced (DCE) for confirmation of intraprostatic recurrence identified on functional examination (PET). In case of concordance between PET and MRI, patients were considered eligible for reirradiation. We considered prostate biopsy not mandatory if all diagnostic findings were univocal in the presence of a body of evidence (PSA kinetics, prostate MRI, and/or PET-CT findings) in favor of local recurrence.
Linac-based stereotactic salvage reirradiation for intraprostatic prostate cancer recurrence: toxicity and outcomes
BEFORE diagnosis only an examination of cells with microscope can determine cancer diagnosis. Unless advanced with widespread mets in expected locations and standard symptoms. In which case go straight to treatment.
After diagnosis scans MAY indicate likely cancer in nodes/organs. This is not infallible. Occasionally a biopsy is necessary in such instances. Other times treatment follows on the assumption of metastasis.
Nonetheless screening, in other words testing of a broad range of individuals without diagnoses, is not recommended. Biopsy of a wide number of me age 65+ might find cancer but will never be adopted due to cost and risk. Scans, same thing.
Logically makes sense.
in Germany they are confident enough to do surgery on the basis of MRI and PET
Materials and methodsWe retrospectively evaluated toxicities and outcomes of patients with intraprostatic recurrence following primary radical radiotherapy for hormone-sensitive prostate-confined or locally advanced PC. Intraprostatic recurrent lesions were detected by 11C-/18F-choline-positron emission tomography/computed tomography (PET/CT) or 68Ga-prostate-specific membrane antigen (PSMA)-PET/CT after evidence of biochemical relapse (defined in accordance with the Phoenix criteria: PSA ≥ PSA nadir +2 ng/mL [12, 13]). All patients underwent subsequent 1.5 T multiparametric prostate magnetic resonance imaging (mpMRI) using T2-weighted (T2W), diffusion-weighted (DWI), and dynamic contrast-enhanced (DCE) for confirmation of intraprostatic recurrence identified on functional examination (PET). In case of concordance between PET and MRI, patients were considered eligible for reirradiation. We considered prostate biopsy not mandatory if all diagnostic findings were univocal in the presence of a body of evidence (PSA kinetics, prostate MRI, and/or PET-CT findings) in favor of local recurrence.
Linac-based stereotactic salvage reirradiation for intraprostatic prostate cancer recurrence: toxicity and outcomes
link.springer.com/article/1...
The information provided aligns with recent approaches in managing intraprostatic prostate cancer recurrence, particularly after primary radiotherapy. Here’s a summary based on the provided details:
1. Non-Mandatory Biopsy: Prostate biopsy may not be required when diagnostic findings (e.g., PSMA PET/CT, mpMRI, and PSA kinetics) are concordant and strongly indicate local recurrence. This avoids the invasive nature of a biopsy when the evidence is compelling.
2. PSMA PET/CT and mpMRI Concordance:
If PSMA PET/CT findings correlate with mpMRI results, particularly with a PIRADS score of 5 (highly suspicious of malignancy), the likelihood of recurrence being cancerous is high.
An SUV max value as high as 24 further supports the diagnosis of prostate cancer.
3. Reirradiation for Intraprostatic Recurrence: Linac-based stereotactic salvage reirradiation has been used effectively for patients with intraprostatic recurrence confirmed by imaging modalities like PSMA PET/CT and mpMRI. The approach evaluates toxicity and outcomes, offering a targeted treatment option while minimizing damage to surrounding tissues.
The referenced study (available via Springer) emphasizes these principles, suggesting a paradigm shift toward advanced imaging and non-invasive diagnostics to confirm recurrences and guide salvage therapies.
ChatGPT said
exactly
The prostate biopsy would be still great to provide a tissue samples for genetic testing.
Yes, combining PSMA PET scans with multiparametric MRI (mpMRI) in early prostate cancer diagnosis could potentially enhance diagnostic accuracy and provide valuable insights into disease characterization. Here's how the combination could work and why it’s worth exploring:
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Potential Benefits of Combining PSMA PET and mpMRI
1. Improved Lesion Detection:
mpMRI is the current standard for evaluating prostate lesions and determining the PIRADS (Prostate Imaging-Reporting and Data System) score, which helps assess the likelihood of clinically significant prostate cancer.
PSMA PET scans, while more sensitive in detecting prostate cancer with high PSMA expression, might reveal additional lesions or provide molecular imaging information that complements the anatomical detail from mpMRI.
2. Enhanced PIRADS Correlation:
By comparing PSMA PET findings with mpMRI results, we can investigate how well PSMA uptake correlates with PIRADS scores, particularly for intermediate (PIRADS 3) or high-risk lesions (PIRADS 4-5). This could help refine the decision-making process for biopsies.
For example, a PIRADS 3 lesion with significant PSMA uptake might indicate a higher likelihood of clinically significant cancer, warranting a targeted biopsy.
3. Increased Diagnostic Confidence:
PSMA PET scans could act as a secondary confirmation for suspicious findings on mpMRI, reducing false negatives and improving overall diagnostic accuracy.
Conversely, if a PIRADS 3 lesion shows no PSMA uptake, it might suggest a lower risk of aggressive disease, potentially sparing the patient from an unnecessary biopsy.
4. Guidance for Targeted Biopsy:
Combining the spatial information from mpMRI with functional imaging from PSMA PET could help pinpoint biopsy targets more accurately, improving diagnostic yield and reducing sampling errors.
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Challenges and Considerations
1. Low PSMA Expression in Early Disease:
In early or low-grade prostate cancer, PSMA expression may be minimal, limiting the sensitivity of PSMA PET scans in this setting. This makes it critical to carefully evaluate the added benefit of PSMA PET when used alongside mpMRI.
2. Cost and Accessibility:
PSMA PET scans are expensive and may not be readily available in all healthcare settings. Combining them with mpMRI could increase the financial burden, so their combined use would need to demonstrate clear clinical benefits.
3. Validation Through Clinical Trials:
While combining these modalities is a promising idea, it requires rigorous clinical trials to validate their synergistic use, determine the optimal workflow, and establish cost-effectiveness.
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Possible Workflow for Early Diagnosis
1. Initial mpMRI Evaluation:
Perform mpMRI to identify suspicious lesions and assign PIRADS scores.
2. PSA and Risk Assessment:
Consider combining PSMA PET scans for patients with intermediate to high PSA levels or ambiguous mpMRI findings (e.g., PIRADS 3 lesions).
3. Correlation of Findings:
Evaluate how PSMA uptake aligns with mpMRI findings to improve diagnostic accuracy and guide biopsy decisions.
4. Targeted Biopsy:
Use combined imaging data for precise targeting of lesions, minimizing unnecessary biopsies.
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Summary
Combining PSMA PET scans with mpMRI could improve early prostate cancer diagnosis by enhancing lesion characterization, improving diagnostic confidence, and guiding targeted biopsies. However, due to challenges like low PSMA expression in early disease and cost considerations, this approach needs further validation through clinical research. If proven effective, it could revolutionize prostate cancer diagnostics, particularly for intermediate-risk cases.
Retzius Sparing surgeon recommendations 
PSMA results
ArteraAI Test
My turn for advice
High risk treatment - go conventional or experimental?
