Advanced Cancer and waiting...
Comments
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The spike in your PSA is concerning for sure.
I've had PSMA PET scans too, but they also haven't shown anything. I'm dealing with biochemical recurrence. My last PSA reading was 0.57 so probably not high enough for anything to be detected. It stands to reason that the higher the PSA, the greater the chance of a scan picking anything up. Some of the more experienced folk around here say that a scan is more beneficial if PSA is over 1.0 but this doesn't help you now, of course. I can understand your frustation that maybe your scan was on the cusp of detecting something, but not quite, so now you have to wait.
Good luck to you.
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On_A_Journey....This is my second PSMA PET since January 2023. It's my understanding that the PSMA PET given at UCSF and UCLA are the only two teaching facilities in the USA that have been grated FDA approved the first PSMA-targeted PET imaging drug, Ga 68 PSMA-11. It is my understanding that Ga 68 PSMA-11 is reliable at .2 or greater. All in all just another pig at a poke with this cancer stuff...Hope all continues well on your journey!
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CentralPA...I seem to be doubling ever 2/3 months since July 2022 but time will tell for sure...It's just a matter of when-funny what we accept as our normal....Thanks for asking about my Hartmann reversal (colon put back together). I had my surgery back on August 3, 2023, and I'm blessed to be fully functional. Between my kidney/bladder surgery and my colon reconnect, I'm pooping and peeing like a 10 year old. I'll take it where I can! All the best in your journey-BD
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Hi,
Surely the increase of the PSA is a matter for concern. Starting ADT is your next step.
In regards to the 68Ga-PSMA PET, my experience includes two exams. The first was done in February of 2019, when the PSA was 1.8, and were described as negative. This was a follow-up exam of a previous 18F-Choline PET (PSA =1.8) done in January of 2018 which indicated suspicious for positive recurrence at prostate bed and in one lymph node.
It is evident that the nuclear physician that interpreted the PSMA results of the scan of 2019 was erroneous in describing it as "negative". He saw PSMA (SUV) accumulation at the prostate bed but he may have interpreted it as the radiopharmaceutical in the bladder which is excrete in the urine.
The second 68Ga-PSMA PET exam was done in October 2023 with a PSA of 9.8. This time the nuclear physician indicated recurrence at the prostate bed due to a higher SUV in the area when compared with the results of the exam of 2019. It also indicated a metastasis at the pubic bone for the accumulation of the PSMA but with lower SUV.
the big difference between the two PSMA exams were the used protocol. In 2019 they would take the "picture" one hour post injection of the radiopharmaceutical. In the exam of 2023, they took two "pictures". One at one hour after injection an the second picture 20 minutes later.
I have been studying the matter in the past 4 years and found out that my experience is not unique. It is a common negative result of 68Ga PSMA exams in recurrences closer to the bladder. The image can be blurred.
It seems that the isotope 18F-PSMA is better in localized recurrences due to the half-life of the radiopharmaceutical. The image is taken in three different timings allowing for more interpretation of the areas where the PSMA accumulate.
I would advise you to do the MRI in a 3-Tesla machine.
Best wishes.
VG
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I had a 90 minute video conference this week (Jan 16) with my first assigned Medical Oncologist in 16 years:
It was a pleasure meeting you. Here's a summary of what we discussed: We discussed that in general that we do not change or initiate therapy for PSA changes alone. If, however, PSA rises correspond with you worsening clinically or having evidence of disease worsening on imaging, we definitely plan treatment options.
These options depend on findings on imaging. In your case, you have a more rapidly rising PSA but recent imaging in October did not show any clear evidence of disease We recommend repeating a PSMA PET scan since it's been 3 months since your last scan and now your PSA has risen > 1.
We discussed evidence that demonstrate sensitivity of PSMA PET for detecting disease increases substantially for PSA values >1 (>80%). We would also recommend this imaging be a combined PSMA/MRI (which you haven't had before) - an MRI allows us to better evaluate the pelvis, where chances of recurrence are highest.
While your initial prostate cancer was 'intermediate risk' (which we assess by the gleason score, bulkiness of the tumor and initial PSA value), your most recent biopsy in 2021 showed a high risk cancer (as the Gleason Score was higher).
Additionally, your PSA has been rising quickly, with a doubling time < 6 months. All this means that we would likely increase the intensity of hormonal therapy if treatment is initiated, by combined both ADT (which you've had before) and a new ASI (androgen signalling inhibitor).
We deferred an in depth discussion of ASI at this visit but note that adding this to a backbone of Lupron has shown to improve outcomes for metastatic prostate cancer. Recent studies have shown it's additionally beneficial to 'intensify' hormonal therapy for localized disease that's high risk, when combined with radiation.
Please get PSA/testosterone checks every 4 weeks. We will work with you to schedule your PSMA/MRI soon. Follow up with us in 2-3 months after your scan to discuss next steps...
The journey continues....
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BD,
Thanks for sharing your video consultation with Dr. Eric Small. His recommendation is similar to what Dr Tucker suggested me in Singapore. The medical oncologist assisting me in the portuguese NHS also follow the principle in attacking the bandit aggressively with the newer drugs. The protocol depends on the toxicity we manage to endure.
Tucker send me to have a cardiovascular exams apart of those related to PCa, probably to check my health status before advising any of those drugs. After the 68Ga PSMA PET in October, that identified the bone metastasis, he recommended ADT plus Xtandi, Erleada or Nubeqa.
Now I am on ADT plus Erleada (Apalutamide) an ASI, adding Avodart (Dutasteride) a 5-ARI, in a triple blockade. The choice for apalutamide was due to my present diagnosis of metastatic castration-sensitive prostate cancer (mCSPC).
The PSMA PET/MRI can show more details than the PET/CT, but I belive that a protocol with two sections in the machine may be more conclusive than the traditional protocol of one section done one hour post injection.
You can discuss this with him.
Let's wait for the PET results.
Wishing you the best in this new phase of your journey.
VG
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VG...
Thank you for your input/insight. Yes, I'll see with my next PSMA what they are going to do...I also have a video call with Radiology this coming up week to discuss their roll in my care...As I understand, if I have 5 or less spots ( if they can get to them) they'll continue with the SBRT... I going to plan a holiday soon...
Take care,
BD
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VG...
As always, thank you for your input/insight.
Yes, I'll see with my next PSMA what they are going to do or not...I also have a video call with Radiology this coming up week to discuss their roll in my care...As I understand, if I have 5 or less spots ( if they can get to them) they'll continue with the SBRT...
Yes, I'm in good hands with Dr. Small and nice to hear you're getting similar advise in AP.
I'll share the "new drug" with all, if and when I go down that path...Yes, as I understand, the PET/MRI provides better images...
All the best down your new path...
Take care,
BD
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Here are the results of my PMSA/MRI last month…and they always find other things to alarm me about :-)…I couldn't be in better hands and have taken a back seat to all of this, on this go around…Truly blessed to be talking about this 16+years later.
Had a follow up today with my medical team and they tell me, I'm stable. So, I'll continue with monthly PSA and Testosterone test...perhaps a trip is due!
Best wishes-BD
PSMA PET/MRI Whole Body: 3/22/2024 2:39 PM
COMPARISON: Prior PET from: 10/4/2023
REASON FOR THE STUDY: biochemical recurrence/subsequent treatment
CLINICAL HISTORY: 69 year old Male with prostate cancer. PSA 1.57 on 2/20/2024
RADIOTRACER: This study was performed with the indicated radiopharmaceutical, which is a PET radiotracer that targets the prostate specific membrane antigen (PSMA) protein found on most prostate cancers.
TECHNIQUE: Following intravenous administration of the radiopharmaceutical, a whole-body MRI was acquired using axial T1 and T2 weighted images with intravenous contrast. The PET study began 89 minutes after injection. Concurrent with the MRI acquisition, whole body time-of-flight PET data was acquired and attenuation correction was performed using MR based attenuation correction algorithms. Additionally single bed position MRI data was acquired of the pelvis.
CONTRAST MEDIA AND RADIOPHARMACEUTICALS:
68Ga-gozetotide - 4.6 millicurie - Intravenous
FINDINGS:
Prostate bed: No evidence of local recurrence in the prostate bed.
mi-T-stage: T0.
Regional lymph nodes: Focus of radiotracer uptake in the pelvis near the rectum (5/317; 850/352), which appears to correspond to a perirectal node.
mi-N-stage: N1a
Distant sites of disease:
Extrapelvic nodes: No evidence of extra-pelvic lymphadenopathy.
Bones: No evidence of osseous metastases.
Soft tissue metastases: No evidence of soft tissue metastases. Low level uptake along the left heart border (5/167; 850/191).
mi-M-stage: M0
IMPRESSION:
1. Compared to prior PET/CT from 10/4/2023, focal uptake in the pelvis adjacent to the rectum, corresponding to a perirectal node suspicious for a nodal metastasis.
2. Otherwise, no additional evidence of tracer avid metastatic disease.
3. Low level radiotracer uptake along the left heart border may reflect a focus of parenchymal infection or inflammation. Consider dedicated CT chest for further evaluation if clinically indicated.
4. miTNM stage: T0N1aM0. miPSMA expression score of lesion with highest uptake: N/A (negative).
5. Please see separate dictation for associated MRI findings.
miTNM/PROMISE: Eiber et al, JNM 2017
* miPSMA expression score: 0 (No: below blood pool), 1 (Low: equal to or above blood pool and lower than liver), 2 (Intermediate: equal to or above liver and lower than parotid), 3 (High: equal to or above parotid).
* T-stage: T0 (no tumor), T2 (organ confined. u=unifocal, m=multifocal), T3 (non-organ confined. a=ECE, b=SVI), T4 (invades adjacent structures), Tr (recurrence after RP).
* N-stage: N0 (no nodes), N1a (single node), N1b (2 or more nodes)
* M-stage: M0 (no mets), M1 (+mets, a=extrapelvic nodes, b=bones, c=other sites)
This study was reviewed by attendings x from Abdominal Imaging and x of Nuclear Medicine.
Report dictated by: A, DO, signed by: , MD
Department of Radiology and Biomedical Imaging
Dictated by: , DO
Signed by: , MD
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Here are the results of my PMSA/MRI last month…and they always find other things to alarm me about :-)…I couldn't be in better hands and have taken a back seat to all of this, on this go around…Truly blessed to be talking about this 16+years later.
Had a follow up today with my medical team and they tell me, I'm stable. So, I'll continue with monthly PSA and Testosterone test...perhaps a trip is due!
Best wishes-BD
PSMA PET/MRI Whole Body: 3/22/2024 2:39 PM
COMPARISON: Prior PET from: 10/4/2023
REASON FOR THE STUDY: biochemical recurrence/subsequent treatment
CLINICAL HISTORY: 69 year old Male with prostate cancer. PSA 1.57 on 2/20/2024
RADIOTRACER: This study was performed with the indicated radiopharmaceutical, which is a PET radiotracer that targets the prostate specific membrane antigen (PSMA) protein found on most prostate cancers.
TECHNIQUE: Following intravenous administration of the radiopharmaceutical, a whole-body MRI was acquired using axial T1 and T2 weighted images with intravenous contrast. The PET study began 89 minutes after injection. Concurrent with the MRI acquisition, whole body time-of-flight PET data was acquired and attenuation correction was performed using MR based attenuation correction algorithms. Additionally single bed position MRI data was acquired of the pelvis.
CONTRAST MEDIA AND RADIOPHARMACEUTICALS:
68Ga-gozetotide - 4.6 millicurie - Intravenous
FINDINGS:
Prostate bed: No evidence of local recurrence in the prostate bed.
mi-T-stage: T0.
Regional lymph nodes: Focus of radiotracer uptake in the pelvis near the rectum (5/317; 850/352), which appears to correspond to a perirectal node.
mi-N-stage: N1a
Distant sites of disease:
Extrapelvic nodes: No evidence of extra-pelvic lymphadenopathy.
Bones: No evidence of osseous metastases.
Soft tissue metastases: No evidence of soft tissue metastases. Low level uptake along the left heart border (5/167; 850/191).
mi-M-stage: M0
IMPRESSION:
1. Compared to prior PET/CT from 10/4/2023, focal uptake in the pelvis adjacent to the rectum, corresponding to a perirectal node suspicious for a nodal metastasis.
2. Otherwise, no additional evidence of tracer avid metastatic disease.
3. Low level radiotracer uptake along the left heart border may reflect a focus of parenchymal infection or inflammation. Consider dedicated CT chest for further evaluation if clinically indicated.
4. miTNM stage: T0N1aM0. miPSMA expression score of lesion with highest uptake: N/A (negative).
5. Please see separate dictation for associated MRI findings.
miTNM/PROMISE: Eiber et al, JNM 2017
* miPSMA expression score: 0 (No: below blood pool), 1 (Low: equal to or above blood pool and lower than liver), 2 (Intermediate: equal to or above liver and lower than parotid), 3 (High: equal to or above parotid).
* T-stage: T0 (no tumor), T2 (organ confined. u=unifocal, m=multifocal), T3 (non-organ confined. a=ECE, b=SVI), T4 (invades adjacent structures), Tr (recurrence after RP).
* N-stage: N0 (no nodes), N1a (single node), N1b (2 or more nodes)
* M-stage: M0 (no mets), M1 (+mets, a=extrapelvic nodes, b=bones, c=other sites)
This study was reviewed by attendings x from Abdominal Imaging and x of Nuclear Medicine.
Report dictated by: A, DO, signed by: , MD
Department of Radiology and Biomedical Imaging
Dictated by: , DO
Signed by:
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