Oligomicrometastatic cancer

I want to thanks to all above posters. You are in my thoughts. I appreciate your comments and hope you too are fairing well in your own struggle with the bandit.

I received a second opinion and second look into the F18-choline PET/CT exam and the good news in the report is that they have not found far metastases or bone involvement. These two negative items would make thinking that I have no systemic disease yet. However, such would be real if micrometastases have not been diagnosed before. Micrometastases may exist but are so tiny that scans do not detect them. These buggers can grown later into apparent metastases if not treated and killed.
The bad news in the report is that they found “viable neoplasia tissue” at the prostate bed, the fossa (which was part of my SRT of 2006) and found abnormal activity at two inguinal lymph nodes on the left. The SUV at the fossa was at 10 minutes 3.4 which increased to SUV 5.5 at 80 minutes in the whole body image. The suspected LN involvement on the left had a SUV 2.0 at 10 minutes and 3.6 in full body image. The second LN presented a SUV of 1.8 but no activity later which could be judged as inflammation. No other relevant absorption of Choline at other relevant places including bone.

Typically, SUV of 10 regards cancer. SUV of 4.0 regards cells with anomalies. The meaning of viable neoplasia tissue refers to an abnormal growth of tissue caused by the rapid division of cells that have undergone some form of mutation. This could mean cancerous cells that could turn into a tumour. The strong uptake of choline could also refer to inflammation. Here is some explanation on the term;

https://www.sciencedirect.com/topics/medicine-and-dentistry/neoplasm

The above report from two nuclear physicians does not present any recommendation. My next step is in the hands of my uro-oncologist but I think that only radiation would be feasible to attack the fossa and the lymph nodes with intent at cure. This is the purposes of oligometastatic treatment and I am curious to hear what he says, however, before meeting him I plan to have a consultation with the radiologist of my previous SRT (2006) to be certain on the risks of “rads over rads” if the area involved received already the full dose in limits of radiation absorption. He has the isodose plan used at that time and knows what was radiated.

Unfortunately, the findings regard previous treated areas and not spot tumors located at propitious places. As you may image, I am very concern with fistulas or chronic wounds at the colon and bladder due to additional radiation which would prejudice much my quality of living.

Recently I have experienced abnormal bowel movements giving me very short time to get to the toilet. I also experienced more frequent urination with traces of blood. All of this seam to relate to late side effects from the radiation. It could be inflammation of the scar tissues and that could also be part of the SUV (choline) uptake in the PET scan. I have requested a colonoscopy to my GP to get more details on the cause of above BM. I also got a PSA which for my surprise turned lower at 1.68, down from 2.05 ng/ml of two months ago. I am again far away from the end of the vacation period of my IADT.
A friend oncologist will try to put me into a 68Ga PSMA PET exam.

Will keep ya informed of any future development.

Best,

VGama

Thanks again for the well wishes and the opinions.
Pan, you are right. The term “oligomicrometastatic” doesn’t exist. This was created in my mind probably to make me believe that I am over the topic and that I know what is happening. This gives me the strengths to be above the bandit and knock it down. ADT is already reserved. I am just investigating any possibility in deceiving the bandit with oligometastatic treatment.

The PET scan did in fact identify neoplasia tissue though to be cancer. However, I believe that the PET exam did not detect the whole cancer. The unseen little ones may develop into big ones in the future leading to additional recurrences. In any case, for people like you and me, the theme Oligometastatic (a fewer number of tumors, 5 max) may be thought as an additional phase in the sequential therapies post failed radical and salvage treatment, before one succumbs to ADT and chemo. There is no proven cure with the subject but the practice has been most successful in extending the period on free-biochemical failure. The lucky ones may hit the jackpot when irradiating the solo existing tumors. Cure is the aim and it can be in the horizon. Surely one should never put into jeopardy the quality of life so that such a treatment should only be done if propitious areas are identified.
In such regard, some of our comrades here have done this sequential by repeating the radiation treatment extensively, not just covering a fewer number of metastases but treating an identical number of areas/spots with identical dose. Dattoli, Sarasota, has been doing this sort of late salvage therapy.
I wonder about your story. Can you please provide more details on the results of the 68Ga PSMA PET exam. What was your PSA at the time of the test? Do you have still the gland in place? What is your present PSA histology?

Two days ago I had an interesting meeting with the radiologist/therapist who did my SRT of 2006. He was surprised with the F18 choline PET indicating “possible recurrence” at the prostate bed (radiated fully by him before). I felt that he did not want to admit RT failure at the areas of 2006. He thinks that the increase of the PSA is from metastases away from the area identified at the scan, and that the detection was due to inflammation. The truth is that other areas did not accumulate high SUV. Denying the results is like not trusting the capability of F18 choline PET exam in PCa detection. Am I right?

According to this radiologist, radiating any apparent metastasis even if that is located at areas already irradiated is valid if the irradiation had been done 5 years before. The risks of “rads over rads” on my case of 11 years post SRT is dismissed because radiated tissues are thought of having recuperated fully. The limits of radiation absorption are not an important issue in my treatment. In any case, before any RT treatment, he recommends to check the condition of any existing scar tissues from previous radiation. I am scheduled already for a colonoscopy and cystoscopy.

If everything is found normal, and we decide on radiation, then he recommends me in having the 68Ga PSMA PET/CT scan at their facilities which CT computer data can then be introduced in their Truebeam RT system for mapping the field to be radiated. Everything fits perfectly but I just wonder if we can trust more such PSMA exam than the F18 choline done with a PSA level of 1.80 ng/ml. I hope someone here can give me ideas.

Another surprising conversation from the radiologist was about his recommendation on a hyperthermia application to improve/strengthen the immune system. It seems to be common advice at radiation facilities to RT patients. He suggested having the hyperthermia now before the next PSA. Why?
I know that hyperthermia is recommended as an adjunct administration to enhance the effects of prime therapies like ADT and chemo. Less resistant hormonal dependant cells may be killed.

http://jcmtjournal.com/article/view/2272

I left a copy (cd format) of the F18 PET for him to check and provide me with a second opinion.

Thanks to all of you.

Will keep ya informed of any future development.

Best,

VGama

I had my annual consultation with the uro-oncologist following my case and was recommended to restart ADT instead of procuring an oligometastatic treatment.

In other words, he rejected radiation intervention or surgically dissections of inguinal lymph nodes set in non propitious areas that have been identified by PET and that have already under gone interventions. He based his response on the PET results, the findings from the cystoscopy and colonoscopy (radiation cystitis), and past history of treatments. In his words the risks of RT outweigh the benefits it could provide.

“… RT could free you from the bandit but it would not free you from the nasty RT side effects that will occur in view of the present clinical status. The area identified by PET is not propitious for additional RT because it has already reached the limits of radiation absorption and due to existing radiation cystitis and proctitis. You may find doctors willing to radiate the area but neither the EUA guidelines nor the NHS recommend such approach in radiating tissues in the pelvis twice.”

Unfortunately the results were not in my favor. I have to abstain from my intent in oligometastatic treatment and continue with my systemic approach (intermittent ADT) of 2010.

This time the uru recommended a monotherapy with Casodex 150 mg daily pill, alone. His reasoning in monotherapy is based on the long indolence period of 6 years I had during the vacation off drugs (since 2012).
Surely this is not what I expected. My understanding is that I should be driven into remission levels (PSA< 0.05 ng/ml) and be kept at that level for a full 12 months before given up again with ADT. I wonder if Casodex alone can do the job.

In any case, this NHS hospital has done some arrangements in its organization and has subdivided urology into separated specialties. The present uro was moved to attend only bladder related cases. That makes me to change doctors so that the next appointment (in December 2018) will be with a specialist in prostate care alone. I got his name and found that this new urologist has been involved in researches involving the famous hyperbaric oxygen treatment (HBOT). He has written several papers on the matter. It may be good to have him as my next attending doctor in case any radiation cystitis or proctitis get worse and I need HBOT treatment. Meanwhile I just hope that he follows the principle of the IADT, that invokes On and Off switches based on PSA levels and periods in remission. I wonder his personality, if we can trust each other.

Best wishes to all reading my story.

VGama