PSMA PET results 6/6/25

Thank Jeff- But no heart problems- from all the imaging and scanning that was done prior to HoLEP surgery clean slate-Do you see something in the report that indicates otherwise.....

With only one lesion, you have a good chance of having everything treated and getting into remission for many years.

Thanks @jeffmarc
Is chemo usually recommended for pt3b after surgical positive margins or are they more likely to recommend radiation +\- ADT (or all 3)

They don’t usually recommend chemo unless there are metastasis spread around the body. T3B could be handled by radiation along with the prostate being radiated. Some doctors might do surgery.

Speak to a urologist that does Prostatectomies and a radiation oncologist, maybe two of each.

So sorry you are facing this beast. Looks like the 'for example' is describing lymph node involvement in other areas of the torso . We faced a metastasis 17 yrs post RARP as a PSMA PET showed as 3 'lung only' nodules with other micro nodules noted. We hoped for SBRT or radiation, or excision, but soon learned that it's not really oligometastatic and that a systematic approach was needed. As much as we wanted to just whack the 3 masses and skip systemic treatment, learning about cancer stem cells ('the seeds') brought us inline with systemic tx. And when a double chemo was recommended and we wanted to go with a more standard of care, ie triplet therapy, again we learned that kickstarting with the double chemo made sense, as much as we didn't like it. We are 3/6 rounds in of Docetaxel + Carboplatin, also on monthly shots of Firmagon (Degarolix) and will have scans net week. PSA which was suspiciously low at 0.36 dropped to < 0.01 in the first 3 wks of tx. The plan is to finish kicking ass with the chemo, then add an ARPI (Daralutamide-Nubeqa) for a time.

Good luck to you and keep us posted here - we learn a ton from each other.

Well, jeff, you nailed it. Orgovyx and Nubequa with a radiation oncology appt in a few weeks. No mention of chemo but I haven't been to oncology yet. They may have a different opinion.

what do you think would be the best course of action?

First, you should be getting a biopsy. Find out what your Gleason score is and if you have any other issues that can’t be seen in a PSMA/PET MRI. You don’t mention having had a biopsy

Speak to both a surgeon and a radiation oncologist. Find out if one considers the other technique preferable in your case.

Come back with more information.

It’s not whack-a-mole. Now that they know where the cancers are, they can attack them. “If you can see them, you can fight them!”

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As a result of your PSMA PET scan results, they assign a number — called SUVmax (Maximum Standard Uptake Value) — as an expression of the aggressiveness of the lesions, as it relates to how “avidly” (i.e., excess PSMA activity) the cancer absorbs the injected radiotracer.

Each of your lesions have been assigned an SUVmax value:

> Neck: no uptake

> LEFT superior mediastinal node: SUVmax = 8.0

> retrocrural node with SUVmax = 6.9

> aortocaval node, SUVmax = 8.7

> presacral node, SUVmax = 7.2

> RIGHT internal iliac node, SUVmax = 5.2

> LEFT external iliac node, SUVmax = 5.8

> Prostate: SUVmax of 14.9 in the LEFT posterior peripheral zone.

> RIGHT aspect of the L5 vertebral body, SUVmax = 11.9.

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As it turns out, PSMA (prostate specific membrane antigen) is not really “prostate specific.” There are other organs, tissues, and fluids that naturally express PSMA (without being cancerous) and will show as physiologic tracer uptake on a PSMA PET scan - particularly in the lacrimal (tear) and parotid (salivary) glands, blood, liver, spleen, pancreas, ganglia, and more, as well as the kidneys, ureters and the bladder (as the body tries to quickly excrete the radioligand that was injected).

“SUV” stands for “standard uptake value” and is a measure of radiotracer uptake that indicates how high grade the cancer is. The higher the SUVmax, the more advanced the cancer.

So, they use the PSMA SUVmax values of your blood (as the lowest level), liver (as the medium level), and parotid or the lacrimal glands (as the highest level) of SUVmax expression for comparison.

If a suspicious area (lesion) is expressing PSMA, and it has:
> a SUVmax score less than blood, then it’s not likely cancer, but instead just normal, background PSMA cellular expression;

> a SUVmax score greater than blood, but lower than liver, then it’s likely low-grade prostate cancer;

> a SUVmax score greater than liver, but lower than lacrimal/parotid glands, then it’s likely moderate-grade prostate cancer;

> a SUVmax score greater than parotid glands, then it’s likely high-grade prostate cancer;

As always, discuss all this with your doctor when you get your SUVmax scores from your PSMA PET scan report.

Dr. Johnson (of Mayo Clinic) talks about all this in his presentation, starting with the scans we’ve all heard about (MRI, bone, & CT scans), and then going into detail about PSMA PET scans: https://youtu.be/JoJomACA5UM

Jeff- John had RP already.
He had no spread of the cancer, gleason 9 , but had positive margins discovered during surgery. Would you be so kind to tell him what are his possible options ? He is new to this, he just had surgery and it all is probably overwhelming.