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PSMA scan conflicting results

Posted by perrychristopher @perrychristopher, Aug 8 7:38am

My RALP was 3 years ago. I had been undetectable until July 2025. My PSA was .24. Got a PSMA pet scan with following results. Mild uptake SUV 4.1 is seen in prostate, inferiorly, for which malignant disease is not excluded. There is a well defined PSMA avid sclerotic lesion of the first left rib suspicious for bony metastatic disease. Everything else appears ok. I went over results with my Urologist who also was my surgeon. He is suspicious of the rib finding as this could be a false positive in his opinion. He said he will confer with my Oncologist and Radiologist who wrote the report. As it turns out I had a meeting setup with the Oncologist the following day. She is more convinced the rib finding is real but will order a bone biopsy if possible. If not, she'll order an MRI but basically she thinks it's 50 50 we will get a definite answer if cancer or not. She showed me the scans in person of the rib and prostate bed. She said the actual pictures of the prostate bed show no uptake. There is a tumor board meeting in two weeks where she will present my scans to get more opinions. She doesn't want to radiate bed and pelvic lymph nodes needlessly at this point which I agree with since the issue may only be in the rib (as rare as that may be). In the meantime I will get another PSA test. I know my Urologist/surgeon did not look at actual scans but only read the report up to now, but the Oncologist will get with him to review all scans further. I know a bone met is bad but she's confident it can be resolved with SBRT external beam radiation. Very confusing. If it wasn't for the rib I'm sure we'd be radiating the bed and pelvic lymph nodes after another confirmed PSA reading. I really don't want to radiate these more sensitive areas unless necessary and feel I should wait the couple of weeks for a bone biopsy or MRI. If inconclusive I'd opt for rib radiation first to see if PSA drops. This is only one weeks worth of radiation. Also, I'd like to know the tumor board's opinion.

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heavyphil | @heavyphil | Sep 19 4:47am
In reply to @perrychristopher "Phil, I am so confused. I went and got a second opinion at a cancer center..." + (show)
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Phil, I am so confused. I went and got a second opinion at a cancer center in Michigan, Karmanos. They believe my first rib is cancer also. I asked why they are saying that and they basing it on the brightness of the lesion which measured 6.3 on the SUV . Karmanos said to treat only the rib and not do SRT to the prostate bed and pelvic lymph nodes as nothing showed up there. They also said no ADT. Both of these things were suggested as to prevent side effects. Well, I started ADT a month ago because PSA jumped from.24 to .42 in 6 weeks. I have been marked up for SRT by first opinion Oncologist and am waiting for SRT to begin. After SRT complete I will start SBRT to rib. I had my prostatectomy in August of 2022 and was clear until this July. I had a Decipher score of .37 which was supposed to be low risk for metastatic disease. Everything I have read is that a solitary first rib lesion being cancer is rare, especially without spread to the spine or pelvis first. My SUV is moderate, squarely in the grey zone of being benign or cancer. The SUV ratio is 3.7 which is also in the middle between cancer or benign. I have clavicular joint arthritis as well as arthritis in knees and back which is supposed to increase chances of being benign but none of that seems to matter to the Oncologists, both Radiologist and Medical oncologists. Karmanos suggested getting rib treatment first. The plan I'm on is getting SBRT to rib after SRT. I have been inputting all my data into AI platforms and I'm receiving odds that rib is probably benign. Right now I'm lost and am losing confidence that anyone knows what is going on. I'm taking the most aggressive path for treatment at this time, side effects be damned. Can anyone on this board offer any advice or first hand experience in this?

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Whoa! You poor guy, your head must be spinning…
Every input says you should be fine, but that PSA jump is a real outlier and indicates need for treatment.
FWIW, I would do exactly what you’ve outlined - ADT, SRT and SBRT. You have no choice BUT to be aggressive!
Pay no mind to scans being ‘clear’; a scan is clear until it isn’t and we all know that this does not happen in a blink - it’s ongoing until it’s big enough to see and by then who knows where else it has gone?
You are covering all the bases - more than that you can’t do…hang in there!
Phil

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swalsh57 | @swalsh57 | Sep 20 5:03pm
In reply to @heavyphil "Whoa! You poor guy, your head must be spinning… Every input says you should be fine,..." + (show)
Profile picture for heavyphil @heavyphil

Whoa! You poor guy, your head must be spinning…
Every input says you should be fine, but that PSA jump is a real outlier and indicates need for treatment.
FWIW, I would do exactly what you’ve outlined - ADT, SRT and SBRT. You have no choice BUT to be aggressive!
Pay no mind to scans being ‘clear’; a scan is clear until it isn’t and we all know that this does not happen in a blink - it’s ongoing until it’s big enough to see and by then who knows where else it has gone?
You are covering all the bases - more than that you can’t do…hang in there!
Phil

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Request PHI test - Prostate Health Index - more accurate & informative than PSA. Make sure you are of motrin, Tylenol, pain meds - scews accuracy. Request multiparametric MRI (mpMRI) then PSMA PET. Newest biopsy with lowest risk of infection is peritoneal biopsy & uses the mpMRI as an overlay for precision biopsy. #1 choice would be Proton Therapy if available in your area. If not - Brachytherapy. If receiving ADT see primary care doctor regularly to monitor, heart,liver, kidney functions & blood pressure - regularly throughout the process.

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