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PSA, MRI, Biopsy why doesn't PSMA Pet Scan
-PSA of 7.
-MRI May/2025 PI-RADS 5, suspicious for extraprostatic tumor extension, suggesting neurovascular bundle involvement. No lymphadenopathy.
-Biopsy June/2025 - Right posterior medial Gleason 3+4, grade 2, pattern 4=40%, involving 3mm (30%) of 1 out of 2 cores.
Right posterior lateral Gleason 4+3, grade 3, pattern 4=80% involving 5mm (70%) , 4mm (40%), 0.7mm (< 5%), 3 out of 6 cores.
PSMA PET Scan July 2025 - No evidence of any Illuccix avid prostate uptake. 3 small lymph nodes demonstrating mild uptake within the upper abdomen. these represent reactive lymph nodes since no abnormal lower abdominal or pelvic lymph node activity uptake
is identified. No evidence of any Illuccix avid osseous metastatic disease.
I Guess PSMA Pet Scan is good news but I don't understand why no uptake in prostate based upon PSA, MRI & Biopsy? Worried we missed something.
65 years old, Started Orgovyx 11/1 and had SBRT x5 just to prostate around Thanksgiving. Doing great with no side effects (yet). Very active strength training regiment. PSA now 1, Testosterone 10.
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@jeffmarc All pre-PSMA PET scans for prostate cancer (F18-FDG, F18-NaF, Choline C11, and Axumin) pale in comparison to PSMA PET scans (Illuccix, Pylarify, and Posluma) as long as there is PSMA expression.
However, when there is no PSMA expression, PSMA PET scans are blind, and all pre-PSMA PET scans are preferable options (with the exception of F18-NaF, which I’ve heard that insurance no longer pays for).
I share your concern with data not aligning. I had just the opposite problem when diagnosed with a local recurrence in June 2025. My PSA hit 0.11, ten years after a RARP (barely above detection). A DRE detected a small nodule in my prostate bed. Conventional medical wisdom would predict that with such low PSA, there would be a very low probability of anything showing up on a PSMA PET scan. Well, not only did the nodule light up, but it did so with high intensity (SUVmax of 13.3). Some docs think that uptake intensity relates to cancer aggressiveness (I’ve yet to see hard science to back this up).
I finished 8 weeks of IMRT on November 18 to treat the local recurrence.
So, in both our cases, the question is, “Which test is telling the real story—PSA or PET scan?” Well, I don’t know, and none of my docs seem to know. Frustrating, but one thing for sure--PSA testing is still the front line test moving forward. Further scanning will only occur if PSA tests warrant it, or some other physical symptoms manifest.
Glad to hear you are doing well with the Orgovyx and RT. Hope you stay on that course.
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2 Reactions@melvinw Often there's not a single source of truth in medical diagnosis. There are many indicators, some major and some minor, and doctors look at them all together to figure out what's likely going on.
If some contradict each-other, then they look for more as "tie-breakers" (that's the way I think of it as a layperson, anyway).
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1 Reaction@northoftheborder Agreed. And in the case of PSMA PET scans, it is relatively new technology. I expect that in five to ten years, and with look back studies, that docs will have a better handle on reading the tea leaves.
I was a research scientist for much of my career. Data that don’t align, statistical outliers and the like are all part of the game. Anomalies are what point the way for new research and breakthroughs.
But then there is the clinical world, which is trying to apply the data to diagnoses. That’s where the frustration and weighing of indicators come in. And yes, in my case, the low, but detectable PSA and palpable nodule were suggestive, but not definitive for a relapse. The PSMA PET scan was the “tie-breaker”, and it circumvented the need for yet another biopsy. I am happy about that.
My urologist, who specializes in advanced PCa, seems to have put little weight on the actual value of SUVmax, while the palpable nodule that definitely lit up were major indicators. He did mention to me that in his experience, men with nodules like mine were typically more advanced in terms of PSA and metastasis. Hopefully, I am the anomaly there.
Wisdom that comes from experience comes in handy when data tell different stories.
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2 Reactions@jeffmarc Jeff, my partner will get a PSMA-PET at a community hospital late next month, where his general urologist is. If he gets treatment, will go to UCLA or UCSD or Cedars Sinai of course. But as far as PSMA-PET scan, should we really care which isotope is used and let that in fact influence where the scan gets done?
@chocchip
You frequently don’t get a choice between gallium 68 or pylarify, The place you were being treated uses one or the other. Pylarify (18F-DCFPyL) often provides better image quality and detail than Gallium-68 (Ga-68) PSMA-11 however.
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4 Reactions@jeffmarc Good point. And I don't think it's worth sweating tiny details on these things.
Any type of scan is imperfect — they can never tell us for sure that we're cancer-free — and there's no evidence even that more-sensitive scans like PSMA-PET improve overall survival over CAT, MRI, and/or bone scans.
The best scan is the one you can get soonest and closest to home. The oncologists will combine the result with bloodwork, genetic testing, and other evidence to form a working model of what's actually going on.
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4 ReactionsThanks’
@brianjarvis
I’m having a pet scan at Mayo Rochester tomorrow. Their website talks mainly about PSMA PET and that they use it. They have only a small paragraph that they Pioneered the choline C-11 pet scan and don’t mention that they use it.
My appointment info says Pet Ct scan , which I just noticed. I just assumed it was going to be PSMA PET.
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1 Reaction@dribbles Yes, these days facilities use one of the 3 PSMA PET scans (Gallium68, Pylarify, or Posluma), and fall back to one of the 3 pre-PSMA PET scans (Axumin, Choline C11, or F18-FDG) should the patient be PSMA negative.
It’s quite well documented, and Mayo even mentions that Choline C-11 is preferable to other forms of “conventional imaging” on their web site: https://www.mayoclinic.org/tests-procedures/choline-c-11-pet-scan/care-at-mayo-clinic/pcc-20384630 (PSMA PET scans are referred to as “next generation imaging.”)
“Pet Ct scan” is a generic term that applies to any of them. You’ll have to ask which one of the PSMA PET scans they’re using.
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
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