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PSMA scan conflicting results
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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Following a prostatectomy, a PSA of >=0.20 is the technical definition of biochemical recurrence.
The PSMA PET scan report should mention the SUVmax scores for your blood, liver, and parotid glands. By comparing the SUVmax score of 4.1 in your prostate, is how they define it as “mild uptake.”
If there is a “well defined PSMA avid sclerotic lesion of the first left rib suspicious for bony metastatic disease,” they would’ve assigned an SUVmax score to that as well (since they say that it’s “ PSMA avid”).
Typically, sclerotic lesions are old injuries that would show up on a CT, bone scan, or possibly an x-ray. But, the fact that it’s “PSMA avid,” means that it’s fairly definitive to be prostate cancer (which is why your urologist wants to confer with your Oncologist and Radiologist).
(I’ve heard that a bone biopsy hurts...badly... Personally, I’ve tried to avoid those.)
(There are a few body organs, tissues, and fluids that are “PSMA avid” but are rarely cancerous —> 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.)
Your doctor’s hesitancy to radiate unnecessarily is well-grounded. Dr. Kwon (of Mayo Clinic) indicates that only 1/3 of men who have recurrence following prostatectomy have recurrence only in the prostate bed, and that they should not get salvage radiation there unless they’re absolutely certain of the location of recurrence. He says to first confirm where the recurrence is.
Sounds like you’ve got a good team looking after you!
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4 ReactionsWell, if it's in the rib maybe with radiation and hormone treatment I'll have 5 years.
My rib SUV is 6.3
I think that I read somewhere that PSMA can be positive on old injuries and inflammation sites but am not sure what uptake level is a cut-off. I am so sorry that you have to worry now : ((( and especially since you do not have clear answers. But may it be comforting to you to know that it seems that you have good and caring doctors that are really looking into your scenario from all possible sides and are not rushing with anything. Also, as far as I know, they can "zap" that bone spot with radiation IF it proves to be a cancer. I am not very versed in BCR cases since I am new here but I read a great deal about it and followed many members here and I really think that you will be living far beyond 5 years < 3 !!! You have a singe small spot on your rib and possibly small recurrence in prostate bed and all of that can easily be zapped and cleaned and controlled with ADT and after that there so many new options and lines of control.
Sending you healing vibes and best wishes < 3
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2 ReactionsThanks. You're right. Just started feeling down. A lot of unknowns. Just hard to deal with being cancer free one day and then not the next. I'll be calling my Oncologist after another PSA test next week. If it increases I may just ask to get the rib zapped and see if PSA drops below 0.1 again. Or possibly start ADT.
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4 ReactionsI feel your anxiety. I had a rib lesion that was treated with ablation. Turned out it was not cancerous. Evidence still shows up on PSMA PET scans.
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2 ReactionsOncologist suggested biopsy, but found out this could not be done. Now suggested an MRI which still may be inconclusive. Getting another PSA test today. Seeing Urologist this week again. My Oncologist is also taking my case to a Tumor Board this week for other opinions on prostate bed and rib finding. In the meantime I have set up a second opinion meeting with Karmanos Cancer center. I don't want to treat things that don't need it but I don't want cancer to get worse. Very frustrating.
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3 ReactionsFor what is worth...I had PSA 7.1 Gleeson 4+3 = 7 early stage PC. My PSMA PET also showed take up on lower rib and the Urologist asked if I had ever had a rib break or injury. Turns out I was thrown off my horse and severely bruised or broke the lower rib about 5 years ago.
I found some videos from experts on PSMA PET and they said "rib injuries are the #1 false positives" in PSMA PET scans. My urologist wanted to do a rib biopsy but the radiation team refused saying it was too small to biopsy.
We proceeded to treat my PC as if it was contained in the prostate and assumed the rib issue was a false positive. I have had no pain in that rib and I understand metastatic spread to bones is often somewhat if not very painful.
I pray my rib issue was in fact a false positive PSMA PET result. I hope the same for you
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3 ReactionsThank you. I pray the same for you. It sounds like your rib issue is not cancerous thankfully. A rib break will cause SUV uptake in a PSMA pet scan.
I just had another PSA test today. In 6 weeks my PSA has risen from.24 to .42. Not good. Called Oncologist with results. Waiting for callback. MRI of rib is this Wednesday. I need to start srt, but to what?
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