1. < Prostate Cancer

Recent PSMA PET does not detect cancer, what’s next?

Posted by learng @learng, Feb 3 4:44pm

I had a prostatectomy in May of 2016. Gleason of 7 = 4+3, psa of 10.5 . First post op psa was .01 and remained there until February 2018. In August of 2018 went to .018. From there psa would go up and down finally reaching .23 in December of 2024. Psa one month later also was .23. Had PSMA Pet CT last week, and got report today saying: No evidence of radiotracer avid nodal or distant metastatic disease. & No aggressive or PSMA-positive osseous lesions. & No enlarged or PSMA-positive abdominal or pelvic lymph nodes.
Have appointment tomorrow to discuss results and probably treatment options. Not looking forward to ADT, but may be the way to go. Also leery of abdominal radiation without any evidence of cancer there. I am interested in hearing any
Suggestions .
Thanks
Steve

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jkoop | @jkoop | Mar 5 2:28pm
In reply to @heavyphil "Well, I totally understand your aversion to the saturation bombing concept of salvage radiation; lots of..." + (show)
@heavyphil

Well, I totally understand your aversion to the saturation bombing concept of salvage radiation; lots of innocent bystanders but a lot of bad guys too…
When I had my PET PSMA something showed up at the edge of the femur; my radiologist said it was a natural biologic process - inflammation or bone cyst. When I asked him how did he know it was NOT prostate cancer metastasis, he said that for bones to show metastasis, other soft tissue areas much closer to the prostate bed would have to show up on the scan as well - even brighter in fact; I did not have any of that and evidently, neither did you. Also, my post surgical PSA never got higher than .18, which he also said ruled out bone metastasis….what was your pre surgical PSA and Gleason score? That might give you an indication of how aggressive your cancer was (absent a Decipher score).
But what gives me pause is your PSA bounce after SBRT. If those lesions were not PCa, why the bounce? And if not PCa, what are they??
If everything else is normal, you have active prostate cancer somewhere in your body (as jeffmarc pointed out) - and even salvage radiation, which usually targets the prostate bed and pelvic lymph nodes, may not even get it if it has already migrated somewhere else.
Not trying to raise alarm, but PCa can travel pretty far from its original home; I saw a case where it traveled to the clavicle and that person was basically put on ADT for life. However, he was still alive 14 yrs later.

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Thank you for the information. My Gleason score was 4+3,,PSA pre RP was 7.5.
That’s what I’m kinda confused about, the rib spots may be nothing. I have no doubt that I have BCR and last PCMA-PET showed nothing new. Your situation with the femur spot makes a lot sense. Do you wait for PSA to keep going up to have a higher chance to see something on the scan, go on ADT and blast away with radiation? SHEESH!

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1 reply
heavyphil | @heavyphil | Mar 6 5:59am
In reply to @jkoop "Thank you for the information. My Gleason score was 4+3,,PSA pre RP was 7.5. That’s what..." + (show)
@jkoop

Thank you for the information. My Gleason score was 4+3,,PSA pre RP was 7.5.
That’s what I’m kinda confused about, the rib spots may be nothing. I have no doubt that I have BCR and last PCMA-PET showed nothing new. Your situation with the femur spot makes a lot sense. Do you wait for PSA to keep going up to have a higher chance to see something on the scan, go on ADT and blast away with radiation? SHEESH!

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Yes, I based my decision on a PSA value that rose very, very slowly for about 4 yrs; and then rose faster with each blood draw every 3 mos. So the rise AND velocity told me that I had BCR.
Other members may have some info on this, but I think the type of tracer used in the scan shows up differently - or not at all - in certain types of PCa. That is the confusing part: having bones light up, but not soft tissue and that PSA bounce definitely indicates prostate origin. And if your next PSA shows a DROP, then you have even more evidence that the bone lesions were PCa.
But other men have had PSMA’s that just showed bone mets and nothing else as well so these scans are clearly (yuk) not the bottom line - It’s steady PSA rise and velocity. Perhaps a PSE test might help here - not that I believe it is definitive either - but it may give you more info that you really need.

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brianjarvis | @brianjarvis | Mar 6 7:20am

Usually, the PSMA PET scan is the best scan to use to detect prostate cancer recurrence/spread.
But, when recurrence/spread is suspected in the absence of PSMA expression (or too little PSMA expressed to be detected), it’s recommended to try one of the older pre-PSMA PET scans to find the recurrence/spread.
Those older scans are: F18-FDG, F18-NaF, Choline C11, or Axumin (whichever one your insurance will pay for).

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jkoop | @jkoop | Mar 6 11:31am

Well today is the day I talk with the radio oncologist about my situation. I was wondering if anyone has any good questions I should be asking her? Maybe another PSMA PET with Choline? I got a feeling I know the answer to that....they do not use that agent at this hospital. Wait for next PSA and see if it stabilizes, maybe rib lesions are PC and they are responding to SBRT. Radiation therapy? ADT, which one? Anyway, just want to know anyone's thought on this.

Thank all of you that have responded, still relatively new at this game.
Thanks.

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1 reply
jeffMar | @jeffmarc | Mar 6 12:50pm
In reply to @jkoop "Well today is the day I talk with the radio oncologist about my situation. I was..." + (show)
@jkoop

Well today is the day I talk with the radio oncologist about my situation. I was wondering if anyone has any good questions I should be asking her? Maybe another PSMA PET with Choline? I got a feeling I know the answer to that....they do not use that agent at this hospital. Wait for next PSA and see if it stabilizes, maybe rib lesions are PC and they are responding to SBRT. Radiation therapy? ADT, which one? Anyway, just want to know anyone's thought on this.

Thank all of you that have responded, still relatively new at this game.
Thanks.

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You can request an FDG or if they say no Axumin. The FDG works better for nodal involvement while the choline test works better for detecting bone lesions.

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1 reply
jkoop | @jkoop | Mar 7 6:23pm
In reply to @jeffmarc "You can request an FDG or if they say no Axumin. The FDG works better for..." + (show)
@jeffmarc

You can request an FDG or if they say no Axumin. The FDG works better for nodal involvement while the choline test works better for detecting bone lesions.

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She wants to wait one month to see where my PSA is headed. I ask about salvage radiation but she said we should hold off on that for now. If PSA goes up then headed for another PSMA-PET. Last PSA was .31 two months ago.

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jkoop | @jkoop | 1 day ago

So my PSA went up, now at .45. Oncologist wants me to go on ADT plus Xtandi indefinitely. Not thrilled about that. Radio oncologist wants to do another PSMA-PET to see if something will show up and if it does, zap it with SBRT. If nothing shows then do SRT. These are my options from them anyway. They took a shot with suspected lesions on the ribs with SBRT but RO thinks that it was a false positive since nothing happened with size or reduced PSA. I’ve read that the chances of PSMA-PET finding a cancer lesion increases with higher PSA levels. I’m going to get another PET and hopefully the scan finds something. Anybody got any suggestions?

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jeffMar | @jeffmarc | 1 day ago

According to Dr Scholz getting a PSMA Pet scan to see if there’s a Metastasis and zapping it is the best way to go. At the PCRI meeting at the end of March he discussed The fact that salvage radiation only works about 1/3 of the time and the rest of the time it’s metastasis somewhere else. Another thing they mentioned is that if the lesion is smaller than 2.7 mm it cannot be seen by the PET scan.

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2 replies
heavyphil | @heavyphil | 20 hours ago
In reply to @jeffmarc "According to Dr Scholz getting a PSMA Pet scan to see if there’s a Metastasis and..." + (show)
@jeffmarc

According to Dr Scholz getting a PSMA Pet scan to see if there’s a Metastasis and zapping it is the best way to go. At the PCRI meeting at the end of March he discussed The fact that salvage radiation only works about 1/3 of the time and the rest of the time it’s metastasis somewhere else. Another thing they mentioned is that if the lesion is smaller than 2.7 mm it cannot be seen by the PET scan.

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Jeff, what were the alternative agents they mentioned when PSMA doesn’t show anything….Axuminand FDG(?)

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2 replies
heavyphil | @heavyphil | 20 hours ago
In reply to @heavyphil "Jeff, what were the alternative agents they mentioned when PSMA doesn’t show anything….Axuminand FDG(?)" + (show)
@heavyphil

Jeff, what were the alternative agents they mentioned when PSMA doesn’t show anything….Axuminand FDG(?)

Jump to this post

Axumen or FDG?

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