New Scan for to evaluate BCR and Persistent PSA

Hope this both updates the forum, and maybe solicits some better informed observations about these two scans. 

Although an ever-increasing number of treatment options exist, an estimated 26,100 men will still die of the disease in the US in 2016, generally after primary local and systemic treatments for prostate cancer have failed.  We don't talk much about that here. One factor contributing to this statistic is the frequent inability of current diagnostic methods to reliably detect the exact location(s) of disease relapse at a time when curative treatment is still possible.

  
The dilemma of biochemical recurrence (BCR): Up to a third of men treated for PCa will experience recurrent disease, most often detected only by rising PSA levels.  Conventional imaging tools such as computerized tomography [CT] and bone scintigraphy [BS] frequently fail to identify the site of recurrent disease, presenting a serious challenge to urologists and radiation oncologists charged with the selection of secondary treatment, and causing significant anxiety for us patients. 

While PCa recurrence may occur locally in the prostate gland or prostate bed, and/or in local lymph nodes in the pelvis, recognition of distant lymph node, bone or other tissue involvement requires different treatment choices.  Potentially curative techniques such as salvage lymphadenectomy, radiotherapy or cryotherapy may be used for local recurrences, especially at lower PSA levels, whereas systemic approaches such as the use of anti-hormonal therapy and/or chemo or immunotherapy may be recommended in the presence of distal metastatic disease.

Enter Axumin™: In May, 2016 the FDA approved Axumin [fluciclovine F 18 Injection; Blue Earth Diagnostics Ltd, Oxford UK] for PET imaging in men with suspected prostate cancer recurrence based on elevated PSA levels following prior treatment.  The approval of Axumin ushered in a new era of F18 PET/CT for the detection of recurrent prostate cancer in the USA.  Data submitted to FDA included results from prospective studies at Emory University and the University of Bologna and from clinical use at two sites in Norway; the pooled data for n= 595 subjects were retrospectively analyzed.  Overall, fluciclovine F 18 PET/CT detected sites of recurrence in 68% (403/595) of patients.  For patients with baseline PSA values in the lowest quartile (<0.79 ng/mL, n=128), 75 patients (59%) were negative with fluciclovine F 18 PET/CT, but 53 (41% of patients) had positive fluciclovine scans; 13 (10%) had prostate bed findings only, and 40 (31%) had extra-prostatic disease. As the location of disease recurrence affects appropriate therapy selection, this finding is highly relevant.

My impression is that an Axumin scan is more valuable for Persistent PSA source detection. For more data, and the source of most of the above:

https://www.urotoday.com/recent-abstracts/urologic-oncology/prostate-cancer/92386-everyday-urology-axumin-fluciclovine-f18-an-accurate-imaging-approach-for-patients-with-biochemically-recurrent-prostate-cancer-full-text-article.html

Here is a 9/16 link comparing Axumin with Gallium 68: 

https://prostatecancerinfolink.net/2016/09/02/comparison-of-gallium-68-and-choline-c11-based-petct-scanning-in-high-risk-and-progressive-prostate-cancers/

Now, as for Gallium 68 PET scans specifically, which appear to me to be more valuable with high risk PCa:

https://radiology.ucsf.edu/patient-care/services/pet-mri/research UCSF clinical research ~2014?

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5439210/   Clinical Utility of Gallium-68 PSMA PET/CT Scan for Prostate Cancer 6/17

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4898465/  Evaluation of ⁶⁸Gallium-PSMA PET/CT in patients with prostate cancer 6/16

https://www.carcinoid.org/2017/04/06/gallium-68-petct-scanning-neuroendocrine-tumors-information-locations/  Gallium 68 PET scanning locations 6/17

Enjoy the readings. I look forward to your comments, but I don't take questions.

Post Edited (garyi) : 10/9/2017 10:51:17 AM (GMT-6)

Excellent article and study, Allen. You are the man!

I have an Axumin scan scheduled in about three weeks that my RO indicated would be approved by Medicare.

In passing, my RO mentioned a scan that's done less expensively in Australia, Israel and somewhere in Europe. He mentioned that patients fly there, have the scan, and come home with less out of pocket expense than having it done in the USA. I guess he was talking about the Ga-68-PSMA-11. If so, and this scan yields better data, I'll spring for it. I haven't even been considering insurance coverage.

What I'm looking for is the most accurate tools for SRT after RALP surgery for my persistent PSA of .32 ng/mL ten weeks post surgery. Hydrogel studies seem focused on protection between the prostrate and the rectum/colon, but I don't have a prostate, so Space OAR won't help. Potential rectal and urinary side effects of salvage IMRT are a major concern given my ongoing LUTS and colitis.

I'll keep trying to figure it out, and thanks for your always most valuable assistance.

Yes, you are right that the Ga-68-PSMA-11 PET is available in Australia and elsewhere. It is also available in some clinical trials in the US (links in the article). It costs $2650 at UCLA. Even better, the DCFPyL is now available at NIH for free (link below). It was developed at Johns Hopkins and has been studied at NIH as well (they studied an earlier version called DCFBC). It has the best chances of finding anything that there is to find at your relatively low PSA.

/clinicaltrials.gov/ct2/show/NCT03181867

I was going to travel to Heidelberg, Germany to have the 68 Ga PSMA Scan, but got into the study at the UCSF. My insurance covered the whole thing, otherwise they quoted $4,000.

Bobby Mac

Very interesting....

Without ADT, my score is 128, about a 54% 10-year probability of remaining free of BCR.

With ADT, it's 83, so better than a 70% chance of 10 years free of BCR.

Lots to consider.

I had the axumin scan when psa reached 2.3 after stoping ADT3 at 13 months in conjunction with RT to pelvic nodes. It disclosed met in femur which was radiated with sbrt . I’m back on ADT3 and Psa is now .16. I’m a believer!
Bob

garyi-

Why are you having an Axumin and a DCFPyL? Axumin has very little chance of finding anything at your PSA, and PET/CTs do expose you to quite a bit of full body radiation - not enough to keep you from getting one if needed, but why do it unnecessarily?

I know of no one offering SBRT for persistent PSA other than a couple of experimental clinical trials. I understand the convenience factor, but any nearby radonc can do the conventional radiation treatment.

If they are both PET/CT, they are both exactly the same amount of radiation, mostly from the full body CT, and secondarily from the F18 in the PET. If NIH is using a PET/MRI instead of a PET/CT, that would cut down on the radiation exposure considerably. Since the NIH scan is better and is free, I don't see much downside. The upside is the off-chance that it might rule out SRT. The amount of extra radiation from a PET/CT is minuscule relative to the dose you will receive from SRT. It's not something to avoid, just something to not have gratuitously.

For what it is worth...UCLA's scan trial using the GA-68-PSMA requires your PSA to be 2.0 ng/ml OVER your nadir AND it is $2650.
Tall Allen do you know if the UCLA is PET/CT or PET/MRI? Also, TA do you know anywhere else to get either the PSMA or Axumin or the DCFPyL in the Los Angeles area that will accept lower PSA's?