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Which scans are suitable for recurrent PCa with very low PSA

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Posted 12/3/2019 3:02 PM (GMT 0)
I had surgery in 2011 and adjuvant IMRT to prostate bed in 2012. Pt3b, Gleason 8 (4+4) with tertiary 5. Psa recurrence 5 years ago, PSA rose from nadir 0.003 to 0.8. Treatment with Casodex since recurrence. Current regimen 50 mg / day.

PSA gradually went down from 0.18 at the beginning of 2019 to 0.05 recently.

My question is : what scans are suitable in my situation? I had a Ga68 PSMA PET/CT two years ago which did not show any mets. Does it make sense to have a PSMA PET/CT at very low PSA? Or FDG PET/CT? Or just don't have any scans and wait until PSA rises?

Thanks
Posted 12/3/2019 3:36 PM (GMT 0)
If your PSA is only 0.05, I'd wait.
Typically, they wait until PSA is at least >0.5
At such a low PSA (0.05), I don't think there are any scans that are that sensitive.
Posted 12/3/2019 3:42 PM (GMT 0)
I agree with Alephnull, save your money on the scans at this point.. Have you considered adding Lupron to your treatment ? Give the Casodex a little help..
Posted 12/3/2019 3:42 PM (GMT 0)
At that PSA there's nothing to see. You'll have to wait for it to get higher, which should be a long, long, long time from now - basically until the Casodex fails.
Posted 12/3/2019 4:25 PM (GMT 0)
All above seems like good advice, especially adding Lupron. Also consider dumping the Casodex and adding Zytiga or Xtandi for the most durable remission. At this point I don't think a scan would provide any useful information.
Posted 12/3/2019 4:34 PM (GMT 0)
At .05...yeh why do anything and being as far post treatment as you are with a minor dose of casodex..what is the issue...try no treatment for a year...even...two if there is any thing going on ...you will know then...extreme advice...maybe...maybe not...some times if you want to die with something other than Pca...you may have to learn to live with it...counter intuitive....so much of this disease...and its effect is dis ease...I know...I know It ain't easy...but work on controlling the body with mind...rather than the reverse...not pie in the sky...good ole biscuits and gravy...down home...go for it gents...I thrive on different opinions...just don't muscle me when you dis agree...get ahead of the future...


what is your age...a signature would help
Posted 12/4/2019 1:44 AM (GMT 0)
Traveller58,

Not an expert on this but have couple links that provide info.

This first (couple years old) one has a table about half way down that's very helpful for me to understand each scan's strengths:

https://pcnrv.blogspot.com/2016/12/pet-scans-for-prostate-cancer.html

And this one is a little more recent:

https://pcnrv.blogspot.com/2019/08/psma-pet-finds-more-cancer-than-axumin.html


My own uro told me Axumin would only be good at .4 or greater. He said PSMA *might* show up something (at low PSA levels you and I currently have) but chances are it could not. This was last year. Didn't ask where he got his info.

Robert
Posted 12/4/2019 4:31 PM (GMT 0)
Glad to hear the Casodex worked for you. I had an Axumin scan after I recurred and my PSA was at .336. It was totally negative. I went on to SRT. As Bobbiesan indicated, a PSMA scan "might" locate something at your low PSA level, but probably not.
Posted 12/4/2019 6:00 PM (GMT 0)

Fairwind said...
I agree with Alephnull, save your money on the scans at this point.. Have you considered adding Lupron to your treatment ? Give the Casodex a little help..


Alephnull,
My disease is under control with Casodex only since recurrence (5 years ago). What would be the benefit of adding Lupron?
Posted 12/4/2019 6:11 PM (GMT 0)

logoslidat said...
At .05...yeh why do anything and being as far post treatment as you are with a minor dose of casodex..what is the issue...try no treatment for a year...even...two if there is any thing going on ...you will know then...extreme advice...maybe...maybe not...some times if you want to die with something other than Pca...you may have to learn to live with it...counter intuitive....so much of this disease...and its effect is dis ease...I know...I know It ain't easy...but work on controlling the body with mind...rather than the reverse...not pie in the sky...good ole biscuits and gravy...down home...go for it gents...I thrive on different opinions...just don't muscle me when you dis agree...get ahead of the future...


what is your age...a signature would help


Logo,
I'm doing fine with casodex monotherapy and don't consider change the current treatment until it fails. This is my MO's recommendation too.
I agree that no scan will show anything at this PSA level. But don't know if the disease is progressing and it is not producing much PSA. I know it's a rare situation. I lost a friend this summer whose PCa mutated to NEPC.
Posted 12/4/2019 6:29 PM (GMT 0)
I'm not sure about the addition of Lupron.
I'm a bit surprised that you are on long term Casodex instead of long term Lupron.
My Onco, started me on Casodex to suppress tumor flair while going on to Lupron.
Once the 30 day Casodex finished, it was dropped.
Posted 12/4/2019 6:33 PM (GMT 0)
Traveller,
to check for a neuroendocrine tumor you can observe the Chromogranin A (CgA) and neuron-specific enolase (NSE) markers. If these rise continuously this can indicate a growing neuroendocrine tumor.
George
Posted 12/4/2019 6:44 PM (GMT 0)

George_ said...
Traveller,
to check for a neuroendocrine tumor you can observe the Chromogranin A (CgA) and neuron-specific enolase (NSE) markers. If these rise continuously this can indicate a growing neuroendocrine tumor.
George


George, thanks. So if these markers are within the ref range and stable, PSA is low and stable, then can we say that the disease is under control?
Posted 12/4/2019 6:46 PM (GMT 0)
Alephnull,

if you have a biochemical recurrence you can have Lupron for many, many years. Bicalutamide has not as many side effects as Lupron. It may not work all that well against cancer though. Some patients decide to take a chance and use a drug that is maybe 10% less effective than Lupron but provides a better QoL for the rest of their life.
The guidelines say you can decide for late ADT, you do not have to start with ADT when the PSA value rises. So instead of early ADT you can use Bicalutamide just as well as a compromise between early or late ADT. I am having intermittent Bicalutamide monotherapy.

George
Posted 12/4/2019 6:55 PM (GMT 0)
Traveller,
I discussed this with a doctor today because he detected neuroendocrine differentiation in my old biopsy probes. His statement was, the absolute CgA and NSE values are of no concern. You have to observe these over time and if they are rising continuously, this is a good indication for a growing neuroendocine tumor.
Regarding the PSA value I personally do not think this alone will indicate everything is ok. It just says only the resistant cells are growing and these may express very little PSA. But I always look at the dark side of life. smile
George

Post Edited (George_) : 12/4/2019 12:01:37 PM (GMT-7)

Posted 12/4/2019 7:03 PM (GMT 0)
George, how long is the bicalutamide holiday? What are the targeted PSA levels?
Posted 12/4/2019 7:14 PM (GMT 0)
George,
So what is the name of the test that has CgA and NSE?
I receive CBC w/auto differential and Comprehensive metabolic panel tests, neither of which has these markers.
The only test result I get that I know is cancer related is Alkaline Phosphatase.
Posted 12/4/2019 7:37 PM (GMT 0)
Alephnull,

this are both blood tests you can ask for when you do your CBC.
https://www.lifeextension.com/lab-testing/itemlc140848/chromogranin-a-blood-test
https://www.lifeextension.com/lab-testing/itemlc140624/neuron-specific-enolase-nse-blood-test

George
Posted 12/4/2019 7:41 PM (GMT 0)
George,
So I have to ask them to be added to the CBC? They aren't a default test of the CBC?
Posted 12/4/2019 7:49 PM (GMT 0)
Traveller,

the doctor who mentioned intermittent ADT did this in the context of late ADT. His objective was that a rising PSA value, when you decide for late ADT, worries patients and this can be avoided with intermittent Bicalutamide monotherapy. He would ask the patient to do six months of Bicalutamide and then six months holiday. He said this works well for a long time.

When my PSA value rises above 1.0 ng/ml during my Bicalutamide holiday I will do a PSMA PET/CT to see if I can debulk the tumor with SBRT. And then do six months of Bicalutamide as an adjuvant ADT for the radiation. So this again is a very special version of intermittent Bicalutamide monotherapy. My doctor just watches what I am doing.

George
Posted 12/4/2019 8:22 PM (GMT 0)
George, very interesting approach
How long have you been doing this? What is the daily bicalutamide dosage?
Posted 12/4/2019 9:44 PM (GMT 0)
Unfortunately, PSA is not always a reliable indicator of disease progression. Although it may be rare, it happens. I am one of those lucky guys who had a very low PSA but developed my first bone met with a PSA of 0.1 at the time. Nobody wanted to believe it was really metastasis and I even had a false negative bone biopsy. Given my experience, I would opt for a scan if other factors are present besides just PSA value. A rapid DT or symptoms are a valid reason to seek sensitive scans despite PSA. My MO affirmed that some PCa puts out very little PSA while others may have a high PSA with little sign of disease progression. I’d err on the side of caution, but that’s just me.
Posted 12/5/2019 5:37 PM (GMT 0)
Traveller, I have no long term data to report. I added six months of Bicalutamide to my last metastasis directed radiation. Now, after over six months of holiday, my PSA value is rising rapidly. I will wait for it to get to 1.0 ng/ml, which will be in February, to be able to get a new PSMA PET/CT and see if I can make another metastastis directed radiation plus six months of Bicalutamide. Otherwise I will just begin with Bicalutamide again.

I start with one month of 150 mg Bicalutamide and then continue with 50 mg Bicalutamide. Adding 10 mg of Tamoxifen to this.

George
Posted 12/5/2019 11:17 PM (GMT 0)
Just me, but I generally get a sodium flouride f-18 pet/ct every 6 months whether I’m on any therapies or not. I have the type of PC that have shown mets at very low psa, but I’d imagine that’s not the case for most guys.
Posted 12/6/2019 10:39 AM (GMT 0)
Jerry,
next time I would get an FDG PET/CT instead. This shows the bone mets just as well as your NA 18F-PET/CT but could detect lymph node and visceral mets too.
https://www.ajronline.org/doi/pdf/10.2214/ajr.13.12158

George
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