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Which scans are suitable for recurrent PCa with very low PSA

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Posted 12/6/2019 12:32 PM (GMT 0)
George,

Thanks for the link. Good read.

For reference for others and a question, their conclusions were:

“Na18F PET/CT is the most comprehensive bone imaging modality for evaluating osseous metastatic disease. Although there is a need for additional cost-benefit analyses for this modality, increasing availability and evolving reimbursement structures will likely continue to increase the attractiveness of Na18F PET/CT in routine patient management. In addition, emerging data suggest that the high target-to-background signal ratio of Na18F PET and advances in low-dose CT technologies may allow further dose reductions for Na18F PET/CT to levels similar to or below those of 99mTc-MDP bone scintigraphy with SPECT. Furthermore, re- cent studies suggest the potential viability of combined Na18F and FDG PET/CT, in some cohorts, for single-session staging of soft tissue and osseous disease, which may provide improved patient convenience and partial mitigation of imaging costs by avoiding acquisition of sequential imaging studies.”

I‘ve always thought the FDG wasn’t very appropriate for PC. This may change my mind. And, I’m wondering - are they saying that a FDG can be done at the same time as the f18?

I’ve had a PSMA through a study a few years ago at NIH. The f18 identified a bone met where the PSMA did not. Not sure if that was because it was an earlier PSMA agent or I’m not sensitive to PSMA.

It’s tough to change old habits, and I’m so used to getting the f18...but probably should be looking it to these other scans more closely...perhaps Auximim or another PSMA.

Thanks.
Posted 12/6/2019 1:05 PM (GMT 0)
It seems that the combined technique is currently just done within trials:
https://www.researchgate.net/publication/233931697_combined_f-18-fluoride_and_f-18-fdg_petct_scanning_for_evaluation_of_malignancy_results_of_an_international_multicenter_trial

I mentioned it because you may want to look for lymph node mets and visceral mets too, not just bone mets.
Posted 12/6/2019 1:19 PM (GMT 0)
George,

Thanks...

I’m hopefully heading into another HT vacation with spot zapped and psa back down to undetectable...I may do a FDG as well in 6 months...or perhaps another PSMA...thanks for the info.
Posted 12/11/2021 9:09 PM (GMT 0)
I hope it's okay that I resurrected this thread since this is something my husband and I are trying to work out.

The last post was from 2019 and I know that there have been many advances since then.

Yes, we know that my husband's PSA is probably too low to show anything, but there is a concern that his PSA is not really correlated with the amount of disease. IF there's something there, and IF my husband's cancer expresses very little PSA (like rcroller, above), then it might show up on the scan. We just want to make sure that we're not overlooking anything.

So what imaging is recommended to make sure there are no bone or lymph node mets? Also I'm kind of confused about F18 vs FDG vs Axumin vs Pylarify. Is the F18 the same as Axumin? Finally, the PSMA Pet at UCLA and UCSF might be off the list because it takes so long to get a scan scheduled, so I think we're looking for the next best thing. Thanks for any help with this.
Posted 12/12/2021 1:17 PM (GMT 0)
Melaine - There are two PSMA tracers with Pylarify being the most recent one. Availability of this tracer is rapidly expanding across the US so you should be able to track down a place offering that PET testing now or soon. I agree that it might be a good idea for your husband but you will have to locate the scan facility and convince his doctor to order it. You will need to checkout the insurance coverage part as well as I have heard it can be expensive.
Posted 12/12/2021 2:31 PM (GMT 0)
A rare recurrence with low psa is possible. Most of us stay here because we have some non-common feature in our PCa journey and it is not so strange somebody has reported this issue. However.... psa remains the more accurate way to watch for an earlier recurrence after surgery.
If you were alarmed because psa is now detectable, I do not understand the rationale you are not trusting psa now that it is detectably low and stable. You plan to be on top of it and I understand your doubts and attitude but I just to want you to consider that the chance of being one of these rare cases is not higher than that chance of harboring any other potentially lethal disease for which you are not being checked.
I guess some new people in the forum with low stable psa after treatment may be reading this. My non-professional advice is to trust in your psa tests. We are lucky we only need this simple and accurate early warning following tests instead of the not so much reliable scans or even minor surgery biopsies required in other types of cancer. And trust in your doctors except when you know they are clearly wrong. Usually, they know more and have more experience than us. Actually, this is supposed the mean reason we are paying them. (I know this us not a very popular opinion in this forum, but it is what I think.) And, most importanty, try to enjoy the most the time remaining before your next psa test, though I know this is not so easy in current times.
Posted 12/12/2021 2:39 PM (GMT 0)
Hi Melaine,

As Mumbo mentioned, the Pylarify PSMA scan has recently been approved and is beginning to be available across the country. Check with your local medical and imaging centers and ask specifically if they are now doing these. I had one done in September in south central PA.

PET scans are confusing partly because of their names…f18, fdg, etc…

Here’s my understanding of imaging that’s available for PC:

TRADITIONAL SCANS
- Bone Scan (Technetium-99m-MDP)
- CT Scan
- MRI

PET SCANS - Most of the following scans combine a PET scan and a low dose CT scan done at the same time to create images.

- Sodium Flouride (NA18F) PET/CT - primarily for bone.

- PSMA PET/CT scans for both bone and soft tissue. A very newly approved type of PC specific scan. There are different types of PSMA scans.

- Auximin (fluciclovine F 18) - this is a fairly new and approved scan which checks bone and soft tissue.

- FDG PET/CT isn’t generally used for PC…at least in my case… done to study your body’s use of glucose (a type of sugar). This is because cancer cells take in glucose faster than normal tissue.

They should give these scans simple names…
Posted 12/12/2021 2:55 PM (GMT 0)
FWIW - I found bone mets at a PSA of .09. But I am a Gleason 9….so each case is different and we all need to do very different things based on our Gleason score, psa, history, etc…
Posted 12/12/2021 3:15 PM (GMT 0)
Melanie, i lean toward agreeing with jmadrid, and here's why, refer to Jerry L's post above. It is my understanding that in the vast majority of cases if not all, low PSA being a false indicator happens with a high Gleason Score. I am 90% sure of this, no doubt if i am wrong someone will correct me.In fact, i dont recall seeing anyone here with a misleading low PSA who was a G6 or G7
Hope this helps
Posted 12/13/2021 6:47 AM (GMT 0)
Mumbo: Thanks for explaining that. It looks like Pylarify is being offered in Seattle. We'll check tomorrow.

jmadrid: I agree with your statement that PSA remains the more accurate way to watch for an earlier recurrence. I should have clarified that my husband is almost certainly going to have the treatment soon as his PSA is not low and stable. It is already at 0.1 with a doubling time of anywhere from 9 months to 18 months. So it's rising and already at the threshold we had previously considered for starting treatment.

Your statement about trusting the doctors really hit home. Unfortunately the treatment journey, so far, has been riddled with mistakes and miscommunications that have left us pretty scarred. While we trust these doctors, we also feel like we have to be hyper-vigilant now to avoid any future surprises.

Jerry L: Thank you for explaining all the scans. That's exactly what we needed. Did you ever look into the FDG scan for yourself per your conversation with George above?

Prato: Thank you for pointing that out. I know it's pretty rare--even for G8s and G9s. That being said, I still plan to push for a scan, however, because I want to be sure. We're trying to make the best decision, based on the best information we have right now--and avoid feeling regrets in the future. Pretty tall order.

Thanks everyone for your help and support!
Posted 12/13/2021 6:14 PM (GMT 0)
Melaine,

Given that PSMA scans are approved, locally available, and and I’m able to get these approved by insurance…I’ll probably use this type of scan moving forward.

about the PSA doubling time - several of my doctors over the years have mentioned to me on numerous occasions that doubling time is not very accurate at such low numbers.

Regardless of scan…for most guys…most PC will not show with such low numbers.

Thanks,
Jerry
Posted 12/19/2021 7:29 AM (GMT 0)
We met with our local RO and he has ordered a Pylarify scan. Should take about two weeks. He told us (again) about the risks of false positives, and that the scan will probably not show anything. But he also mentioned another patient who did "light up" at only 0.12. This patient, he quickly added, had negative pathology that my husband doesn't have including tertiary 5 cells.

Jerry, yes, we've been told the same thing: that doubling time is difficult to calculate when the numbers are so low. That's why my husband's doctors give it such a wide range, anywhere from 9 months to 18 months. He has another PSA test coming up next month so that will provide another data point.

Thanks everyone for your help and advice.
Posted 12/19/2021 2:30 PM (GMT 0)
Melaine,

Let us know how you make out…

I’m curious about something with the Pylarify scan…on the order, does it say full body or something that is not the entire body…I’m just curious if it is skull base to mid thigh….or something else…I think the PET part is not the complete body…I find that interesting…not good or bad…just interesting.

BTW..Sorry you both have to deal with this at such a young age….trust me, I can relate…
Posted 12/19/2021 4:17 PM (GMT 0)
Thank you for your kind words, Jerry. I’m sorry you’ve been through this, too.

The resident ordered the scan while we were on a tele-call with him and the RO, so we never saw the order. We never discussed the imaging options. I’m assuming we want to make sure it’s full body? Or are you saying that full body doesn’t show the tracer uptake in the full body?

Melaine
Posted 12/20/2021 12:16 AM (GMT 0)
The tracer will be circulated throughout the whole body when he is injected…I’m just saying that I think the normal Pylarify Pet/CT uses procedure code 78815…I’m not sure why they don’t scan the entire body….I think the CT part of the scan is the entire body…but I don’t think the PET side is…I may be wrong but I’d be interested in what the docs ordering the scan would say…

78812-Tumor imaging (PET) skull-thigh
78813-Tumor imaging (PET) full body
78814-Tumor imaging (PET/CT) limited
78815-Tumor imaging (PET/CT) skull-thigh
78816-Tumor imaging (PET/CT) full body
Posted 12/20/2021 2:56 AM (GMT 0)
Hi Jerry,

We'll send a note to the RO through the patient portal and see what it is that they've ordered. Thanks for bringing this up.

Melaine
Posted 1/31/2022 2:36 AM (GMT 0)
I know it's been a while but I thought I'd update this.

Jerry, my husband had his PSMA scan a couple weeks ago. You're right in that the order says that the PSMA part was from the base of skull to proximal thighs. But they gave us results for the nasopharynx and other areas that are clearly in the skull. So I guess I'm a little confused. Sorry if that doesn't help much.

We had been told that insurance would not cover the PSMA scan because my husband's PSA was only 0.1. Apparently the bump up to 0.15 (the week before the scan) changed things. We're not sure how this happened but we're glad the insurance company decided to cover it.
Posted 1/31/2022 3:02 AM (GMT 0)
Thanks for the update…glad that the insurance covered it….take care…
Posted 1/31/2022 7:36 AM (GMT 0)
Thanks Jerry. You too!
Posted 2/1/2022 2:31 PM (GMT 0)
Melaine,
I had a Pylarify scan this last Friday, 1/28.
My PSA was about 1.3, the scan sure picked up a bunch of "bright" lymph nodes.
So, I hope your husbands wasn't quite so "bright".
Posted 2/1/2022 3:40 PM (GMT 0)
I saw Dr. Sartor around Jan. 5th., his plan for me is when my PSA hits .5 ( I had RP and radiation), then the PSMA scan would be ordered. Last PSA was .42 and next draw is Feb 7. Dr. Sartor said he would not make a treatment decision based on one PSA test. So if my PSA is .5 or greater, I would not be surprised if he holds off until a repeat PSA is completed to confirm. Dr. Sartor is of the opinion that at .5 the PSMA scan has a good chance of finding the mets.

Dr. Sartor said in Jan. that Tulane is doing the PSMA scans now, which I am so glad to hear Dr. Sartor also said more private insurance companies are beginning to cover the cost of the PSMA scan.

I read on this forum somewhere that up to 5 spots found with the PSMA scan can be radiated. Dr. Sartor confirm that 5 was his limit and some areas of the body like places in your guts and esophagus could not be zapped.

Best of luck to all of us dealing with this PC.

Post Edited (ntzguy) : 2/1/2022 9:13:23 AM (GMT-7)

Posted 2/1/2022 6:19 PM (GMT 0)
Oligometastatic (oligo is Greek for few) is typically 1-3 or 1-5 lesions and hopefully in treatable locations. It is a subset of metastatic cancer that indicates a doctor may be able to play "whack-a-mole" and keep the disease knocked down. The key is being able to identify the correct number through sensitive scans. Makes sense to wait until you can be sure you find the lesion(s) so you have a better idea of what to do next. A premature scan that locates one lesion might not be telling the whole story.

My wife is doing well so far after knocking out a single BCa recurrence to a nearby rib (after 16+ years). She gets scans every 6 months now to keep an eye on things and if another shows up, it will be zapped early if possible.
Posted 2/2/2022 5:53 AM (GMT 0)
Aleph, sorry to hear about your bright nodes. What is the plan now? My husband's scan showed mild uptake for one internal iliac node. Although the report said it was indeterminate for cancer, the doctors are all assuming it is cancer. It's a very small area. The hope is that hormone and RT will kill it--and any micro-mets. Happily nothing was found in the bones or distantly. Oddly nothing showed up in the prostate bed, but they also said that the bladder uptake made it difficult to see that area. (Not sure I got that part right.) They've assured us that a lung nodule and three bone lesions (bone islands?) are not cancer. We hope they're right, of course.

Ntzguy, that sounds like a reasonable plan. Our private insurance had a threshold of 0.2 for coverage, but they ended up covering the scan when my husband's PSA was 0.15. I hope it's covered for you, and I hope that if they find something they can zap it.

Thanks for that explanation, Mumbo. I have been using the whack-a-mole analogy, too. I'm so happy to hear that your wife is doing well. Must be very hard after 16 years. When can you finally stop worrying about this insidious disease?
Posted 2/2/2022 4:19 PM (GMT 0)
Great discussion and this confirms what my RO told me about the uniqueness of high GS. Mine was a GS 9 (see history). I went from a PSA <0.1 in 5/21 to PSA 0.4 in 11/21. This is after 3.5 yrs. of <0.1 PSA. My one bone Met. observed (Spine T-11, Lamina) by fluciclovine F 18 PET/CT Scan, was 20 mm in size. My RO said that GS 9's don't typically show as much PSA.

Also, due to only having 1 (observable) Met, I was diagnosed with Oligometastatic Cancer (5 or less Mets.). The Met was treated, 1/22, with 5 rounds (167 X-rays/ea) of CyberKnife, at 500 CGy per dose. Generally treatment is done with no more than 3 treatments per week. 5 rounds, total, were selected to lessen the dosage on the Spinal Cord per round.

I will then have the newer PSMA PET Scan in April 2022 and a follow-up PSA. So, I would say with higher GS, Scans are even more important than just PSA. Again great discussion, confirming what my RO concluded.
Posted 2/2/2022 6:55 PM (GMT 0)
I am a G-9r, pT3bNO, with SVI and close margins - RP (Oct 2015) and 8 weeks radiation ( started Feb 2016).

At DX, I had just turned 57 years old and My PSA was 5.75, they never retested to see if PSA was higher or lower as my biopsy came back 8 of 12 + and first Pathologist graded me a G10. I too have wondered about G9 with a low PSA, would allow the cancer to grow even after RP and RT. But when I asked was there any other test other than a PSA draw, the answer has been no.

PSA creeped up end of 2020 and Jan. 2021 when I started to treat with Dr. Sartor, PSA hit the .2 mark. Then for the rest of 2021 we tested monthly for a while and then spaced it out and PSA stayed at .2 until Oct 2021, when it creeped up to I think .37. So now one year after BCR, Jan 2022, my PSA hit .47. I am really wishing the PSA will level off again and are hoping for the best. for all of us.
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