Newly diagnosed. Confused about possible bone metastasis

Hello Everybody!

I have recently been diagnosed with PC and need your help to understand my current diagnosis. The key question is whether there are bone metastasis.

I'm 58 years old. PSA is 6.1. One year ago, it was 3.9. Gleason score (Gleason group): 3+4=7 (2) based on 13-core biopsy. Cancer stage: have not been told yet.

Systematic Biopsies
LLB: PCA, 3+4=7 (2), 40%, 8 mm, PNI present
LLM: PCA, 3+4=7 (2), 70%, 4 mm
LB: PCA, 3+3=6 (1), 50%, 5 mm
LM: PCA, 3+4=7 (2), 90%, 6 mm
LA: PCA, 3+3=6 (1), 5%, <1 mm
RB: PCA, 3+4=7 (2), 20%, 2 mm
RM: Benign
RA: Benign
RLB: Benign
RLM: Benign

Targeted Biopsies
TB 1: PCA, 3+4=7 (2), 90%, 8 mm, AIP, PNI present
TB 2: PCA, 3+4=7 (2), 70%, 5 mm AIP
TB 3: PCA, 3+4=7 (2), 90%, 11 mm, AIP, PNI present

Shortly after the biopsy I had 68Ga PSMA PET CT. The primary tumor ~ 16 mm is localized within the organ. The report from a radiologist suggests bone metastasis in the right iliac bone (SUV max 2.5) and right lateral fifth rib (SUV max 1.8). In accordance with the Molecular Imaging TNM classification I have: mi T2u(LM) N0 M1b(oligo), which means that the tumor is localized, there are no cancer cells in the lymph nodes but there may be two bone metastasis. I requested a second opinion (from another radiologist) regarding this PET CT. The second opinion was about the same, suggesting two bone metastasis. Anyway, my urologist-oncologist from UCLA told me that there is no spreading into bones. His explanation is the following: " I have read the PSMA PET and yes I think these are not metastasis. These findings were borderline significant. So, I reviewed the images with a bone radiologist. Isolated faint rib uptake is a frequent cause of false positive. When there are no imaging features that are clearly evocating a metastasis (such as here) and we follow these isolated rib lesion they are almost all the time benign (62/63, 98%).The pelvis lesion was also indeterminate."

Since the urologist was confident that the rib does not have metastasis but less confident about the hip, he sent me for another test, which is Pelvis MRI with dedicated bone marrow sequences. This test did not show a metastasis in my right hip.

Despite this very encouraging conclusion I still doubt if it is correct. First, the 68Ga PSMA PET CT is known to be the most sensitive test (still not FDA approved). Second, the SUV uptakes 1.8 and 2.5 seem to be small but not negligibly small. Third, the Pelvis MRI is less sensitive test compared to the PSMA PET CT and therefore cannot be used to verify results of a more accurate PSMA PET CT.

Based on my common sense, it is hard to believe that there are distant bone metastasis, because: 1) no local metastasis, 2) the primary tumor is localized within the gland, 3) relatively low PSA 6.1, 4) Gleason score (Gleason group) 3+4=7 (2). At the same time, the biopsy shows localization of cancer cells around the nerves: PNI is present at LLB, TB 1 and TB 3, which suggests higher risk of metastasis.

As you can understand, it is particularly important to me to make sure that there is no bone metastasis. My urologist pushes me for prostatectomy. However, if the bone metastasis does exist, the treatment should be different, and the radical surgery might be useless. I talked to my primary physician, but he does not have an opinion. Please help me to better understand this situation. Any advice will be very much appreciated.

So if it were me, I would be at once happy and nervous. Happy because newer tech may have picked up something that you would have been blind to just a few years ago. Nervous because it shows potential metastatic issues. I would however have hope. The stats you read about 5 year survival with distant mets (stage Iv) do not take into consideration things like psma scans.

You actually have insight others have not had in the entire history of humankind.

It is time to go on offense. There is no use arguing with it.

Find a good radiation oncologist and get that opinion. I think radiation to your prostate and the mets (real or not) is the way to go. You will also likely be on some sort of hormone therapy for a period of time.

I do like the approach outlined in the above post. It seems quite reasonable, given the data.

Sorry you're dealing with all this confusion. It certainly would not be typical for a G7 to have bone mets at this stage. In fact, I'm surprised they even did the scan for a G7--either standard of care has changed over the years or they had some reason to suspect something.

I do think you should speak with a radiation oncologist for a different perspective than your urologist. I was also treated at UCLA, but the personnel in the RO department has changed since my treatment. I do know Dr Chang runs the brachytherapy department (UCLA has a great brachy program), but I don't have much of an idea on who to see to discuss SBRT or IMRT. Good luck to you!