PSMA PET Scan - Help Interpreting Report?

[FaithOverFear104]

Hello, My husband had his first PSMA PET scan done today, and I am hoping someone who understands PSMA PET reports can help us interpret/understand the results as well as what to expect or ask for in terms of any further testing and/or treatment?

My profile is updated with his history, but in a nutshell he was diagnosed on January 5, 2022 at 56 years old with mets to a few spots in bones and pelvic lymph node. He underwent Triplet Therapy and responded amazingly well. He was declared to be in remission in November 2022. That was the only treatment he has had. No radiation or anything else as of yet.

My husband, unfortunately, suffered very difficult effects from treatment - not only physical but also mental health issues, as well. They became intolerable and he requested a break from ADT. Although his MO at Sloan Kettering preferred for him to stay on ADT at least 18 months and consider entering the A-Dream Trial on Intermittent ADT which is currently underway, he agreed to my husband's request for a break. We are aware of the risks of course. In any case, his PSA remained undetectable from February through May, but has been creeping up in the last couple of months. He had clear CT and Bone Scans in August, but with the continued rise in PSA, he had a PSMA PET today. His last PSA reading on November 6 was 2.68.

His MO has left Sloan Kettering and he will be getting a new one, but we are not scheduled to see her until December 1, unless my request for an earlier appointment is granted. If anyone can share thoughts that would help us prepare for that appointment, we'd be grateful. Thank you in advance.

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CLINICAL STATEMENT: Prostate cancer. Patient referred for extent ofdisease evaluation following therapy. Rising PSA. TECHNIQUE:Radiopharmaceutical: 7.1 mCi Ga-68 PSMA intravenouslyUptake time: Body: 60 minutes, Body: 94Field of view: Vertex of skull to upper thighEquipment: GE Discovery 710 (MSKMON Room G380) (Station: MNPT01) 

Oral Contrast: Not administeredIV Contrast: Not administeredThe CT protocol used for this PET/CT study is designed for attenuationcorrection and anatomic localization of PET abnormalities. This companionCT is not designed to produce, and cannot replace, state-of-the-artdiagnostic CT scans with specific imaging protocols for different bodyparts and indications.The standardized uptake values (SUV) are normalized to patient body weightand indicate the highest activity concentration (SUVmax) in a givendisease site. 

COMPARISON: FDG PET/CTAugust 9, 2022CORRELATION: Bone scan and CT of chest, abdomen, and pelvis August 25, 2023   

FINDINGS:REFERENCE REGIONS: Parotid gland SUV mean: 14.4. Liver SUV mean: 5.6. Blood pool at aortic arch SUV mean: 1.2. 

HEAD/NECK: No abnormal uptake. 

CHEST/BREAST: No abnormal uptake. 

LUNGS: No abnormal uptake. Unchangedright upper lobe calcified granuloma. 

PLEURA/PERICARDIUM: No abnormal uptake. 

MEDIASTINUM/THORACIC NODES: No abnormal uptake. 

HEPATOBILIARY: No abnormal uptake. 

SPLEEN: No abnormal uptake. 

PANCREAS: No abnormal uptake. 

ADRENAL GLANDS: No abnormal uptake. 

KIDNEYS/URETERS/BLADDER: No abnormal uptake.  

ABDOMINOPELVIC NODES: No abnormal uptake. 

GI/PERITONEUM/MESENTERY:No abnormal uptake. 

PELVIC ORGANS: Diffuse bilateral peripheral zonetracer avidity with more focal uptake in the posterior right and mid lineprostate base peripheral zone, for example, image 266, SUV 20.9. 

BONES/SOFTTISSUES: Nontracer avid subtle sclerotic lesions, forexample, right ischium, image 278 and left T9, image 147. Minimally traceravid peripherally sclerotic lesion with internal lucency along the rightiliac wing, image 230, SUV 1.2, and similar-appearing lesion in the leftiliac wing, image 229, SUV 1.0.  

 OTHER FINDINGS: None.   

IMPRESSION: Since CT and bone scan August 25, 2023, 

1. Diffuse bilateral peripheral zone PSMA avidity with more focal uptakein the right and midline posterior prostate base peripheral zone,suspicious for recurrent malignancy. 

2. Unchanged nontracer avid subtle sclerotic lesions, probably treateddisease. 

3. Unchanged minimally tracer avid peripherally sclerotic lesions withinternal lucency in the bilateral iliac wings, probably treated disease orbenign etiology.   

[Tall_Allen]

The PSMA PET showed PSMA-avidity in the prostate, and nowhere else.

How many bone metastases did the bone scan in January 2022 show?

[FaithOverFear104 in reply to Tall_Allen]

Thank you, Tall_Allen so much for your reply. I am a little embarrassed to say I am not entirely sure. The report has a lot of "could be this" and "could be that" - but I will paste it here for your reference:

NM BONE IMAGING, WHOLE BODY ------ 1/13/2022 Bone scan

CLINICAL STATEMENT: Prostate cancer. PSA>1000 ng/ml. High risk for metastatic disease. Initial staging.

TECHNIQUE: 2 hours and 16 minutes following intravenous injection of 19.4 mCi99m-Tc-MDP, scan of the whole body from the vertex to the feet and spot images of the chest and skull were obtained.

COMPARISON: None

CORRELATION:CT of chest, abdomen, and pelvis January 13, 2022 and MRI prostate December 24, 2021

FINDINGS: SKULL: Slightly heterogeneous uptake in the skull, nonspecific.

SPINE: Multifocal uptake in spine, corresponding to slightly sclerotic lesions on CT, for example in T9 and L3. Focal uptake in the cervical spine, possibly degenerative. Focal uptake laterally along L4 and T12 possibly degenerative.

RIBS, SCAPULAE, CLAVICLES, STERNUM: Focal uptake in left posterior ninth rib, corresponding to slightly sclerotic lesion on CT. Focal uptake in the sternal body, corresponding to a slightly sclerotic changes on CT. Mild uptake in the lateral right rib, corresponding to healed fracture on CT. Focal uptake in the right third and left seventh costochondral junction

KIDNEYS/BLADDER: Both kidneys are visualized. Excreted activity is present in the urinary bladder.

IMPRESSION: Findings consistent with osseous metastasis.

[Tall_Allen in reply to Tall_Allen]

I was wondering if there were only a couple — but it appears there were many.

[FaithOverFear104 in reply to Tall_Allen]

His MO never really went over the initial scans very specifically with us. We should have asked for a better explanation - but just knew that there were multiple mets in bones and in pelvic lymph nodes that required systemic treatment. (I always thought it was only in maybe three spots in bones - and other findings were degenerative disease and/or healed broken ribs from over the years).

But in any case, in light of the new report, we assume my husband will go back on ADT right away. But, based on this, are you able to suggest other treatment we might discuss with his new MO?

Since it seems to be contained to prostate right now and since he has yet to have radiation to the prostate, do you think that would possibly be appropriate at this point? Or something else?

[Tall_Allen in reply to FaithOverFear104]

That's why I asked. But prostate radiation when there are many metastases has no benefit and only has side effects.

[FaithOverFear104 in reply to Tall_Allen]

Understood. Thank you. I appreciate your input very much.

[FigureGround in reply to Tall_Allen]

TA - interested in your comment and how it might apply to oligometastasis, which I apparently have. Both my MO at the time and the RO with whom I consulted recommended radiating "The Mother Ship" as well as the sites on the pelvic girdle. My gut feeling was to leave the prostate itself alone due to potential side effects and only irradiate the external sites. So far I've done nothing other than continuing with ADT (Orgovyx + Nubeqa).

[Tall_Allen in reply to FigureGround]

There is evidence that irradiating the prostate has a benefit in oligometastatic patients:

prostatecancer.news/2018/09...

OTOH, there is no convincing evidence that irradiating the "external sites" has any benefit.

[Oatmeal2]

hi, I noticed you are being treated at Sloan. Dr. Wassim Abida is an MO that my husband sees at MSK and he specializes in PCA. He is excellent, with a great bedside manner and explains everything in detail. I highly recommend him.

[MoonRocket in reply to Oatmeal2]

I use Dr. Abida for second opinions. I agree, super nice and smart as heck.

[FaithOverFear104 in reply to MoonRocket]

Thank you - if Dr. Slovin isn't taking over permanently, perhaps we'll see about Dr. Abida.

[FaithOverFear104 in reply to Oatmeal2]

Thank you so much for your reply. I know Dr. Abida's name for sure. Glad to hear he's a good one. Dr. Susan Slovin is taking my husband's and other cases at the location we go to since his previous MO has left. I am not sure if it is permanent or a temporary solution. I guess we will find out when we meet her. I know she is a top PCa doc but I have not come across anyone yet who has personal experience with her.

[MoonRocket]

Your husband isn't alone in this battle. Unfortunately there are no shortcuts in treatments...time to restart ADT and Nubeqa. Get that cancer back under control. Also get a liquid biopsy performed or if mets are large enough, get a biopsy. My biopsy from my RP found ATM mutation which opens the door to additional treatments and clinical trials.

[FaithOverFear104 in reply to MoonRocket]

Thanks so much. I hope you are doing well with everything. He had a lymph node biopsy when first diagnosed in early 2022 and had the genetic testing done through MSK Impact. He had no mutations that were actionable for immunotherapy or anything. This may be a silly question - but I wonder, and planned to ask his doctor, if it would be useful to re-do the testing to look for mutations, etc. or is there no point since the first go around showed nothing of note for PCa...

[MoonRocket in reply to FaithOverFear104]

That is a very good question. My gut says restart the hormone treatments...and when that starts to wane, then retry the genetic tests.

I was dx'd at 53 and I'll be 58 in Feb...so I'm very similar to your husband except I'm non-metastatic.

[FaithOverFear104 in reply to MoonRocket]

Definitely plan to discuss with his doc.

You are so young too. I hope your treatments are going okay and it stays non-metastatic.

[ADTMan in reply to FaithOverFear104]

Repeat genetic testing might be a good idea. I say this because the latest video by Dr. Kwon produced by the PCRI on Youtube makes that point that prostate cancer is heterogeneous and also changes over time. So, you might start off with one treatment modality and then when it comes back, it may be genetically different and require a different modality, etc. He does repeat genetic testing after each treatment failure to see if the genetics has changed which may be amenable to a different treatment. I highly recommend this video.

[FaithOverFear104 in reply to ADTMan]

Thank you so much for weighing in. I will look for the video for sure.

[FaithOverFear104 in reply to FaithOverFear104]

I found the video and the section on genetic testing. So very helpful. Thank you again!

[Jewelrylady in reply to MoonRocket]

My husband has ATM mutation (not genetic). What treatment is available for this.

[MoonRocket in reply to Jewelrylady]

Lynparza is approved but ATR Inhibitors are being tested right now that should work better.

[Jewelrylady in reply to MoonRocket]

Do you need to be castrate resistant before starting this treatment

[MoonRocket in reply to Jewelrylady]

ATM does respond favorably to ADT so if your husband is responding, I wouldn't look to switch treatments. As for needing to be CR, usually the trials require that but each trial is set up differently.

[Nfler]

I too didn’t like the adt n how harmful it was to my body n mind. Very similar time frames n age as your husband’s and researched non stop for months, decided to stop adt when I came across ivermectin and cbd oil treatments. You can read all my previous posts but In a nutshell I had a psa of 1.92 after all trx and it is now down to 1.29 after 9 months of using ivm n cbd oil w curcurmin predominantly. Maybe something you guys may want to research on your own and at the very least studies show ivermectin can make cancer cells hormone sensitive again after going castrate resistant if you guys continue the adt route. Good luck n we’ll b praying for you…😊😇😇😇

[FaithOverFear104 in reply to Nfler]

Thank you for this - and for the prayers. I am glad that your plan is helping. It's something to consider. Prayers for you as well.

[mangeycritter]

I emphatically agree with the other posts suggesting you see Dr. Wassim Abida if you can. I have personal experience with Dr. Abida at the 68th St. location. If necessary, you might petition Dr. Johnathan Rosenberg (Chief at Sidney Kimmel).

Dr. Abida explained at length my SPOP mutation and its prognostic implications.

Anecdote: On one occasion while in the waiting room I saw Dr. Abida enter the room and apologize to a patient for being late.

[FaithOverFear104 in reply to mangeycritter]

Thank you for this. It is nice to hear such good things about Dr. Abida. We went down the road of trying to change MOs at Sloan early on because friends with connections to top PCa docs at Dana Farber gave us recommendations for top PCa docs at MSK (Dr. Abida was actually one of them), and it is (or was at the time) pretty much impossible to switch. We eventually gave up and stuck with the MO my husband was assigned to at the local center he goes to. The MO assured us he'd collaborate with the docs in NYC and he did so everything ended up being okay. We will see what happens and will definitely push harder for a change if we feel like we need to.