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Psma testing

User
Posted 03 January 2017 15:00:42(UTC)
Hi
Has anyone have any info on Psma testing ?
Does it pick up the smallest of cancer cells , the reason I ask is I m in a bit of no mans land with my current result not high enough to treat but not sure if the reading is a result of other organs producing pas
Thanks
John
User
Posted 06 February 2017 19:31:13(UTC)

Hi everyone
Have been told today it's unlikely I will be funded for PSMA PET even though I am funded for CHOLINE PET. But apparently I have the right to choose my treatment wherever I want in the country. My best bet is to insist on PSMA and refuse Choline scan. So I'm firing an email off and see what happens. Surely there can't be a major cost difference in the two scans apart from the tracing agent ?? I've asked for private cost too. If I'm going to have another PET scan then I'm damn well going to get the gold standard. I'm stamping my feet !!




If life gives you lemons , then make lemonade
Thanked 4 times
User
Posted 03 January 2017 22:32:29(UTC)

Interested to have a link to the trials you are referring to Lyn as I read

Conclusion:

Hybrid
68
Ga-PSMA ligand PET/CT shows substan-
tially higher detection rates than reported for other imaging mo-
dalities. Most importantly, it re
veals a high number of positive
findings in the clinically important range of low PSA values (
,
0.5
ng/mL), which in many cases can substantially influence the
further clinical management. Here is the link. https://www.snmmi.org/fi...8-74_1430513550878_2.pdf
also,

Review

Received: 25 March 2016

Accepted: 16 May 2016

Published: 8 June 2016
Abstract

Recently, positron emission tomography (PET) imaging using PSMA-ligands has gained high attention as a promising new radiotracer in patients with prostate cancer (PC). Several studies promise accurate staging of primary prostate cancer and restaging after biochemical recurrence with 68Ga-PSMA ligand Positron emission tomography/computed tomography (PET/CT). However, prospective trials and clinical guidelines for this new technique are still missing. Therefore, we summarized our experience with 68Ga-PSMA ligand PET/CT examinations in patients with primary PC and biochemical recurrence. It focuses on the technical and logistical aspects of 68Ga-PSMA ligand PET/CT examination as well as on the specific background for image reading discussing also potential pitfalls. Further, it includes relevant issues on free-text as well as structured reporting used in daily clinical routine.
Keywords
Prostate cancer Prostate specific membrane antigen Positron emission tomography
Background

Prostate cancer (PC) represents the most common cancer in men and accounts for the third most cause for cancer-associated death in men [1]. Early detection of primary disease and its metastases is highly relevant in terms of prognosis and therapy management. Primary staging with conventional imaging modalities such as computed tomography (CT) or magnetic resonance imaging (MRI) is limited as these techniques focus on morphologic information and LN involvement is mainly assessed by size. Up to 50 % of all patients undergoing radical prostatectomy (RP) or radiotherapy (RT) for primary treatment of PC develop biochemical recurrence [2, 3, 4]. Therefore, precise diagnosis of recurrence is crucial for patient counselling and treatment selection. However, the limited accuracy of CT or MRI in the detection of local disease in patients with biochemical recurrence is well appreciated [5, 6].

Positron emission tomography/computed tomography (PET/CT) as a hybrid imaging technique combining functional and morphological information has been proven to exhibit high diagnostic accuracy and is increasingly established as the primary staging tool in PC and in patients with suspicious recurrent disease. Several radiotracers have been proposed for molecular imaging of PC including choline as a marker of membrane cell proliferation. For recurrent PC, choline based (i.e. either 18F-Choline or 11C-Choline) PET/CT is currently widely used in clinical routine, however, there have been numerous studies reporting a low sensitivity and specificity [7, 8]. Especially in patients with prostate-specific antigen (PSA)-values below 3 ng/ml the detection rate is reported to be only 40–60 % [9, 10, 11].

Other radiotracers evaluated for PC include 11C-Acetate and 18F-FACBC. 18F fluciclovine, a radiolabeled leucine analog (1-amino-3-fluorocyclobutane-1-carboxylic acid in the ‘anti’ configuration [18F FACBC]), is used to depict amino acid transportation and has been found to be successful in the assessment of primary and metastatic PC showing also statistically significant superior detection rates in comparison to 11C-Choline PET [12, 13, 14]. 11C-Acetate is used as a PET radiotracer for imaging PC via incorporation into intracellular phosphatidylcholine membrane microdomains in cancer cells.
Current clinical and scientific evidence for 68Ga-PSMA ligand PET/CT and potential indications

The prostate specific membrane antigene (PSMA) is a transmembrane protein with significantly elevated expression in PC cells compared to benign prostatic tissue. So far, several, mainly retrospective studies describe the value of 68Ga-PSMA ligand PET/CT in different clinical scenarios. All of them demonstrate a higher diagnostic efficacy of 68Ga-PSMA ligand PET/CT compared to conventional imaging including PET with other tracers (e.g. 18F-Choline, 11C-Choline) [7, 15, 16, 17, 18, 19]. In particular, 68Ga-PSMA ligand PET/CT promises accurate staging of primary PC and re-staging after biochemical recurrence. In a large study in primary intermediate to high-risk PC, 68Ga-PSMA-ligand imaging has been reported to clearly improve detection of lymph node metastases compared to morphological imaging thus potentially allowing for a more tailored therapeutic concept [16].

Similar encouraging results were obtained for patients with biochemical recurrence after radical prostatectomy [17]. Here, 68Ga-PSMA ligand PET imaging has been shown to increase detection of metastatic sites even at low PSA-values in comparison to conventional imaging or PET examination with different tracers [7]. More specifically, in a study of Afshar-Oromieh et al. 68Ga-PSMA ligand PET/CT detected 78 lesions characteristic for recurrent PC in 32 patients while 18F-fluoromethylcholine PET/CT detected only 56 lesions in 26 patients resulting in a significant higher detection rate for 68Ga-PSMA ligand PET/CT [7]. The advantage of 68Ga-PSMA ligand PET is especially evident in patients with low PSA levels (PSA below 1 ng/ml). A recent study reported a detection rate of 73 and 58 % in patients with biochemical recurrence after radical prostatectomy in a PSA-range of 0.5–1.0 ng/ml and 0.2–0.5 ng/ml, respectively [17]. This facilitates the use of salvage procedures (e.g. secondary lymphadenectomy, targeted radiation therapy) with a potentially curative intent [20]. Although 68Ga-PSMA ligand PET seems to have an edge over morphological imaging in patients with PC, the evaluation of PSMA-negative PC comprising around 8 % of the examined patients remains a challenge [16].
In nuclear medicine, bone imaging with 99mTc-phosphonates plays an important role in the management of PC patients according to current guidelines providing a fast whole-body overview evaluating the presence of bone metastases. Preliminary results from our department indicate that the detection rate of 68Ga-PSMA ligand PET/CT is clearly superior to traditional bone scan xaminations. It focuses on the technical and logistical issues as well as on the specific background for image reading with an emphasis on the PET-part since contrast enhanced computed tomography as the second part of a hybrid 68Ga-PSMA ligand PET/CT examination is an already very standardized and common imaging technique.
Synthesis, application and imaging protocol of 68Ga-PSMA ligand PET/CT

A number of different PSMA-targeted PET tracers have been developed [24, 25, 26, 27]. The most widely used PSMA-ligand for PET-imaging in Europe is a 68Ga-labelled PSMA inhibitor Glu-NH-CO-NH-Lys(Ahx)-HBED-CC (68Ga PSMA HBED-CC) followed by the theranostic agent 68Ga-labelled PSMA I&T [26, 27]. Details on the synthesis of 68Ga-labelled PSMA HBED-CC and 68Ga-labelled PSMA I&T have been described previously [27, 28]. Here is a link to the article https://cancerimagingjou...0.1186/s40644-016-0072-6

The 68 Gallium PSMA scan developed in Heidelberg and shown to be superior to the Chlorine one is now available in other European countries and at UCLH in the UK. It may well be available at other UK hospitals by now.


Barry
Thanked 1 time
User
Posted 05 January 2017 10:49:23(UTC)

UCLH have confirmed they do this scan with a wait of 4 weeks , so I'm chasing Onco now !


But as ever it looks like a funding thing !!



If life gives you lemons , then make lemonade
Thanked 1 time
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User
Posted 03 January 2017 17:54:12(UTC)

The trials found it to be less helpful than hoped but if used in conjunction with high level body scanning may have some uses in relation to diagnosing / pinpointing recurrence.

"Life can only be understood backwards; but it must be lived forwards." Soren Kierkegaard


User
Posted 03 January 2017 18:47:33(UTC)

I am soon to go for a second C11 Choline PET scan at Oxford.
In trials PSMA used as a tracing / indicator injection has given significant improvements over Choline apparently , but although I asked for it I was denied as it is still at trial stage ? One of our members went to Munich privately for a PSMA PET scan I believe.
I too am rapidly producing PSA ever since radical prostatectomy , but it's location or source cannot be found. Hopefully next scan will provide some answers !




If life gives you lemons , then make lemonade
User
Posted 03 January 2017 22:32:29(UTC)

Interested to have a link to the trials you are referring to Lyn as I read

Conclusion:

Hybrid
68
Ga-PSMA ligand PET/CT shows substan-
tially higher detection rates than reported for other imaging mo-
dalities. Most importantly, it re
veals a high number of positive
findings in the clinically important range of low PSA values (
,
0.5
ng/mL), which in many cases can substantially influence the
further clinical management. Here is the link. https://www.snmmi.org/fi...8-74_1430513550878_2.pdf
also,

Review

Received: 25 March 2016

Accepted: 16 May 2016

Published: 8 June 2016
Abstract

Recently, positron emission tomography (PET) imaging using PSMA-ligands has gained high attention as a promising new radiotracer in patients with prostate cancer (PC). Several studies promise accurate staging of primary prostate cancer and restaging after biochemical recurrence with 68Ga-PSMA ligand Positron emission tomography/computed tomography (PET/CT). However, prospective trials and clinical guidelines for this new technique are still missing. Therefore, we summarized our experience with 68Ga-PSMA ligand PET/CT examinations in patients with primary PC and biochemical recurrence. It focuses on the technical and logistical aspects of 68Ga-PSMA ligand PET/CT examination as well as on the specific background for image reading discussing also potential pitfalls. Further, it includes relevant issues on free-text as well as structured reporting used in daily clinical routine.
Keywords
Prostate cancer Prostate specific membrane antigen Positron emission tomography
Background

Prostate cancer (PC) represents the most common cancer in men and accounts for the third most cause for cancer-associated death in men [1]. Early detection of primary disease and its metastases is highly relevant in terms of prognosis and therapy management. Primary staging with conventional imaging modalities such as computed tomography (CT) or magnetic resonance imaging (MRI) is limited as these techniques focus on morphologic information and LN involvement is mainly assessed by size. Up to 50 % of all patients undergoing radical prostatectomy (RP) or radiotherapy (RT) for primary treatment of PC develop biochemical recurrence [2, 3, 4]. Therefore, precise diagnosis of recurrence is crucial for patient counselling and treatment selection. However, the limited accuracy of CT or MRI in the detection of local disease in patients with biochemical recurrence is well appreciated [5, 6].

Positron emission tomography/computed tomography (PET/CT) as a hybrid imaging technique combining functional and morphological information has been proven to exhibit high diagnostic accuracy and is increasingly established as the primary staging tool in PC and in patients with suspicious recurrent disease. Several radiotracers have been proposed for molecular imaging of PC including choline as a marker of membrane cell proliferation. For recurrent PC, choline based (i.e. either 18F-Choline or 11C-Choline) PET/CT is currently widely used in clinical routine, however, there have been numerous studies reporting a low sensitivity and specificity [7, 8]. Especially in patients with prostate-specific antigen (PSA)-values below 3 ng/ml the detection rate is reported to be only 40–60 % [9, 10, 11].

Other radiotracers evaluated for PC include 11C-Acetate and 18F-FACBC. 18F fluciclovine, a radiolabeled leucine analog (1-amino-3-fluorocyclobutane-1-carboxylic acid in the ‘anti’ configuration [18F FACBC]), is used to depict amino acid transportation and has been found to be successful in the assessment of primary and metastatic PC showing also statistically significant superior detection rates in comparison to 11C-Choline PET [12, 13, 14]. 11C-Acetate is used as a PET radiotracer for imaging PC via incorporation into intracellular phosphatidylcholine membrane microdomains in cancer cells.
Current clinical and scientific evidence for 68Ga-PSMA ligand PET/CT and potential indications

The prostate specific membrane antigene (PSMA) is a transmembrane protein with significantly elevated expression in PC cells compared to benign prostatic tissue. So far, several, mainly retrospective studies describe the value of 68Ga-PSMA ligand PET/CT in different clinical scenarios. All of them demonstrate a higher diagnostic efficacy of 68Ga-PSMA ligand PET/CT compared to conventional imaging including PET with other tracers (e.g. 18F-Choline, 11C-Choline) [7, 15, 16, 17, 18, 19]. In particular, 68Ga-PSMA ligand PET/CT promises accurate staging of primary PC and re-staging after biochemical recurrence. In a large study in primary intermediate to high-risk PC, 68Ga-PSMA-ligand imaging has been reported to clearly improve detection of lymph node metastases compared to morphological imaging thus potentially allowing for a more tailored therapeutic concept [16].

Similar encouraging results were obtained for patients with biochemical recurrence after radical prostatectomy [17]. Here, 68Ga-PSMA ligand PET imaging has been shown to increase detection of metastatic sites even at low PSA-values in comparison to conventional imaging or PET examination with different tracers [7]. More specifically, in a study of Afshar-Oromieh et al. 68Ga-PSMA ligand PET/CT detected 78 lesions characteristic for recurrent PC in 32 patients while 18F-fluoromethylcholine PET/CT detected only 56 lesions in 26 patients resulting in a significant higher detection rate for 68Ga-PSMA ligand PET/CT [7]. The advantage of 68Ga-PSMA ligand PET is especially evident in patients with low PSA levels (PSA below 1 ng/ml). A recent study reported a detection rate of 73 and 58 % in patients with biochemical recurrence after radical prostatectomy in a PSA-range of 0.5–1.0 ng/ml and 0.2–0.5 ng/ml, respectively [17]. This facilitates the use of salvage procedures (e.g. secondary lymphadenectomy, targeted radiation therapy) with a potentially curative intent [20]. Although 68Ga-PSMA ligand PET seems to have an edge over morphological imaging in patients with PC, the evaluation of PSMA-negative PC comprising around 8 % of the examined patients remains a challenge [16].
In nuclear medicine, bone imaging with 99mTc-phosphonates plays an important role in the management of PC patients according to current guidelines providing a fast whole-body overview evaluating the presence of bone metastases. Preliminary results from our department indicate that the detection rate of 68Ga-PSMA ligand PET/CT is clearly superior to traditional bone scan xaminations. It focuses on the technical and logistical issues as well as on the specific background for image reading with an emphasis on the PET-part since contrast enhanced computed tomography as the second part of a hybrid 68Ga-PSMA ligand PET/CT examination is an already very standardized and common imaging technique.
Synthesis, application and imaging protocol of 68Ga-PSMA ligand PET/CT

A number of different PSMA-targeted PET tracers have been developed [24, 25, 26, 27]. The most widely used PSMA-ligand for PET-imaging in Europe is a 68Ga-labelled PSMA inhibitor Glu-NH-CO-NH-Lys(Ahx)-HBED-CC (68Ga PSMA HBED-CC) followed by the theranostic agent 68Ga-labelled PSMA I&T [26, 27]. Details on the synthesis of 68Ga-labelled PSMA HBED-CC and 68Ga-labelled PSMA I&T have been described previously [27, 28]. Here is a link to the article https://cancerimagingjou...0.1186/s40644-016-0072-6

The 68 Gallium PSMA scan developed in Heidelberg and shown to be superior to the Chlorine one is now available in other European countries and at UCLH in the UK. It may well be available at other UK hospitals by now.


Barry
Thanked 1 time
User
Posted 04 January 2017 16:23:24(UTC)

I am due a Choline PET scan in the next six weeks and saw my Onco today. I asked directly for a PSMA scan but he said trials are over and being assessed at present. He agrees the outlook seems good , and that very high calibre imaging is without doubt the best hope for people like myself with oligo-metastases. Now I want to phone him and suggest UCLH but he said he would know if it was available??




If life gives you lemons , then make lemonade
User
Posted 04 January 2017 19:39:30(UTC)

Hi Chris,

You will recall the experience of Roy in this thread http://community.prostat...3-PET-CT-SCAN#post117114

I will take the opportunity of asking Prof E at my appointment at UCLH next month if they are still doing the 68 Gallium test as my consultant at UCLH had previously told me it was available there.

I am sure with the time you have spent on this forum that you are aware that you sometimes have to be a bit pushy to get what is not generally available.

Hope whatever scans you have prove helpful.

Barry
User
Posted 04 January 2017 20:14:39(UTC)

Barry thanks , I am going to chase this for sure. Having had one Choline PET already at approx psa 2.2 I'm not in a rush to have another at psa 3
It is obvious to all I have psa producing tumors that aren't going to go away. Choline PET only picks up tumorurs bigger than 6 to 7 mm whereas PSMA can pick up minute tumours apparently. If I'm going to have it done again I want the best job possible even if I have to pay for it. Also with the last scan it was cancelled twice , the second time I was 70 miles up the motorway.
Thanks for replying




If life gives you lemons , then make lemonade
User
Posted 05 January 2017 10:49:23(UTC)

UCLH have confirmed they do this scan with a wait of 4 weeks , so I'm chasing Onco now !


But as ever it looks like a funding thing !!



If life gives you lemons , then make lemonade
Thanked 1 time
User
Posted 06 February 2017 19:31:13(UTC)

Hi everyone
Have been told today it's unlikely I will be funded for PSMA PET even though I am funded for CHOLINE PET. But apparently I have the right to choose my treatment wherever I want in the country. My best bet is to insist on PSMA and refuse Choline scan. So I'm firing an email off and see what happens. Surely there can't be a major cost difference in the two scans apart from the tracing agent ?? I've asked for private cost too. If I'm going to have another PET scan then I'm damn well going to get the gold standard. I'm stamping my feet !!




If life gives you lemons , then make lemonade
Thanked 4 times
User
Posted 06 February 2017 20:55:27(UTC)

Good for you. Fingers crossed you get what you want.

User
Posted 06 February 2017 22:31:17(UTC)

Yes indeed.., choice means choice!

Go for it!

User
Posted 06 February 2017 23:41:05(UTC)
Originally Posted by: Online Community Member

Interested to have a link to the trials you are referring to Lyn as I read .... p>




Sorry, I missed this Manwith - but I think we are referring to the same sets of findings - conclusions that PSMA is most useful in diagnosing / pinpointing recurrence at very low PSA. The earliest trials hoped that isolating PSMA would lead to new treatments but that doesn't seem to have got off the ground.

CJ, fingers crossed x
"Life can only be understood backwards; but it must be lived forwards." Soren Kierkegaard


User
Posted 07 February 2017 13:34:19(UTC)

The answer is no haha but my Uro and Onco writing to my doc asking him to refer me. All politics. There's a slight chance the tab will be picked up by the NHS at London but the scan costs £1800 and I am more than willing to pay this. After all my reading the evidence is that it will be far more conclusive so we can tailor treatment properly and effectively.




If life gives you lemons , then make lemonade
User
Posted 04 November 2017 00:11:41(UTC)

By opportunity of this thread I would be grateful if anybody could tell me if they know of any hospitals in the UK (other than UCLH and the Marsden) who have the 68 Gallium PSMA test for private patients and if known the cost. (I may have to go this route or to Germany as UCLH declined to offer me the scan on the NHS notwithstanding I am still a patient there following HIFU). The reasoni is they would not give me any further radical treatment, only HT regardless of wherever a scan showed PCa. I might be able to have the scan as a private patient there circa £2,200 or at the Marsden £3,077 plus a subsequent consultant's fee, ( priced yesterday). Hopefully, another hospital in the UK would prove less costly?? Some patients from the USA report they are having the scan at one of several hospitals in Australia at a fraction of the above quoted figures but my wife has developed a phobia about airports and flying, particularly long distance and I would not go without her as she is becoming increasingly dependent on me - another reason why I need to maximize my lifespan.

Barry
User
Posted 04 November 2017 00:38:42(UTC)

Are you quite determined on the G68 Barry? Would you not consider the FACBC instead? You probably remember that after a false start John didn't meet the criteria but you might?


"For anyone interested, this is the report on FACBC which has had great results in Italy and is now being trialled at a small number of hospitals in England (but again, with very narrow criteria)


https://tinyurl.com/y9uw3ukb
"

"Life can only be understood backwards; but it must be lived forwards." Soren Kierkegaard


User
Posted 04 November 2017 03:16:10(UTC)

Yes Lyn! but thank you for reminding me about FACBC and for the link, although this does not make a comparison with the PSMA test which this link does and it is well referenced. https://www.ncbi.nlm.nih...pmc/articles/PMC4171844/

I am only a lay person as you are aware so have to base my judgement on what I read from good sources and just about all who include or speak of the PSMA test using the radio tracer 68 Gallium put it at the top for those with likely recurrence of PCa. There is another scan used by a hospital in the Netherlands which seems to be highly rated by members on a US forum and some of their oncologists. The cost of this scan was reported as being about 4K there and the facility recommend the 68 Gallium PSMA scan be done too which costs a further 2K. When I find the link again I will add it out of interest.

Before taking up the offer of University Hospital Heidelberg to have the PSMA scan there (I am already past the 0.7 PSA they suggested I have this scan and more RT treatment if they can identify the source), I will ask my Dr to refer me back to the Marsden who suggested I could do this if my PSA continued to rise. They might give me the PSMA scan on the NHS if they think differently about further treatment, perhaps Cyberknife. I would't expect them to do this scan if like UCLH they would only suggest HT regardless.

PS The centre in the Netherlands is Radbond University Medical Centre, Nijmegen Netherlands and the scan is called Iron Nano (formerly Combidex) It is said to be particularly good for finding lymph node metastases as small as 2 mm.  I have not looked into this one.....yet!

Barry
User
Posted 04 November 2017 07:41:13(UTC)

I think there is a Birmingham prostate clinic which is private that offers the PSMA Barry. It ain’t fool-proof and my scan was still negative even though my psa is now over 7. We simply don’t understand unless all my nets are micro in my lymph system. After all the PET scan palavers I’ve had , I have little faith in the tracer Ligands being delivered in the right condition




If life gives you lemons , then make lemonade
User
Posted 04 November 2017 11:33:59(UTC)

Thank you for your suggestion Chris. I believe you may be thinking of the Birmingham Prostate Clinic but their patients go to Germany for the PSMA scan - our member Roy was one of them and he had his scan in Munich. https://www.birminghamprostateclinic.co.uk/prostate/assessments/pet-scans-for-prostate-cancer/ However, one of their consultants is also at the Q E  Birmingham with whom I have a link having had a second opinion there when I was originally diagnosed.  He has stated how impressed he was by the quality of the scan done in Germany so he may have persuaded the Q E to do it now, something I will check on.

Sorry all the scans you have had have not provided more definitive information for you. Like many other aspects of PCa, different things seem to work better for some patients than others and when it comes to scans you don't know until after you have them.

Barry
Thanked 1 time
User
Posted 04 November 2017 13:10:15(UTC)
Hi Barry

As you probably know I am being treated at the QE Birmingham and know the person you are referring to and am aware he and his colleagues have tried to persuade the trust as to the advantage of PSMA but as always money talks and it hasn't been adopted yet as far as I know. The PET/CT scan is carried out by a private company on campus and is attached to the Cancer Centre, so whether they can obtain the Gallium I don't know.

All the best

Roy
 
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