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Strange bone scan result Pseudo Progression ?

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User
Posted 27 Nov 2021 at 14:13

I am on Enzalutimide  and ADT and  have been for 18 months it's a first line treatment for me as I'm still hormone sensitive .My PSA is undetectable has been since starting on Enza  and all blood chemical  bone markers normal .However my most recent bone scan (only requested by consultant because I developed shingles and the pain was initially unexplained at the time  ) shows a tiny, tiny little hotspot in my left side pelvis (shingles was right side ).Its equivocal so the radiologist doesnt know what it is and says a confirmatory ct scan is needed .Now there is data available saying that in cases where unexplained new  hot spots are shown on bone scans and the patient is taking Enza and PSA is undetectable and  all other signs are stable ( as is the  case with me I only had lymph node involvement initially ) then the possibility of Pseudo progression is occurring as the Enzalutimide is working and healing the affected area of bone and outcomes for patients are just as good as those who do not have not such indications of spread .I did fall over a couple of times about two months ago but there is no indication of any bone damage on the affected side no pain at all  Has anyone else heard of this phenomina ?

User
Posted 28 Nov 2021 at 08:49

I haven't heard of this phenomina, although it sounds plausible.


Hormone Therapy is not normally curative in bone though. In the case of a small number of bone mets (up to 3) discovered after radical treatment, what can be done is some stereotactic radiotherapy on them with curative intent, providing the radiologists can plan beam paths which allow treatment without overdosing any tissues because of the previous radiotherapy doses they received. If your spot was found to be due to cancer, then you should ask about that. If your current hospital doesn't offer it, then you may need to request having it elsewhere. It doesn't have a very high cure rate, but even if it doesn't cure, it puts off further treatment by some time and is regarded as worthwhile.

User
Posted 28 Nov 2021 at 10:21

Well whatever it is they said its  so small they cannot define what it is  without a CT scan


There is no evidence of any PSA progression or any rise in the blood markers specifically APL which any bone met would normally raise above normal levels but would also apply to any form of  bone healing .There are a few articles on the internet relating specifically to Enzalutimide and pseudo progression in  circumstances the same as mine . It could be a small fracture healing as I've been on ADT for 18 month which does weaken bones or degenerative disease .It seems strange to me and an unusual situation .

User
Posted 28 Nov 2021 at 11:14
It is possible for progression to occur without the PSA rising, or more likely, for a bone met that was missed in early scans to be noted in a subsequent scan. Hopefully the CT scan will shed further light.
"Life can only be understood backwards; but it must be lived forwards." Soren Kierkegaard
User
Posted 28 Nov 2021 at 16:23
Choline doesn't always pick up micromets - and weirdly, PSMA scan can sometimes come back clear while an old fashioned choline scan picks up a problem. No tracer agent is 100% fool-proof
"Life can only be understood backwards; but it must be lived forwards." Soren Kierkegaard
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User
Posted 28 Nov 2021 at 08:31

Can't answer your questions, just bumping you back up the page.

User
Posted 28 Nov 2021 at 08:49

I haven't heard of this phenomina, although it sounds plausible.


Hormone Therapy is not normally curative in bone though. In the case of a small number of bone mets (up to 3) discovered after radical treatment, what can be done is some stereotactic radiotherapy on them with curative intent, providing the radiologists can plan beam paths which allow treatment without overdosing any tissues because of the previous radiotherapy doses they received. If your spot was found to be due to cancer, then you should ask about that. If your current hospital doesn't offer it, then you may need to request having it elsewhere. It doesn't have a very high cure rate, but even if it doesn't cure, it puts off further treatment by some time and is regarded as worthwhile.

User
Posted 28 Nov 2021 at 10:21

Well whatever it is they said its  so small they cannot define what it is  without a CT scan


There is no evidence of any PSA progression or any rise in the blood markers specifically APL which any bone met would normally raise above normal levels but would also apply to any form of  bone healing .There are a few articles on the internet relating specifically to Enzalutimide and pseudo progression in  circumstances the same as mine . It could be a small fracture healing as I've been on ADT for 18 month which does weaken bones or degenerative disease .It seems strange to me and an unusual situation .

User
Posted 28 Nov 2021 at 11:14
It is possible for progression to occur without the PSA rising, or more likely, for a bone met that was missed in early scans to be noted in a subsequent scan. Hopefully the CT scan will shed further light.
"Life can only be understood backwards; but it must be lived forwards." Soren Kierkegaard
User
Posted 28 Nov 2021 at 12:57

Thank you for your reply I had a choline pet scan when my psa didnt go down after my prostectomy .Cancer was shown in only a couple of lymph nodes not bones  I  was put on Enzalutimide and ADT and had a course of  RT .As you say a CT scan should show up any new  problems I have no other symptoms  just this unexplained small hot spot .

User
Posted 28 Nov 2021 at 16:23
Choline doesn't always pick up micromets - and weirdly, PSMA scan can sometimes come back clear while an old fashioned choline scan picks up a problem. No tracer agent is 100% fool-proof
"Life can only be understood backwards; but it must be lived forwards." Soren Kierkegaard
User
Posted 29 Nov 2021 at 08:20
Yes indeed however APL and bloods are all normal ,no pain at all so its puzzling what this could be. Enzalutimide is known to have an effect on Bone mets hence pseudo progression would appear to be a possibility along with degenerative disease or healing from a small RT induced stress fracture and I did fall down two months ago .
Wont know more until CT scan is done .
User
Posted 05 Jan 2022 at 12:04

Well result of CT scan is still equivicol very small area in left illiac joint they don't know if it's an insufficiency fracture or bone met .But consultant said percentage wise it is more likely to be a insufficiency fracture due to undetectable PSA and normal bone markers so MRI scan ordered now for another look .The waiting and stress goes on and on however good news CT scan revealed nothing else going on no sign of any other spread at all which is what you would expect with undetectable PSA .Apparently single bone hot spots are notorious for being anomalous and very difficult to diagnose especially when all other markers such as PSA and blood are normal .

User
Posted 12 Jan 2022 at 17:40

Well had nurse call today should have been consultant but expect as all things looking normal nurse was deemed suitable .PSA undetectable still, all bloods normal ,kidney function excellent no indication in any blood  markers  of cancer progression so MRI ordered to try and find out what on earth this slight uptake of bone tracer is .Backlog of MRI scans so will be waiting a little while before my turn as no obvious cancer progression .Asked if lab tested PSA to lower ultra ultra sensitive level as any small progression could be showing there, told by very serious nurse (with no sense of humour) no they don't test to that level .Then I asked if because of lack of PSA rise did they test for Neuroendocrine /small cell cancer, nurse rather grumpy by this time said that any abnormal results would show up in blood results though I doubt the specialist tests required for NEcancer would be covered unless specially requested .I then asked if the cancer affected Lymph nodes had responded to treatment as shown on recent CT scan nurse unaware of CT scan went away for a few mins and then  grumpily  said they looked normal .So all in all not bad news at all .She did say rather  crossly that everything was under control ,but as far as I'm concerned an uptake of tracer however small on a bone scan is not cancer under control until a full resolution of said problem is found .Still I'm a lot less worried than I was   notwithstanding Nurse Grump .

User
Posted 10 Mar 2022 at 10:22

Well after 5 long months after an equivocal bone scan picked up a very small  hot spot in my left SIJ, followed by a similarly equivocal CT scan in January and a MRI scan in February the Specalist nurse has just rung to confirm no cancer in bone just an insufficency fracture showing up.


Phew 5 months of worry all over Christmas and New Year and its just a small stress fracture caused by the RT and Hormone therapy .Apparently the bone surgeons want to take a good look at my the MRI to see if there are other problems, well I have had back problems for ever due to heavy lifting over the years I worked. They want to see if there is anything they can give me to strengthen the bones and if medication is needed .I cannot thank the wonderful oncology team enough they are superb nothing gets past them and they are very quick to act .


Apparently my cancer has gone into hibernation according to the nurse  in other words  remission which is great news .I've been PSA undetectable for 18 months now which is reassuring and I feel very well indeed seeing I was classed high risk Gleason 4 3 5 after prostectomy with spread to  local lymph nodes  and a persistant PSA that never dipped below 17 after the op  it was doubling very quickly and at the time of first ADT treatment had risen to 28  .There is much to be positive about for anyone with advanced Prostate Cancer the consultant said there is now a smorgasbord of treatments available now  and more and better treatments are on the Horizon .I was given Enzalutimide as a first line treatment after my prostectomy failed and it is indeed a wonder drug for those men who respond to it .


I hope my story gives some hope to those who find themselves in this situation things are improving on the treatment side all the

 
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