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Biochemical recurrence - but PET ok?

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User
Posted 17 Jul 2022 at 10:58

Hi,


My dad 69 yo got his prostate completely removed last year following a prostate cancer.


 


A year later, his PSA jumped worryingly to 0.38 ng, which got everyone very worried.


 


He went through a a PET 18F-PSMA-1007 scan and they didn’t find anything. The report ends with: “ No 18F-PSMA-1007 avid lesion in remaining body survey to suggest distant metastasis to account for his increasing PSA level to 0.38.”


 


He is meeting with his oncologist in a few weeks, but in the meantime I just wanted to know if anyone had any clue of what could be going on.


Thanks a lot! 

User
Posted 17 Jul 2022 at 14:12

I'm in a similar situation. My post op PSA was 0.28, so I was referred for an F18 PET scan. It just showed up a slightly suspect area on the pelvis which was undetectable with a follow-up MRI scan of the pelvic area. I'm now waiting for a referral to an Oncologist. The Urologist reassured me it was nothing to be immediately concerned  about (easier said than done). Detection can be a bit hit and miss at low PSA levels. Was the F18 scan just confined to the abdominal area or was it full torso?

User
Posted 17 Jul 2022 at 14:19

Hi Chris,


 


they scanned from the base of the skull till the upper thighs. 


So even if the PET scan is negative. It’s still quite worrying that PSA is still detectable :(


 


 

User
Posted 17 Jul 2022 at 16:06

Dr, I had an F18 scan a few days ago, I was slightly concerned when it said it was a half body scan, when I checked it was from the top of the skull to mid thighs.


At a PSA of 1.6 my scan picked up one lymph node, but that does not mean there are not cancerous cells lurking elsewhere. 


I am sure our scholars will be able to explain the meaning of the letter.


Do you have a list of dates and PSA values.


Thanks Chris 

User
Posted 17 Jul 2022 at 16:31
Certainly scans and just as importantly the interpretation of them has improved over recent years. However, if cancer cells cannot be seen, a consultant has to decide whether in the light of how PSA has increased and individual patient histology, whether to wait for a further period or RT the Prostate bed or initiate any other treatment. The Oncologist and the medical team are best equipped to make the decision although the best way forward can nevertheless be uncertain.
Barry
User
Posted 17 Jul 2022 at 16:34

Thanks all. My dad has a appointment in two weeks with the oncologist.


 


On the one hand it’s good that nothing is visible on the 18F PSA scan, but on the other hand it’s stressing everyone not knowing what’s going on or what to do… it’s hard to be patient for two weeks I guess. 

User
Posted 17 Jul 2022 at 21:08

Originally Posted by: Online Community Member


So even if the PET scan is negative. It’s still quite worrying that PSA is still detectable :(



Yes, there is active cancer somewhere even though they can't see it. The onco might suggest repeating the scan but with a different tracer, or may recommend whole pelvis radiotherapy with hormone treatment in the hope that is just some cancer left behind in the prostate bed or local lymph nodes, or it may be sensible to wait for the PSA to go higher and then scan again to see if it can be found. 

"Life can only be understood backwards; but it must be lived forwards." Soren Kierkegaard
User
Posted 17 Jul 2022 at 21:18

Thanks, the oncologist said that the 18F-PMSA PET was really specific/sensitive, more than the usual glucose one.


I think the hardest at the moment is the wait, the unknown and a whole worried family. 

User
Posted 17 Jul 2022 at 22:51

Hi,  It must have been his 3rd or 4th psa test as they're usually 3 monthly.   Was his psa undetectable then jumped to 0.38 or did it rise slower.   


Undetectable can be <0.02 to <0.1 depending what the hospital decides to use.  A jump to 0.38 from <0.1 in 3 months is unusual.  If it had never been undetectable or if it was a jump from <0.1 to 0.2 then 0.38 it would have rung alarm bells earlier so perhaps it did go from a very low figure in 3 months.  Rate of change can be indicative.  They're ruling out a test error presumably.  Also there is a small chance it's a bit of prostate left behind.


0.38 is getting to a level where a psma scan has a better resolution if it's a single lesion.  I seem to recall that at a psa of 0.5 it has a 50% chance of seeing it, a bit like using a telescope to look at something just too small to make out, but they can see something.

User
Posted 17 Jul 2022 at 22:54

Thanks, 


 


i will ask my dad tomorrow, but I’m pretty sure it was undetectable and slow increased over a year.


it’s just that a careless doctor scared everyone saying they 0.38 meant metastases and therefore we rushed to get a  scan… 

User
Posted 18 Jul 2022 at 09:19
A post-op PSA rising suddenly from undetectable to 0.38 probably does mean mets - but they could be micromets spread around the body in tiny clusters that cannot be seen. If the PSA has been creeping up slowly, it is more likely some left behind from the op.

The 18F PSMA is really sensitive but some cancers are not PSMA positive and micromets will be too small to see anyway. So waiting for the PSA to rise further and then repeating the scan but with a different tracer such as Gallium might be a good idea.
"Life can only be understood backwards; but it must be lived forwards." Soren Kierkegaard
User
Posted 18 Jul 2022 at 12:18
Lynn, I'm a bit confused. Paco has a F 18 TAC PSMA.
I thought this test was the very last one in terms of image and tracers improvement. You've mentioned "gallium" tracer. Did I miss anything? Something beyond that test OH and many other guys had here? Maybe st expected?
I'd appreciate some clarification to my confusion.

Thanks in advance.

Best wishes.
User
Posted 18 Jul 2022 at 13:05
There are many different tracers Lola, even a PSMA scan can be done with different tracers. It isn't possible to say whether F18 or Ga68 are better or worse than each other, they are just different. There is also 18F which is not a PSMA tracer but can sometimes pick up cancer clusters that PSMA couldn't find, because not all prostate cancers are PSMA positive. And it is just possible that all the fancy tracers in the world can't find anything and then good old reliable choline comes good.
"Life can only be understood backwards; but it must be lived forwards." Soren Kierkegaard
User
Posted 18 Jul 2022 at 16:35
When my PSA rose to over 0.2, I was told that scans (don't know which sort they would have used though) are rarely informative until PSA exceeds 0.5, but the prospects for successful salvage radiotherapy are much better if PSA is below 0.5 and doubling time greater than 6 months (you won't be able to tell what your dad's is unless there is a track record of rising values over time).

I didn't wait. Started on hormones, and my radiotherapy starts in a fortnight (planning scan this morning).
User
Posted 18 Jul 2022 at 22:19

So, dear Lynn, must we assume that what most of us had taken as an extremely relevant milestone in PCa or PCR early detection and, consequently, a new weapon for fight an control of it isn't that fabulous?


In other words: is it all about new tracers, different tracers, new equipment or in fact, nothing new under the sun.


Sorry to insist, but right now Paco has ended his SRT based on F16 TAC PSMA information and I'm feeling kind of disappointed or insecure. 

User
Posted 19 Jul 2022 at 00:29

F18 isn't the newest development - it has advantages over Ga68 and some disadvantages - it may just be that your hospital has easier access to F18 and some other hospitals have easier access to Ga68


https://www.google.com/amp/s/ichgcp.net/es/amp/clinical-trials-registry/NCT04159090    


No tracer is perfect. There is no doubt that F18 and Ga68 are better than choline in most cases but it isn't always the case. As I said, not all prostate cancers are PSMA+ although we know Paco's is because his iliac node lit up. In your case, the PSMA scan came up with pretty much the same findings as the MRI which is reassuring. However, the doctors should have explained to Paco that there may be cancer elsewhere which is just too small to see at present time.

Edited by member 19 Jul 2022 at 00:30  | Reason: Not specified

"Life can only be understood backwards; but it must be lived forwards." Soren Kierkegaard
User
Posted 09 Aug 2022 at 10:11

Hi All,


 


Just an update. My dad saw his doctor and he was told not to worry too much and to have a close monitoring. They are planning to do some photodynamic therapy.

 
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