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Bone scan and CT scan - different results?

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User
Posted 24 May 2023 at 11:32

My dad went through localised treatment with hormones and radiation back in 2020 (Gleason 4+5=9, PSA=2.4).

 

The cancer has come back and potentially spread to the bones. The consultant said it has definitely spread somewhere because the Gleason score has increased to 18.5 (17th May 2023).

 

We are confused since the consultant said the probability of spreading to the bones is not 100% given the test results:

 

(1) Bone scan - not spread.

(2) CT scan - it has spread to bones.

--------------

(Q1) Can anyone explain why the bone scan could not detect spread, but the CT scan did? Does this suggest they have detected it early?

(Q2) Is spread to the lymph nodes more serious than spread to nearby bones?

 

He has restarted the hormone treatment (bicalutmide tablets for 4 weeks). He has his first 3 monthly LHRH agonist injection on 1 June, so after two weeks of tablets to minimise testosterone flare). He will go to the hospital soon to discuss treatment and they have mentioned the possibility of chemotherapy).

Thanks, Richard. 

 

 

 

User
Posted 25 May 2023 at 14:22
Well best left to patient to decide what he can afford or be prepared to pay and most people can get to a scanner centre, have the scan and get back home the same day as I did from Devon to London. A PSMA scan can be potentially life changing in what it leads to, yet is less than some people pay for a family holiday or cruise and look at the high cost of new cars people are prepared to pay for, even if they are leased. I would have thought people would prioritise their health over luxuries but accept that even by later life some find the cost of living leaves little spare cash/assets. But we shouldn't assume a man can't/won't pay, neither should he not do so if he is 78. The purpose here is to suggest how a man might benefit if he is suitable, which will normally involve a Consultant's referral.
Barry
User
Posted 25 May 2023 at 05:42
Hi Richard,

Well, there you have an alternative view and in the light of my experience one that I would not advocate. At about your dad's age, I had HIFU as salvage treatment for failed RT. However, my PSA began to rise gradually to the point that UCLH agreed to give me a Choline scan from which they thought I might have cancer in an Iliac Lymph Node as well as in my Prostate. Therefore, they just proposed to treat me with HT. (They gave me some anti flare tablets and a syringe of Zoladex, which I never started.) Instead, In view of the equivocal assessment of the Choline scan, I sent this to other major hospitals with whom I had a connection. All 3 considered the aforementioned Iliac Lymph Node was not cancerous. Furthermore, The Royal Marsden opined not to start HT and Heidelberg University Hospital suggested I have the 68 Gallium PSMA scan they had developed in conjunction with the dkfz (German Cancer Research Centre). I asked UCLH to give me this scan on the NHS but they refused so I paid for it elsewhere. It showed the only cancer was within my Prostate. Presented with this result, UCLH eventually and following my persistence, agreed to repeat HIFU.. This they did when I was 84 years of age. This year, following a recent mpMRI and following some 16 months of low and stable PSA, I was told by my Consultant that I am PCa free and in remission. I am hopeful to reach 97 or more to match or surpass my father's age at death.

My case is of course different to that of the OP's father, although there is doubt in scans here too. In a substantial number of varied cases the treatment plan has changed after PSMA. It could be that depending on what is seen and where, it may be possible to treat a few mets with precision RT or another form of treatment such as photodynamic therapy. There is nothing lost in investigating and if the PSMA scan can't be obtained on the NHS, it should be available somewhere at cost even though the tracer is in short supply. It's up to the individual. Some men get even more than 10 years on HT, albeit with varying side effects, but others very much less.

Interesting comment from National Library of Medicine

'Conventional imaging techniques like CT and MRI face significant restriction as they fail to detect lymph nodal lesions measuring smaller than 8 mm (2). It is not uncommon for MRI, more precisely for DWI, to be unable to differentiate infiltrated from non-metastatic lymph nodes and consequently, lymph nodal secondaries are missed, especially in high-risk and intermediate-risk patients (3). Furthermore, CT and MRI often fail to correctly identify non-PC lymphadenopathies. Similarly, BS is in many cases not specific enough with regards to bone findings in PC patients. In all these cases, PSMA PET(/CT) eventuates to better delineate or/and clarify the status of the disease' .

Barry
User
Posted 24 May 2023 at 13:22
I think they mean the PSA has increased to 18.5 max Gleason is 10 (5+5).

CT scan will detect bone metastases earlier than a traditional bone scan so in that respect it has been detected earlier than would have been the case PRD CT scan.

Ask about localised radiation treatment for the bone tumours, also ask if 2nd line hormone treatment is more or less appropriate at this stage rather than chemo.

User
Posted 24 May 2023 at 14:35
Ask about PSMA scan which is a do it all scan including bones although a mp MRI is good in certain areas. Local radiation may be possible if no more than 3 mets found but also will depend on location.
Barry
User
Posted 24 May 2023 at 21:58
Hi Richard,

sorry to say that I don't think the other replies are necessarily helpful or proportionate. Your dad is 78, the cancer is back and quite active - I can see no benefit in you asking for and possibly having to wait for a PSMA scan - which may not be available on the NHS in your area anyway and if it is, the NHS may not prioritise it for a man who is pushing 80 when the scan results would make no difference to the treatment plan.

You can't really compare bone mets and lymph node mets to say which is better. A man with advanced uncontrolled bone mets may suffer bad bone pain and fractures or spinal cord compression (but he may not). A man with lymph node mets may get lymphodema and lose mobility or suffer organ damage (but my not). The worst mets in terms of longevity are mets to the soft organs (kidney, liver, lung or brain) or to the skull. Fortunately, no one is suggesting that your dad has any of these.

I would accept that there are mets somewhere and just get on with the HT. If he responds well to the HT and gets a run of luck he may still be here in 10 years time.

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

User
Posted 25 May 2023 at 06:55
Must admit I read this post and assumed that CT scan meant PSMA CT because it had shown bone spread AND that seems to be the defacto staging scan these days.

I am with Barry at least ask your consultant.

Be an informed patient...

User
Posted 26 May 2023 at 23:12
If the PSA goes nice and low and then stays quite stable, it means the cancer is being starved and cannot multiply.

‘Remission’ is when someone has had radical treatment and then no signs of recurrence in the next 10 years (sometimes doctors will talk about remission when the person has been clear for 5 years).

It is great news that he is being offered apalutimide alongside traditional HT. Trials suggest that this can be effective for many years.

CT scans sometimes pick up bone activity that has nothing to do with cancer - damage from a fall, for example, or osteoporosis.

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

User
Posted 30 May 2023 at 00:41
Chemotherapy cannot cure prostate cancer, until recently it was only given to men at the end stage of life to try to reduce some of the discomfort and extend life by a little bit. More recently, it has been realised that chemo given earlier can make the HT more effective for longer although the side effects of chemo can be quite serious. Then apalutimide came along duting the pandemic as a new treatment - all the data shows that apa is better than traditional chemo and with a lower risk of serious side effects. Honestly, your dad is so lucky to be being offered this - there are a lot of men on here who would snap your hand off!

Just so you know, apalutime is a form of chemo - the word just means a chemical treatment that attacks cells all over the body. So it may be that when the doctor said dad would have chemo + HT, he meant apalutimide. Or it might be that they had to apply for funding to get your dad onto apa and didn't want to raise your hopes before they knew

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

User
Posted 03 Jun 2023 at 22:40
Sclerosis means thickening - so, as you were advised, this could be bone mets or it could be age-related
"Life can only be understood backwards; but it must be lived forwards." Soren Kierkegaard

User
Posted 26 Jun 2023 at 21:40

My PSA was about 25 at diagnosis. After about three months of HT it was under 1.0 it got as low as undetectable after another 3 months.

Dave

Show Most Thanked Posts
User
Posted 24 May 2023 at 13:22
I think they mean the PSA has increased to 18.5 max Gleason is 10 (5+5).

CT scan will detect bone metastases earlier than a traditional bone scan so in that respect it has been detected earlier than would have been the case PRD CT scan.

Ask about localised radiation treatment for the bone tumours, also ask if 2nd line hormone treatment is more or less appropriate at this stage rather than chemo.

User
Posted 24 May 2023 at 14:35
Ask about PSMA scan which is a do it all scan including bones although a mp MRI is good in certain areas. Local radiation may be possible if no more than 3 mets found but also will depend on location.
Barry
User
Posted 24 May 2023 at 21:58
Hi Richard,

sorry to say that I don't think the other replies are necessarily helpful or proportionate. Your dad is 78, the cancer is back and quite active - I can see no benefit in you asking for and possibly having to wait for a PSMA scan - which may not be available on the NHS in your area anyway and if it is, the NHS may not prioritise it for a man who is pushing 80 when the scan results would make no difference to the treatment plan.

You can't really compare bone mets and lymph node mets to say which is better. A man with advanced uncontrolled bone mets may suffer bad bone pain and fractures or spinal cord compression (but he may not). A man with lymph node mets may get lymphodema and lose mobility or suffer organ damage (but my not). The worst mets in terms of longevity are mets to the soft organs (kidney, liver, lung or brain) or to the skull. Fortunately, no one is suggesting that your dad has any of these.

I would accept that there are mets somewhere and just get on with the HT. If he responds well to the HT and gets a run of luck he may still be here in 10 years time.

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

User
Posted 25 May 2023 at 05:42
Hi Richard,

Well, there you have an alternative view and in the light of my experience one that I would not advocate. At about your dad's age, I had HIFU as salvage treatment for failed RT. However, my PSA began to rise gradually to the point that UCLH agreed to give me a Choline scan from which they thought I might have cancer in an Iliac Lymph Node as well as in my Prostate. Therefore, they just proposed to treat me with HT. (They gave me some anti flare tablets and a syringe of Zoladex, which I never started.) Instead, In view of the equivocal assessment of the Choline scan, I sent this to other major hospitals with whom I had a connection. All 3 considered the aforementioned Iliac Lymph Node was not cancerous. Furthermore, The Royal Marsden opined not to start HT and Heidelberg University Hospital suggested I have the 68 Gallium PSMA scan they had developed in conjunction with the dkfz (German Cancer Research Centre). I asked UCLH to give me this scan on the NHS but they refused so I paid for it elsewhere. It showed the only cancer was within my Prostate. Presented with this result, UCLH eventually and following my persistence, agreed to repeat HIFU.. This they did when I was 84 years of age. This year, following a recent mpMRI and following some 16 months of low and stable PSA, I was told by my Consultant that I am PCa free and in remission. I am hopeful to reach 97 or more to match or surpass my father's age at death.

My case is of course different to that of the OP's father, although there is doubt in scans here too. In a substantial number of varied cases the treatment plan has changed after PSMA. It could be that depending on what is seen and where, it may be possible to treat a few mets with precision RT or another form of treatment such as photodynamic therapy. There is nothing lost in investigating and if the PSMA scan can't be obtained on the NHS, it should be available somewhere at cost even though the tracer is in short supply. It's up to the individual. Some men get even more than 10 years on HT, albeit with varying side effects, but others very much less.

Interesting comment from National Library of Medicine

'Conventional imaging techniques like CT and MRI face significant restriction as they fail to detect lymph nodal lesions measuring smaller than 8 mm (2). It is not uncommon for MRI, more precisely for DWI, to be unable to differentiate infiltrated from non-metastatic lymph nodes and consequently, lymph nodal secondaries are missed, especially in high-risk and intermediate-risk patients (3). Furthermore, CT and MRI often fail to correctly identify non-PC lymphadenopathies. Similarly, BS is in many cases not specific enough with regards to bone findings in PC patients. In all these cases, PSMA PET(/CT) eventuates to better delineate or/and clarify the status of the disease' .

Barry
User
Posted 25 May 2023 at 06:55
Must admit I read this post and assumed that CT scan meant PSMA CT because it had shown bone spread AND that seems to be the defacto staging scan these days.

I am with Barry at least ask your consultant.

Be an informed patient...

User
Posted 25 May 2023 at 08:35

I don't think PSMA is defacto at all unless a man has deep pockets and happens to live near London, Oxford or Manchester! It is available at only a handful of hospitals and so difficult to produce and only has NICE approval for a limited range of recurrence circumstances or where Lu177 is being considered. 

Edited by member 25 May 2023 at 08:38  | Reason: Not specified

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

User
Posted 25 May 2023 at 14:22
Well best left to patient to decide what he can afford or be prepared to pay and most people can get to a scanner centre, have the scan and get back home the same day as I did from Devon to London. A PSMA scan can be potentially life changing in what it leads to, yet is less than some people pay for a family holiday or cruise and look at the high cost of new cars people are prepared to pay for, even if they are leased. I would have thought people would prioritise their health over luxuries but accept that even by later life some find the cost of living leaves little spare cash/assets. But we shouldn't assume a man can't/won't pay, neither should he not do so if he is 78. The purpose here is to suggest how a man might benefit if he is suitable, which will normally involve a Consultant's referral.
Barry
User
Posted 26 May 2023 at 13:10

Just gotten back from the hospital. They have suggested hormone therapy (3 monthly LHRH injections) with the addition of apalulatamide. He will be on hormone treatment for the rest of his life.

 

I asked about the psma scan and he said it wouldn't change the suggested treatment plan. He said the bone scan indicated no active cancer. The CT scan has picked up something in the bones, but it could be early cancer or just normal ageing.

 

Anyway, a little emotionally numb at the moment. Just hoping the hormone treatment gets the PSA level down soon. 

 

If the PSA levels go down to close to zero, then I assume this means it is in remission? 

 

Thanks for the previous comments.

 

Richard. 

Edited by member 26 May 2023 at 15:57  | Reason: Not specified

User
Posted 26 May 2023 at 23:12
If the PSA goes nice and low and then stays quite stable, it means the cancer is being starved and cannot multiply.

‘Remission’ is when someone has had radical treatment and then no signs of recurrence in the next 10 years (sometimes doctors will talk about remission when the person has been clear for 5 years).

It is great news that he is being offered apalutimide alongside traditional HT. Trials suggest that this can be effective for many years.

CT scans sometimes pick up bone activity that has nothing to do with cancer - damage from a fall, for example, or osteoporosis.

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

User
Posted 29 May 2023 at 21:20

We are a little confused why they decided against chemotherapy and the hormone injections. Over the phone, they said he would be offered chemotherapy and the hormone injections. When we got there, they suggested apulutamide and the hormone injections instead. The hormone treatment is now for the rest of his life. The chemotherapy could lead to a cure I believe. 

 

Generally, do they usually go for chemotherapy if the scans indicates active mets in say the bones?

 

In my dads case, they know the cancer has spread given the PSA increased to 20'ish after the radiation treatment, but the bone scan was clear. Hence, the hormone injections and apalutamide tablets is preferred in this type of case?

 

My dad is quite fit for a 78 year old and plays golf regularly.  He was Gleason 4+5=9 before the radiation treatment back in 2020. 

 

 

 

 

Edited by member 29 May 2023 at 21:45  | Reason: Not specified

User
Posted 30 May 2023 at 00:41
Chemotherapy cannot cure prostate cancer, until recently it was only given to men at the end stage of life to try to reduce some of the discomfort and extend life by a little bit. More recently, it has been realised that chemo given earlier can make the HT more effective for longer although the side effects of chemo can be quite serious. Then apalutimide came along duting the pandemic as a new treatment - all the data shows that apa is better than traditional chemo and with a lower risk of serious side effects. Honestly, your dad is so lucky to be being offered this - there are a lot of men on here who would snap your hand off!

Just so you know, apalutime is a form of chemo - the word just means a chemical treatment that attacks cells all over the body. So it may be that when the doctor said dad would have chemo + HT, he meant apalutimide. Or it might be that they had to apply for funding to get your dad onto apa and didn't want to raise your hopes before they knew

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

User
Posted 03 Jun 2023 at 15:54

Can someone decode what this means with relation to the CT scan?

 

Ill-defined sclerosis in the right side of the vertebral body of C7, left side of the L1/L3 vertebral bodies anteroposteriorly, right side of L5 vertebral body. 

 

User
Posted 03 Jun 2023 at 22:40
Sclerosis means thickening - so, as you were advised, this could be bone mets or it could be age-related
"Life can only be understood backwards; but it must be lived forwards." Soren Kierkegaard

User
Posted 26 Jun 2023 at 20:42

I appreciate this question is patient dependent, but how quickly does hormone therapy start to reduce the PSA if the treatment is seen to be working?

Is the most likely outcome for the PSA to stay the same after say 6 weeks of hormone treatment if the treatment is working, or should a reduction be seen?

 

Google searches with this question isn't helping! :-)

Edited by member 26 Jun 2023 at 20:43  | Reason: Not specified

User
Posted 26 Jun 2023 at 21:40

My PSA was about 25 at diagnosis. After about three months of HT it was under 1.0 it got as low as undetectable after another 3 months.

Dave

User
Posted 26 Jun 2023 at 21:51

My dad has had the following (his PSA was 29 in May 2023 and about 2 in December 2022):

(1) 17/05/2023 - bicalutmide for 4 weeks to stop flare.
(2) 02/06/2023 - 1st Goserelin 3 monthly injection.
(3) 15/06/2023 - apalulatamide daily tablets.

He is having a blood test on the 3rd of July and results discussion on the 6th of July.

We are naturally hoping for the PSA to be lower, but is a drop one month after the first injection unlikely?

Down to 1 after three months is possible, but how about after a month?

Thanks.

Edited by member 26 Jun 2023 at 21:54  | Reason: Not specified

 
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