How to understand PSMA report

In a nutshell it seems that you may have some lung mets, but no evidence of mets elsewhere. Apparently, the PSA threshold for these scans is about 0.2. So the 0.85 is "well" above that number, but it still seems kinda low for a guy like me who is accustomed to the older scans.

I would hate to speculate too much on what your doctor might say, but I think a strong possibility is that you will eventually go on combination ADT drugs. That probably doesn't sound great, but if it is required the combination drugs usually work for a long time.

Please let us know what the docs say.

PS, I probably should have emphasized that you **may** have lung mets. Has your PSA been steadily increasing? If so, then you most likely have a recurrence somewhere which will eventually require ADT treatment.

Andy - Just a thought, PSMA scans are pretty new and radiologists are just learning how to interpret the imaging. You may want to consider getting a second opinion on the imaging from someone with more specific experience if there are any in your area. We routinely think of doing that with pathology but imaging has a similar issue when it has not been established for years and taught in medical schools.

Thank you mumbo, I have the same thought.

andyatii said...
Thank you Stephen for your advice. Do you think MRI is better in viewing the lungs as the lungs are kinds of soft tissues?

I was only relating what my experience was. I know you get excellent images out of an mri but my dr’s just went with a ct of the chest with contrast for whatever reason.

So my journey was/is
Psma pet (1 met, less than 1 cm) 8/22
ct scan (1 met, less than 1 cm) 8/22
wait 3 months
ct scan (1 met, less than 1 cm) 11/22
wait 3 months
psma pet (3 mets all less than 1 cm) 4/23
at this point my psa was 1.86
dr started hormone therapy and have been undetectable since
i have a ct scan scheduled in August

Everyone was skeptical that the lung met was a pca met at first because nothing else showed up on the psma pet. Not a hot lymph node. Not a spot on a bone.

So i think a possible next step (one of your original questions) is a scan to confirm.

Thank you all. I am waiting for an appointment with thoracic that my RO has referred. What they will do? Will see. I will post updates.

My thought is: Since my PSA is at 0.85, there must be a recurrence some where of my body. The PSMA only find 1 spot on my left lung. Even though the SUV score is very low at 1, it is still should be considered as the PC recurrence. In this case, is a biopsy needed? If it is resectable, should I just go ahead to do the resection and to do the pathology for the resected lung tissue later? In this way, I avoid a suffer from the biopsy procedure. What should I do?
Thanks

Thank you so much Cyclone-ISU.
Look like that you have been using ADT since 2014. I think I might should to start use ADT instead of doing lung biopsy or lung surgery . After using ADT, if the nodule decreased in size, that means it is a metastatic. The big problem to using ADT for me is that the side effects are so strong. in2015， my RO wanted me using Lupron 5 injections within 2 years. However, after the second injection, I had to stop it because of the strong common side effects plus my WBC went to 1.1 range. If I start the ADT again, I may need to use some drug which has less side effects than Lupron. Any suggestions?
Thanks
Andy

Andyati said...
Even though the SUV score is very low at 1, it is still should be considered as the PC recurrence. In this case, is a biopsy needed? If it is resectable, should I just go ahead to do the resection and to do the pathology for the resected lung tissue later? In this way, I avoid a suffer from the biopsy procedure. What should I do?

So many questions in there.

Removing a tumor from a lung is not a walk in the park. It all depends on its location as to how much they need to remove. Your choices are a wedgectomy (what it sounds like) , a lobectomy, or removal of one of your lungs in its entirety. A lobe is a section of a lung. Your right lung has 3 lobes, your left just 2.

On the other hand A biopsy involves a dr, called an interventional radiologist, with a needle that tries to hit the tumor through your chest wall as you are getting scanned. I was told 1cm is way to small for such an imprecise methodology, and there is risk.

There is a newer technology called robotic assisted bronchoscopy https://www.lung.org/lung-health-diseases/lung-procedures-and-tests/rab but even with that tech 1cm was too small to gather a sample.

A psma pet will light up other cancers including lung and sarcoma.

Faced with an increasing PSA and multiplying nodules, my mo decided to start me on adt. He called it a “poor mans biopsy”, which is ironic given the copays for one of the meds (xtandi in my case) is really expensive. I am hoping I get the same result as Cyclone did! If the nodules shrink/disappear then its a pca met.

If they don’t i have bigger problems.

fyi: Orgovyx is “new” form of hormone therapy and has fewer side effects compared to lupron. Its a pill, not a shot, but is more expensive.

As to what you should do?
- confirm the met with a second scan
- talk to the thoracic dr they set you up with to see what they think (is it in a good location for a wedgectomy? How big do they need it to be before they can biopsy?
- consider a period of hormone therapy if you have to wait until the nodule gets big enough to biopsy. If it shrinks then you know it was pca and not something else and a biopsy would not be necessary.

Hope this helps.

Thank you all for all your valuable words.
My update: My RO initially referred me to thoracic surgeon but re-referred to RO specialized for lung cancer. I am waiting to hear from the lung RO now. Yesterday, I did a PSA and it was 1.1 now. The lung RO may wants me to do SABR as the doctor has published some paper on lung metastasis. Now, I am hesitated to make a decision. Should I go ahead to do the SARB or to do the lung resection surgery. Also, should I start ADT at the mean time to control the PSA increase or even shrink the nodule ?
Any comments and suggestions are highly appreciated.
Thanks

Andyatli,

I think the PSA evidence is pointing towards a probable recurrence. As such, you will **eventually** likely be headed for long-term ADT treatment. I emphasized the "eventually" because the reality is that there isn't an urgent need for you to start ADT immediately, at your current stage of treatment. Your PSA is still quite low. You're in a treatment phase where there is not universal agreement for when to start ADT. But that's not really important right now. I'm just trying to quell any worries you may have about feeling the need to get on ADT right away.

The potential lung lesion is confounding things. Your doctors should be able to tell you if there is urgency for determining origins of the lung "lesion."

Just my thoughts...

Andy - I previously mentioned my wife’s experience with SBRT (same as SARB) to a rib and adjacent lung tissue. This treatment is not without effect to the lungs. There are side effects like nagging cough, shortness of breath, and a list of possible other things.

She also has a small lung nodule that they keep eye on but it appears to be benign. The problem is not having a history of chest scans to compare against until you have cancer then you get plenty of them. The radiologist has to guess if the nodule was there previously or something related to new cancer until enough scans show no change.

I am still thinking that waiting and doing another PSMA scan to help locate the source(s) makes some sense (at least to me). ADT is not without health risk either so I would not jump at the opportunity to start it before necessary. This is “the lessor of evils” decision making process at work.