Posted 11/16/2020 8:45 PM (GMT -7)
I have recently been diagnosed with PC and need your help to understand my current diagnosis. The key question is whether there are bone metastasis.
I'm 58 years old. PSA is 6.1. One year ago, it was 3.9. Gleason score (Gleason group): 3+4=7 (2) based on 13-core biopsy. Cancer stage: have not been told yet.
LLB: PCA, 3+4=7 (2), 40%, 8 mm, PNI present
LLM: PCA, 3+4=7 (2), 70%, 4 mm
LB: PCA, 3+3=6 (1), 50%, 5 mm
LM: PCA, 3+4=7 (2), 90%, 6 mm
LA: PCA, 3+3=6 (1), 5%, <1 mm
RB: PCA, 3+4=7 (2), 20%, 2 mm
TB 1: PCA, 3+4=7 (2), 90%, 8 mm, AIP, PNI present
TB 2: PCA, 3+4=7 (2), 70%, 5 mm AIP
TB 3: PCA, 3+4=7 (2), 90%, 11 mm, AIP, PNI present
Shortly after the biopsy I had 68Ga PSMA PET CT. The primary tumor ~ 16 mm is localized within the organ. The report from a radiologist suggests bone metastasis in the right iliac bone (SUV max 2.5) and right lateral fifth rib (SUV max 1.8). In accordance with the Molecular Imaging TNM classification I have: mi T2u(LM) N0 M1b(oligo), which means that the tumor is localized, there are no cancer cells in the lymph nodes but there may be two bone metastasis. I requested a second opinion (from another radiologist) regarding this PET CT. The second opinion was about the same, suggesting two bone metastasis. Anyway, my urologist-oncologist from UCLA told me that there is no spreading into bones. His explanation is the following: " I have read the PSMA PET and yes I think these are not metastasis. These findings were borderline significant. So, I reviewed the images with a bone radiologist. Isolated faint rib uptake is a frequent cause of false positive. When there are no imaging features that are clearly evocating a metastasis (such as here) and we follow these isolated rib lesion they are almost all the time benign (62/63, 98%).The pelvis lesion was also indeterminate."
Since the urologist was confident that the rib does not have metastasis but less confident about the hip, he sent me for another test, which is Pelvis MRI with dedicated bone marrow sequences. This test did not show a metastasis in my right hip.
Despite this very encouraging conclusion I still doubt if it is correct. First, the 68Ga PSMA PET CT is known to be the most sensitive test (still not FDA approved). Second, the SUV uptakes 1.8 and 2.5 seem to be small but not negligibly small. Third, the Pelvis MRI is less sensitive test compared to the PSMA PET CT and therefore cannot be used to verify results of a more accurate PSMA PET CT.
Based on my common sense, it is hard to believe that there are distant bone metastasis, because: 1) no local metastasis, 2) the primary tumor is localized within the gland, 3) relatively low PSA 6.1, 4) Gleason score (Gleason group) 3+4=7 (2). At the same time, the biopsy shows localization of cancer cells around the nerves: PNI is present at LLB, TB 1 and TB 3, which suggests higher risk of metastasis.
As you can understand, it is particularly important to me to make sure that there is no bone metastasis. My urologist pushes me for prostatectomy. However, if the bone metastasis does exist, the treatment should be different, and the radical surgery might be useless. I talked to my primary physician, but he does not have an opinion. Please help me to better understand this situation. Any advice will be very much appreciated.