Who Should Have A Psma Scan
Currently the exact role of the scan is in development as the technology is new. You need to discuss this with your treating doctor or surgeon . The Tc-PSMA scan requires a patient by patient application , since we import the tracer for each patient on a case by case basis. It comes from Germany and it is not yet approved by our TGA . Nevertheless we feel it is completely safe to use and have already used it extensively.
Clinical Scenario: Diagnostic Imaging And Nuclear Medicine
Although at present radionuclide procedures are affected by a low diagnostic accuracy in diagnosing primary PCa, radiolabeled agents can trace almost any pathophysiological pathway, thus being able to characterize the disease in an early stage and/or allowing a prognostic stratification. Among the used radiotracers, 18F-fluoro-deoxyglucose , a biological analogue of glucose, occupies a pivotal role in a great number of neoplasms, due to the increased concentration of glucose and glucose transporters in malignant tumor cells where there is an enhanced anaerobic glycolysis . Nonetheless, 18F-FDG results in PCa are not as good as in other tumors because of the low metabolic activity usually present in PCa cells and due to an unfavorable lesion/background ratio determined by the high activity in the bladder . Therefore, 18F-FDG PET is only limited in the restaging of selected PCa patients with high-grade hormone-resistant disease and poorly differentiated lesions, due to the increase of FDG uptake with increasing malignancy.
Summary Of The Main Findings
The most thoroughly validated tests in clinical trials and in clinical practice are the good old tests such as bone scan and contrast-enhanced thorax, abdomen, and pelvis CT.
Nevertheless, most of the evidence based for bone scan and CT are old and retrospective. There is actually a much larger amount of prospective data for modern PET/CT. Prospective data also shows clear superiority of PSMA-PET or fluciclovine-PET to choline-PET. Data from a new study suggests that PSMA-PET imaging is superior to fluciclovine-PET for detecting biochemical recurrence in men with prostate cancer . However, whether one of these radiotracers improves patient survival over the other is unknown and further research is needed to determine which has the greater effect.
The new tracers do not have the same accessibility and need further validation in clinical trials to evaluate their benefits and clarify their usage in routine clinical practice. It is important that we consider the imaging requirements of the PCWG as this defines the imaging definitions for subjects in those clinical trials. EORTC algorithms also need to be considered for the imaging strategies. Experts in nuclear medicine and radiology should be represented in medical decision-making teams for PCa.
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Why You Might Need One
Nuclear medicine scans are especially useful for cancer because they show tumors and track if they spread inside the body. Theyâre also a way to check how well treatment is working.
These scans have some limits. For example, a scan might show areas that could be cancer. But your doctor will need more focused pictures of those areas and to look for smaller tumors that may not show up on the nuclear scan. To know for sure if thereâs cancer, you may need a biopsy, when a surgeon removes a small piece of a tumor to check under a microscope.
Doctors also use nuclear medicine scans for conditions other than cancer, including:
- Neurological disorders
Preparing For A Bone Scan
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Imaging Evaluation Of Extraprostatic Extension Of Primary Tumor
An important contribution of mpMRI in the setting of local staging is evaluation for the presence of extraprostatic extension, which can best be assessed on T2-weighted imaging as broad contact of the tumor with the prostatic capsule, bulging of the capsule beyond the expected boundary of the gland, obliteration of the rectoprostatic angle, and asymmetry of the neurovascular bundles. Signs of seminal vesicle invasion are low signal on T2-weighted imaging in the seminal vesicle, tumor location at the prostate base, loss of normal tubular architecture of the seminal vesicle, and associated diffusion restriction . A systematic analysis by de Rooij et al. showed moderate sensitivity but very high specificity and negative predictive value for mpMRI in prediction of extraprostatic extension and seminal vesicle invasion.
Although MRI has been the primary imaging modality used for the evaluation of extraprostatic extension, more recently there has been an interest in using combined PSMA PET/MRI for improved accuracy of local T staging and evaluation of extraprostatic extension .
What Is The Psma Scan Procedure
The scan is done much like any other nuclear scan and requires an injection of a radio-isotope tracer followed by a series of scans, usually ~3-4hrs after the injection. The scan procedure itself will probably take 30-45 minutes. More detail about nuclear scans can be found here and the actual procedure here. For patients who have previously had a prostatectomy we also do a second scan the day after as this gives us a much better evaluation of the prostate bed and around the bladder.
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Spectrum Of Pet Radiopharmaca In Pc
18F-FDG remains the workhorse in PET imaging, however with very restricted applications for PC, as its role is limited in cases of neuroendocrine differentiation or of progressive disease presenting such characteristics. This occurs because of low to no glucose consumption by the classic prostatic primary and thereafter by its spread. Thus, the need for specific targeting arose.
Up to recently Choline labeled tracers either by 11C or 18F, were used as promising markers. This radiotracer, initially applied to restaging after biochemical recurrence and staging of high-risk patients has been practically abandoned due its low sensitivity . Other tracers like 11C -acetate or 18F-uorocyclobutane-1-carboxylic acid had been tested without standing up to the expectations presenting equal characteristics to Choline. Similarly, 18F-Uciclovire met the same fate to previously referred tracers .
Up to now, Prostate-specific membrane antigen seems to reign over all other tracers in PET PC imaging. PSMA also known as glutamate carboxypeptidase II, is a transmembrane glycoprotein highly expressed in prostate cancer cells. PSMA expression tends to increase with increased pathological Gleason grade and is thought to be upregulated with the emergence of androgen independence . An example of a PC patient imaged at the same time period with various tracers is illustrated in Figure 1.
How It Works And What To Expect
Most scans donât take more than an hour or so, though you may have to wait a few hours as health care workers prep you for the test.
These scans are usually done at a nuclear medicine or radiology department at a hospital. A little bit of radioactive material will go into your body. Doctors call this material a radioactive âtracer,â radionuclide, or radiopharmaceutical.
Hospital staff may inject this tracer or give it to you to swallow in a pill or inhale as a gas.
It can take from a few seconds to several days for the tracer to collect in the part of the body that will get scanned.
Before the scan, youâll remove all jewelry and metal that could interfere with the images. Medical staff may ask you to wear a hospital gown, though in some cases you can wear your own clothes.
Youâll lie on a table or sit on a chair for the scan. Technicians use a special camera, or âscanner,â on the appropriate parts of your body to detect gamma rays from the tracer. Technicians might ask you to change positions to get different angles as the scanner works.
The scanner sends the information to computer software that creates pictures, sometimes in three dimensions and with color added for clarity.
A specialized doctor called a radiologist will review the pictures and talk to your doctor about what they show.
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Diagnostic Performance Of Whole
Among the papers published studying the performance of bone scan in prostate cancer, none evaluated the performances of systematic whole-body bone SPECT/CT in BR of PC. These previously published studies rather evaluated the performances of planar bone scintigraphy an out-of-date procedure , or the performances of non-systematic SPECT/CT indicated on the basis of planar scintigraphic findings .
Our study confirms the good diagnostic performances of WB bone SPECT/CT in prostate BR with sensitivity, specificity, positive and negative predictive values of 86.7% , 98.8% , 96.3% , and 95.5% when equivocal WB bone SPECT/CT were considered as negative, in comparison to the BVC and regardless of the PSA level.
Picchio et al. classified equivocal results from scintigraphy as either positive or negative, inducing a quite large range for sensitivity and specificity . However, an optimal strategy taking into account both the medical and medico-economical perspectives obviously requires the classification of equivocal studies as negative since all equivocal cases require an additional test to establish a reliable diagnosis.
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Use In Men Already Diagnosed With Prostate Cancer
The PSA test can also be useful if you have already been diagnosed with prostate cancer.
- In men just diagnosed with prostate cancer, the PSA level can be used together with physical exam results and tumor grade to help decide if other tests are needed.
- The PSA level is used to help determine the stage of your cancer. This can affect your treatment options, since some treatments are not likely to be helpful if the cancer has spread to other parts of the body.
- PSA tests are often an important part of determining how well treatment is working, as well as in watching for a possible recurrence of the cancer after treatment .
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What Do My Scan Results Mean
Your TNM stage is used to work out if your cancer is localised, locally advanced or advanced. This can help your doctor see how far it has spread and which treatment might be suitable for you.
Cancer that’s contained inside the prostate. Sometimes called early prostate cancer. Possible TNM stages are:
- T stage: T1 or T2
- N stage: N0 or NX
- M stage: M0 or MX.
Cancer that’s started to break out of the prostate, or has spread to the area just outside it. Possible TNM stages are:
- T stage: T1 or T2
- T stage: T3 or T4
- N stage: N0 or N1
How Is Psma Pet Imaging Different From Current Prostate Cancer Imaging
- Current standard technique called fluciclovine PET, involves physicians injecting patients with a synthetic radioactive amino acid.
- PSMA PET imaging is a FDA approved scan with more precise detection of prostate cancer for better treatment planning and targeted care.
- More effective in pinpointing and eliminating tumors not only in the prostate but also throughout the pelvis and the body in cases where the tumors have migrated.
- Imaging with PSMA PET was able to detect significantly more prostate lesions than fluciclovine PET in men who had undergone a radical prostatectomy but had experienced a recurrence of their cancer.
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What Are The Benefits Of Psma Pet Treatment At Ucsf
- FDA approved imaging technique for prostate cancer.
- The PSMA PET scan can identifiy cancer that is often missed by current standard-of-care imaging techniques.
- The PSMA tracer can also be used in conjunction with CT or MRI scans.
- UCSF is only one of two medical centers in the U.S. that offers the FDA approved PSMA PET.
- PSMA PET is more effective and precise for localizing mestatic prostate cancer.
- UCSF researchers, along with colleagues at UCLA, studied PSMA PET for several years to better precisely locate prostate cancer.
- PSMA PET works using a radioactive tracer, called 68Ga-PSMA-11, which is manufactured on site at UCSF.
Getting The Results Of The Biopsy
Your biopsy samples will be sent to a lab, where they will be looked at with a microscope to see if they contain cancer cells. Getting the results usually takes at least 1 to 3 days, but it can sometimes take longer. The results might be reported as:
- Positive for cancer: Cancer cells were seen in the biopsy samples.
- Negative for cancer: No cancer cells were seen in the biopsy samples.
- Suspicious: Something abnormal was seen, but it might not be cancer.
If the biopsy is negative
If the prostate biopsy results are negative , and the chance that you have prostate cancer isnt very high based on your PSA level and other tests, you might not need any more tests, other than repeat PSA tests sometime later.
But even if many samples are taken, biopsies can still sometimes miss a cancer if none of the biopsy needles pass through it. This is known as a false-negative result. If your doctor still strongly suspects you have prostate cancer , your doctor might suggest:
- Getting other lab tests to help get a better idea of whether or not you might have prostate cancer. Examples of such tests include the Prostate Health Index , 4Kscore test, PCA3 tests , and ConfirmMDx. These tests are discussed in Whats New in Prostate Cancer Research?
- Getting a repeat prostate biopsy. This might include getting additional samples of parts of the prostate not biopsied the first time, or using imaging tests such as MRI to look more closely for abnormal areas to target.
Prostate cancer grade
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What Do Nuclear Scans Show
Nuclear scans make pictures based on the bodys chemistry rather than on physical shapes and forms . These scans use liquid substances called radionuclides that release low levels of radiation.
Body tissues affected by certain diseases, such as cancer, may absorb more or less of the tracer than normal tissues. Special cameras pick up the pattern of radioactivity to create pictures that show where the tracer travels and where it collects.
If cancer is present, the tumor may show up on the picture as a hot spot an area of increased cell activity and tracer uptake. Depending on the type of scan done, the tumor might instead be a cold spot a site of decreased uptake .
Nuclear scans may not find very small tumors, and cannot always tell whether a tumor is really cancer. These scans can show some internal organ and tissue problems better than other imaging tests, but they dont provide very detailed images on their own. Because of this, theyre often used along with other imaging tests to give a more complete picture of whats going on. For instance, bone scans that show hot spots on the skeleton are usually followed by x-rays of the affected bones, which are better at showing details of the bone structure.
Some nuclear scans are also used to measure heart function.
What Is It Like Having A Nuclear Scan
In most cases you will be given a tracer that sends out small doses of radiation. If its put into your blood, a needle will be used to put it into a vein in your hand or arm.
Because of the special materials and equipment needed, these scans are usually done in the radiology or nuclear medicine department of a hospital. You might be able to wear your own clothing or you might be given a gown to wear during the test. Youll need to remove all jewelry or metal items that could interfere with the scans.
The scanner has a hole in the middle and looks like a large doughnut. You lie on a padded table which moves back and forth through the hole in the scanner. You will need to be very still while the scans are done. The technician may ask you to change positions to allow different views to be taken. The table may become uncomfortable after a while.
For a thyroid scan, you may sit in a chair that faces the scanner. The scanner is set up so that its right in front of your neck and your chin rests on top of it.
To get a MUGA scan, you lie on a flat table and a large camera is positioned above your chest.
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What Are The Possible Complications Of A Nuclear Scan
For the most part, nuclear scans are safe tests. The doses of radiation are very small, and the radionuclides have a low risk of being toxic or causing an allergic reaction.
Some people may have pain or swelling at the site where the material is injected into a vein.
Rarely, some people will develop a fever or allergic reaction when given a monoclonal antibody.