PET Tumor Board: Case #6
In this discussion, E. David Crawford, MD, Jack A. Vickers Director of Prostate Research and Professor of Urology at the University of California, San Diego, leads a discussion of the case study of a 63 year old patient with a strong family history of prostate cancer. He presents this case study to a panel of experts comprised of:
Wayne G. Brisbane, MD – Assistant Professor of Urology at the University of California, Los Angeles.
Phillip J. Koo, MD – Division Chief of Diagnostic Imaging and Northwest Region Oncology Physician Executive at the Banner MD Anderson Cancer Center.
Daniel P. Petrylak, MD – Director of Genitourinary Oncology, Professor of Medicine and Urology, Co-Leader of Cancer Signaling Networks, and Co-Director of the Signal Transduction Program at Yale University Cancer Center.
Dr. Crawford informs the panel that the patient, a physician with a history of low-grade prostate cancer, initially presented with a PSA of 4.9 ng/ml, his germline test was negative, and his MRI revealed a 40g prostate with a PI-RADS 3 lesion at the left base. After a negative SelectMDx scan and low-risk OncotypeDX score, along with a course of finasteride which lowered his PSA to 1.43 ng/ml, Dr. Crawford asks the panel to weigh in on further steps.
Dr. Brisbane suggests exploring reclassifying the patient’s risk score, given his family history, in order to qualify them for a PSMA. Dr. Petrylak supports the suggestion, mentioning that it has been common practice to reimage patients after finasteride use.
Dr. Crawford shows the results from the patient’s POSLUMA scan which showed uptake in multiple foci. Dr. Koo digs into the results, noting that there are alternate explanations for the results showing multiple uptakes. Given the patient’s risk profile, the panel suggests a confirmatory biopsy of the prostate in the highest activity areas.
Dr. Crawford reveals that the patient’s confirmatory biopsies showed the presence of Gleason 6 (3+3) prostate cancer in the uptake areas. Given the discordance between the biopsies and the scans, the panel discusses possible next steps, including sending the biopsy samples for Decipher testing, treating the patient with targeted focal therapy, and options for whole-gland therapy. The panel also discusses the dangers of over-reliance on scan results in treatment selection and cautions against over-treatment.
This is the sixth in a series of discussions on PSMA PET supported by Blue Earth Diagnostics. For the first installment, click here. For the second installment, click here. For the third installment, click here. For the fourth installment, click here. For the fifth installment, click here.
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