Month: December 2016
An Excellent Review of Current Imaging and Positron Emission Tomography (PET) Scanning and Their Use in Managing Recurrent and Advanced Disease
This website initially posted a review of positron emission tomography (PET) scanning on March 9th, 2015.
More recently, the Prostate Cancer Research Institute (PCRI) November Insights contained an updated and very informative review of the latest PET imaging techniques for managing recurrent and advanced prostate cancer. Their major utilities, advantages and their limitations are discussed clearly. The review was written by Dr. Fabio Almeida, Medical Director of Phoenix Molecular Imaging in Arizona. Rather than summarize the entire readable review, I will merely mention the various sections herein and provide the following link to the entire review.
In the November article, conventional types of imaging such as ultrasound, CT scans and prostate MRI and their uses are discussed initially. A section describing detection of bone metastases using Technetium-99 and sodium fluoride PET/CT scans follows. Carbon-11 acetate (available at Phoenix Molecular Imaging, Arizona) and C-11 choline (available at the Mayo Clinic, MN) are lipid metabolism PET agents both of which are useful for detecting recurrent disease and PSA relapse. In both cases, detection rates were dependent upon PSA values and doubling times.
Axumin (18F-FACBC) is a fluorine-18 radiolabeled synthetic leucine amino acid was has been recently approved by the FDA for detection of recurrent cancer in men with rising PSA after previous surgery or radiation. Amino acids are absorbed into cancer cells because of the increased metabolic demands of the growing cancer. In cited studies, optimal detection rates were seen when PSA levels were above 1.78. Direct comparison with C-11 choline scans indicated better performance for Axumin. For additional information on Axumin, see the website blog dated May 30, 2016.
The prostate-specific membrane antigen (PSMA) is a transmembrane glycoprotein that occurs much more commonly in prostate cancer cells compared to benign prostate tissue. One of the PSMA agents under development is 68-gallium-PS-MA-11, which has demonstrated a higher diagnostic efficiency compared to C-11 choline. Detection rates were dependent on PSA values. For example, a 93% detection rate was observed when the PSA was over 2.0 but only 50% when the PSA was 0.2-0.5. There are limitations to PSMA-targeting agents. Not all prostate cancers exhibit PSMA overexpression. In one study, about 8% of prostate cancer patients did not show PSMA overexpression. Benign lesions and several other types of cancers may also exhibit increased PSMA expression. False positive celiac lymph nodes have frequently been noted in the upper abdomen and detection of small locally-recurrent lesions and lymph nodes in the lower pelvis is challenging.
There is still no perfect imaging methodology with 100% accuracy. However, PSMA-targeted agents are becoming the major focus of future attention and development. “Despite some limitations, PSMA-targeted imaging appears to provide high sensitivity and specificity and is likely to become part of the routine evaluation and management of men with prostate cancer in the near future.”
For an initial review of PET imaging, see this website post dated October 9th, 2012.
How to Find an Expert Prostate Surgeon
Radical prostatectomy can be a very difficult operation. The very best urological surgeons specialize in the prostate gland. They do a lot of these procedures annually. How do you find the right surgeon? The Prostate Cancer Foundation has published a checklist of things to consider before choosing the right surgeon.
1) First, locate a high-volume center that performs a lot of these procedures. Often this is an academic center. Not only are surgeons involved but supporting teams e.g. nursing, specialize in caring for prostatectomy patients. Websites that can help locate such high-volume centers include the National Cancer Institute’s website namely http://www.cancer.gov/research/nci-role/cancer-centers/.
The National Comprehensive Cancer Network (NCCN) also has a useful website for all types of cancer including prostate. See the following web address, https://www.nccn.org/patients.
2) Look for a place where different specialties work together in multi-disciplinary teams such as urology, radiation oncology, medical oncology and pathology. Since prostate cancer is not a “one size fits all” condition, one can get opinions from a team of experts who may recommend treatment modes other than surgery.
3) Ask the surgeon about his patient results. Does he keep results of his many patients regarding their outcomes, side effects such as incontinence and/or impotence, cancer recurrences, etc? Come prepared with a list of questions to ask as well as a detailed description of your specific condition and hopes.
4) Ask the surgeon to provide you with names of his patients who have agreed to speak to other patients about their experiences. If possible, contact some of them. This is helpful in demonstrating that the surgeon has many “happy” patients who comprise a support network to help prospective patients decide what’s best for them. Also check the prostate cancer support groups in your area and ask these men about their experiences and specific surgeons.
5) How many radical prostatectomies has the surgeon performed? The answer should be in the hundreds. If it’s something like “quite a few”, seek elsewhere.
6) Ask more than one doctor to recommend the best prostate surgeon in your area. Some doctors are in practice groups and therefore recommend the specialist in that group. That’s why it is good to ask different doctors in different practices.
7) Beware of the reviews or ads on the internet. The internet is full of false accusations or glamorization of surgeons, and specific hospitals and departments. One urologist said that online reviews are totally unreliable. This is not “Angie’s List of plumbers.” Medical groups or individual physicians may have ulterior motives or “good urology friends” who may or may not be the best choice for you.
8) Don’t worry about offending the doctor with questions or by getting a second opinion. Don’t be rude or disrespectful but don’t feel intimidated either. Do your homework. It’s your prostate and your recovery and your life. You don’t want to be one of those men who say afterward “I wish I had listened to good advice; my surgical experience was not as good as I had hoped.”
The Trap of Discouragement

Photo BJ Gabrielsen