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Episode #15 - PSMA Results

Steve Abbott:

Hello everyone, and welcome back to episode 15 of our Cincinnati Cancer Advisors Medical Minute podcast. So Jill, last week, we reviewed the results of my Guardant360. I'll put it in air quotes, liquid biopsy, that I submitted a sample on December 22nd. You were so helpful on that, thank you. So to get everyone up to speed with what we talked about last week, what those results were, I'm going to enumerate this. And Jill, I want you to do something different than you normally do, which feels free to correct me if I say anything wrong. So, the Guardant360 identified a specific biomarker called TP53 V216L, or as I like to call it, good old TP53 V216L.


Jill Hunt, CNP:

Easy for you to say. Absolutely.


Steve Abbott:

Yeah, it's very easy for me to say. And so you've got a variant there being the V26, I still can't say it V216L. But that's one it's often seen in lung cancer, colon cancer, and also prostate cancer.


Jill Hunt, CNP:

Right. And multiple others. But those are the top ones that you'll see it in.


Steve Abbott:

Okay. Gotcha. And then, so of those three, we can pretty much rule out colon cancer because they just had a clean colonoscopy a year or two ago. And then, so we know that someone with lung cancer could have this biomarker, but not necessarily. And then we also know that prostate cancer can invade the lung and kind of look like lung cancer on a scan, but it may not be. It still could be metastatic prostate cancer.


Jill Hunt, CNP:

Correct. And it does help that it shows in prostate cancer. And we do know that you have active prostate cancer.


Steve Abbott:

Correct. So now comes the detective work through a PSMA, what the heck's wrong with me, PSMA PET scan, and then we'll see where it leads from there. So we'll talk about that today.


Jill Hunt, CNP:

So did you enjoy your road trip up north?


Steve Abbott:

I did. Thankfully it's only like four hours to the middle of a cornfield with nowhere to stop. Although there are some adult novelty stores that truckers go to, apparently that is like on every other exit, but that's not really of many benefits to me these days. So anyway, so we got the PSMA done, we got the PSMA results back, and so we'll discuss those today. So if you can just kind of quickly remind people kind of what a PSMA PET scan is, why it's so valuable in terms of highlighting maybe where prostate cancer might be hiding.


Jill Hunt, CNP:

So a PSMA PET scan is a PET scan that is specific for prostate cancer. If you were a cancer patient, a PET scan was most likely part of your initial staging at diagnosis. And then, quite often, they'll do one at the end of treatment, just as another data point. With a standard PET scan, you get injected with a radioactive type of contrast that it's like a radioactive sugar, and the patients get injected with it. They have to wait an hour, and then they get scanned. And then, what the scan looks for is areas that are breaking down sugar at a faster rate. That's what a standard CT PET scan does. And what makes a PSMA scan different is that it is a prostate-specific membrane antigen. So that radioactive type of contrast that the patients get is specific to that prostate membrane. So it essentially attaches to that membrane. And then, when they do the scan, they're looking for those areas that are lighting up on the PET scan, which are going to identify those areas of prostate cancer.


Steve Abbott:

Got it.


Jill Hunt, CNP:

The other piece to that, it's recently been FDA approved, that contrast is mixed individually for the patient the day of the scan. And it's not offered readily. You had to go to Michigan in order to be able to get it done. That was the closest site for us here. So for our prostate cancer patients, that is something else to consider that if a PSMA scan is something that's recommended as part of your treatment plan, that is something that depending on your location, you may have to travel for.


Steve Abbott:

Did I tell you I got to drink a vanilla milkshake with mine? Vanilla smoothie.


Jill Hunt, CNP:

I do believe that you sent us a photo of the fabulous smoothie that you got.


Steve Abbott:

Yeah. Vanilla berry chocolate. And then I don't know if [MoCo 00:04:51] is just because I'm special. As you know, I am fancy, but I don't know if that was just for me or whether that's-


Jill Hunt, CNP:

Bougie.


Steve Abbott:

Yeah. I don't know if that's normal or not, but anyway. Okay. So then why don't we go ahead and walk through what they found?


Jill Hunt, CNP:

All right. So I want to preface the review of these results with the fact that we have already read these results and gone over them with Steve. I like to say that because as a clinician when I review scan results, the last thing that I ever want to be looking at is a camera or a computer screen. So most often, when I'm sitting down with scan results, I'm looking directly at the patient. So I don't want anybody to be like commenting how ice-cold princess I would be. It's that I'm sharing these results with our listeners and our viewers for the first time. And I want to make sure that everybody has a clear understanding of what you are aware of already. So we're not going to read line for line the entire body of the PSMA scan. We're going to kind of jump to the cliff notes version and go into the specific interpretation.


Jill Hunt, CNP:

So when we look at the interpretation of the scan report, number one tells us that there is focally increased PSMA expression consistent with prostate cancer described in the full body of the report. So that's telling us that it did pick up increased activity specific to prostate cancer. Number two is the overall progression of disease in the pelvis with new enlarged hypermetabolic left common iliac and left internal iliac lymph nodes.


Jill Hunt, CNP:

Additionally, there is a progression of metastatic disease with new enlarged hypermetabolic lymph nodes in the left supraclavicular region. Now, as we've talked about, we would expect to see enlarged lymph nodes in the prostate if we've got disease progression with prostate cancer. The thing about this part of the report that was a little eye-opening and definitely warrants additional just for us to dig a little bit deeper into is the fact that we have a lymph node that's now lighting up in the left supraclavicular region. And for those of you that don't know medical terminology, supraclavicular is above the collar bone. It's that area kind of at the base of the neck, that kind of squishy part right above your collarbone. So that's obviously a far distance from the pelvis.


Steve Abbott:

Right, right.


Jill Hunt, CNP:

And then number three, new left upper lobe lung nodule measuring one centimeter associated with hypermetabolic, an additional more medial satellite mildly hypermetabolic pulmonary nodule. This is favored to reflect a new primary lung malignancy. Recommend FDG PET, which is just a standard PET, for further characterization and pulmonary referral. So what this is showing us is that there are two small pulmonary nodules that are showing up on this PSMA scan that were not there before. They are new, and they are hypermetabolic, which means that they're breaking down that contrast at a faster rate than normal cells would.


Steve Abbott:

Got it.


Jill Hunt, CNP:

So to kind of just briefly review, what this is showing us is that we've got disease progression in the lymph nodes in the pelvis. We also have a new lymph node just above the collarbone that was not there before. And we now have two new lung nodules that were also not there before.


Steve Abbott:

Okay. So basically, this is the worst report card I've gotten since I got a D in geometry, pretty much when I didn't think I was going to be able to be let into the house by my father, but who gave me the disappointment speech by the way.


Jill Hunt, CNP:

I'm still staggered at the fact that you got a D in geometry.


Steve Abbott:

Well, geometry's not math. Geometry is some; I don't know what it is, but it's not math, I can tell you that. It's certainly not algebra.


Jill Hunt, CNP:

We are going to make a lot of people unhappy. We have slammed Michigan. You're saying that geometry is not math.


Steve Abbott:

It's not. I don't even know-


Jill Hunt, CNP:

We're so sorry. We're just going to apologize now for anything that we have said that would offend anyone.


Steve Abbott:

All right. So anyway, so then, and I think you may be even kind of touched on it a little bit, but I'm not sure the specific thing. So what do you make of this neck and lung thing? That is kind of a far away to go, right?


Jill Hunt, CNP:

Absolutely. And the hard part of this is is that quite often, patients will just say, well, I've got prostate cancer. There are new spots, so obviously, that's prostate cancer. And that's where you have to make sure without a shadow of a doubt that that is actually the case. And so, obviously, the treatment team has talked, and your next steps are going to be doing a biopsy of that supraclavicular lymph node. The reason that we access that node for a biopsy is because there's a lot less risk associated with biopsying that lymph node.


Jill Hunt, CNP:

When you biopsy areas in the lung, there are a lot of complication risks that go along with it. And so, if we have a new area that is easier to access with less risk to the patient, then that's the route that we tend to go. And we're not talking small risk. Patients who have lung biopsies can collapse the lung during the procedure. That can be severe enough that you would need a chest tube and end up in the intensive care unit. So it's not a small risk. So if you have an not necessarily easier route but a less risky route, that's the way that most clinicians will go.


Steve Abbott:

All right. So we often use movie references, right? So this kind of reminds me of Clark Griswold and Christmas Vacation-


Jill Hunt, CNP:

And his rant.


Steve Abbott:

When he goes on his complete rant, and then he ends up with, like, where's the Tylenol? That's kind of how I feel right now. Now I do have one concern with this biopsy thing. What about pumping iron? Am I going to have to take some time off from that?


Jill Hunt, CNP:

No, no, no.


Steve Abbott:

Because you know, I'm all about that.


Jill Hunt, CNP:

I know, I know. You're looking look looking for a reason not to have to run the vacuum. So the nice thing about a core needle biopsy is that it's an outpatient procedure. They may or may not offer some sedation, like a little bit of twilight. Sometimes depending on the location, they will or won't. It just depends on how in-depth of a potential biopsy it has to be. And then if, either way, that they go, whether you get the sedation or not, then they numb the surface of the skin.


Jill Hunt, CNP:

And then usually, they'll use some sort of ultrasound guidance, and they will follow the needle into the lymph node that they're trying to access. And they have these great needles that it's a one-stop-shop. You insert that straight into the lymph node, and it actually takes a chunk or a little core of that lymph node. And then it removes it, and you pull the needle straight out. And then that core piece of tissue goes off to pathology, and the pathologist will run additional stains and testing to essentially confirm what exactly it is that we're looking at.


Steve Abbott:

All right. So I'm going to have that done tomorrow. So to recap, no food or anything, nothing to eat or drink in the morning. Moderate alcohol consumption this evening, which is what I think you said.


Jill Hunt, CNP:

I said no alcohol consumption this evening. None.


Steve Abbott:

All right.


Jill Hunt, CNP:

Thank you.


Steve Abbott:

And then we'll see what those results look like, and we'll report back on that as well. So once again, everybody thanks for joining in. This is a really important series that we're doing because, as we mentioned before, it's early detection, and we know that that leads to better outcomes. And that's what we want here at Cincinnati Cancer Advisor. So please like and share our podcast and subscribe and we'll see you all back here next week.

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