A Patient with Advanced Metastatic Prostate Cancer

Extraordinary Subjective and Objective Response to Lu-177
PSMA (Pluvicto) Therapy.

Case Study

An 87-year-old male underwent prostatectomy for Gleason 7 (4+3) adenocarcinoma of prostate in February 2015. In 2016 he was found to have increased Alkaline Phosphatase on routine blood work, which led to imaging work up. CT scan showed presence of lymph node metastases in the pelvis and bone scan confirmed presence of bone metastases. His PSA at that time was 159.88 ng/mL. He was then started on docetaxel and androgen deprivation therapy. PSA declined to less than 1 ng/mL and CT scan showed resolution of lymphadenopathy.

Over subsequent years his PSA remained less than 1 and imaging work up with CT continued to show stable skeletal sclerotic lesions. In October 2023 the patient reported increasing lower back pain. PSA increased to 1.04 and in November 2023 it increased to 1.15.

Figure 1
Figure 2

Therefore, a PSMA PET/CT was ordered, which showed (figure 1) several skeletal metastatic lesions, including the one at the site of patient’s lower back pain (figure 1, purple arrow). This patient with castrate resistant metastatic prostate cancer therefore underwent four cycles of 177Lu-PSMA-617 treatments December 2024 through April 2024. The patient reported complete resolution of lower back pain.

A repeat PET/CT (figure 2) showed considerable interval improvement in skeletal metastatic lesions, including the site of lower back pain.

Taking advantage of unique quantitative assessment of PET/CT we performed tumor burden assessment before and after 177Lu-PSMA-617 treatment cycles (figure 3), which showed 85% decrease in his total body tumor burden after 4 cycles of Lu-177 PSMA therapy.

Figure 3

PSA levels went down from 1.15 ng/mL before initiation of 177Lu-PSMA-617 to 0.48 after four cycles of therapy. Since the most recent PSMA PET/CT still shows small volume of residual PSMA-avid skeletal metastatic lesions our plan is to continue remaining 2 cycles of therapy.

Discussion

177Lu-PSMA-617 therapy is shown to improve survival of metastatic castrate-resistant prostate cancer patients with tracer-avid lesions as shown on PSMA PET/CT (reference-1). It is overall very well tolerated by the patients. In addition to improvement in survival this revolutionary treatment modality also improves patients’ quality of life (reference-2).

References

Lutetium-177-PSMA-617 for metastatic castration-resistant prostate cancer. N Engl J Med. 2021 Sep 16,385(12):1091-1103. Health-related quality of life and pain outcomes with 177Lu-PSMA-617 plus standard of care versus standard of care in patients with metastatic castration-resistant prostate cancer (VISION): a multicenter, open-label, randomized, phase 3 trial. Lancet Oncol. 2023 Jun;24(6):597-610

Dr. Munir Ghesani, MD, FACNM, FACR, FSNMMI

Munir Ghesani, MD, FACNM, FACR, FSNMMI is the Medical Director of United Theranostics, Princeton and Chief Medical Officer of United Theranostics. Previously, he served as Systems Chief of Nuclear Medicine and Molecular Imaging at Mount Sinai Health, New York. Dr. Ghesani has been actively involved in clinical practice, research, clinical trials and education for more than 25 years, primarily focusing on nuclear medicine, molecular imaging and radiopharmaceutical therapy.

Dr. Ghesani has more than 200 publications in peer-reviewed journals and is the Editor-in-Chief of a three-part book on nuclear medicine and molecular imaging. He has given more than 150 presentations at regional, national, and international conferences.

Dr. Ghesani has served in leadership roles in various societies and colleges, including the Immediate Past President of the Society of Nuclear Medicine and Molecular Imaging (SNMMI), Past-President of the Education and Research Foundation of Nuclear Medicine and Molecular Imaging, Past Chairman of the American Board of Nuclear Medicine, Past Chairman of the Government Relations Committee and the FDA Task Force of the SNMMI and Past Chairman of the Nuclear Medicine and PET Accreditation Committee of the American College of Radiology. In January 2020, he was awarded the ACNM Personal Best Mentor of the Year. He has been awarded as the Fellow of the American College of Nuclear Medicine (2006), the American College of Radiology (2018) and the Society of Nuclear Medicine and Molecular Imaging (2023).