PSMA RLT for prostate cancer

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For most essential points to best prepare for the procedure, please download the patient information brochure (PDF).
For a more elaborate explanation of the procedure and related points, please continue to read ahead.

Brief introduction

Principle

Prostate specific membrane antigen (PSMA) is a protein that is present on normal as well as cancer (adenocarcinoma) cells of prostate. For more information about PSMA and the ligand binding with it, please read the entry on PSMA ligand PET-CT for prostate cancer.

The beta emitter lutetium-177 (or ¹⁷⁷Lu) complexed with PSMA ligand is used as the radiopharmaceutical (RP) at SSNI for PSMA radioligand therapy (RLT). It has a physical half-life of 162 h. Apart from beta particles, it also emits gamma photons that allow for its imaging (performing scan) following administration of RLT.

It is mandatory for patients to undergo PSMA ligand PET-CT to ascertain PSMA expression and assess its avidity for binding with the ligand.

Indications (conditions in which advised)

Treatment of patients with known metastasis and proved PSMA expression who have shown suboptimal response to conventional chemotherapy and/or hormonal therapy.
Treatment of patients with known metastasis and proved PSMA expression in who there is risk of severe adverse effects from conventional chemotherapy.

Considerations / steps before procedure

Written advice for PSMA RLT by a medical doctor is a must for consideration of therapy. This doctor must be the same with who the patient could follow up for long term following RLT.
PSMA ligand PET-CT for prostate cancer must have been carried out within 2 months before planned RLT.
Prior appointment is a must. Availability of lutetium-177 is highly regulated, and order for it needs to be placed several days to weeks prior to the planned RLT.
Other medications (apart from those mentioned above) must not be stopped, and must be continued as advised by your doctor.
Wear loose-fitting but warm clothes.
Do not bring expensive jewellery or accessories along with you for the scan.
Proof of doctor's request is necessary for starting the procedure.
Food.
- 4 hours' fasting is needed. Avoid much longer durations of fasting.
- Avoid any food item that is likely to induce heart burn or nausea (e.g., excessively spicy or oily food).
The patient must be accompanied by a responsible carer.

What to expect as part of procedure?

Important steps

Patient registration and consent.
Handing over medical documents to the staff.
Patient preparation (change of dress, IV cannula insertion, explanation of procedure, etc.).
Pre-medications are injected in preparation for RP infusion.
Normal saline may be infused for hydration.
RP is injected over 10 min.
Normal saline infusion continues for ~2 hours after RP infusion.
Patient's heart rate and blood pressure would be recorded a few times during the infusion.
Patient is released for the day.
Next day: Post-therapy scan is performed, which could take ~1 hour.
Expect discharge summary to be issued within 4 hours of scan completion.

Discomfort / risks during procedure

Pain during IV cannula insertion.
There is small risk of flare up of symptoms (especially bony pain) that were experienced before RLT few minutes to hours after starting RP infusion.

Time taken for the entire patient visit

Day 1: 4 - 5 hours.
Day 2: 2 hours.

What to expect after procedure?

Precautions / special care

Maintain at least 1 metre distance from pregnant ladies and young children below 10 years' age (10 days).
Avoid sharing bed with adults (6 days).
Avoid sharing bed with pregnant ladies and young children (18 days).
10 days: have at least 3 litres water everyday. Do not hold urine, and try to pass urine as many times as possible.
Flush twice after using the washroom (10 days).
Avoid eating from the same plate and spoons as others without washing (10 days).
Clothes and utensils need not be washed separately.
Patient must avoid cooking food for others (10 days).
There is no need to use discardable plates and spoons.
Patients must avoid fathering a child (at least 3 months).

Discomfort / risks

There is small risk of flare up of symptoms (especially bony pain) that were experienced before RLT few minutes to hours after starting RP infusion.
There is a small risk of bone marrow suppression (with possibly increased risk of infections, anaemia and low platelets). However, you will monitored for the same, and you are expected to be in touch with your main treating doctor.

Time taken for summary generation

4 hours following post-therapy scan completion.

Additional reading

For additional information, please visit the following links.

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