How do you approach a prostate cancer patient with oligomet disease on PSMA PET?

I think there is a spectrum of 'PSMA-PET Avid lesion suspicious for metastasis'. In some locations, such as ribs, I worry more about false positives. For lesions with PET avidity without CT correlate, I worry about false positives and may advocate for a biopsy if it will change the treatment plan. Sometimes for equivocal things, we will proceed with definitive treatment and monitor on future scans.

However, most of the time, on the size of PET avidity and significant CT correlation, a multidisciplinary discussion can frequently lead to all parties agreeing (with shared decision-making with the patient as well) to proceed as if the patient is metastatic.

In a patient being treated as synchronous metastatic disease, I would, at minimum, offer r...

I would try to biopsy the site to prove metastases. Always a good idea to prove the first metastasis with a biopsy. Assuming it is proven or I am convinced it is real, such a patient is not someone who would have qualified for studies showing a benefit to SBRT (SABR-COMET, STOMP, ORIOLE). So, I would treat a la STAMPEDE ADT (leuprolide + abiraterone) + prostate/SV IMRT. Reserve SBRT to metastases for oligoprogression.