How do you approach rising PSA many years after prostatectomy with negative PSMA PET?

The devil is in the details.

What is the status of the patient? In other words, what is the expected survival of the patient given his age, performance status, and medical conditions? There are online calculators that can be used to help.

At what PSA value was the PSMA scan obtained? The utility of the test is dependent on the PSA. There is a lot written about this in the radiologic literature. The higher the PSA, the more likely the test will be positive. Also, PSA value is important in determining treatment and likely hood of success. Basically, the lower the better.

What will you do with information? Is your patient a candidate for post operative radiation? Metastasis directed therapy? If the scan was positive. For instance, are there co...

I have felt slightly less comfortable using the finding of a negative PSMA PET/CT to omit pelvic lymph node coverage when administering post-operative radiotherapy. Based on the results of RTOG 0534, the inclusion of pelvic nodal irradiation has become the default for me given the benefit seen in this practice in the entire study population with some remaining uncertainty in patients with low pre-salvage PSA. I now recommend pelvic nodal irradiation more liberally with omission only in cases which I feel have a low risk of nodal metastases as estimated by clinical factors or which I estimate have a high probability of durable biochemical response with prostate bed volumes alone, such as low-grade disease with positive margins. While I know ...

We have decades of experience making decisions about post-prostatectomy salvage radiation therapy in the setting of negative restaging scans. The data from that era informs us that the rPSA value declines >90% of the time with prostate bed-only XRT fields, even after a late relapse many years after the prostatectomy. In the setting of a negative PSMA PET scan, it would be appropriate to rely on the negative PSMA PET to treat the prostate bed, which might harbor the only area of residual disease. I would certainly use the negative PSMA PET to omit elective pelvic LN irradiation.

First off, the patient has biochemical recurrence, even if the PSMA scan is negative. At low PSAs, PSMA scans frequently do not show anything. Given what we know about treating at lower PSAs, we should still initiate salvage radiation at that time. Whether to include lymph nodes and/or ADT will depend on the PSA value at that time. Much has been written on theMednet regarding appropriate PSA thresholds for both of these.

Personally, I do not recommend ADT at PSA values < 0.7, and do not offer it for anyone considered early salvage (my personal cut-off is < 0.5).

I always treat pelvic nodes for anyone with PSA > 0.34, and consider omission for those with PSA < 0.34 with features that may be a sign of either:

1. Failure in the prostate bed, suc...