How would you treat margin positive, node positive (pN+) prostate cancer with detectable post-op PSA but negative PSMA-PET after radical perineal prostatectomy?

Ideally, enroll the patient in a clinical trial like NRG GU-008. Off trial, would treat with salvage RT to the prostate bed and lymph nodes with long term (2 years) ADT. You can consider an MRI to see if there's a nodule in the prostate bed to boost, which may be more likely given a positive margin.

With the advent of molecular imaging, there is a temptation to observe patients with negative imaging even with a rising PSA, and only initiate treatment with a visible target. I would caution agains...