PSA levels started to rise again but negative PSMA PET

@susanocl Are you on any special diet? Are you still eating sugar? Are you doing any alternative treatment after surgery?

Underwent proton radiation in 2010. Last four years PSA slowly rising; now about 4.0. Had MRI and PET scan. Nothing..no indication of prostate cancer. My take on understanding this disease after all these years includes the summation that as one gets older, PSA generally increases...with age. Is this cancer prone? Most doctors say No..it is just the aging process. Aside from yearly reads from the physician, I use Quest for lab test usually every 3 to 4 months....just $75.00 and worth the monitoring process. Again, MRI and PET scan resulted in negative indications of prostate cancer. It seems "every guy" is different in many ways and there is no definitive "standard" of validation.

@tdoriausername Thanks for asking. The PSA at 1.5 was his first PSA test post surgery. They said to wait at least 12 weeks and his was at 13 weeks. Before that it was just healing from surgery. First follow up with surgeon was at 14 weeks. Diet changes have been me adding in more fish and seafood at least 2-3 times per week for hubby, he doesn’t eat much sugar - not a sweets person, cutting back to half-caff coffee, and I have finally convinced him that even 1 or 2 drinks (crown and dr. Pepper) is not good and he’s now just doing that Fri-Sat-Sun nights.
Our current plan is salvage radiation (but I don’t think it can be called salvage since the cancer was never fully gone - so I’m calling it adjuvant) but we are worried about radiating the prostate bed and lymph nodes when nothing is showing up on any PSMA PET or MRI scans.
New PET/MRI scan is Jan. 30th and planning meeting with radiation on Feb. 3rd and CAT simulation for planning same day.

@jeffmarc
Thank for the reply and I’ve shared with my husband. We’re planning to proceed with recommended radiation because the effects of that are less than cancer metastasizing cancer’s ultimate outcome. During surgery, only right side nerves spared. Current some incontinence but ED is an issue even with daily cialis 5 mg and added viagra as needed.
We were hoping for some continued improvement in this area as time went ton. Will radiation of prostate bed damage the nerves that are remaining? Should we prepare for this outcome? We’d like it to improve but again, this versus ultimate outcome of cancer is a no brainer.
Husband was just uneasy about radiating when nothing was showing but he realizes that the scans can not pick up microscopic cells that escaped during the extra capsular extensions prior to surgery.

@susanocl Curious if they have considered using other scanning technology? Pet PSMA isn't the only scanning tech out there. JeffMar might have more information on that. My GU second opinion at a center of excellence suggested waiting until I hit PSA 2.0 if I BCR again stating it would increase the chance of finding it and actually treating it.

My husband has had 2 PMSA PET CT Scans one when his PSA was 6 the other when it was about 12, both were negative. (These were post his prostatectomy) He is one of the unfortunate ones that do not react to the radioactive material used, I think its something like 97% successful.
The location of the cancer was eventually found by taking HT to induce a 'flare' and it then showed on a nuclear bone scan.
Good luck.

@susanocl
I’m not sure about them being able to avoid the nerves when they’re radiating the prostate bed. You should ask the doctor about this. There are solutions to ED. Having Cialis regularly can be important to keep the blood flowing. Using a penis pump can keep the erections working though it’s probably not stiff enough for relations. At that point you can use the bimix or Trimix Injections to get an erection. There are a number of people in this group that are doing that and it works quite well. It can take a little bit of practice to get it right.

I didn’t post this information for you but it now sounds like it could be what you’re looking for about adjunct radiation.

Dr. Efstathiou concluded as follows:b
* Early salvage radiotherapy is favored over adjuvant radiotherapy in most patients
* Consider adjuvant radiotherapy in otherwise fit, motivated, very high-risk patients with ≥2 of the following risk factors:
* pT3b-4
* Gleason score 8-10
* pN+ Lymph node Metz
* Decipher score >0.6
* In high-risk patients, use lower thresholds to initiate ‘ultra-early salvage or adjuvant-plus’ radiotherapy
* If giving adjuvant radiotherapy, it implies high-risk disease. Thus, Dr. Efstathiou would recommend treating the prostate bed and pelvic lymph nodes, in addition to short-term versus long-term ADT, depending on risk factors
* May consider genomic classifiers or artificial intelligence tools to help with informed decision-making
* The goal is to avoid (or delay) radiotherapy in those who we can, without missing a window to cure patients who are guaranteed to recur

Here is a link to the article supplied by @surftohealth88 originally
https://www.urotoday.com/conference-highlights/apccc-2024/151546-apccc-2024-debate-how-to-best-manage-a-fit-patient-with-high-risk-localised-and-locally-advanced-prostate-cancer-how-to-select-patients-for-adjuvant-therapy-after-radical-prostatectomy-and-how-to-treat-them.html

I am surprised that your physician ordered the PET Scan in your post-prostatectomy status. I had asked the same thing of my urologist while discussing possible diagnostic and treatment options if/when my cancer returns (PSA level starts to rise). He said that your PSA can start to rise with a relatively small group of cells producing the PSA, and the problem is, those cells are not numerous enough to have "enough" Gallium-68 radioactive tracer "taken up" by the prostate cells to be detected by the PET Scanner. You'll likely be referred to a radiation oncologist because it seems your cancer may have returned. The good news is that it is so early, that Proton Beam treatment could probably successfully treat the prostate bed, without frying your urethra, bladder, and rectum like regular radiation does. Good luck to you.

The point I was looking for is under Detection Rate below. The "generally high" detection rate is still only 50-65%, so not finding the actual nodes is a pretty common situation. I have a friend in stage 4 (metastatic) but still unable to find the nodes, just knows that the cancer is there because of the progression and the PSA after RALP (and much further treatment.)
Of course, the situation is different after RALP than after radiation because the prostate can still be generating PSA if it's still there, but not so much if it's completely removed :-).
I copied the following from Gemini AI: "A PSMA PET scan at a PSA level of 0.5 ng/mL is considered highly appropriate for detecting recurrent prostate cancer, with studies indicating a 38% to over 50% positivity rate in this range. This advanced imaging is recommended when PSA rises after treatment (biochemical recurrence) to identify the location of cancer, often finding disease in the prostate bed or lymph nodes, even at low PSA levels.
Key Findings for PSMA PET at PSA 0.5
Detection Rate: At a PSA of 0.5–0.99 ng/mL, detection rates are generally high (approximately 50%–65%), allowing for precise identification of recurrent, metastatic, or persistent disease.
Optimal Timing: While some studies show lower, yet still useful, detection rates (around 35%–40%) for PSA levels between 0.2 and 0.5 ng/mL, the 0.5 ng/mL threshold often provides a better balance for finding localized recurrences.
Management Impact: A positive scan at this level can guide treatment, such as salvage radiation therapy to the prostate bed or metastasis-directed therapy (MDT) (targeted radiation) for nodal disease.
Negative Results: If a PSMA PET is negative at 0.5 ng/mL, it does not mean cancer is not present, as the sensitivity increases with higher PSA levels.
Clinical Context
Post-Prostatectomy: For patients whose PSA rises after surgery, a PSMA PET is a standard tool to locate the recurrence, especially as levels approach or exceed 0.5 ng/mL.
Pre-Radiation: It is often utilized before administering salvage radiation therapy to ensure the targeting of the correct area (e.g., prostatic fossa vs. lymph nodes). "

@susanocl Unfortunately, rising PSA or persistent PSA after surgery with nothing showing on a PET scan is probably what occurs in 90% of cases.
My own SRT - and that of countless others - is based on PSA only. Waiting for something ‘to show’ is risky - as you aptly point out with undetectable micro-metastases being possible.
We are told to act at the first sign of smoke, and not wait until we see the actual fire. Best,
Phil