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Second Opinion????? Recurrence Post RALP
Hi all,
I’m looking for some perspective as I work through the next steps after prostatectomy.
**Brief background:**
* Age 67
* Radical prostatectomy: August 2025
* Pathology: Gleason 4+3 (Grade Group 3), ~80% pattern 4
* Cribriform and intraductal features present
* Extraprostatic extension (pT3a) and lymphovascular invasion
* Negative margins, lymph nodes negative
* PSA: 0.10 about 3 months ago → 0.17 this week
**Current situation:**
I’m being followed at a major center and have PET and MRI pending.
The main question I’m trying to think through is what to do **if imaging is negative**.
Specifically:
* Whether to proceed with **early salvage radiation** vs continued monitoring
* Whether to include **pelvic nodes vs prostate bed only**
* Role and duration of **ADT in this setting**
Given my pathology (cribriform/intraductal, LVI, etc.) and the PSA trend, I’m concerned about missing the optimal window for treatment if I wait too long, especially since I may be a lower PSA producer.
I did ask about genomic testing (Decipher) and was told it’s not necessary at this point.
After thinking this through, I realize I would be uncomfortable if the recommendation were to wait for something to declare itself on imaging. Because of that, I’m wondering whether I should start the process of getting a second opinion now, or wait until imaging results are back.
**My question:**
For those who have been in a similar situation (especially with higher-risk features but low PSA), how did your team approach:
* Timing of salvage radiation
* Field selection
* Use of ADT
Also—did anyone pursue a second opinion between major centers, and did that change your plan?
Appreciate any perspectives or experiences.
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@begreat99
Would you be so kind to share of how long will you be on Orgovyx and Nubequa ?
Thanks so much in advance .
At least 24 months. Very little side effects. Mainly fatigue.
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2 Reactions@begreat99
Thanks 🙂 ! I forgot to ask - did you end up doing salvage to the whole pelvic area inclooding nodes , or you did just one node that was positive ? Was you PET actually PSMA PET ?
Good questions. PSMA PET and just radiation to the 1 pelvic lesion. While I did have some seminal vesicle invasion I had zero lymph node issues. Radiologist said there was no reason to treat prostrate bed at this time, but it’s likely down the road. Next blood test is this week, and monthly thereafter. I am a healthy 67 year old retired real estate executive and active athlete. I have finally moved past the diagnosis shock, painful reflection about why and death planning (my Will), and realized this is a long term fight with decisions and analysis step but step. Exercise, sun, healthy diet and family priorities maximized. Keep charging!
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4 Reactions@begreat99
Thanks @begreat99 for finding time to answer my additional questions and for sharing your way of dealing with PC diagnosis. I know that every case is different but I find it comforting to hear insights of members who already successfully went through salvage therapy :). I really like your fighting spirit : ) and may this be the first and last BCR for you 🍀🍀🍀 !
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Hug
2 ReactionsIm not as experienced as some of the contributors, but based on my personal scenario, i think you should consider moving forward on salvage treatment. I think a decipher would help, not sure why they are saying you dont need. Helps define the aggressiveness of your cancer, and appropriate next steps. But given the pretty rapid rise of your PSA, and your cribiform, and other risk factors, I would consider beginning treatment sooner than later. Of course, your RO and his/her team should be working with you on this, defining the treatment most appropriate for you.
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Hug
5 ReactionsMy profile is nearly identical to yours, and I am considering firing up the hormone/radiation engine with a uPSA of .051. Because of my Decipher test, i know i have a luminal B cancer and using an hormone doublet recently shown to kick its ass (medical terminology). Plus, my Decipher score was .93, which means i have aggressive little suckers. I meet with my RP on the 24th to try to finalize some things. Dont mess around with cribiform.
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4 Reactions@mlabus3
Hi @mlabus3 , would you be so kind to tell me what "doublet" was recommended to you and for how long will you be taking it ? Also, I suppose IMRT is planed for the whole pelvic floor and lymph-nodes ?
Thanks in advance .
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1 ReactionNothing is finalized yet, but its looking like Orgovyx to start - maybe 2 weeks or so, then add apalutamide. the 2025 Balance NRG GU006 Study shows it really works well against Luminal B cancer. Initial conversations were 6 months, which may be a little short. Another discussion point. Darolutamide is emerging as one with slightly similar (slightly less) results but considerably lower side effects.
Radiation is one thing we really havent talked through yet. I would like to the a shorter course of 25 or so. With my risk factors probably will do radiate both to be safe. JHU is still using CT guided, no MRI-guided. From what ive read the benefit of MRI guided isnt as pronounced in salvage as it is on the prostate itself. JHU has invested in their proton baby, although i havent sensed a lot of pressure to go that way.
If i can answer anything else let me know.
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2 Reactions@mlabus3
I am very grateful for you insights and for sharing info about possible plan for salvage RT. My husband has uPSA that is slowly creeping up and depending of results that his next uPSA tells us, there will be talks about possible early salvage RT. His last uPSA was 0.026 but the first post op uPSA was 0.014 , so something might be brewing there (or not). He also had large cribriform, IDC and Decipher 1, and all of that makes me very nervous ( read freaking out).
There is a study from 2011 that claim that uPSA does not have the same predictive value as does regular PSA and it's doubling time so it gives me some comfort. BUT, with such high risk features one can not relax, no matter what.
My husband was considering adjuvant RT but was advised by surgeon and MO to wait and see how his PSA would behave and to give his body time to heal from surgery which we think was a good advice because he regained full continence.
His salvage would also be IMRT and his center also does not have Meridian (?) machine but RO is well known and probably would make a good plan.
Do you know if they will insert gold fiduciary markers inside your body and if they plan to use gel spacer for colon ?
Once again, thanks for all the help and info < 3.
PS: If you have any links for relevant research papers or results would you be so kind to attach them for me to read 🙏.