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Summary of Mayo Consult (PSA Recurrence, PSMA-Negative)
Summary of Mayo Consult (PSA Recurrence, PSMA-Negative)
I had my consult at Mayo following a rising PSA (now 0.24) after prostatectomy. My PSMA scan was essentially negative, with one very small indeterminate pelvic node that their team ultimately felt was unlikely to represent cancer.
Because of the negative imaging, I was offered participation in a clinical trial comparing immediate salvage treatment vs PSMA-guided observation. The observation arm involves close PSA monitoring and repeat imaging, with treatment triggered if/when disease becomes more clearly detectable.
The rationale they explained is that older studies supporting early salvage radiation were done before PSMA imaging, and may have included patients with more advanced disease than we can detect today. The trial is designed to see whether some patients can safely delay or avoid treatment without compromising outcomes.
We had a very balanced discussion of risks:
Immediate treatment (standard approach): reduces risk of progression/metastasis but carries known side effects from radiation and short-term ADT.
Observation (trial approach): may avoid or delay treatment and its side effects, but carries uncertainty about timing and potential disease progression.
They were clear that both approaches are reasonable, and the decision comes down to individual risk tolerance.
My decision:
I chose to proceed with standard treatment — radiation to the prostate bed and pelvic lymph nodes with ~4 months of ADT. My reasoning was that, given my pathology (cribriform/IDC features, LVI, early recurrence), I am more likely to need treatment eventually, and I prefer to treat early rather than accept the uncertainty of delaying.
The trial made sense to me and I think it will be important in answering a real question in the field — it just wasn’t the risk profile I wanted for myself.
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Choline is only available at the Mayo Clinic at their HQ in Rochester, Minnesota. It's half life (shelf life) is minutes which is the reason for it's exclusive availability. It is 'brewed' up in the 'shop' rather than transported there.
The FDA has approved a newer version of a PSMA PET CT chemical. It has a longer shelf life which will make it more available for facilities that cannot afford to stock the current version with its shorter half life. The diagnostic accuracy has improved between observers.
Key Clinical Summary:
Design/Regulatory Context: Piflufolastat F 18 is a new formulation of fluorine-18 PSMA PET imaging and is indicated for PSMA-positive lesion detection among patients with suspected metastatic or recurrent prostate cancer.
Key Findings: In clinical trials, PSMA PET imaging with Piflufolastat F 18 demonstrated high specificity and improved positive predictive value compared with standard imaging modalities. Safety findings were consistent with prior experience, with low rates of mild adverse events.
Clinical Relevance: The new formulation is designed to enhance manufacturing efficiency and distribution capacity while maintaining diagnostic performance. Broader access to PSMA PET imaging may support timely and accurate staging and recurrence detection in prostate cancer.
On March 6, 2026, the US Food and Drug Administration (FDA) approved piflufolastat F 18 (PYLARIFY TruVuTM), a new formulation of the fluorine-18 prostate-specific membrane antigen (PSMA) PET imaging agent, for detection of PSMA-positive lesions among patients with prostate cancer.
This approval was supported by efficacy and safety data from the OSPREY and CONDOR trials. In cohort A of the phase 2/3 OSPREY trial, 252 patients with high-risk prostate cancer undergoing radical prostatectomy with pelvic lymphadenectomy received piflufolastat F 18 PET/CT. Median sensitivity was 38%, and median specificity was 96%. Median positive predictive value (PPV) received piflufolastat F 18 PET/CT. PSMA-targeted PET imaging achieved a correct localization rate of 85% to 87% across 3 independent readers. was 77%, and median negative predictive value (NPV) was 83%. Compared with standard imaging and confirmed by histopathology, piflufolastat F 18 PET/CT demonstrated higher specificity (97.9% vs 65.1%), nearly threefold higher PPV (86.7% vs 28.3%), and similar sensitivity (40.3% vs 42.6%). In the phase 3 CONDOR trial, 208 patients with suspected recurrent or metastatic prostate cancer and negative or equivocal standard imaging
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2 Reactions@brianjarvis Yes the topic came up indirectly in the sense that they would be monitoring PSA and doing PSMA as indicated if the PSA hit certain points. They will still do PSA and such if I chose radiation now but then that signal would not exist for a while.
@bens1 ADT alone as far as drugs go.
My persistent PSA of .19 post RP was treated with SRT to pelvic floor and pelvic lymph nodes in early 2023, at age 72/73.
And 4 mos of ADT, even though the guidelines that I have seen would have been 6 mos for less aggressive PCa and 18 - 24 mos for aggressive PCa.
G 9 w/ EPE
My uPSA gratefully has been undetectable since.
I like to believe and have faith that my RO at Johns Hopkins made an educated and experienced recommendation that will serve me well.
And my observation from MCC has been that different ROs have been Rxing different ADT doses, and I hope that mine hit a home run.
I am not challenging the NCCN guidelines; just sharing my individual treatment course.
And, I would elect current treatment of your PCa at .24 if it were me.
Best wishes.
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