How long after biochemical failure for positive PSMA PET scan?

I had my prostate removed 15 years ago. 3 1/2 years later it reoccurred and I had prostate bed radiation that gave me another 2 1/2 years before it came back again, I was not on ADT until it returned. Mine comes back because I have BRCA2.

They can’t find it, possibly because it’s so small, micro size. They have to grow big enough to be seen, but there could be a number of those spots. They have more likely than not spread to the prostate bed and maybe somewhere else. Prostate bed is almost a certainty to be where things start, and why they so often do salvage radiation. It can put you into long-term remission again. If another spot pops up, they can use SBRT on it.

Taking ADT at this point can kill growth and future spread, how long you take it depends on your Gleason score. You were probably a seven since it took so long to come back. That would be a six month of ADT. Without it who knows.

Someone on the forum had a PSA of 10.0 after rising for many years and nothing showed with PSMA. It was suggested by @jeffmarc that he try a scan with a different tracer - perhaps Axumin or FDG(?). Don’t let your current PSA go above .7 - that’s the threshold that many RO’s are using to determine the need for ADT. I chose to have it, however, at .18….
If you decide to radiate, insist on the pelvic nodes as well - the cancer is also there 35% of the time in salvage situations. Best,
Phil

Acceptance is a process. I have accepted a number of treatments that I was initially resistant to having.
See SPPORT trial
I condidered my clear PSMA PET Scan to be a good result, which directed treatment to prostate region and pelvic lymph nodes.
I had short term ADT; a friend w/ BCR 5 yrs postop is completing radiation treatment this week w/o ADT at MD Anderson.
I think that the trend is to treat BCR earlier in the .2 - .4/.5 sweetspot.
Best wishes.

More of your clinical data would be useful in answering...

More and more. SRT to the prostate bed only in one who experiences BCR is not the standard of care, rather, SRT to the prostate bed and pelvic lymph nodes along with short term ADT is the "norm."

My experience with BCR and SRT was it happened 15-18 months afte a highly "successful" surgery when PSA first came back at .2, then 90 days later, .3.

I advocated, albeit, not very strongly for SRT to the prostate bed, PLNs and six months ADT. At the time it was not the SOC and my medical team said there was no long-term data to support it. I discussed the data Mayo had showing that in high-risk patients more often than the BCR had already spread to the regional lymph. nodes.

In my latest recurrence m y medical team and I had decision criteria about when to image, three or more consecutive increases in PSA spaced 90 days apart and PSA between .5-1.0. When my third increase hit .48, radiologist said close enough. I said, no, wait for the next one. It was .77, we imaged, it showed a single PLN which we hit with SBRT and added 12 months Orgovyx to deal with micro-metastatic disease too small to be seen on imaging. Would imaging at .48 have shown the same thing, we'll never know. But the risk-=benefit of waiting was favorable in my eyes, so we did.

Your choices at this point are to initiate treatment or wait.

If you and your medical team decide to initiate now based solely on PSA, then consider a more aggressive approach of prostate bed, pelvic lymph nodes and six months ADT.

If you decide to wait and image again, you may have more clarity about where the recurrence is which can inform your treatment decision.

There is some data that in low risk PCa doing "nothing" but actively monitoring is an option given the time to onset of metastases, There is also data that says in low risk PCa, MDT can delay the need for ADT.

For intermediate and high risk PCa, those options are still possible but more likely you move to SRT to the prostate bed and PLNs and include short term ADT which can include an ARI.

Intuitively, the higher one's PSA, the greater statistical probability imaging locates the recurrence

I acquiesced, SRT to the prostate bed was an epic failure. I would graduate to triplet therapy. Would the outcome of SRT been different had I stuck to my guns, we'll never know but intuitively, yes.

This may help - https://www.urotoday.com/conference-highlights/eau-2025/eau-2025-prostate-cancer/159158-eau-2025-how-to-optimize-outcomes-in-men-with-biochemical-recurrence-after-local-treatment-with-curative-intent.html

Kevin

Thank you for your informative reply Kevin. Pre-surgery PSA was 17. I was a Gleason 4-3 with extracapsular extension towards the bladder neck, clear lymph and pelvic nodes. Going to repeat PSA in 90 days and urologist ordered another PSMA PET for the same time. My urologist's thinking is given 8-9 yrs between surgery and BCR, growth is likely in the bed. I agree with repeating the scan (not sure how many of these $15k scans BCBS will approve in a year) and radiating when something is identified for a targeted attack.

I agree with Squash05, what a helpful post. Thank you, Kevin!