PSA detected after salvage radiation and prostectomy

This is one of those cases where with such a low PSA (0.24), a PSMA PET scan will miss cancers about half the time (even though you know there’s likely recurrence due to the rising PSA).
> how did they know where to target the radiation if the PSMA PET scan showed nothing?
> in conjunction with the salvage radiation, did they include hormone therapy (ADT)?

In Dr. Kwon’s (of Mayo Clinic) presentation about recurrence and salvage radiation, they always include ADT: https://youtu.be/Q2joD360_pI)

Again, with such a low PSA now (0.11), will the PSMA PET scan see nothing again?

Have you asked about using an older PET scan (called Axumin)? It doesn’t rely on PSMA so, it might show something. (Usually PSMA PET is better than the older PET scans; but, with PSA that low, there’s no telling……
> Mayo Clinic uses an older PET scan called Choline C11 if the PSMA PET scan shows nothing. Ask them about that PET scan option.

Also, since your husband had his prostatectomy in 2014 - long before PSMA PET scans came out, he’s never had a positive one, has he? (They say that about 15% of prostate cancers don’t even express PSMA so, the scan would never show anything. He may be one of those 15%.)

@brianjarvis thank you for responding. We asked how they would target the radiation since not showing on scans. Told aimed at the highest zone. Was not given ADT with radiation because Decipher indicated low risk. I will look at Dr. Kwon prevention, thank you for that! And also look into and ask about the older PET scan options. He has never had a positive PSMA PET, as you mentioned was not available in 2014. Again, thank you. Knowledge is power and need to hear what others have learned from their experience.

It's obviously very upsetting, and I understand why you feel so worried.

Let's look at the other side of the coin: there must have been some cancer already outside the prostate back in 2014, but it took 11 years to become detectable, still at a *very* low level. Your husband's prostate cancer seems to be a slow-moving type.

In another 11 years, he'll be 84. And 11 years after that, he'll be 95. Even if they can't eliminate the cancer, there's a good chance his medical team will be able to keep a few steps ahead of it with periodic refresher treatments while he lives out the rest of a long, wonderful natural life. That would be a win, I hope. ❤️

What you have is very treatable without a clinical trial. I had a prostatectomy and 3 1/2 years later my PSA started rising and I had 8+ weeks of radiation. PSA started rising again 2 1/2 years later went on Lupron. I’m now 16 years past the prostatectomy, I have BRCA2, which makes my cancer very aggressive, but I’m still around and in good shape at 78.. I’ve been undetectable for the last 24 months taking Orgovyx (ADT) and Nubeqa. I’ve had four reoccurrences but the drugs keep me under control.

Getting on ADT alone is not a good idea, You can become castrate Resistant within a couple of years with just ADT. That happened to me after 2 1/2 years, Once you become castrate resistant median survival is two years, I’ve been six years past that. If they give you an ARPI along with the ADT, it can delay, castrate resistance for a long time. Ask your doctor about this.

Some doctors like to just wait for the metastasis show up on a PSMA Scan and zap them with SBRT radiation. That can work.

@jeffmarc thank you for relying. This is the real life information I was hoping to receive. I will print and take to our Jan appointment for discussion. Happy to hear you are doing well. Again, appreciate your time.

@northoftheborder that would be a win, thank you!

That is very disappointing news and I, too, could be in that boat in the future.
Do you know if your husband’s pelvic lymph nodes were targeted during his IMRT?
Even though it has become standard protocol after the SPORTT trial many doctors still only target the prostate bed and not the pelvic lymph nodes; it has been estimated that 30% of all radiation failures come from this fact.
You can ask your current RO if radiation can be given to the pelvic nodes without causing any damage to areas already radiated.
Phil

@aprapr Decipher is a great new tool to use in predicting cancer aggressiveness (metastasis risk) for improving treatment decision.
Since it has high sensitivity (~93%) but lower specificity (~40%) for clinically significant cancer, it doesn't catch every aggressive case or eliminate false positives entirely when used as a screening tool alongside PSA/MRI.

As with every number - PSA, PIRADS, Gleason, SUVmax, etc. - I would use it cautiously.

Ouch @aprapr , I have same situation. RAPL 2022, then PSA rised to 0.2 at 2024. ADT 6months and Salvage Radiation 33times. No positive scans. Spring 2025 PSA undetectable. November 2025 PSA 0.1! Urologist informed next scan within 3 months and new operations(?) if the PSA is still up/rising.

@heavyphil I am 99% sure the radiation was only targeted to the prostate bed. Will put your response in my file of questions to ask. Thank you very much for your response and best of luck to you!