Rising PSA at 5 months post-RALP

Hello,

With all the fantastic expertise and valuable experiences from the members of this forum, which have provided great help for me in this rugged journey during the past months, I am hoping to receive some feedback regarding my current situation. At 5 months post-RALP, my PSA is at 0.19, practically at the 0.20 cutoff to be considered biochemical recurrence.

At this time, the Oncologist has indicated that we wait another 3 weeks to have another PSA test, and then another PSA test 2 weeks after that, with the intention of confirming an upward trend or a possible stabilization of the value in that range. He has also indicated that I get a PSMA PET/CT at this time, to rule out any signs of possible spread to other areas. He would like to have these test results before we can confirm that SRT is required, which he has pointed as the most likely path for me, along with ADT.

For reference, below is a summary of my clinical profile.

*** My concerns are:
- With a PSA of 0.19, if we wait another 5 weeks for the tests are we risking a further quick rise in PSA that could put me at a less favorable situation to begin SRT/ADT? Should the treatment not be started right away, as I am now within the optimal early salvage window?

- Would ADT really be required? My understanding is that my factors in favor of considering adding ADT are: Gleason 4+3, Positive margin (3 mm, pattern 4), PSA post-RALP: 0.02 → 0.18 → 0.19 (early recurrence) // However, factors against considering the need to add ADT: pT2 (organ-confined), PSA ~0.19, pN0 (nodes negative at surgery), Low tumor volume (~5%).
Would the improvement in cure probability that ADT would add for me be worth the negative side effects?

- Is a PSMA PET/CT scan really required, given that all my image and pathology reports have shown no signs of extracapsular extension? Also, with a PSA of 0.19, will the CT scan show anything (microscopic / below detection)?

Thank you in advance for reviewing my case and concerns, and for providing any possible comments or suggestions.

//// Clinical Profile ////

**Age:** 56 years
**Diagnosis:** Acinar adenocarcinoma of the prostate
---
## **PSA Evolution**
* Aug 2019: 0.599
* Sep 2021: 0.732
* Jan 2023: 0.98
* May 2024: 2.53
* Jun 2025: 3.90

---
## **MRI (July 2025)**
* Single lesion, PI-RADS 4
* Location: left peripheral zone (posterolateral, lower third)
* Size: 8 mm

---
## **Prostate Biopsy (August 2025)**
* 5 out of 15 cores positive
* 2 cores: Gleason 6 (3+3) → low volume
* 2 cores: Gleason 7 (3+4) → significant volume (up to 61%)
* 1 core: Gleason 8 (4+4) → present (transitional zone)

---
## **PSMA PET/CT (September 2025)**
* Focal uptake in prostate (left peripheral zone)
* **miTNM:** T2u N0 M0
**No evidence of:
* Extracapsular extension
* Nodal involvement
* Distant metastases

---
## **Robotic Radical Prostatectomy (November 2025)**
# **Final Pathology**
* **Type: Acinar adenocarcinoma
* **Gleason score: 4+3=7 (Grade Group 3)
* **Pattern 4 predominance in tumor: 90%

**Tumor characteristics:**
* Prostate involvement: 5%
* Multifocal
* No extracapsular extension (pT2)
* Seminal vesicles: negative
* Lymph nodes: 0/1 negative (pN0)
* Perineural invasion: present
* No lymphovascular invasion

**Key finding:**
* **Positive surgical margin**
* Location: left posterior apex
* Length: 3 mm
* Gleason pattern 4 at margin

---
## **Postoperative PSA**
* Dec 2025 (5 weeks): 0.02
* Mar 2026 (4 months): 0.18
* Apr 2026 (4.5 months): 0.19

---
## **Overall Risk Assessment (Post-Prostatectomy)**

### **Adverse Factors**
* Positive surgical margin (pattern 4)
* Gleason 4+3 (high proportion of pattern 4)
* Early PSA rise (< 6 months)

### **Favorable Factors**
* pT2 (no extracapsular extension)
* pN0
* Negative PSMA PET
* Low tumor volume (5%)