Rising PSA at 5 months post-RALP

Posted by animate @animate, Apr 15 3:28pm

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%)

Interested in more discussions like this? Go to the Prostate Cancer Support Group.

Jeff Marchi | @jeffmarc | Apr 18 10:59am

In reply to @clevelandguy "Well we are both welcome to our own opinions based on our past knowledge." + (show)

@clevelandguy
Micrometastases of prostate cancer are very small clusters of cancer cells, typically defined as having a maximum diameter of 2 mm or less. These tiny deposits often escape detection on standard imaging scans (MRI or CT). While often under 2 mm, some clinical definitions in research contexts may refer to lesions up to 1 cm as "micrometastases" in lymph nodes.

Those are exactly what they cannot see when doing a PSMA Pet Scan.

begreat99 | @begreat99 | Apr 18 2:27pm

In reply to @animate "@clevelandguy Thank you for your response. I am getting the sense that getting the PET scan..." + (show)

@animate
100% support getting the PET scan. Similar diagnosis to yours. My PSA rose to .2 after 9 months and we discovered via scan a cancer lesion in my pelvis bone. 8 focused radiation treatments on the lesion, plus Orgovyx and Nubequa, have reduced my PSA to near 0.

clevelandguy | @clevelandguy | Apr 18 2:46pm

In reply to @jeffmarc "@clevelandguy Micro metastasis are smaller than 2 mm So neither scan is gonna find them." + (show)

@jeffmarc
What I am saying is that the PET scan is very sensitive in picking out micromets cancer locations and is one of the better if not the best tool for finding them. If it does not pick them up until it’s 2.999mm I don’t care. When your PSA starts to rise the doctor is not going to say oh, it’s on 1.99mm so we are not going to give you a PET scan. It shows up in the scan when it shows up. You get scans until something shows. It is not so much the size which you seem to be hung up on but the fact that the PET scans will find small metastatic cancers sites to zap with radiation. Metastatic cancer is defined as cancer that has spread from the original site. Ya can’t kill it without finding it.

Jeff Marchi | @jeffmarc | Apr 18 3:32pm

In reply to @clevelandguy "@jeffmarc What I am saying is that the PET scan is very sensitive in picking out..." + (show)

@clevelandguy
The problem is that most people who get PSMA pet scans after having surgery, and then having their PSA rise, Almost always find nothing. If they do have Mini metastasis, they don’t show up so they don’t know to treat them. That’s why they do salvage radiation so often. Same thing with radiation.

Some doctors will wait around until the PSA rises a lot, and they can actually see metastasis. You just can’t expect that PET scan to find them after initial treatment.

clevelandguy | @clevelandguy | Apr 18 4:39pm

In reply to @jeffmarc "@clevelandguy The problem is that most people who get PSMA pet scans after having surgery, and..." + (show)

@jeffmarc
I would think you get a PET scan after you have had treatment and your PSA is starting to rise again. Then take repeated scans until something shows. I never said that you should get a PET scan right after treatment.

Jeff Marchi | @jeffmarc | Apr 18 5:12pm

In reply to @clevelandguy "@jeffmarc I would think you get a PET scan after you have had treatment and your..." + (show)

@clevelandguy
I didn’t think you were saying that. I know you know that you don’t do it until your PSA starts rising. Some doctors will start doing the scan at .2. They were talking about it at the UCSF conference. I went to yesterday. .2 PSA can show more things that I had suspected.

I do know one guy Whose doctor was having him get a scan every three months even though he had a .2. The doctor wanted to catch it as soon as it showed up.

michaelcharles | @michaelcharles | Apr 18 5:25pm

The SPPORT trial results may be of interest to you.
My RO prescribed 66.6 gy radiation to the whole pelvic floor region, including 45 gy to the pelvic lymph nodes, together with a short course of ADT.
G 9, persistent PSA post-op .19 w/ EPE, surgery age 72.
Over 2 yrs post SRT, PSA thankfully has been "undetectable".
ROs and MOs seem to be finding their different comfort levels with ADT - yea or nay - and length of treatment.
My RO definitely recommended ADT (in the face of my protestation), but only a 4 mo course.
I have put my faith in his treatment plan.
While I am hopeful that I will never hear from my PCa again, I do anticipate that I will have a future recurrence and hope that it can be managed as a chronic disease at that time.
Best wishes.

surftohealth88 | @surftohealth88 | Apr 18 7:06pm

In reply to @heavyphil "@clevelandguy It’s been reported that different tracers bear out better results - even some of the..." + (show)

@heavyphil

Yes, now copper is in trials and so far showed superior detection by 3 fold ! Stanford has a trial and I am trying to find a way to squeeze my hubby there ... 🍀

heavyphil | @heavyphil | Apr 19 8:17am

In reply to @clevelandguy "@jeffmarc I would think you get a PET scan after you have had treatment and your..." + (show)

@clevelandguy Dr Kwon seems to be in your camp; he doesn’t seem big on SRT based on PSA until you can see something on a scan - then he will treat THAT lesion.
But it begs the question: if you have a visible lesion do you have many more NOT YET visible and therefore, would not be treated?
In my own case, I wanted full pelvic SRT as soon as I hit 0.18 (6 mos Orgovyx as well).
My thinking was that hopefully - and that’s all we’ve got folks - any cancer was still in the bed and the nodes and I wanted to kill it before it left the immediate area.
If I waited and waited for something to ‘show’ on a PET scan (mine was negative at 0.18) maybe it would have made its way to a lung, a rib or some other distant area.
True, that can still happen, and then treatment will probably be SBRT - whack-a-mole - and ADT for a long time. Best,
Phil

clevelandguy | @clevelandguy | Apr 19 9:00am

In reply to @heavyphil "@clevelandguy Dr Kwon seems to be in your camp; he doesn’t seem big on SRT based..." + (show)

@heavyphil
Yes you are correct,either radiate the whole area(hopefully the cancer is in that area) and has not spread to the hips or lungs or wait till it shows up and play whack a mole. Due to the radiation side effects I personally would rather do the whack a mole.