Second Opinion????? Recurrence Post RALP

I am surprised they didn't do a decipher test initially, I would be asking for one. I was given one and had less issues than you are mentioning. I am scheduled for RP. This is all new to me, but you are at the right place to get some advise from knowledgeable folks , wishing you the best.

I agree you should get a Decipher test on the prostate. Not on your biopsy but have them send the prostate to the Decipher lab for testing. My urologist did that when I asked.

Best wishes to you! My husband is currently dealing with recurrence but at almost 5 years post-op. He's 52 now: Gleason 8, stage 3Tb with perineural invasion presented on surgical pathology report, and clear surgical margin. PSMA in Feb show one PSMA-positive lymph node on right external iliac. We're Americans but live in Germany. My husband has been to couple major prostate cancer centers here.

At the beginning of the recurrence, we requested to have a clinical case manager (we use US health insurance here: international plan). She suggested that we also should get second opinions that provide at no extra fees by our insurance with or without the option to share with the insurance. We did and got a full medical review report from one of the directors of urology departments at the major cancer center in Germany. It contains my husband's medical file review, the doctor's opinions on treatments, and his recommendation. We then saw 3 different radiation oncologists and two urologists all in 6 weeks. We compared the notes, did all research, made pros and cons lists of each offered treatment, and dug more into each cancer center's medical reviews on German medical website. Then my husband made a decision. It took a lot of time and effort, but I'm glad I did all I can to help him make his own informed decision on his treatment.

He's also on Orgovyx, starting on 14 March and will be on it for at least one year.

My husband had very similar pathology findings - pT3a, cribriform plus IDC. His tumor burden was very small but enough to push his 4+3 pre op. to 4+5 post op. since he had those very aggressive features present inclooding specs of comedonecrosis.

We insisted on talking with RO and MO as soon as pathology was revealed and on doing ultra sensitive tests every month since surgery (which was also in August 2025). We seriously considered having adjuvant RT (RT done even while uPSA is undetectable) but were advised to wait to see if uPSA would start rising. His first uPSA was 0.014 and I can tell you without a doubt that if it was 0.1 we would have had that adjuvant RT.

When we had discussion with MO, he suggested to wait until (or when) uPSA reaches 0.05 and than seriously start preparing for so called "early salvage" and start it no later than 0.1.

My husband's uPSA is now at 0.026 and we are still doing monthly checking and if it continues to rise we will take MO's advise and start preparing for RT.

Regarding protocol - it will include whole pelvic floor and lymph-nodes and 6 mos ADT.

Hope this was of some help and I am wishing you super successful RT and forever remission after this step. Please keep us posted < 3

@surftohealth88 It is. I am at Mayo Rochester. They do not answer what will happen if it does not show on the PSMA, which makes me want to reach out somewhere else. I wanted ultra-sensitive PSA testing, and they said no. I asked for Decipher, they said no. I wanted to get started at .10, They said to wait. Now I am at .17 and told to wait four more weeks. I will see a radiologist at that time but they said it was not time to see an oncologist. Geographically, I am closer to U of Mich and the Cleveland Clinic. I don't want to be a pain in the ass but I feel uneasy and want to know if I am off base.

This was discussed at one of the ancan.org weekly meetings last month. They were trying to come up with a solution for somebody that had both intraductal and cribriform. Unfortunately, there was no real answer given at the meeting. I suggested IMRT radiation followed by HDR brachytherapy, But it was not a long-term solution.

As the following document says “no consensus treatment guidelines exist” for somebody with that combination.
https://pubmed.ncbi.nlm.nih.gov/40186732/
Both radiation and surgery have been tried, but the results have not been satisfactory.

You could have adjunct radiation, But it is really not clear that it makes a difference, it may give a few more years of remission.

Here’s some information on.adjunct radiation from an Oncologist that is highly respected.

Adjunct radiation
Dr. Efstathiou concluded as follows:b
* Early salvage radiotherapy is favored over adjuvant radiotherapy in most patients
* Consider adjuvant radiotherapy in otherwise fit, motivated, very high-risk patients with ≥2 of the following risk factors:
* pT3b-4
* Gleason score 8-10
* pN+ Lymph node Metz
* Decipher score >0.6
* In high-risk patients, use lower thresholds to initiate ‘ultra-early salvage or adjuvant-plus’ radiotherapy
* If giving adjuvant radiotherapy, it implies high-risk disease. Thus, Dr. Efstathiou would recommend treating the prostate bed and pelvic lymph nodes, in addition to short-term versus long-term ADT, depending on risk factors
* May consider genomic classifiers or artificial intelligence tools to help with informed decision-making
* The goal is to avoid (or delay) radiotherapy in those who we can, without missing a window to cure patients who are guaranteed to recur

Here is a link to the article supplied by @surftohealth88 originally
https://www.urotoday.com/conference-highlights/apccc-2024/151546-apccc-2024-debate-how-to-best-manage-a-fit-patient-with-high-risk-localised-and-locally-advanced-prostate-cancer-how-to-select-patients-for-adjuvant-therapy-after-radical-prostatectomy-and-how-to-treat-them.html
It’s always possible you could go into long-term remission, There’s no real specific answers in prostate cancer.

@dhasper

I agree and I understand your frustration. We were denied MO and RO consultations initially but my husband was very insistent and persistent until he got referral ! He is treated in a big center here on the West Coast. In our experience one has to be a "pest" to get any attention, unfortunately. If we did not get what we asked for we would change provider, that is for sure.

Regarding uPSA , it is a norm in this particular center and it was ordered every 3 mos. We did uPSA "in between months" on our own in local lab. because I just do not trust anybody any more.

I forgot about PSMA - we were told that yes, PSMA will be performed if there is ever BCR but the chance of seeing anything at 0.1 is very small. Regardless, we will proceed with treatment because when BCR happens so fast after RP it is a greater chance that something was left in a prostate bed or is in lymph-nodes than that it is very far away, at least according to some suggestions.

It is completely normal to seek second or even third opinion. We considered going to UCLA for second opinion but one member here had exact situation as we had and he went to that exact RO that we were considering. He shared the info he got and it was the same that we got here in the Bay Area so we did not seek second opinion, but it does not mean that we will not in the future.

@jeffmarc

Yes, it is real conundrum.
Some studies showed that IDC has the best result with initially having RP , but I am sure that it might change over time.
Same way that studies can not agree about cribriform lately.

I found the newest study at ASCO 2026 that concluded this :

"After adjustment for comorbidities, stage, grade, and treatment, IDC-P was not independently associated with higher mortality. Conclusions: Our population-level analysis confirmed that IDC-P is associated with a more aggressive clinical phenotype. Despite this, we found that oncologic outcomes did not differ once disease severity and treatment were accounted for. Guideline-concordant management remains appropriate, though the rising detection of IDC-P and its biologic underpinnings merit ongoing investigation."

All in all - it all can look like "dooms day" or just as "mehhh, it is just a stronger bugger than a regular bugger" 😋, depending of how one wants to see it. When one looks at OS , one really wonders if it really makes such a HUGE difference - one just needs to be very vigilant and treat accordingly. All else is in "god's hands". *sigh

@jeffmarc — thanks, that was helpful.

Just to clarify, I’ve already had RALP, so my question is really about **timing of salvage**, not adjuvant therapy.

At this point, with a rising PSA, I’m assuming I’m in early recurrence. The questions I’m trying to think through are:

* If PSMA PET is negative, should I proceed with early salvage radiation rather than wait?
* How should field selection be approached (prostate bed vs pelvic nodes)?
* What role and duration of ADT makes sense in this setting?

It doesn’t seem like there’s a single clear answer. On one hand, treating early may offer the best chance of control given my pathology. On the other, there’s the risk of treating more broadly without knowing exactly where disease is.

Balancing that uncertainty—especially with negative imaging—is what I’m trying to sort through. That’s also why I’m considering a second opinion, just to make sure I’m approaching this correctly.

Appreciate any additional thoughts.

@surftohealth88 Thanks so much. I have been reading your posts for a while as I know we are navigating the same terrain. Even when you think you know the answers, it just helps to hear them from someone else. I find I lose my ability to think objectively. I do need to be more of a pest with my Dr.. My inclination with this thing is to "DO IT NOW" which I don't think is a bad strategy based on what we know. Dave