Prostate Cancer Case Review: PSMA PET Before Definitive Therapy

"Prostate Cancer Case Review: PSMA PET Before Definitive Therapy" takes up a 77-year-old with newly diagnosed high-risk prostate cancer whose PSMA PET findings shape his path to definitive therapy.

Dr. Ghesani presents the second case: a 77-year-old retired physician newly diagnosed with high-risk prostate cancer, PSA 8.7, and Gleason 8 disease on biopsy. Conventional CT and bone scan were negative, and a PSMA PET was subsequently obtained before definitive treatment planning. Dr. Yonover says he considers PSMA PET essential before proceeding with therapy in a case like this, since surgeons must rule out occult distant metastases and characterize nodal status before recommending prostatectomy or lymphadenectomy. He explains that PSMA PET also helps assess extraprostatic extension, seminal vesicle involvement, and concordance with MRI and biopsy findings, all of which build confidence going into surgery. Dr. Mendel adds that he would want molecular testing results and the pathology report alongside imaging, noting he has been burned before by PET-avid lesions that template biopsies missed entirely. Reviewing the scan, showing two right-sided peripheral zone foci with no extraprostatic uptake, Dr. Yonover explains that unilateral, well-localized disease would lead him to omit nerve-sparing on the involved side while confidently sparing the other bundle. Dr. Mendel describes using the same imaging for radiation planning, noting technical considerations like bowel preparation for fusion accuracy and adjusting margins based on lesion location relative to the rectum. Both physicians discuss how they counsel patients choosing between surgery and radiation, with Dr. Yonover explaining that surgery is agnostic to tumor biology while radiation depends on radiosensitivity, and that highly multifocal, avid disease worries him more for radiation failure. The patient chose prostatectomy and remains undetectable nearly two years later. Dr. Yonover explains that with an undetectable PSA and no adverse pathologic features, he sees no further role for molecular imaging unless PSA becomes detectable or rises, while Dr. Mendel describes waiting until PSA reaches roughly 0.1 to 0.2 before ordering a PET scan and initiating salvage therapy.

Up next, in "Prostate Cancer Case Review: Selecting Radioligand Therapy Candidates," the panel considers a patient with metastatic disease being evaluated for radioligand therapy.