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Expert Opinion / Cases · March 21, 2022

72-Year-Old Male Status Post Radical Prostatectomy, Now Comes With Biochemical Relapse

Written by
Kamal Sahu MD


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  • Charles Maack

    Mar 24, 2022

    #5 - in view of STEMI leuprolide/ADT would be a concern. As an initial alternative I would recommend check testosterone (T) level to ascertain threat. Check prolactin level and if 5 or over, reduce with cabergoline.. Start dutasteride/Avodart to inhibit any T presence converting to DHT. Monitor closely to see if PSA level subsides. Any use of ADT would require very close monitoring and likely lower doses than usually prescribed.

  • stephen vaughan

    Mar 25, 2022


  • Alfonso Rivera

    Mar 25, 2022

    # 3

  • Jaime Lozano

    Mar 25, 2022

    It is important to look at the original pathology in order to be able to make the right decision on his current treatment. What was the original Gleason score? Pathologic staging? Seminal vesicle invasion? Extracapsular extension? Positive pelvic nodes? PSA post op? What does the rectal exam show now? The answer to these questions will guide us to the proper management. PSA 7.5 ng/ml is a very high level for a post prostatectomy patient. He must have gross disease somewhere.

  • Fabio Almeida

    Mar 25, 2022

    Assuming the PET study that was done was a FDG which is typically not helpful for PCa. 
    - Consider PSMA PET/CT for accurate re-staging. With a PSA of 7.5ng/mL unlikely that a PSMA imaging study would be negative. The rapid PSAdT is concerning for bony mets, but recurrence limited to the pelvic soft tissues still in the 20-40% range. He may have options for focal or pelvic salvage radiotherapy. 
    - Consider relugolix for ADT as this has a better CVD profile compared to Lupron (this should actually be the new SOC for ADT)
    - Consider secondary hormonal treatment with bicalutamide (or similar next generation versions enzalutamide, darolutamide, apalutamide)

  • pamela bayer

    Mar 25, 2022

    5- would run a PSMA/Pet to see if possible treatment alternatives with radiation or PSMA Lu and to determine where the tumors are located.  Need risk assessment. Too high risk for ADT with heart condition, Regulorix has the least cardio toxic effect if determine need some ADT treatment. 

  • Charles Maack

    Mar 25, 2022

    Where am I missing the comments regarding a supposed #10? Provided status mentioned "PET/CT with no definite evidence of metastatic disease." What form of PET/CT? #5 continues for me. This man's condition of STEMI requires careful consideration as to treatment with radiation or chemo since either can have an effect on heart issues

  • Fabio Almeida

    Mar 25, 2022

    There is an error on formatting of these posts. If you add a line return it is adding "
    " - so to be ignored

  • edgard ramirez

    Mar 31, 2022

    Debe re-estadificarse. Practicarle un psma-pet/ct o rm.Si no se dispone de este examen,practicar imagenes convencionales (Gammagrafia osea,TC Abdominopelvico y  TC Torax)
    y de acuerdo a los resultados se toma la decision terapeutica

  • Marko Vukovic

    Apr 01, 2022

    I would measure testosteron level, repeat PSA and PSAM-PET CT in one month. Although the patient developed BCR for sure, he may develop castration resistance in the mean time (no date of follow up between 2016 and 2019, so he may developed BCR way before 2019). In that case, it would be reasonable to start with Enzalutamid (if no mets were detected on PSMA-PET)

  • Charles Maack

    Apr 01, 2022

    Any chance we can be provided the actual treatment that ensued and results? We provide our opinions but have no idea how reasonable they are/were.

  • Prasanta Kumar Pradhan

    Apr 03, 2022

    Qualifying PET scan is essential.PSMA PET is required for staging the disease status.However,if FDG PET/CT scan has been done and negative ,then its an advantage and may predict the prognosis.
    i am sure PSMA PET will be positive with the current level of PSA

  • Khoury Elie

    Apr 03, 2022

    Hypofrration radiothérapie plus2year hormotherapie

  • Swapan Kumar   Nath

    Apr 12, 2022

    I would suggest local salvage radiotherapy with ADT for at least two years. 

  • Muhammad Bulbul

    Apr 17, 2022

    It is important to examine the pathology for Gl score, PSM, SVI..., Our practice is to do PET PSMA. It is unusual with a PSA of 7.5 not to see anything on PET PSMA, we are encountering it it with BCR ; PSA under 1.0. Yet our approach to these with documented BCR and short doubling time is a short course of ADT (6 months) and EBRT.

  • Ramon Caballero

    Sep 21, 2022

    PSMA PET Relugolix NHA. While not in guidelines there is evidence for apalutamide (3Presto).

  • Apr 19, 2024

    Pending Moderator approval.

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