After an elevated serum PSA 22 ng/mL is noted, patient presents to his urologist
Family history of breast cancer (patient’s mother diagnosed at age 82)
Digital rectal exam (DRE) unremarkable, overall physical exam unremarkable
MRI revealed a 40 gm prostate; no extra-prostatic extension, no nodal involvement; 1 ROI, PIRADS-5
Transperineal (TP) MRI fusion biopsy demonstrated prostate adenocarcinoma andGleason score 8/Grade Group 4 in 9 of 12 tissue samples and Gleason score 9/Grade Group 5 in the region of interest
Germline genetic testing revealed no actionable mutations; CT and bone scan revealed no extra-prostatic involvement.

Initial Treatment (starting July 2022)

Patient underwent robotic assisted lap radical prostatectomy (RALP) + PLND; no surgical complications
Pathology confirmed GG5 prostate disease with pT3bN1R1 designation
- Positive surgical margins; 1 of 12 obturator lymph nodes were positive

12-week Follow-up Notes (October 2022)

Post-surgical PSA is undetectable at 12 weeks
Minimal GSI (<1 pad/day)

This is a synopsis of a Case-Based Peer Perspectives series featuring Paul M. Yonover, MD, FACS, of Uropartners/SolarisHealth Partners.

Dr. Paul Yonover discussed additional testing and imaging considerations for the 66-year-old very high risk prostate cancer patient.

He stated that he relies heavily on pre-treatment PSMA PET/CT scans rather than conventional imaging with bone and CT scans for metastatic evaluation. He would order a PSMA PET scan for this patient unless unavailable due to limited access or insurance denial. PSMA PET has been supplanting conventional imaging in his practice for unfavorable intermediate, high and very high risk patients per NCCN guidelines.

The patient had germline genetic testing, which Dr. Yonover finds appropriate by NCCN and other guidelines for patients with a strong family history, Ashkenazi Jewish ancestry, or cribriform/intraductal pathology. He typically uses a panel that includes homologous recombination pathway genes and HOXB13, as well as Lynch syndrome genes. He is aggressively obtaining germline testing on appropriate patients at diagnosis.

Dr. Yonover stated he would not order additional somatic tumor testing or prognostic biomarker tests like Decipher or Polaris for this patient, as it would be unlikely to change management given his clearly very high risk disease. He looks forward to future refinements in PSMA PET analysis that may provide prognostic information on PSMA expression levels.

Regarding choice of PET tracer, Dr. Yonover considers 18F-based and 68Ga-based PSMA PET scans to be relatively equivalent for metastatic evaluation, though 68Ga scans tend to have fewer indeterminate bone lesions. Tracer choice is often dictated by institutional availability and insurance coverage. He uses PSMA PET imaging liberally for high risk prostate cancer patients regardless of tracer type.

*Video synopsis is AI-generated and reviewed by Urology Times editorial staff.