How to cite: Morris, David S., Garmezy, Benjamin, Phillips, John G. “A PCa Case of PSA Rising After RP, Salvage XRT, ADT & a Case of Rising PSA After Triplet Therapy.” November 2025. Accessed Jan 2026. https://grandroundsinurology.com/a-pca-case-of-psa-rising-after-rp-salvage-xrt-adt-a-case-of-rising-psa-after-triplet-therapy/
E. David Crawford, MD, Editor in Chief of Grand Rounds in Urology and Professor of Urology, University of California, San Diego, San Diego, California, introduces a multidisciplinary panel that discusses two complex cases of men with advanced prostate cancer. Panelists include David S. Morris, MD, FACS, Urology Associates, PC, Nashville, Tennessee, Benjamin Garmezy, MD, Sarah Cannon Research Institute, Nashville, Tennessee, and John G. Phillips, MD, MPH, Tennessee Oncology, Nashville, Tennessee.
In the first case, a man with unfavorable intermediate-risk prostate cancer was initially treated with radiotherapy and androgen deprivation. After developing castration-resistant disease, he underwent metastasis-directed therapy (MDT) with stereotactic body radiation to three bone lesions while receiving enzalutamide. Although prostate-specific antigen (PSA) initially became undetectable, recurrence soon followed with multiple new PSMA-avid bone lesions. Dr. Morris presents the imaging and treatment history, while Dr. Garmezy discusses diminishing returns of repeated MDT in the setting of systemic progression. Dr. Phillips emphasizes marrow safety and the value of considering lutetium-177 prostate-specific membrane antigen (PSMA) (PluvictoⓇ) once lesions show widespread uptake, noting that repeated focal therapy risks undertreating diffuse disease. The panel agrees that systemic therapy is preferred when prostate-specific membrane antigen positron emission tomography (PSMA PET) demonstrates extensive progression beyond limited oligometastatic disease.
The second case involves a 77-year-old man with Gleason 9 prostate cancer and an initial PSA of 200, treated with androgen deprivation and apalutamide. He later developed pulmonary and nodal metastases with low PSMA standardized uptake value (SUV) uptake and concurrent pulmonary embolism. Dr. Garmezy explains that low PSMA expression and visceral disease suggest dedifferentiated or neuroendocrine features, where chemotherapy with docetaxel or carboplatin is favored over radioligand therapy. Dr. Morris adds that Pluvicto could still be considered if the patient declines chemotherapy, but expectations for response should be modest. The panel concludes that PSMA PET phenotype, disease distribution, and patient preference all drive sequencing decisions, reinforcing the importance of multidisciplinary input for optimal care.
ABOUT THE AUTHOR
David S. Morris, MD, FACS, graduated summa cum laude from Vanderbilt University and earned his doctorate from Vanderbilt University School of Medicine in Nashville, Tennessee. Dr. Morris completed his residency training at the University of Michigan in Ann Arbor, Michigan, with a special research interest in genetics that predict the aggressiveness of prostate and bladder cancers. He authored and co-authored multiple scientific papers throughout his training and has presented research findings at regional and national meetings. He helps coordinate the genitourinary cancers program at Urology Associates’ Advanced Therapeutics Center as well as the Urology Associates Clinical Trials Program.
Benjamin Garmezy, MD, is the Associate Director of Genitourinary Research and Executive Co-Chair of the Genitourinary Cancer Research Executive Committee at SCRI Oncology Partners. He specializes in genitourinary oncology research, overseeing clinical trials for prostate, kidney, testicular, and bladder cancers while offering a variety of treatment options to patients, including immunotherapy, chemotherapy, targeted therapy, and precision oncology.
John G. Phillips, MD, MPH, is a board-certified radiation oncologist at Tennessee Oncology in Nashville, Tennessee, and one of the founders of Health Tech Startup. He previously worked as a radiation oncologist and the medical director of Radiation Oncology Pathways at the Dana-Farber Cancer Institute in Boston, Massachusetts. His clinical specialties include internal and external beam radiation therapy, brachytherapy, and systemic radiation therapy.
