E. David Crawford, MD, presents “PET Tumor Board – Case 2: A Case of a 72-year-old with Rising PSA and MRI Showing PI-RADSv2.1 Categories 4 and 5.”

How to cite: Crawford ED. PET Tumor Board – Case 2: A Case of a 72-year-old with Rising PSA and MRI Showing PI-RADSv2.1 Categories 4 and 5. Published February 19, 2025. Accessed Aug 2025. https://grandroundsinurology.com/pet-tumor-board-case-2/

PET Tumor Board – Case 2: A Case of a 72-year-old with Rising PSA and MRI Showing PI-RADSv2.1 Categories 4 and 5 – Summary

In this multidisciplinary PET Tumor Board discussion, E. David Crawford, MD, Editor in Chief of Grand Rounds in Urology and Professor of Urology at the University of California, San Diego, presents a real-world case from his clinical practice, extracting meaningful, applicable learning points. Discussion participants include:

  • Wayne G. Brisbane, MD, Assistant Professor of Urology, University of California, Los Angeles, Los Angeles, California
  • Sean P. Collins, MD, PhD, Professor and Vice Chair of Faculty Affairs in the Department of Radiation Oncology, University of South Florida, Tampa, Florida
  • Sherief H. Gamie, MD, Nuclear Medicine Physician, University of California, San Diego, San Diego, California
  • Daniel P. Petrylak, MD, Professor of Medicine (Medical Oncology) and of Urology, Yale School of Medicine, New Haven, Connecticut

In this 13-minute conversation, Dr. Crawford presents a case involving a 72-year-old physician-scientist with a rising PSA and suspicious MRI findings (PI-RADS 4–5) who initially delays biopsy. When eventually performed, the biopsy reveals Grade Group 1 disease on the right but Grade Group 5 (Gleason 9) on the left base. The panel discusses appropriate imaging and management, with consensus that this high-grade disease justifies PSMA PET for staging.

Dr. Gamie affirms that Gleason 9 meets imaging guidelines. Dr. Brisbane emphasizes shared decision-making and recommends discussing both surgery with extended pelvic lymph node dissection and radiation with long-term ADT. Dr. Collins outlines dose-escalated radiation approaches, noting that focal boosting may be limited by tumor diffuseness and possible prostatic urethra involvement.

Dr. Petrylak supports 18 months of ADT, reserving anti-androgens for cases with nodal involvement. Dr. Collins references data from India supporting whole-pelvis radiation even in the absence of PET-positive nodes, arguing that microscopic nodal disease may still benefit from treatment.

The case underscores critical teaching points on imaging utility, intermodality coordination, and PET’s impact in guiding treatment fields and clinical decision-making.