E. David Crawford, MD, presents “PET Tumor Board – Case 3: 62-year-old BRCA2-Positive Prostate Cancer Survivor with PSA Recurrence.”

How to cite: Crawford ED. PET Tumor Board – Case 3: 62-year-old BRCA2-Positive Prostate Cancer Survivor with PSA Recurrence. February 19, 2025. Accessed Aug 2025. https://grandroundsinurology.com/pet-tumor-board-case-3/

PET Tumor Board – Case 3 – 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 11-minute PET Tumor Board session, Dr. Crawford presents a case involving a 62-year-old BRCA2-positive prostate cancer survivor initially treated with radical prostatectomy for Gleason 7 disease. Despite negative surgical margins, he experiences a PSA recurrence years later, treated with salvage radiation and four months of androgen deprivation therapy. His PSA subsequently rises from 0.14 to 0.19.

Dr. Sean Collins recommends a PSMA PET scan, which reveals a suspicious rib lesion without correlating structural abnormalities, raising concerns about false positives. Dr. Sherief Gamie explains that isolated rib findings are frequently misleading and often represent benign post-traumatic changes or fibrous dysplasia, particularly in the absence of corresponding CT or MRI findings. He also notes improved resolution with F-18 tracers like PYLARIFY compared to older gallium-based agents.

Dr. Dan Petrylak characterizes the rib lesion as a red herring and emphasizes the clinical context, noting the PSA remains below the typical salvage threshold of 0.2 ng/mL. He considers either continued observation or eventual salvage systemic therapy. Dr. Collins advises against radiating the rib.

Dr. Gamie recommends reassessment in six to eight months unless PSA doubling accelerates. Dr. Brisbane references the EMBARK trial criteria, noting that a PSA doubling time under 12 months signifies a more aggressive course and may justify earlier intervention. The group discusses the growing use of PSMA PET below formal thresholds when clinical judgment or patient anxiety warrants it.

This case highlights the challenges of interpreting isolated PET findings, the influence of tracer selection, and evolving criteria for imaging and systemic treatment in biochemical recurrence.