E. David Crawford, MD, presented “PET Tumor Board – Case 6: A Case of a 57-year-old with an Elevated PSA and Small Prostate Volume” on July 15, 2025.

How to cite: Crawford, E. David. PET Tumor Board – Case 6: A Case of a 57-year-old with an Elevated PSA and Small Prostate Volume. July 15, 2025. Accessed Nov 2025. https://grandroundsinurology.com/pet-tumor-board-case-6/

PET Tumor Board – Case 6: A Case of a 57-year-old with an Elevated PSA and Small Prostate Volume – Summary

Why Watch: This case provides insights into integrating prostate-specific membrane antigen (PSMA) positron emission tomography (PET) with magnetic resonance imaging (MRI) and pathology, focusing on a rib finding that affects treatment decisions.

E. David Crawford, MD, presents a 57-year-old man with rising prostate-specific antigen (PSA; 14.9 ng/mL) over 18 months, small prostate volume (~25.8 cc), and concerning PSA density. MRI identified a region of interest. A biopsy confirmed a Gleason score of 3+4=7 in 5 out of 12 cores, consistent with National Comprehensive Cancer Network (NCCN) favorable-intermediate risk disease. Molecular assays (e.g., MyProstateScore 2.0 and Select mdx) were positive for clinically significant cancer. The panelists discuss how such tests can refine risk when deciding between active surveillance and definitive therapy. Discussion participants include:

  • Wayne G. Brisbane, MD, Assistant Professor of Urology, University of California, Los Angeles, California
  • Sean P. Collins, MD, PhD, Radiation Oncologist, University of South Florida, Tampa, Florida
  • Sherief H. Gamie, MD, PhD, Chief & Director Molecular Imaging and Theranostics, Professor of Clinical Radiology, UC San Diego Health, San Diego, California
  • Andrew W. Hahn, MD, Assistant Professor, The University of Texas MD Anderson Cancer Center, Houston, Texas
  • Daniel P. Petrylak, MD, Professor of Medicine (Medical Oncology) and of Urology, Yale School of Medicine, New Haven, Connecticut

In this case, the PSMA PET identified a possible metastasis in a rib, leading to an imaging discussion centered on PSMA PET versus MRI and the potential future role of PET/MRI fusion. Rib “hot spots” on PSMA imaging frequently reflect benign or traumatic causes instead of metastatic disease, which is a possible outcome but uncommon. The panel recommends studying the CT component of PET/CT for osseous changes, reviewing the patient’s physical trauma history, and reserving targeted MRI for cases in which confirmation would alter management.

Management consensus treats this as a localized disease, considering radical prostatectomy and radiotherapy, with urology and radiation oncology consultations. Given the patient’s age (57) and risk category, the patient chose prostatectomy. 

Panel members emphasized the PSA density’s value, the judicious use of molecular tests, careful interpretation of PSMA rib findings, and multidisciplinary decision-making for favorable-intermediate risk prostate cancer.