How to cite: Crawford, E. David. PET Tumor Board–Case 7: A Case of a 71-year-old with PSA of 6.3; High PSA Density, and a PI-RADS 4 Lesion. August 15, 2025. Accessed Jan 2026. https://grandroundsinurology.com/pet-tumor-board-case-7/

PET Tumor Board–Case 7: A Case of a 71-year-old with PSA of 6.3; High PSA Density, and a PI-RADS 4 Lesion – Summary

Why Watch: A multidisciplinary prostate cancer tumor board highlights how prostate-specific membrane antigen (PSMA) positron emission tomography (PET) can detect clinically significant disease after a negative magnetic resonance imaging (MRI)-guided biopsy.

In this multidisciplinary prostate cancer tumor board, E. David Crawford, MD, Editor in Chief of Grand Rounds in Urology and Professor of Urology, University of California, San Diego, California, moderates a case discussion featuring urology, radiation oncology, medical oncology, and nuclear medicine perspectives. The case involves a 71-year-old man with a prostate-specific antigen (PSA) of 6.3 ng/mL, an MRI showing a PI-RADS 4 lesion, and an initial Artemis transperineal biopsy (systematic and targeted) that was negative. Despite this, PSA density was elevated, and later rose to 10 ng/mL. 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, University of California, San Diego, 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

Panelists emphasized the importance of PSA density as a low-cost, underutilized risk stratification tool and noted Confirm mdx and other molecular assays as adjuncts when biopsy is negative but clinical suspicion persists. When PSA continued to rise, this patient underwent PSMA PET at UCLA as part of a clinical trial. Imaging revealed a lesion not visible on prior MRI, highlighting the superior sensitivity of PSMA PET in the anterior prostate. A targeted fusion biopsy confirmed Gleason 4+5 disease.

The patient underwent local therapy, and his PSA has remained undetectable for four years. The panelists emphasized that imaging and biopsy are complementary rather than absolute tests. This case underscores the emerging role of PSMA PET in patients with persistently elevated PSA and negative biopsy/MRI.