Figure 3.

A 66-year-old presented 3 years out from radical prostatectomy with rising prostate-specific antigen to 1.62. Radical prostatectomy pathology was pT2 Gleason 4 + 3 Nx R0. Standard imaging showed no metastases and fluciclovine positron emission tomography showed bilateral hypogastric lymph nodes as indicated on the circle on the various fused and computed tomography images on the right (a) and left (b). A robot-assisted salvage extended template lymph node dissection was performed with tumor seen in 2/11 nodes seen on the right, but 0/10 on the left. Prostate-specific antigen declined to 0.3 and stable at 15 months follow-up. The case demonstrates multiple challenges in biochemical recurrence: (1) patient selection, (2) ideal imaging modality and localizing disease, (3) performing salvage lymph node dissection without a visible target, and (4) measuring and interpreting clinical benefit