What would Mack Roach do? 
Gustave has biochemically recurrent PCa following RP and no evidence of disease on CT and bone scan. His PSA is currently 3.8 ng/ml with a PSA-DT of 8.8 months.
My choice would be to perform a PET/CT scan before initiating further treatment.
The LOCATE trial evaluated the impact of 18F-fluciclovine on treatment plans in the setting of biochemical recurrence of PCa [Andriole GL et al. J Urol 2019;201:322-31]. Included patients had undergone curative intent treatment of PCa, had a rising PSA and had negative or equivocal findings on standard of care imaging. Overall, 59% of patients (126 out of 213 patients) had a change in management after the scan, which were major in 78% of cases. For Gustave, I would change the management plan based on the outcomes of the PET/CT scan. I would perform a PET scan directed boost to the bulky lymph node but also include prophylactic irradiation of pelvic lymph nodes to include common iliac and para-aortic nodes, preceded by neoadjuvant ADT.
I’m happy to discuss these data in more detail during PROSCA on 23-24 October in Paris.