## Clinical Assessment This patient has **locally advanced prostate cancer (cT2c, Gleason 8, PSA 12)** — intermediate-to-high risk disease with no distant metastases. ### Gleason Score Interpretation **Key Point:** Gleason score 8 (4+4) represents **intermediate-to-high risk** disease and mandates definitive local therapy, not observation. ### Risk Stratification | Risk Category | Gleason Score | PSA (ng/mL) | T Stage | Management | |---|---|---|---|---| | Low | ≤6 | <10 | T1–T2a | Active surveillance or monotherapy | | Intermediate | 7 | 10–20 | T2b–T2c | Definitive therapy ± ADT | | High | ≥8 | >20 | ≥T3 | Multimodal therapy (surgery + ADT or EBRT + ADT) | ### Treatment Options for Intermediate-High Risk Localized Disease **Radical prostatectomy** is the gold standard for fit men with life expectancy >10 years because: 1. Provides definitive pathological staging (lymph node assessment, margin status) 2. Allows for curative intent in a single modality 3. Avoids long-term ADT toxicity if no nodal involvement found 4. Superior oncologic outcomes vs. radiation alone in this age group **High-Yield:** Pelvic lymph node dissection is essential in intermediate-to-high risk patients to assess N-stage; if positive nodes found, adjuvant ADT is added. **Clinical Pearl:** At age 68 with no comorbidities mentioned and intermediate-high risk disease, this patient is an ideal candidate for surgical intervention. ## Why Other Options Are Suboptimal - **EBRT alone:** Acceptable but inferior to surgery in fit candidates; typically combined with ADT for Gleason ≥7 - **ADT monotherapy:** Not curative; used only for metastatic or very high-risk disease unfit for local therapy - **Active surveillance:** Contraindicated in Gleason 8 disease; reserved for Gleason ≤6, PSA <10, T1–T2a (low-risk only)
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