A 68-year-old man from Delhi presents with lower urinary tract symptoms and elevated PSA of 12 ng/mL. Digital rectal examination reveals a firm, nodular prostate with loss of median sulcus. Transrectal ultrasound-guided biopsy confirms adenocarcinoma of the prostate with a Gleason score of 7 (3+4). Staging investigations including pelvic MRI and bone scan show no evidence of metastatic disease. What is the most appropriate next step in management?

Explanation

## Clinical Context This patient has localized prostate cancer (Gleason 7, PSA 12 ng/mL, no metastases) in a 68-year-old with good performance status and life expectancy >10 years. ## Staging & Risk Stratification | Feature | Finding | Risk Category | |---------|---------|---------------| | PSA | 12 ng/mL | Intermediate | | Gleason | 7 (3+4) | Intermediate | | T-stage | T1c–T2 (on DRE) | Localized | | Metastases | Absent | M0 | | **Overall** | **Intermediate-risk** | **Curative intent indicated** | **Key Point:** Intermediate-risk localized prostate cancer in a fit, younger-elderly man (age 68, presumed life expectancy >15 years) warrants definitive therapy—either radical prostatectomy or radiotherapy with ADT. ## Why Radical Prostatectomy is Optimal Here 1. **Age & Life Expectancy:** At 68 with no comorbidities mentioned, this patient has >10–15 years of life expectancy, making curative intent appropriate. 2. **Gleason 7 (3+4):** Favourable intermediate-risk disease; 3+4 has better prognosis than 4+3. 3. **PSA 12 ng/mL:** Below threshold for high-risk disease; intermediate-risk. 4. **Surgical Candidacy:** No mention of contraindications; patient appears fit for surgery. 5. **Definitive Local Control:** Radical prostatectomy with pelvic lymph node dissection provides excellent oncologic outcomes in intermediate-risk disease and allows pathologic staging. **High-Yield:** For intermediate-risk localized prostate cancer in men with >10 years life expectancy, radical prostatectomy and external beam radiotherapy (±ADT) are both acceptable. Prostatectomy is preferred in younger, fit men because it provides definitive pathologic staging and avoids long-term radiation toxicity. ## Why Not the Other Options? - **ADT alone:** Androgen deprivation without local therapy is suboptimal for localized disease; reserved for metastatic or very high-risk disease where life expectancy is limited. - **EBRT + brachytherapy:** Also acceptable for intermediate-risk disease, but less favoured in this age group due to late toxicity (bowel, bladder) and lack of pathologic staging. - **Active surveillance:** Appropriate only for low-risk disease (PSA <10, Gleason ≤6, T1c–T2a); Gleason 7 mandates active treatment. **Clinical Pearl:** The D'Amico risk classification guides therapy: low-risk (PSA <10, Gleason ≤6, T1–T2a) → surveillance or monotherapy; intermediate-risk → prostatectomy or EBRT ± ADT; high-risk → EBRT + long-term ADT or prostatectomy + ADT. [cite:Harrison 21e Ch 97]