## Clinical Assessment This patient has **locally advanced prostate cancer** (cT2b-T3, Gleason 8, PSA 18) without distant metastases — classified as **high-risk disease** by D'Amico criteria. **Key Point:** High-risk localized prostate cancer (Gleason ≥8, PSA >20, or clinical stage ≥T3) requires **multimodal therapy** for optimal oncologic outcomes. ### Why Radical Prostatectomy is Correct 1. **Definitive local control:** Radical prostatectomy with extended pelvic lymph node dissection (ePLND) is the gold standard for high-risk localized disease in fit, younger patients (age 68 is reasonable). 2. **Gleason 8 (4+4) justifies surgery:** This intermediate-high grade tumor is still curable with surgery; adjuvant ADT ± RT can be added based on final pathology. 3. **Staging accuracy:** ePLND provides accurate nodal staging and therapeutic benefit in high-risk cases. 4. **Multimodal approach:** Postoperative ADT ± EBRT will be tailored to final pathologic stage (pT3, margin status, nodal involvement). **High-Yield:** For **cT2b-T3, Gleason ≥8, PSA >20** → **surgery ± adjuvant therapy** is preferred over primary radiation in fit candidates. [cite:Harrison 21e Ch 97] ### Why Other Options Are Suboptimal | Option | Rationale for Rejection | |--------|-------------------------| | **EBRT alone** | Inferior to surgery for high-risk localized disease in fit patients; typically reserved for unfit/metastatic cases or combined with long-term ADT. | | **ADT alone** | Palliative, not curative. ADT monotherapy is for metastatic/castration-sensitive disease, not localized high-risk cancer. | | **Active surveillance** | Contraindicated in Gleason 8 and PSA 18; reserved only for **low-risk** disease (Gleason ≤6, PSA <10, cT1c). | **Clinical Pearl:** The combination of hard DRE nodule + Gleason 8 + PSA 18 + no metastases = **high-risk localized disease** → **curative intent surgery** is the standard of care.
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