A 68-year-old man from Delhi presents with lower urinary tract symptoms (LUTS) including hesitancy and nocturia for 6 months. Digital rectal examination reveals a hard, irregular prostate with loss of the median sulcus. PSA is 18 ng/mL (normal <4). Transrectal ultrasound-guided biopsy shows adenocarcinoma of the prostate with a Gleason score of 8 (4+4). Staging investigations including pelvic MRI and bone scan show no distant metastases. What is the most appropriate next step in management?

Explanation

## Clinical Assessment This patient has **locally advanced prostate cancer (cT2c, Gleason 8, PSA 18)** with no distant metastases — a candidate for **curative intent therapy**. ### Key Staging Features **Key Point:** Gleason score 8 (4+4) indicates **high-grade disease** with intermediate-to-high risk of progression. The hard, irregular prostate with loss of median sulcus on DRE suggests **extraprostatic extension** (cT2c or cT3a). ### Treatment Algorithm for Localized/Locally Advanced Prostate Cancer ```mermaid flowchart TD A[Prostate cancer diagnosed]:::outcome --> B{Metastatic disease?}:::decision B -->|Yes| C[Palliative ADT ± chemotherapy]:::action B -->|No| D{Risk stratification}:::decision D -->|Low risk| E[Active surveillance OR RT/RP]:::action D -->|Intermediate risk| F[RP with PLND OR EBRT + ADT]:::action D -->|High risk| G[RP with PLND + ADT OR EBRT + ADT]:::action F --> H[Curative intent]:::outcome G --> H ``` ### Why Radical Prostatectomy with PLND? 1. **Curative potential:** Patient is fit, non-metastatic, with localized/locally advanced disease — surgical cure is the goal. 2. **Gleason 8 + PSA 18:** High-grade disease warrants **pelvic lymph node dissection (PLND)** to stage and treat potential nodal involvement. 3. **Age 68:** Reasonable life expectancy (>15 years) justifies aggressive curative therapy. 4. **Complete staging:** PLND provides pathological staging; negative nodes improve prognosis. **Clinical Pearl:** For high-risk localized prostate cancer (Gleason ≥8, PSA >20, or cT3), **RP + PLND is equivalent to EBRT + ADT** in terms of oncologic outcomes [cite:EAU Prostate Cancer Guidelines 2023]. However, RP offers the advantage of **complete pathological staging** and avoids long-term ADT toxicity if nodes are negative. **High-Yield:** The **D'Amico risk classification** stratifies prostate cancer: - Low risk: PSA <10, Gleason ≤6, cT1–T2a - Intermediate risk: PSA 10–20 OR Gleason 7 OR cT2b - High risk: PSA >20 OR Gleason ≥8 OR cT3a This patient is **high-risk** → curative intent therapy mandatory. ### Why Not the Other Options? **Watchful waiting** is reserved for **low-risk, early-stage disease** with limited life expectancy; this patient has high-grade, locally advanced cancer. **EBRT alone** (without ADT) is suboptimal for high-risk disease; **EBRT + ADT** would be acceptable, but RP + PLND offers superior staging and avoids ADT toxicity if nodes are negative. **ADT monotherapy** is palliative, not curative; used for metastatic disease or as neoadjuvant/adjuvant to RP or EBRT, never as sole therapy for localized disease.