A 68-year-old man from Delhi presents with lower urinary tract symptoms (LUTS) for 6 months: nocturia (×4), weak stream, and incomplete emptying. Digital rectal examination (DRE) reveals a hard, irregular, asymmetric prostate with loss of the median sulcus. Serum PSA is 18 ng/mL (reference <4 ng/mL). Transrectal ultrasound-guided biopsy of the suspicious area shows adenocarcinoma with a Gleason score of 4+4=8. Bone scan and CT abdomen/pelvis show no metastases. What is the most appropriate next step in management?

Explanation

## Clinical Assessment This patient has **locally advanced prostate cancer** (cT2–cT3, Gleason 8, PSA 18 ng/mL) with no evidence of distant metastases. ### Risk Stratification **High-risk disease** is defined by at least one of: - Gleason score ≥8 - PSA >20 ng/mL - Clinical stage ≥T3 **Key Point:** This patient meets high-risk criteria (Gleason 8 and PSA 18 ng/mL). ### Treatment Options Analysis | Feature | Radical Prostatectomy | EBRT + ADT | ADT alone | Watchful waiting | |---------|----------------------|-----------|-----------|------------------| | **Indication** | Localized–locally advanced, fit patient | Locally advanced, unfit for surgery | Metastatic/palliative | Low-risk, limited life expectancy | | **Cure potential** | High (if R0 resection) | Moderate–high | No | No | | **Lymph node staging** | Pelvic dissection provides staging | Clinical staging only | No staging | No staging | | **Morbidity** | Incontinence, erectile dysfunction | Rectal toxicity, erectile dysfunction | Hot flushes, metabolic effects | Progression risk | ### Rationale for Correct Answer **Radical prostatectomy with pelvic lymph node dissection** is the gold standard for: 1. **Fit, younger patients** (age 68 with no comorbidities mentioned) with localized–locally advanced disease 2. **Gleason 8 disease** — aggressive histology warrants curative intent 3. **Pelvic lymph node assessment** — essential for staging and prognostication in high-risk disease 4. **Potential for cure** — PSA <20 ng/mL and no distant metastases make surgery feasible **Clinical Pearl:** In high-risk localized prostate cancer, surgery offers the best oncologic outcomes in fit candidates. Neoadjuvant ADT (2–3 months) may be considered preoperatively to downstage the tumor, but the definitive treatment remains radical prostatectomy. ### Why Other Options Are Suboptimal - **EBRT alone:** Inferior to surgery for localized disease; typically combined with long-term ADT (2–3 years) for high-risk disease, not monotherapy - **ADT monotherapy:** Palliative, not curative; reserved for metastatic disease or patients unfit for local therapy - **Watchful waiting:** Inappropriate for high-risk disease; reserved for low-risk, life-expectancy-limited patients **High-Yield:** Gleason ≥8 + PSA >10 = **curative intent** (surgery or EBRT + ADT), not observation. [cite:Harrison 21e Ch 97]