A 68-year-old man from Delhi presents with lower urinary tract symptoms (LUTS) for 6 months: nocturia (×4), hesitancy, and weak stream. Digital rectal examination (DRE) reveals a hard, irregular prostate with loss of the median groove. Serum PSA is 18 ng/mL (reference <4 ng/mL). Transrectal ultrasound-guided biopsy shows adenocarcinoma, Gleason score 7 (3+4). MRI pelvis shows tumour confined to the prostate with no extracapsular extension. What is the most appropriate next step in management?

Explanation

## Clinical Assessment This patient has **localized, intermediate-risk prostate cancer** (Gleason 7, PSA 18, clinical stage T2) with no evidence of metastatic disease or extraprostatic extension on imaging. ### Risk Stratification **Key Point:** Prostate cancer risk is stratified using the **D'Amico classification**: | Risk Group | PSA | Gleason | Clinical Stage | |---|---|---|---| | Low | <10 | ≤6 | T1–T2a | | Intermediate | 10–20 OR | 7 | T2b | | High | >20 OR | ≥8 | ≥T3 | This patient: PSA 18, Gleason 7, T2 → **Intermediate risk**. ### Treatment Options for Intermediate-Risk Localized PCa **High-Yield:** For intermediate-risk disease with no metastases and life expectancy >10 years, **curative intent** is indicated. The two main options are: 1. **Radical prostatectomy (RP)** with pelvic lymph node dissection (PLND) - Gold standard for fit patients <70 years - Allows histopathological staging and margin assessment - This patient is 68 with no comorbidities mentioned → suitable candidate 2. **EBRT + ADT** (6–36 months depending on risk) - Equivalent oncologic outcomes in intermediate risk - Better for older or medically unfit patients - Longer treatment duration; late GI/GU toxicity risk **Clinical Pearl:** At age 68 with intermediate-risk disease, **radical prostatectomy is preferred** if the patient is fit for surgery, as it offers: - Complete histopathological assessment - Potential for cure with single intervention - Lower long-term toxicity vs. EBRT - Pelvic PLND staging (15–20% risk of nodal involvement in intermediate risk) ### Why Other Options Are Incorrect **Active surveillance** is reserved for **low-risk disease** (Gleason ≤6, PSA <10, T1–T2a). This patient's Gleason 7 and PSA 18 make him ineligible. **TURP** is palliative for LUTS in advanced/metastatic disease; it is NOT a curative modality and is contraindicated in localized cancer (risk of capsular perforation and tumour seeding). [cite:Harrison 21e Ch 97]