68-year-old man with PSA 9.8 and prostate nodule
A 68-year-old man is evaluated for urinary hesitancy and nocturia. He has hypertension and well-controlled type 2 diabetes. Digital rectal examination reveals a firm, irregular nodule in the peripheral prostate. PSA is 9.8 ng/mL, up from 4.1 ng/mL 18 months ago. Multiparametric MRI shows a PI-RADS 4 lesion confined to the gland, and transrectal biopsy demonstrates adenocarcinoma, Gleason grade group 2, in 3 of 12 cores. CT and bone scan show no metastases. He is otherwise healthy with a life expectancy greater than 10 years. Which of the following is the most appropriate next step in management?
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C
Explanation
Clinical Pearl:
Localized intermediate-risk prostate cancer in a patient with substantial life expectancy is generally treated with definitive local therapy. Active surveillance is preferred for many low-risk cases, not for otherwise healthy patients with clearly intermediate-risk disease.
Explanation:
This patient has clinically localized prostate adenocarcinoma with intermediate-risk features, including PSA between 10 and 20 or Gleason grade group 2 disease, and he has a long enough life expectancy to benefit from curative treatment. Current practice supports definitive local therapy, most commonly radical prostatectomy or radiation-based treatment, for appropriate patients in this setting. Active surveillance is less appropriate because his biopsy already shows intermediate-risk cancer, making observation a poorer choice than curative treatment in an otherwise healthy man. Androgen deprivation therapy alone is not standard definitive management for localized intermediate-risk disease without a separate indication. Chemotherapy is reserved for more advanced settings, such as metastatic or selected very high-risk disease, not organ-confined grade group 2 cancer. Reassurance without treatment ignores a malignancy that is potentially curable and risks preventable progression.
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