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Locally advanced non-metastatic prostate adenocarcinoma — MSRA MCQ

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HardProstate CancerLocally advanced non-metastatic prostate adenocarcinomaMSRA

A 64-year-old man has newly diagnosed prostate adenocarcinoma. Multiparametric MRI shows extracapsular extension without seminal-vesicle invasion (cT3a). Targeted biopsy shows Gleason score 4+3=7 (grade group 3). PSA is 18 micrograms/L. PSMA PET/CT shows no nodal or distant metastases. He is fit for curative treatment and, after MDT discussion, chooses radical external beam radiotherapy rather than prostatectomy. Using the Roach formula, his estimated risk of pelvic lymph-node involvement is 22%. Which radical treatment plan is most appropriate to discuss with him?

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Correct answer: A — Radical external beam radiotherapy with androgen deprivation therapy, with pelvic radiotherapy considered

Explanation lettering: C = shown as A · E = shown as B · B = shown as C · A = shown as D · D = shown as E

This is locally advanced (cT3a) disease and therefore CPG4, despite the PSA being below 20 micrograms/L. For CPG2–5 localised or locally advanced disease treated non-surgically with curative intent, NICE recommends radical radiotherapy combined with androgen deprivation therapy (ADT), rather than either treatment alone. Six months of ADT should be offered; for CPG4 disease, continuing ADT for up to 3 years can also be discussed. The additional discriminator is pelvic nodal risk. The Roach estimate is 2/3 × 18 + 10 × (7−6) = 22%. NICE advises considering pelvic radiotherapy when locally advanced disease has a lymph-node risk above 15% and the person is receiving neoadjuvant hormonal therapy with radical radiotherapy. Negative PSMA PET/CT does not remove this risk-based consideration. A omits ADT. B provides the core combined treatment but fails to consider elective pelvic treatment despite a 22% calculated nodal risk. D incorrectly requires radiologically visible nodal disease; the NICE threshold is estimated risk above 15%. E is not appropriate for a fit person choosing curative treatment for non-metastatic locally advanced disease.

Reference: NICE NG131: Prostate cancer: diagnosis and management — Recommendations (Last updated 15 December 2021) — https://www.nice.org.uk/guidance/ng131/chapter/Recommendations NICE NG131: Prostate cancer: diagnosis and management — Locally advanced prostate cancer (Last updated 15 December 2021) — https://www.nice.org.uk/guidance/ng131/chapter/Recommendations NICE Quality Standard QS91: Prostate cancer — Quality statement 3, Combination therapy (Last updated 30 December 2021) — https://www.nice.org.uk/guidance/qs91/chapter/Quality-statement-3-Combination-therapy