High-risk localised or locally advanced prostate adenocarcinoma — MSRA MCQ

Correct answer: E — Image-guided IMRT of 60 Gy in 20 fractions with 6 months of androgen deprivation therapy, consideration of continuing androgen deprivation for up to 3 years, and consideration of pelvic radiotherapy

Explanation lettering: E = shown as B · B = shown as E

This is CPG 5 disease: he has two CPG 4 features, namely cT3 disease and Gleason score 8. He remains suitable for curative treatment because staging has shown no distant metastases. For CPG 2–5 disease treated with radical external beam radiotherapy, NICE recommends combining radiotherapy with androgen deprivation therapy (ADT), with 6 months of ADT before, during or after radiotherapy. In CPG 4–5 disease, continuing ADT for up to 3 years should also be discussed rather than imposed as a fixed duration. Hypofractionated image-guided IMRT (60 Gy in 20 fractions) is the standard radical external beam schedule unless contraindicated. His estimated pelvic nodal risk exceeds 15%, so pelvic radiotherapy should be considered in the context of neoadjuvant hormonal therapy and radical radiotherapy. A omits the indicated discussion of extended ADT and pelvic radiotherapy. C incorrectly presents 3 years of ADT as mandatory and excludes pelvic treatment. D omits ADT, despite its recommended combination with radiotherapy in this risk group. E is inappropriate because brachytherapy alone should not be used for CPG 4 or 5 disease.

Reference: NICE NG131: Prostate cancer: diagnosis and management — risk stratification (Last updated 15 December 2021) — https://www.nice.org.uk/guidance/ng131/chapter/Recommendations NICE NG131: Prostate cancer: diagnosis and management — radical treatment (Last updated 15 December 2021) — https://www.nice.org.uk/guidance/ng131/chapter/Recommendations NICE NG131: Prostate cancer: diagnosis and management — radiotherapy and locally advanced disease (Last updated 15 December 2021) — https://www.nice.org.uk/guidance/ng131/chapter/Recommendations