Post-prostatectomy management of high-risk pathological prostate cancer — MSRA MCQ

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HardProstate CancerPost-prostatectomy management of high-risk pathological prostate cancerMSRA

A 64-year-old man underwent radical prostatectomy for clinically localised prostate adenocarcinoma. Histology shows pT3b disease, Gleason score 4+5=9 (grade group 5), seminal-vesicle invasion and a positive posterolateral surgical margin; pelvic lymph nodes are negative. His PSA is <0.1 micrograms/L at both 8 and 12 weeks after surgery using the same assay. He is fit, has a life expectancy of more than 10 years, and asks whether his adverse pathological features mean he should start further treatment immediately. Which is the most appropriate MDT recommendation?

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Correct answer: C — Start PSA-led surveillance without adjuvant treatment.

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

Despite very high-risk pathological features, including pT3b disease, grade group 5 cancer and a positive margin, he has no current biochemical evidence of residual or recurrent disease: PSA remains undetectable on serial measurements after prostatectomy. NICE specifically advises against immediate postoperative radiotherapy after radical prostatectomy, including for margin-positive disease, except in a clinical trial. It also advises against adjuvant hormonal therapy after prostatectomy, including in margin-positive disease. He should therefore have PSA-led follow-up rather than adjuvant treatment. PSA should be monitored using the same assay, at least every 6 months for the first 2 years after radical treatment. If biochemical relapse develops and metastatic disease is not demonstrated, radical radiotherapy to the prostate bed is then offered. A is inappropriate because adverse histology alone does not justify adjuvant ADT after prostatectomy. B is tempting because of the positive margin and seminal-vesicle invasion, but would be premature without biochemical relapse. D combines two treatments that are used with definitive radiotherapy in other settings, not routinely as adjuvant therapy after prostatectomy. E similarly confuses management after surgery with primary radical radiotherapy for high-risk or locally advanced disease. ([nice.org.uk](https://www.nice.org.uk/guidance/ng131/chapter/Recommendations?utm_source=openai))

Reference: NICE NG131: Prostate cancer: diagnosis and management — Recommendations (Last updated 15 December 2021; exceptional surveillance reviewed May and August 2025) — https://www.nice.org.uk/guidance/ng131/chapter/Recommendations