After an elevated serum PSA 22 ng/mL is noted, patient presents to his urologist
Family history of breast cancer (patient’s mother diagnosed at age 82)
Digital rectal exam (DRE) unremarkable, overall physical exam unremarkable
MRI revealed a 40 gm prostate; no extra-prostatic extension, no nodal involvement; 1 ROI, PIRADS-5
Transperineal (TP) MRI fusion biopsy demonstrated prostate adenocarcinoma andGleason score 8/Grade Group 4 in 9 of 12 tissue samples and Gleason score 9/Grade Group 5 in the region of interest
Germline genetic testing revealed no actionable mutations; CT and bone scan revealed no extra-prostatic involvement.

Initial Treatment (starting July 2022)

Patient underwent robotic assisted lap radical prostatectomy (RALP) + PLND; no surgical complications
Pathology confirmed GG5 prostate disease with pT3bN1R1 designation
- Positive surgical margins; 1 of 12 obturator lymph nodes were positive

12-week Follow-up Notes (October 2022)

Post-surgical PSA is undetectable at 12 weeks
Minimal GSI (<1 pad/day)

This is a synopsis of a Case-Based Peer Perspectives series featuring Paul M. Yonover, MD, FACS, of Uropartners/SolarisHealth Partners.

Dr. Paul Yonover discussed treatment options and considerations when counseling the very high risk 66-year-old prostate cancer patient who has excellent performance status and long life expectancy.

He stated that every effort should be made to deliver curative therapy despite the high risk features. Options include radiation therapy or surgical prostatectomy, relying on NCCN guidelines to guide discussions. He routinely refers patients to radiation oncology for opinions on external beam radiation plus androgen deprivation therapy (ADT) with a gonadotropin releasing hormone (GnRH) agonist or antagonist for 18-36 months. Additional radiation options include brachytherapy boost or addition of abiraterone and prednisone to EBRT and ADT for very high risk patients.

If prostatectomy is chosen instead of radiation, Dr. Yonover mandates a pelvic lymph node dissection given the high risk features. He noted most prostatectomies today are performed robotically. With either radiation or surgery, patients must understand side effects and impact on quality of life. Radiation requires readiness for long term ADT and potential cardiovascular and metabolic side effects. Large prostates, baseline lower urinary tract symptoms, or high retention risk should steer away from radiation towards surgery. However, patients who are poor surgical candidates due to co-morbidities may need radiation despite urinary risks. Severe gastrointestinal conditions may also preclude radiation, though hydrogel spacers can help reduce rectal radiation exposure.

Finally, Dr. Yonover emphasizes that curative therapy failure rates are high even with multimodal approaches. Salvage prostatectomy after radiation has many difficulties. Patients need to understand upfront that prostatectomy alone may not be sufficient treatment, and adjuvant or early salvage radiation is frequently recommended after surgery to achieve cure in very high-risk cases.

*Video synopsis is AI-generated and reviewed by Urology Times editorial staff.