In a packed session room, expert members of the Guidelines panel on Prostate Cancer discussed the latest developments in prostate cancer based on three case presentations. A multidisciplinary approach and a central role for patients are increasingly important in advanced prostate cancer.
In this case presentation the patient is diagnosed with locally advanced prostate cancer cT3b N0-X M0. Within the framework of a multidisciplinary approach – based on the EAU Guidelines – two strategies may be discussed.
Radical prostatectomy with an extensive pelvic lymph node dissection presents the first treatment option. Before surgery the patient should be fully informed about potential post-operative treatment options. In case the surgical specimen is positive for high risk pathological factor(s) of local relapse (pT3-4), immediate post-operative irradiation will be proposed – provided that the post-operative PSA value is undetectable and the pelvic lymph node dissection is negative. If more than 2 lymph nodes are involved, the irradiation will include the pelvic lymph node pathways (up to 45 Gy) and long-term androgen deprivation therapy (ADT) with an LHRH agonist will be proposed (at least 5 years).
The other treatment option is image-guided intensity modulated radiotherapy (IMRT). Prior to IMRT, an extended pelvic lymphadenectomy may be needed since it will enable the radiation oncologist to modulate the pelvic target volume (no pelvic irradiation should be given in case of pN0 or pN1 < 3 nodes without rupture of the lymph node capsule) and the duration of ADT which should not exceed 3-years if the patient is declared pN0. After surgery and before the simulation CT-scan, two gold fiducial markers will be implanted into the prostate to position the isocentre of the beam with great accuracy before each fraction and to be able to escalate the dose (78 Gy/39 fractions) without increasing the risk of acute and late morbidity.
Beyond their medical expertise, surgeons and radiation oncologists should take into account the technical and human resources at their disposal, quality assurance of their centres, and their patients’ views, in order to be able to provide them with a reasonable hope of cure and good quality of life.