Case Discussion: Intermediate-risk Prostate Cancer: The Case for Radical Treatment

Abstract

any urologists will be familiar with this interesting case. As 66-yr-old man, the patient has good life expectancy, which, sing Australian data [1], I estimate to be around 16 yr. He ppears to have little sexual or urinary dysfunction, and his ather had a good outcome from prostate cancer (PCa) reatment, so I assume this man is expecting cure if possible. is cancer appears to be confined to the prostate on adiologic and statistical grounds, but his tumour has leason pattern 4 elements, and maybe the 1-mm biopsy selected men with Gleason 3 + 4 PCa may have lower risk disease than others. Gandaglia et al. [6] demonstrated that patients with organ-confined Gleason 3 + 4 PCa did not have poorer outcomes compared with counterparts with Gleason 3 + 3 disease, and they defined unfavourable disease as Gleason 4 + 3 or non–organ-confined disease on final pathology. Moreover, Ploussard et al. [7] calculated the risk of missing such clinically significant disease in patients with biopsy-proven Gleason 3 + 4 PCa. When applying very strict selection criteria (PSA 10 ng/ml, PSA density 0.15 ng/ml per gram, 2 cores positive for T1c, and age 70 yr), this risk is reduced to < 20%. This compares with a reclassification rate of 28% in patients in the Prostate Cancer Research International Active Surveillance study [4]. In any case, an important message for all men considering AS for localised PCa is that the possibility of understaging and undergrading must always be considered, but in the case of already established intermediate-risk disease, additional caution is warranted because the safety of AS in such patients has not E U R O P E A N U R O L O G Y F O C U S 1 ( 2 0 1 5 ) 2 0 7 – 2 1 1 10