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PROSCA2019 - case 3

Your case challenge (apply data presented at ESTRO 2019)

Rémi, 72 years old, used to be a molecular biologist, but he had to quit because his bacteria plates were always infected with fungi. He changed careers and became a cheesemaker. He’s happily married and otherwise well. Rémi takes statins and no other regular medication.

He presents with a reduced urinary stream, frequency every 2 hours and nocturia x 3 to 4. A PSA test returns with a level of 16.8 ng/ml. DRE reveals a firm normal sized prostate. MRI identifies an index lesion in the left peripheral zone and radiological stage T2b.

Biopsies :

  • 10 cylinders (template): Gleason 3+4 [ISUP grade 2] bilateral in peripheral zone; 8/10 positive
  • 2 cylinders directed to dominant lesion: Gleason 4+5 [ISUP grade 5] in dominant lesion; 2/2 positive

A CT scan for staging identifies an enlarged right obturator lymph node 14 mm diameter and a smaller common iliac node 11 mm. It is otherwise clear and an isotope bone scan is also clear.

Which treatment would you recommend for Rémi?