Risk Stratification
What are the three main clinical factors used to determine NCCN prostate cancer risk stratification?
PSA level, Gleason Grade Group, and clinical T stage
What Gleason Grade Group corresponds to Gleason score ≤6?
Grade Group 1
What clinical T stage describes a tumor that is not palpable or visible by imaging but diagnosed via needle biopsy?
T1c
What is the preferred management for very low risk patients with life expectancy <20 years?
AS
What treatment is often added to radiation for unfavorable intermediate-risk disease?
Short-term ADT (4–6 months)
What defines very low risk prostate cancer?
T1c, PSA <10 ng/mL, Gleason Grade Group 1, <3 positive cores, ≤50% cancer in any core, and PSA density <0.15.
What Gleason score corresponds to Grade Group 5?
Gleason score 9–10
What does clinical T3a disease indicate in terms of local spread?
Extracapsular extension (beyond the prostate capsule), but not involving the seminal vesicles.
What management strategy is appropriate for favorable intermediate-risk prostate cancer in older patients or those with significant comorbidities?
AS
What is the mechanism of ADT?
LHRH (GnRH) agonists/antagonists suppress luteinizing hormone release from the pituitary gland, which decreases testosterone production by the testes.
Examples: Leuprolide (agonist), Degarelix (antagonist).
b. Blocking androgen receptor binding
Anti-androgens block androgen receptors on prostate cancer cells, preventing testosterone/DHT from activating them.
Examples: Bicalutamide, Enzalutamide.
What defines low risk prostate cancer?
T1–T2a, PSA <10 ng/mL, Gleason Grade Group 1
True or False: A Gleason score of 7 can be both Grade Group 2 and 3.
True
What imaging or exam finding differentiates T3b from T3a staging in prostate cancer?
Invasion of the seminal vesicles (T3b), typically seen on MRI or confirmed by biopsy or intraoperative findings.
After radical prostatectomy, what pathological features might indicate the need for adjuvant or early salvage radiation therapy?
Positive surgical margins, seminal vesicle invasion, extracapsular extension, or rising postoperative PSA (≥0.2 ng/mL)
In which localized risk groups is brachytherapy alone considered an appropriate monotherapy option?
Low and favorable intermediate-risk prostate cancer, assuming adequate urinary function and prostate anatomy
What defines favorable intermediate risk prostate cancer?
One intermediate-risk factor, Grade Group 1–2, and <50% biopsy cores positive
What are the intermediate risk factors?
?cT2b–cT2c ?Grade Group 2 or 3 ?PSA 10–20 ng/mL
A patient has a tumor that is not visible on imaging but was found incidentally during TURP. What clinical stage applies?
T1a: <5% of resected tissue involved
T1b: >5% of resected tissue involved
What treatment is often added to radiation for unfavorable intermediate-risk disease?
Short-term ADT (4–6 months)
What is a key reason to offer nerve-sparing surgery during radical prostatectomy, and for which patients is it most appropriate?
To preserve erectile function; most appropriate for younger patients with low to intermediate risk disease and no evidence of extracapsular extension
What distinguishes unfavorable intermediate risk from favorable intermediate risk, according to the NCCN?
Unfavorable intermediate risk includes: ≥2 intermediate risk factors, Grade Group 3, or ≥50% of biopsy cores positive. Favorable intermediate risk has only 1 risk factor, Grade Group 1–2, and <50% positive cores.
A 68-year-old male has a PSA of 9.5 ng/mL, Gleason 3+4=7 (Grade Group 2), and tumor involving 40% of 8 biopsy cores. What NCCN risk category does he fall into, and why?
Favorable Intermediate Risk — He has one intermediate-risk factor (Gleason Grade Group 2), <50% of biopsy cores positive, and PSA <10 ng/mL. These meet the criteria for favorable intermediate risk.
What is the significance of differentiating between T2a, T2b, and T2c stages in localized prostate cancer?
These sub-stages reflect the extent of tumor involvement within the prostate: T2a = <50% of one lobe, T2b = >50% of one lobe, T2c = both lobes. While all are organ-confined, risk increases with greater volume and bilateral involvement.
For high-risk localized prostate cancer, why is ADT typically combined with radiation, and what is the recommended duration?
ADT improves overall survival by sensitizing cancer cells to radiation. For high-risk cases, long-term ADT (18–36 months) is typically recommended alongside EBRT.
A 70-year-old male with a life expectancy of 12 years presents with T1c prostate cancer, PSA 8.2 ng/mL, Gleason 6 (Grade Group 1), with <3 positive cores and <50% involvement in each. What is the most appropriate initial management option based on NCCN guidelines, and what factors support this choice?
Active Surveillance — The patient meets very low risk criteria (T1c, PSA <10, GG1, limited core involvement, PSA density presumed <0.15), and has >10-year life expectancy. NCCN recommends active surveillance as the preferred initial approach in such cases.