What is the treatment approach for a patient with prostate cancer having a Gleason score of 7 (4+3) and 12 out of 18 biopsy cores containing cancer, with low consideration for External Beam Radiation Therapy (XRT)?

Treatment Approach for Prostate Cancer with Gleason 4+3 in 12/18 Cores and Low Decipher Score

For a patient with Gleason 4+3 prostate cancer involving 12 of 18 biopsy cores and a low Decipher score, radical prostatectomy with pelvic lymph node dissection is the recommended treatment approach, especially if external beam radiation therapy (XRT) is not preferred.

Risk Classification and Assessment

• This patient has high-risk prostate cancer based on the extensive involvement of biopsy cores (12/18 = 67%) and Gleason score 4+3=7 1
• Gleason 4+3 is more aggressive than 3+4, as the predominant pattern is 4, which indicates poorer differentiation and worse prognosis 1
• The extensive involvement of biopsy cores (12/18) is an unfavorable risk factor that shifts this patient toward the higher risk category 1
• The low Decipher score suggests a lower genomic risk of metastasis, which is a favorable prognostic factor to consider in treatment planning 2

Treatment Options for High-Risk Disease

• For high-risk prostate cancer patients with life expectancy ≥5 years, recommended treatment options include:

  • Radical prostatectomy with pelvic lymph node dissection 1
  • External beam radiation therapy (EBRT) with 2-3 years of androgen deprivation therapy (ADT) 1
  • EBRT plus brachytherapy with or without ADT 1

• Since XRT is not preferred in this case, radical prostatectomy with pelvic lymph node dissection becomes the primary treatment option 1

Evidence Supporting Surgical Approach

• For patients with intermediate to high-risk disease, radical prostatectomy provides excellent cancer control when the disease is organ-confined 1
• Surgery allows for precise pathological staging and identification of adverse features that may guide adjuvant therapy decisions 2
• Patients with unfavorable intermediate-risk features (including Gleason 4+3) have worse PSA recurrence-free survival and higher rates of distant metastasis compared to those with favorable features 1

Considerations for Adjuvant Therapy

• If adverse pathological features are found after surgery (positive margins, seminal vesicle invasion, extracapsular extension), adjuvant therapy should be considered 1
• Options for adjuvant therapy include:
  • Observation with early salvage radiation if PSA rises 1
  • Adjuvant radiation therapy 1
  • Adjuvant ADT with or without radiation therapy 1

Importance of the Decipher Score

• The low Decipher score suggests a lower genomic risk of metastasis, which may influence decisions about adjuvant therapy after surgery 2
• Despite the low Decipher score, the high volume of disease (12/18 cores) and Gleason 4+3 pattern warrant definitive treatment rather than observation or active surveillance 1

Common Pitfalls and Caveats

• Underestimating the significance of Gleason 4+3 versus 3+4: The former has worse outcomes and requires more aggressive management 1, 3
• Focusing solely on Gleason score without considering tumor volume: The high number of positive cores (12/18) indicates extensive disease that requires definitive treatment 1
• Overreliance on genomic testing: While the low Decipher score is favorable, it should not override the high-risk features of extensive disease and Gleason 4+3 pattern 2
• Delaying treatment: High-risk features warrant prompt definitive therapy to optimize cancer control 1

Follow-up After Treatment

• After radical prostatectomy, serum PSA should fall below detection level within 2 months 2
• Regular PSA monitoring is essential to detect early biochemical recurrence 2
• First follow-up visit should be at 3 months after surgery, including PSA measurement, digital rectal examination, and assessment of treatment-related symptoms 2