Management of T3N0M0 Prostate Cancer
The standard treatment for T3N0M0 prostate cancer is external beam radiotherapy combined with long-term androgen deprivation therapy (ADT) for 24-36 months, with the addition of abiraterone plus prednisone for 24 months in patients meeting very high-risk criteria. 1, 2
Primary Treatment Approach
Radiation Therapy Plus Hormonal Therapy (Preferred)
External beam radiotherapy combined with long-term ADT (24-36 months) is the standard of care for locally advanced T3 disease. 1, 2, 3
Radiation should be delivered using conformal techniques to a minimum target dose of 70 Gy in 2.0 Gy fractions or equivalent. 2
For very high-risk patients (defined as N1 disease OR at least two of: T3-T4, PSA >40 ng/ml, Gleason 8-10), add abiraterone plus prednisone for 24 months to the radiation and ADT regimen. 1 This combination significantly improves both metastasis-free survival (HR 0.54) and overall survival (HR 0.63) compared to radiation plus ADT alone. 1
This approach achieves superior outcomes compared to radiation alone or ADT alone, with 5-year overall survival rates around 88-91%. 1, 4
Radical Prostatectomy (Alternative for Selected Patients)
Prostatectomy can be considered for T3 disease, but only in highly selected patients with PSA <10 ng/ml and ideally within a clinical trial setting. 2, 3, 5
Patients with cT3a disease and PSA <10 ng/ml can achieve PSA-free survival rates exceeding 70% at 24 months and estimated 5-year PSA-free survival >60% with surgery. 5
Surgery is NOT recommended for patients with Gleason score >7 and node-positive disease (pN1). 3
If surgery is performed and pathology reveals pT3a with positive margins or node involvement, adjuvant radiotherapy or hormonal therapy should be considered. 1, 3
Required Staging Workup Before Treatment
Perform renal ultrasound and CT scan of abdomen/pelvis to exclude metastatic disease before initiating treatment. 2
Abdominal and pelvic CT is mandatory for T3 disease to assess for nodal involvement. 2
Treatment Approaches NOT Recommended
Chemotherapy is NOT recommended for nonmetastatic T3N0M0 prostate cancer. 1, 2, 3
Hormone therapy alone should NOT be used if curative treatment is feasible, as it results in inferior overall survival (67% at 5 years) compared to radiation-based approaches (88-91%). 3, 4
Neoadjuvant hormonal therapy before prostatectomy provides no benefit and is not indicated for T3 cancers outside clinical trials. 1
Follow-Up Protocol
Measure PSA and perform digital rectal examination every 6 months indefinitely. 2, 3
After prostatectomy, measure total serum PSA at 1-3 months, then every 3 months during the first year, then every 6 months for 7 years if undetectable. 3
Progression after external beam radiotherapy is defined as PSA increase on three successive occasions at monthly intervals (Phoenix definition). 2
Critical Decision Points
When to Intensify Treatment with Abiraterone
Add abiraterone-prednisone to radiation plus ADT if the patient has: 1
- Node-positive disease (N1), OR
- At least 2 of the following: T3-T4 stage, PSA >40 ng/ml, Gleason score 8-10
When Surgery May Be Appropriate
Consider prostatectomy only if ALL of the following are met: 5
- Clinical stage T3a (not T3b or T3c)
- PSA <10 ng/ml
- No evidence of seminal vesicle or nodal invasion on imaging
- Patient willing to participate in clinical trial setting
Life Expectancy Considerations
- Ensure life expectancy exceeds 10 years before pursuing aggressive curative treatment, as patients with shorter life expectancy may not benefit from the morbidity of definitive therapy. 2
Common Pitfalls to Avoid
Do not use short-course ADT (<24 months) with radiation for T3 disease—long-term ADT (24-36 months) is required for optimal outcomes. 1, 2
Do not omit staging CT scans—approximately 25% of clinical T3 cases may have occult nodal involvement that changes management. 5
Do not delay salvage ADT excessively after PSA relapse—initiating salvage hormonal therapy at PSA values around 5 ng/ml appears effective in maintaining favorable outcomes. 4, 6
Do not assume biopsy Gleason score accurately reflects final pathology—there is poor concordance between biopsy and specimen Gleason scores in T3 disease. 5