What is the best description of a tumor in an asymptomatic middle-aged or older adult male with a firm prostatic nodule on digital rectal examination (DRE), high-grade tumor cells on transrectal prostate biopsy, and iliac lymph node involvement on imaging?

Higher-Gleason Score and Higher Stage (Answer A)

This patient has a high-grade prostate cancer (higher Gleason score) with lymph node metastases (higher stage), making Answer A the correct description.

Gleason Score Assessment

The histopathologic description reveals features diagnostic of high-grade prostate adenocarcinoma:

• Sheets of tumor cells with no glandular differentiation indicate poorly differentiated cancer, which corresponds to Gleason pattern 5 1
• Large vesicular nuclei and prominent nucleoli are characteristic features of high-grade prostate cancer 1
• The absence of glandular architecture places this tumor in Grade Group 5 (Gleason score 9-10), representing the highest grade category 1

The International Society of Urological Pathology classification system defines Grade Group 5 as Gleason score 9-10, which includes tumors with predominantly pattern 5 (no glandular differentiation) 2, 3. This patient's biopsy clearly demonstrates these high-grade features.

Stage Assessment

The presence of enlarged iliac lymph nodes on imaging indicates regional nodal metastases:

• Lymph node involvement classifies this as at least N1 disease (regional lymph node metastases) 1
• According to the AUA/ASTRO guidelines, patients with high-risk prostate cancer should undergo pelvic imaging (mpMRI or CT) to evaluate for nodal disease 1
• The European Association of Urology confirms that nodal metastases represent advanced stage disease 1
• This patient meets criteria for high-risk prostate cancer based on Grade Group 4-5 alone, and the nodal involvement further confirms higher stage 1

Clinical Context and Staging Workup

For patients with high-grade tumors on biopsy:

• Bone scan and pelvic imaging (CT or mpMRI) are strongly recommended to evaluate for metastatic disease 1
• The NCCN guidelines recommend CT or mpMRI if clinical stage is T3-T4 or if the nomogram probability of lymph node involvement exceeds 10% 1
• Patients with Grade Group 4-5 tumors have significantly elevated risk of nodal metastases, warranting comprehensive staging 1

Common Pitfalls to Avoid

• Do not confuse Gleason grading with staging: Gleason score reflects tumor differentiation (grade), while TNM classification reflects anatomic extent (stage) 1
• Nodal size criteria have limitations: CT and MRI assess nodal metastases based on size, which has imperfect sensitivity and specificity, but enlarged nodes in this clinical context are highly suspicious 1
• The firm prostatic nodule on DRE suggests at least T2 disease (clinically palpable tumor), but the nodal involvement supersedes this in determining overall stage 1