Prostate Cancer Staging Work-Up
Risk-Stratified Staging Approach
The staging work-up for prostate cancer should be risk-stratified based on clinical T stage (by DRE), PSA level, and Gleason score, with low-risk patients requiring minimal imaging while intermediate- and high-risk patients need comprehensive metastatic evaluation. 1
Initial Assessment for All Patients
All patients with suspected or biopsy-proven prostate cancer require:
- Digital rectal examination (DRE) to determine clinical T stage 1, 2
- Serum PSA measurement 1, 3
- Histopathologic assessment including Gleason score, number of positive cores, and extent of cancer involvement 1, 3
These three parameters form the foundation for risk stratification and guide all subsequent staging decisions 1, 3.
Risk-Stratified Imaging Protocol
Low-Risk Disease (T1/2, Gleason ≤6, PSA <10 ng/mL)
No additional imaging is required for patients with low-risk disease who are candidates for curative treatment 1. The ESMO guidelines explicitly state that men with low-risk disease do not require further imaging beyond the initial diagnostic work-up 1.
Intermediate-Risk Disease
Patients with intermediate-risk features require:
- MRI or CT of abdomen and pelvis to evaluate for nodal involvement 1
- Bone scan to assess for skeletal metastases 1
The threshold for ordering these studies is: T2a or higher stage, PSA >15 ng/mL, or Gleason score ≥7 1.
High-Risk Disease
Patients with high-risk features require comprehensive staging:
- CT chest, abdomen, and pelvis for nodal and visceral metastases 1, 4
- Bone scan for skeletal metastases 1
Bone scan is specifically indicated when: bone pain is present, locally advanced tumor (≥T3Nx or T1-4N1-3), Gleason grade 4 or 5 present, or PSA ≥10 ng/mL 1.
Role of Advanced Imaging
While PSMA-PET-CT and whole-body MRI demonstrate superior sensitivity and specificity compared to conventional CT or bone scan, the ESMO guidelines note that these modalities have not been shown to improve clinical outcomes 1. Therefore, the evidence is insufficient to recommend their routine use, and patients should not be denied radical local treatment solely based on metastatic lesions identified on novel imaging techniques 1.
Lymph Node Assessment
Pelvic lymphadenectomy should be considered when:
- Partin tables indicate >15% risk of nodal involvement 2, 3
- Patient is undergoing radical prostatectomy 1
- Limited to ilio-obturator regions 1
Lymphadenectomy may be omitted in patients with excellent prognostic factors: T1 stage, Gleason score <6, and PSA <10 ng/mL 1.
Special Considerations
MRI for Local Staging
Pelvic or endorectal coil MRI can be performed if:
- Radical prostatectomy or radiotherapy is planned 1
- Extraprostatic extension is suspected 1
- Results would modify the treatment plan 1
MRI provides T staging and informs surgical technique regarding nerve-sparing and wide excision 1.
Patients Not Suitable for Curative Treatment
Patients who are not candidates for curative treatment due to poor general health or life expectancy <10 years do not normally require staging investigations 1. This avoids unnecessary procedures in patients who will not benefit from aggressive treatment.
Very High PSA Levels
For patients with PSA >100 ng/mL or severe constitutional symptoms, conventional CT imaging is sufficient as the disease burden will be readily visible on standard modalities 4. These patients require urgent palliative intervention rather than extensive staging work-up 4.
Common Pitfalls to Avoid
- Do not order bone scans in low-risk patients with PSA <10 ng/mL, Gleason score <7, and no bone pain—this represents unnecessary testing 1
- Do not perform isolated lymphadenectomy prior to radiotherapy—it should only be done if risk of nodal invasion is high and results will change management 1
- Do not deny curative treatment based solely on novel imaging findings (PSMA-PET or whole-body MRI) if conventional staging shows localized disease 1
- Do not stage patients with life expectancy <10 years who are not curative treatment candidates 1