Advanced prostate cancer presenting as bulky loco-regional disease without distant metastasis: a case report with review of the management - What is the optimal treatment?

BACKGROUND

Prostate cancer is the most common solid tumor in males, with a significant incidence worldwide. PSA screening and digital rectal examination are standard screening methods, yet some patients present with advanced disease because of delayed detection. We present the case of locally advanced prostate cancer presenting with large pelvic lymphadenopathy as a unique presentation.

CASE PRESENTATION: A 65-year-old man presented with lower urinary tract symptoms and a significantly elevated PSA of 226 ng/mL. Physical examination revealed a large, non-tender pelvic mass. Multiparametric MRI revealed a large PIRADS 5 lesion in the prostate (5.6 × 3.6 cm) with extensive invasion, including seminal vesicles and the right posterior bladder wall. PET PSMA scan showed extensive regional lymph node involvement but no distant metastasis. Prostate biopsy showed Gleason 8 (4 + 4) adenocarcinoma. The patient was classified as having Stage IVa (T3bN1M0) prostate cancer and underwent treatment with androgen deprivation therapy (ADT), androgen receptor pathway inhibitors, and intensity-modulated radiotherapy (IMRT), targeting the prostate and pelvic lymph nodes. The patient achieved a PSA at 6 months 1.5 ng/mL, and <0.006 ng/mL at 15 months with significant regression of the pelvic mass and lymphadenopathy.

DISCUSSION: De novo metastatic prostate cancer is more prevalent in developing countries, likely due to delayed detection and under-screening. Our case is unique in presenting a pelvic mass as the initial manifestation of locally advanced prostate cancer. While existing guidelines do not subclassify stage IVa prostate cancer patients based on size of the lymph node, our case highlights the importance of personalized treatment strategies based on lymph node involvement.

CONCLUSION

This case presents a unique manifestation of prostate cancer as a large pelvic mass. It emphasizes the importance of early screening and advanced treatment strategies to enhance patient outcomes.