Clinical staging:

T1: cannot be felt, cannot be seen on US. Found on biopsy

T2= confined to within the prostate

T2a: can be felt, <50% of one half
T2b: can be felt, >50% of one half of prostate
T2c: can be felt, bilateral

T3= extraprostatic tumor, not fixed

T3a=extraprostatic extension
T3b=invasion to seminal vesicles

T4=fixed or invades adjacent structures other than seminal vesicles such as external sphincter,
rectum, bladder, levator muscles, pelvic wall

Lymph Nodes: NX = cannot be assessed, N0=no positive regional lymph nodes, N1=mets in
regional lymph nodes (pelvic lymph nodes below the common iliac bifurcation)

M0=no distant mets, M1=distant mets; M1a=nonregional lymph nodes, M1b=bone, M1c=other
PCa Risk Stratification:

very low: cT1c, GG1, PSA <10, PSA density <0.15, fewer than 3 cores positive (<50% cancer in
each core). MUST HAVE ALL OF THESE
 Management: Active surveillance: PSA q6-12 months, DRE q12-24 months, pBx q12-24
months, mpMRI q12-24 months

low: cT1-cT2a, GG1, PSA <10. DOES NOT QUALIFY TO VERY LOW RISK
 Management: Active surveillance: PSA q6-12 months, DRE q12-24 months, pBx q12-24
months, mpMRI q12-24 months

Intermediate: 1 or more of IRF = cT2b-cT2c, GG2-3, PSA 10-20, no high risk or very high risk
features

Favorable: all of 1 IRF, GG1-2, <50% cores positive

 Management: Active surveillance: PSA q6-12 months, DRE q12-24 months, pBx q12-24
months, mpMRI q12-24 months
 EBRT or brachytherapy
 RP +/- PLND:
o If there are adverse features: +margins, +seminal vesicles, +extracapsular
extension, +detectable PSA and NO +lymph nodes:  EBRT +/-ADT or
monitoring with RT for PSA >0.1
o Lymph nodes +  ADT +/- EBRT or monitoring with tx if PSA >0.1
 Follow up:
o Undetectable PSA after RP or PSA nadir after RT: PSA q6-12 months for 5 years –
then q1 year
o PSA persistence/recurrence after RP: PSA doubling time, consider: PSMA and
prostate bed biopsy
 Studies negative for distant mets and pelvic recurrence or imaging not
performed  EBRT +/- ADT
 Progression after further tx 
 Studies + for pelvic recurrence  EBRT + ADT +/- abiraterone
 Progression after further tx 
 Studies + for distant mets 
o PSA recurrence or +DRE after RT: PSA doubling time, PSMA and consider:
prostate bed biopsy
 -biopsy and -workup for mets  ADT
 Progression after further tx 
 +biopsy and - workup for mets  RP+PLND, brachytherapy, cryotherapy,
or HIFU
 Progression after further tx 
 +pelvic recurrence  ADT, pelvic LN radiation, or PLND
 Progression after further tx 
  +distant mets 

Unfavorable: One of 2-3 IRF, GG3, >50% biopsy core positive. Obtain bone scan and pelvic
imaging (Technetium bone scan + CT/MRI CAP or PMSA-PET/CT or MRI)
 Management: EBRT + ADT (4-6 months) or EBRT+ brachytherapy + ADT (4-6 months)
 RP + PLND
o If there are adverse features: +margins, +seminal vesicles, +extracapsular
extension, +detectable PSA and NO +lymph nodes:  EBRT +/-ADT or
monitoring with RT for PSA >0.1
o Lymph nodes +  ADT +/- EBRT or monitoring with tx if PSA >0.1
 Follow up:
o Undetectable PSA after RP or PSA nadir after RT: PSA q6-12 months for 5 years –
then q1 year

High: No very high risk features. One of: cT3a, GG4-5, PSA >20. Obtain bone scan and pelvic
imaging (Technetium bone scan + CT/MRI CAP or PMSA-PET/CT or MRI)
 Management: EBRT + ADT (1.5 – 3 years) or EBRT+ brachytherapy + ADT (1-3 years)
 RP + PLND
o If there are adverse features: +margins, +seminal vesicles, +extracapsular
extension, +detectable PSA and NO +lymph nodes:  EBRT +/-ADT or
monitoring with RT for PSA >0.1
o Lymph nodes +  ADT +/- EBRT or monitoring with tx if PSA >0.1
 Follow up:
o Undetectable PSA after RP or PSA nadir after RT: PSA q6-12 months for 5 years –
then q1 year


Very high: one of the following: cT3b-cT4, primary Gleason pattern 5 (Gleason 9-10), 2-3 high
risk features, >4 cores with GG4-5. Obtain bone scan and pelvic imaging (Technetium bone scan
+ CT/MRI CAP or PMSA-PET/CT or MRI)
 Management: EBRT + ADT (1.5 – 3 years) or EBRT+ brachytherapy + ADT (1-3 years) or
EBRT + ADT (2 years) + abiraterone
 RP + PLND
o If there are adverse features: +margins, +seminal vesicles, +extracapsular
extension, +detectable PSA and NO +lymph nodes:  EBRT +/-ADT or
monitoring with RT for PSA >0.1
o Lymph nodes +  ADT +/- EBRT or monitoring with tx if PSA >0.1
 Follow up:
o Undetectable PSA after RP or PSA nadir after RT: PSA q6-12 months for 5 years –
then q1 year
