A 66-year-old man, with two prior transurethral prostate surgeries
for prostatism, presented with gross painless hematuria. Digital rectal examination
(DRE) revealed a markedly enlarged prostate without induration or nodularity,
and serum prostate-specific antigen (PSA) was 22 ng/mL. Urothelial evaluation
was unremarkable. Transrectal sextant prostate needle core biopsies showed prostatic
adenocarcinoma, Gleason’s score 3 + 4 = 7/10. Radionuclide bone scan showed
no evidence of osseous metastasis. The patient elected radiotherapy with neoadjuvant
androgen deprivation. After four months of total androgen blockade, serum PSA
was undetectable. At the time of computed tomography (CT) scan planning for
conformal radiotherapy, multiple small bowel loops were noted in the pelvis,
as well as a large prostatic volume (Figs 1-2).
Which of the following answers is most appropriate?
1. The patient is not a candidate for radiotherapy and should
be referred for radical prostatectomy.
2. The patient is not a candidate for radiotherapy or surgery,
and hormonal ablation therapy only should be continued.
3. The patient is not a candidate for external radiotherapy,
so interstitial implantation (brachytherapy) should be administered.
4. The patient can be treated with conformal radiation therapy
in a prone position so that the small bowel may be outside the field.