An otherwise healthy 59-year-old man who was recently diagnosed with American Joint Committee on Cancer (AJCC) 8th edition clinical stage IVB (T3aN1M1b) prostate adenocarcinoma presents to the radiation oncology clinic for consideration of radiation therapy. After he was found to have an elevated prostate-specific antigen (PSA) level of 16.7 ng/mL, he underwent a standard transrectal ultrasound–guided biopsy that revealed a prognostic grade group 4 (Gleason score 4+4) in 7 of 12 core biopsies, with lower-grade adenocarcinoma present in the remaining 5 core biopsies. A multiparametric prostate MRI revealed a large (4 cm) Prostate Imaging Reporting and Data System (PIRADS) 5 lesion with extracapsular extension, as well as pelvic lymphadenopathy, including a 2.2-cm left internal iliac node (Figures 1 and 2). A staging bone scan showed focal uptake in the seventh right rib (Figure 3), corresponding to a sclerotic lesion on follow-up CT, which was deemed highly suspicious for an isolated focus of metastatic prostate cancer after careful review in multidisciplinary conference. He was started on upfront systemic therapy with leuprolide, abiraterone acetate, and prednisone. Three months later, his PSA level had decreased to 0.03 ng/mL, and 1 month after that, imaging showed a mixed response to systemic therapy with reduced bilateral pelvic lymphadenopathy and persistent focal uptake in the seventh right rib metastatic lesion. No new lesions were identified.
What is the most appropriate management for this patient?
A. Radical prostatectomy with pelvic lymph node dissection
B. Pelvic external beam radiotherapy (EBRT) and stereotactic body radiation therapy (SBRT) to the bony metastatic lesion
C. Continue with current systemic therapy
D. Intensify systemic therapy with6 cycles of docetaxel
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