How would you approach a patient with Gleason 9 prostate cancer and regional lymphadenopathy as well as inguinal lymphadenopathy (M1a) but no bone metastases?

Definitely warrants a balanced discussion. Systemic therapy as the mainstay is definitely the right answer--long-term ADT for sure, at minimum. I think offering to treat the prostate with RT is fair, based on STAMPEDE. For a fit patient with good life expectancy, I would explain to the patient that we are extrapolating, but I would also offer treatment to the pelvic and inguinal lymph nodes. The likelihood of distant disease in the future remains high, though, even with local treatment.

I think this patient has stated above fits the high-risk category in the STAMPEDE trial. Although not a significant survival advantage but close to it and very impressive freedom from progression. Therefore, I would treat the prostate with radiation and add ADT with abiraterone. I think they did not treat regional nodes, and I doubt the benefit with the additional effective systemic treatment I also think an inguinal node is still N1, but remain to be corrected.