What is your approach to a patient with prostate cancer with suspicion of rectal wall invasion but otherwise localized disease?

My approach in a prostate cancer patient with "suspicious" rectal involvement is to verify, in fact, if he has actual rectal involvement, or not and NOT "suspicious" involvement.

I guess my point is that I WOULD BE VERY hesitant to start RT intervention without verifying if the patient had rectal invasion, or not, because the consequent morbidity and outlook for this extent of cancer could be problematic. You are talking potential fistula formation and such, especially in light of the RT higher doses that are used today, especially with brachytherapy added to the mix. So you have to do your 'due diligence' and work him up to the extent possible, so there is no 2nd guessing later. Besides, the area of concern is, presumably, directly adjacen...

I would recommend 3TmpMRI to better characterize local extent of disease. If the patient has clear T4N0 disease, I'd favor giving this patient an extended course of neoadjuvant ADT for 6-9 months with repeat imaging to assess regression. This may be a case where the use of a rectal balloon may be warranted to get dose to the anterior lip of the rectum where the invasion occurred and spare the remainder of the wall.

Number one point: we should not assume that a note on the prostate MRI report along the lines of "possible rectal wall invasion" means (1) that there is any certainty invasion is present or (2) that invasion is through the wall. Of course, degree of suspicion varies, and there is not one answer for all patients here.

These difficult situations should be managed by a multi-disciplinary team. The most common scenario is a posterior prostate tumor with gross EPE and suspicion of possible rectal wall invasion noted on prostate MRI. I discuss with the radiologist to gauge how likely the invasion is. If invasion is thought to be well into the thickness of the wall, I refer for proctoscopy to see if there is any disruption of the rectal mucosa. Usu...