Sample report for a synthetic prostate cancer patient
A whole Delibera review, as the treating physician receives it: the case as the records state it, the board’s position, each specialty’s opinion and where it disagreed, the evidence, what the record still needs, and open trials.
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The report
Clinical deliberation summary · Decision support, not a clinical decision · Research-drafted — not clinician-verified
Delibera · GU Tumor Board · Deliberation Summary
70-year-old Grade Group 2 prostate cancer
No PHI
De-identified — this document carries no name, date of birth, or MRN.
Every position in this record was generated by a model configured to a specialty's remit. “The board” and the specialty titles below name those configurations, not people; no clinician authored or reviewed them.
Run 2026-09-28 22:32 UTC
Patient case record
What the referring documents say about this patient, as we read them. Nothing here is the board's opinion.
Staging
- Clinical T stage
- Not provided
- Clinical N stage
- Not provided
- Clinical M stage
- Not provided
- Disease state was used to compute D'Amico risk classification and NCCN risk group (prostate).
- indeterminate
Pathology
- Gleason score was used to compute D'Amico risk classification, Gleason -> ISUP/WHO Grade Group, NCCN risk group (prostate) and AJCC 8th edition prognostic stage group (prostate).
- 3+4=7 (Grade Group 2)
- Cribriform pattern
- present
- IDC-P
- absent
- Histology
- Acinar adenocarcinoma
- Positive margin
- present
- EPE
- present
- SVI
- present
- Nodes positive
- 2/16
Imaging
- study 1 of 5 [earliest] MRI
- Transition zone: PI-RADS 5: 3.0 cm mass anterior left base to midgland. No pelvic adenopathy or suspicious osseous lesions.
- study 2 of 5 [+3 mo] CT
- No evidence of metastatic disease in the abdomen or pelvis.
- study 3 of 5 [+4 mo] NM
- No scintigraphic evidence of osseous metastasis.
- study 4 of 5 [+5 mo] PET/CT
- Radiotracer avid right internal iliac and left common iliac lymph nodes, most consistent with nodal metastases. No osseous uptake to suggest osseous metastases.
- study 5 of 5 [latest] PET/CT
- Posterior to the left posterior bladder wall at the resection site, there is a small area of markedly intense uptake separate from the bladder with SUV max 20.0 (passage shortened) Enlarged left para-aortic lymph nodes with mild PSMA uptake measuring 1.6 x 1.1 cm with SUV max 2.8 and inferiorly 1.5 x 2.0 cm, previously nonenlarged without radiotracer uptake. (passage shortened)
Labs
- PSA was used to compute AJCC 8th edition prognostic stage group (prostate), D'Amico risk classification, NCCN risk group (prostate) and PSA density.
- 06/2025 38.6 (also reported 38.56) · 12/2025 40.67 · 03/2026 1.38 · 05/2026 2.56 · 08/2026 3.46
Performance status, history & goals of care
- Patient age
- 70 years
- ECOG performance status
- 0
He remains very active daily as a personal trainer, has been working as one for 40 years. (passage shortened) PSA nadir to 1.38 after surgery, now with rising PSA
Board consensus — primary recommendation
What the board recommends, why, and what has to be true first. The treating clinician makes the final call.
Primary recommendation
No definitive call until serum testosterone, prior-therapy timeline, and formal cM adjudication return — then treat as conditional framework below.
This is a post-prostatectomy recurrence (pathology pT3b pN1, Grade Group 2, positive margins, extraprostatic extension, seminal-vesicle invasion, focal A high-risk architectural pattern of prostate cancer linked to worse prognosis. pattern) with Prostate-specific membrane antigen PET imaging — more sensitive than conventional imaging for detecting small or nodal/distant disease.–confirmed macroscopic resection-site recurrence (SUV max 20.0, read by Nuclear Medicine) and progressive multi-station nodal disease including new left para-aortic uptake. The disease is under active progression; active surveillance is off the table on the imaging and rising-PSA findings alone. Beyond that, the plan forks on data that are not yet in the record, so no single confident plan is defensible here.
The most likely branch, if confirmed, is metastatic hormone-sensitive prostate cancer, metachronous and The CHAARTED trial — the source of the high-volume vs low-volume metastatic burden definition. low-volume (no bone or visceral disease). In that branch the treating consensus (Medical Oncology, Radiation Oncology, Urology) is: start Androgen-deprivation therapy — lowering testosterone to castrate levels. plus an overall-survival–backed androgen-receptor pathway inhibitor as a doublet, coordinated with consolidative radiotherapy to the prostate bed and involved nodes. Do not add docetaxel routinely in this metachronous, low-volume, age-70 setting.
Two disease-state facts must be established before entering that branch. First, castrate status is undocumented — testosterone has not been measured, so hormone-sensitive versus castration-resistant cannot be assigned, and the whole systemic algorithm hinges on it.
Alternative if equipoise
If formal adjudication returns Clinical metastasis stage: no distant metastases on conventional imaging. / regional-only disease, the emphasis shifts to postoperative prostate-bed plus pelvic-nodal radiotherapy with ADT; SPPORT is indirect (pN1 excluded, PSA capped at 2.0), so field and duration require radiation-oncology planning rather than direct extrapolation.
Patient Goal Alignment
This case record documents no explicit patient goal or care preference. The record notes he is 70, ECOG performance status (0-5) — a functional-status scale; 0 is fully active, 2 means up and about more than half the day but unable to work. 0, and has worked as a personal trainer for 40 years — a functional context, not a stated goal.
Cited references:
- ARCHES (NCT02677896, Armstrong et al.), final OS: enzalutamide+ADT Hazard ratio — the relative rate of an event between two arms; below 1.0 favours the treatment arm. 0.66 (95% Confidence interval — the range of values compatible with the data; a 95% CI crossing 1.0 for a hazard ratio means the result is not statistically significant. 0.53–0.81). [OS] Moderate applicability (nodal-only metachronous subset less represented).
- SPPORT / RTOG 0534 (PMID 35569466) — pelvic-nodal RT + prostate-bed RT + short-term ADT superior to prostate-bed RT alone in N0/Nx, pre-RT PSA 0.1–2.0. Does not apply directly (this patient is pN1, PSA 3.46). [OS/biochemical control in a different population].
- National Comprehensive Cancer Network — the guideline body whose risk groups and category tiers this report cites. Prostate Cancer Guidelines v5.2026 — germline-testing triggers (cribriform, node-positive disease); computed risk classifications INDETERMINATE pending cT/cM (verify against current NCCN document).
Next steps and prerequisites
What to do next. Prerequisites always apply; conditional steps apply only if their "if" turns out to be true.
Prerequisites — recorded with no condition attached
- Serum testosterone — assigns hormone-sensitive versus castration-resistant status; decisive for the entire systemic algorithm.
- Complete prior ADT/ARPI/chemotherapy exposure timeline — the SATURN pooled analysis (PMID 40541485) signals worse outcomes in metachronous patients with prior ADT, so this changes both disease-state assignment and expected benefit.
- Formal clinical M-stage adjudication of the para-aortic nodes (expert PSMA-PET re-read; biopsy if safe and genuinely decision-changing) — reclassification to M1a changes systemic duration and radiation intent. (passage shortened)
- Germline testing and somatic/ctDNA Homologous-recombination-repair genes (BRCA1/2, ATM, PALB2, CHEK2…) — alterations open PARP-inhibitor options. + Microsatellite instability — a mismatch-repair-deficiency marker that can open immunotherapy (pembrolizumab) options./MMR + TMB profiling — not yet ordered; both to be sent now (neither germline nor somatic is recorded as sent). NCCN germline-testing triggers are met on cribriform histology and node-positive disease.
- Baseline cardiovascular, hepatic, renal, and metabolic status (blood pressure, LFTs, renal function, glucose/HbA1c, medication-interaction review) before ARPI selection.
- Patient goals of care — the preference that would select between intensive multimodal therapy and a lower-intensity pathway is not documented and should be elicited.
Conditional steps — each applies only if its condition is met
IF testosterone is non-castrate AND para-aortic nodes are confirmed Clinical metastasis stage: distant metastases present.
treat as metachronous, low-volume metastatic hormone-sensitive disease — ADT + an OS-backed ARPI (doublet, not triplet), coordinated with consolidative radiotherapy to the prostate bed and involved nodes.
IF testosterone is non-castrate AND disease is adjudicated cM0/regional-only
prioritize prostate-bed + pelvic-nodal radiotherapy with ADT; individualize systemic intensification.
IF testosterone is already below castrate level with progression
this is castration-resistant disease — reconstruct the full prior ADT/ARPI/chemotherapy timeline and select the next line accordingly; avoid an empiric ARPI-to-ARPI switch after prior ARPI progression.
IF germline/somatic testing returns a qualifying HRR alteration or MSI-H/Mismatch-repair deficient — the tumor has lost DNA mismatch repair; pairs with MSI-high and can open immunotherapy options.
it opens a future targeted-therapy line at castration resistance — it does not displace the mature-OS ARPI doublet now.
Specialty opinions
Each specialist's final position and reasoning, in their own words.
Model-generated positions — see the authorship note at the head of this record.
Medical Oncologist
Position revised during the deliberation — the earlier wording is not retained in this record
Conditionally endorse ADT plus an OS-backed androgen receptor pathway inhibitor if non-castrate cM1 disease is formally established, generally without docetaxel, while Radiation Oncology evaluates prostate-bed and nodal treatment. First document serum testosterone, complete prior systemic-treatment exposure, cardiovascular and organ-function status, and formal clinical M stage; consider biopsy or expert imaging adjudication of the mildly PSMA-avid para-aortic nodes if their classification would materially change treatment intent.
Where this specialty disagreed
- Partial agreementwith Radiologist: Agree that imaging shows progression and suspicious para-aortic disease, but disagree with describing this as CHAARTED high-volume disease.
- Partial agreementwith Radiation Oncologist: Agree with multidisciplinary radiation review, but MDT or extended-field RT has no established OS benefit and must remain individualized.
- Dissentwith Nuclear Medicine: The PSMA read is useful, but present-tense RLT eligibility is premature and wrong for the unresolved disease state.
Radiation Oncologist
Position revised during the deliberation
Conditional recommendation for consolidative radiotherapy coordinated with systemic therapy, pending confirmation of hormone-sensitive status. (passage shortened)
Important cautions: This extended-field treatment increases acute GI/GU toxicity and marrow exposure; discuss potential travel burden. Patient-specific factors: His active lifestyle and work as a personal trainer make ADT/RT side effects (fatigue, urinary/bowel changes) particularly consequential; involve supportive care early.
Where this specialty disagreed
- Partial agreementwith Radiologist: Agree on imaging findings but refined 'polymetastatic' vs 'low-volume' terminology.
- Partial agreementwith Medical Oncologist: Agree on systemic backbone (ADT+ARPI if HSPC) and need for testosterone confirmation. My role adds the radiation component.
- Dissentwith Nuclear Medicine: Disagree on framing RLT eligibility as current-line actionable.
Urologist
Position revised during the deliberation
No urologic surgical re-intervention is indicated; management is systemic plus radiation, with handoffs to Medical Oncology and Radiation Oncology. New urologic constraint for RT planning: this patient's R1 resection (positive surgical margin), pT3b pathology, and macroscopic resection-site recurrence (SUVmax 20) place him in the prostate-bed-inclusive RT cohort — the Challis data supporting prostate-bed omission applied to R0/lower-stage patients and does not apply here.
Radiation Oncology should include the prostate bed in any field design. (passage shortened)
Where this specialty disagreed
- Partial agreementwith Radiation Oncologist: MDT/extended-field RT framing is appropriate but did not explicitly anchor prostate-bed inclusion to R1/pT3b pathology; MDT OS benefit correctly limited to PFS claim
- Dissentwith Nuclear Medicine: RLT-eligibility per VISION is a wrong-disease-state claim; patient is likely HSPC, ARPI/taxane-naive; RLT is not a current-line option
Radiologist
Position revised during the deliberation
The latest PSMA-PET/CT report states a small area of markedly intense uptake (SUV max 20.0) at the resection site, suspicious for residual or recurrent prostate cancer. (passage shortened) This constitutes progression by Prostate Cancer Working Group 4 — the standard framework for disease-state terminology and trial endpoints. criteria due to new lesions, specifically new M1a nodal disease.
(passage shortened) This pattern of recurrence, with local recurrence and multi-station nodal involvement including new para-aortic nodes, indicates a significant disease burden that is low-volume by CHAARTED definition but extensive for Metastasis-directed therapy — treating individual metastatic lesions (usually with radiotherapy) rather than the disease as a whole. considerations.
Pathologist
Position revised during the deliberation
The post-prostatectomy pathology report describes acinar adenocarcinoma with a Gleason score of 3+4=7 (ISUP Grade Group 2), positive surgical margins, extraprostatic extension, seminal vesicle invasion, and involvement of 2 out of 16 regional lymph nodes (pN1). A focal cribriform pattern is present. (passage shortened) The presence of pN1 disease and cribriform histology are aggressive features.
Nuclear Medicine
Position revised during the deliberation
F-18-PSMA-PET demonstrates macroscopic local recurrence at the prostate bed (SUVmax 20.0, markedly intense) and progressive PSMA-avid nodal disease (right internal iliac, left obturator, left common iliac, and new left para-aortic nodes). (passage shortened)
This confirms PSMA-avidity adequate for RLT, but RLT is not an indicated current-line option—it is hypothetical for a future CRPC line only. (passage shortened)
Testosterone level and formal M1a adjudication remain critical gaps.
Supporting evidence
The papers and guidelines the board drew on, and which specialty used each one.
Source
- The addition of androgen deprivation therapy and pelvic lymph node treatment to prostate bed salvage radiotherapy (NRG Oncology/RTOG 0534 SPPORT): an international, multicentre, randomised phase 3 trial.pubmed · PMID 35569466 · cited by a board statement
- Salvage prostate bed plus elective pelvic node radiation without androgen deprivation therapy.pubmed · PMID 37480525 · retrieved, not cited by any specialty
- Avoiding prostate bed radiation for the PSMA-PET detected nodal recurrence patient post prostatectomy.pubmed · PMID 39676999 · cited by a board statement
Show all 18 sources
- Pattern of recurrence after stereotactic body radiotherapy for para-aortic oligo-recurrent prostate cancer, a multicentric analysis.pubmed · PMID 37597125 · cited by a board statement
- Optimizing the therapeutic ratio of PSMA-PET-guided para-aortic radiotherapy for prostate cancer: A systematic review and structured quantitative synthesis.pubmed · PMID 42691517 · cited by a board statement
- Germline and somatic mutations in prostate cancer: Implications for treatment.pubmed · PMID 38718711 · cited by a board statement
- DNA repair deficiency as circulating biomarker in prostate cancer.pubmed · PMID 36793600 · cited by a board statement
- Recent and Future Developments in the Use of Poly (ADP-ribose) Polymerase Inhibitors for Prostate Cancer.pubmed · PMID 39638687 · cited by a board statement
- Clinical applications of PARP inhibitors in breast, ovarian, and prostate cancer: current insights and future directions.pubmed · PMID 42283711 · retrieved, not cited by any specialty
- Comparative Survival in Metastatic Hormone-sensitive Prostate Cancer by Volume of Disease and Timing of Metastasis: A Living Network Meta-analysis.pubmed · PMID 41193370 · cited by a board statement
- First-Line Systemic Treatments of Metastatic Hormone-Sensitive Prostate Cancer: Updated Systematic Review and Network Meta-Analysis.pubmed · PMID 42171515 · retrieved, not cited by any specialty
- Age and Treatment Intensification in Metastatic Hormone-Sensitive Prostate Cancer.pubmed · PMID 41147826 · cited by a board statement
- Development and Validation of a Computational Histology Artificial Intelligence-Powered Biomarker in Metastatic Hormone-Sensitive Prostate Cancer on Randomized Phase III Trials.pubmed · PMID 42418739 · retrieved, not cited by any specialty
- Impact of comedonecrosis on prostate cancer outcome: a systematic review.pubmed · PMID 37195595 · cited by a board statement
- Oncological outcomes of cribriform histology pattern in prostate cancer patients: a systematic review and meta-analysis.pubmed · PMID 36216967 · cited by a board statement
- SPARKLE: a new spark in treating oligorecurrent prostate cancer: adding systemic treatment to stereotactic body radiotherapy or metastasectomy: key to long-lasting event-free survival?pubmed · PMID 36503429 · cited by a board statement
- Pooled Analysis of the SOLAR and SATURN Clinical Trials Comparing Progression of Synchronous Versus Metachronous Prostate-specific Membrane Antigen-defined Oligometastatic Prostate Cancer Following Systemic and Tumor-directed Therapy.pubmed · PMID 40541485 · cited by a board statement
- Best therapeutic approach in metastatic hormone-sensitive prostate cancer based on disease volume: a systematic review and network meta-analysis.pubmed · PMID 41247101 · cited during the deliberation, not in a final statement
Missing & unconfirmed data
Facts the board wanted and did not have. Anything above that depends on one of these is an assumption until it is confirmed.
The board never established
Unestablished — not retrieved, not confirmed
The completeness assessment flagged the following as missing, and no structured input in the record supplies them. Any board argument resting on one of these rests on assumption.
- disease state (clinical M stage (cM0/cM1))
- clinical T stage
- NCCN risk group (prostate): INDETERMINATE (deterministic gate could not classify -- missing cT stage)
Retrospective: case facts this record has not established or did not use. The forward-looking actions the plan depends on are listed under “Next steps and prerequisites”, earlier in this document.
Clinical trials
Trials in the public registry for this diagnosis. Listing one here says nothing about eligibility — enrollment criteria were not evaluated.
This section lists registry entries matching the diagnosis and reproduces each entry's enrollment criteria exactly as the registry publishes them; it does not assess eligibility, and no criterion has been checked against this patient's record.
Searched “prostate cancer” (recruiting or not yet recruiting). Not narrowed by M stage: this case’s M stage is not recorded or not assessable.
PSMA PET/CT-Guided SBRT Plus Darolutamide in mHSPC NCT07649421
- Status
- Not yet recruiting
- Phase
- Phase 2
- Study type
- Interventional
Using Rectal Hydrogel Spacer for Salvage SABR in Prostate Cancer NCT05597852
- Status
- Recruiting
- Phase
- Not applicable
- Study type
- Interventional
Predictive and Prognostic Markers for Treatment Outcomes in Prostate Cancer Patients NCT03237026
- Status
- Recruiting
- Phase
- Not applicable (observational)
- Study type
- Observational
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