A 47-year-old man presents with dysuria. Digital rectal examination revealed a nodule in the left lobe of the prostate. The prostate-specific antigen (PSA) level was 65.5 ng/mL. Transrectal biopsy of the prostate revealed adenocarcinoma. CT, MRI, and bone scan showed no metastasis. After 2 months of neoadjuvant hormonal therapy (leuprolide and enzalutamide), retropubic radical prostatectomy and obturator lymph node dissection was performed. He had two positive lymph nodes at that time. Pathologic study showed a poorly differentiated adenocarcinoma (Gleason score of 4 + 4 = 8).

The patient was considered at high risk for recurrence. Therefore, postoperative radiotherapy was started immediately. Three years later, the PSA rose to 0.73 ng/mL. CT showed no metastasis. He was diagnosed with biochemical recurrence and refused to receive salvage radiotherapy. Complete androgen blockade was started, and an intensive follow-up was performed every 1-1.5 months. Eleven months after biochemical recurrence, the PSA increased to 10.4 ng/mL and CT showed left inguinal lymphadenopathy with lymph nodes ~ 2 cm in diameter. A swollen inguinal lymph node was obtained by open biopsy, and pathology revealed metastatic prostate cancer. The patient was treated with estramustine and dexamethasone for 1 year.