How would you approach de novo metastatic castrate sensitive prostate cancer with extensive locoregional spread causing rectal compression, retroperitoneal lymphadenopathy, and PSA > 3000 but no visceral or bone metastases?  

It sounds like from the question that the patient has T4 disease invading the rectum. This makes the patient ineligible for surgical resection with curative intent. He might still be a candidate for curative intent radiation therapy/ADT +/- abiraterone per STAMPEDE. His highly elevated PSA is very w...