Do you treat pelvic lymph node positive prostate cancer with definitive radiotherapy?

Unfortunately, there is relatively little data to guide us in the management of clinically lymph-node positive prostate cancer. As mentioned above, previous RTOG trials included patients with clinically and pathologically positive prostate cancer, however, these only addressed the question of whether adding ADT leads to improved outcomes (it does). RTOG 9608 attempted to answer the question of whether adding RT to lifelong ADT improves outcomes, but this trial was closed due to poor accrual. We do have evidence from the recently published Swedish (Widmark, Lancet 2009) and NCIC/MRC (Warde, Lancet 2011) trials that adding RT to ADT in patients with high-risk prostate CA improves outcomes. Of note, although these patients were clinically lymp...

In the postoperative literature, we are seeing more data to justify treatment of men with higher risk prostate cancer – this includes both the 3 classic adjuvant RCTs (although these only included node-negative patients), and retrospective analyses for LN+ cancer that show reduced cause specific mortality with adjuvant radiation. Although the intact prostate cancer patient with LN+ disease is arguably higher risk than the post-op prostate cancer patient with LN+ disease, it can be fair to extrapolate these data to treat the men with intact prostate cancer and pelvic LNs+, especially when they are young and healthy. An NCDB analysis (Lin et al) supports this rationale as well, to at best, offer a man a chance for improvement in survival. A...

Great question, this always comes up in our GU tumor board and I don’t think there is a right answer, but I would be interested to hear the practice patterns of experts in our field. At our institution we do not treat with definitive radiation for patients with clinically positive lymph nodes on imaging and believe these patients are at too high risk for distant failure and recommend ADT alone. In the post-prostatectomy pathologic positive lymph node setting this is also controversial. The most quoted data is the Messing paper which compared immediate ADT compared to delayed ADT and showed a prostate cancer specific survival benefit. It is unclear how many of these patients also received radiation therapy. RTOG 8531 compared patients with p...

Our dose to involved node is 55 Gy in 25 fraction