Do you treat pelvic lymph nodes in patients with high-risk prostate cancer who refuse ADT?

The treatment of pelvic lymph nodes for prostate cancer indeed is a controversial issue. I do treat pelvic lymph nodes in high-risk patients in the absence of ADT even though I do not have a phase III study to support its use. My rationale for treatment of pelvic nodes comes from RTOG 75-06. This study compared the use of pelvic vs pelvic and paraortic RT in patients with node positive pelvic nodal disease. In this cohort, there was no difference between the two arms. However, what is interestin...

I assume the rationale for the question is that perhaps ADT is treating microscopic nodal disease and if it is not being given, perhaps pelvic RT should replace it. While I appreciate the theoretical concern, I do not think the data supports it. Although I believe the weight of evidence is against the treatment of pelvic nodes in prostate cancer, the best support for it from prospective trials is in combination with ADT. To my knowledge, RTOG 94-13 is the only prospective randomized trial, of se...