How would you manage a patient with localized prostate cancer treated with radical prostatectomy and found to have a single involved pelvic lymph node on final pathology and a detectable postoperative PSA?

This patient is now in the salvage setting with PSA recurrence after RP and with PSA persistence and node-positive disease. This is a grey area of medicine without level 1 evidence from RCTs but there are some sources of data to help guide optimal outcomes. This patient is at high risk for further metastatic progression in lymph nodes without therapy, and a combined approach of best systemic therapy and radiation is reasonable. Many options exist here which should involve shared decision making with the patient:

1) ADT alone

2) ADT with salvage RT to the prostate bed/pelvis

3) Prostate-specific PET imaging and metastasis directed radiation therapy

4) ADT with PET-directed radiation therapy

5) Addition of a more potent AR inhibitor such as abira...

I largely agree with @Dr. First Last. This is an area more data is needed.

Fortunately, the open and enrolling NRG GU008 is one of the few trials specifically aimed at determining the optimal treatment for pN+ patients post-RP with BCR.

The control arm is salvage RT + 2 years of ADT.

Experimental arm is salvage RT + 2 years of ADT + Abiraterone and apalutamide.

After extensive literature review and discussion in NRG, NCI Prostate Task Force, NCI GU Steering Committee, the functional standard of care was deemed to be salvage RT + 2 years of ADT based on current available evidence. We are lucky this trial is up and running and people should enroll in it to finally have level 1 evidence to establish a new benchmark.

RTOG randomized trials have repo...