How would you manage prostate cancer with isolated presacral nodal metastasis?

Unfortunately, we can't really use RTOG 0521 to guide us here, as men with involved nodes detected by imaging were excluded. Also, according to the AJCC 8th edition staging manual, pre-sacral nodal involvement would be considered N1 rather than M1a, so although this man is at high risk for subsequent development of metastases, he isn't in that category yet. In this case, I would treat him as a very high risk M0 patient, with long term androgen deprivation combined in addition to comprehensive nodal radiation and treatment to the prostate and seminal vesicles. In cases such as these, if the involved node is not immediately adjacent to bowel, I will try to use a simultaneously integrated boost to bring the dose up to around 60 Gy in 4.5-5 wee...