Would you recommend definitive XRT with extensive lymph node involvement of prostate cancer?

In cases of lymph node positive disease, I favor RT to the prostate and lymph nodes (with long termADT ± abiraterone) if I believe all the gross disease can be encompassed in a tolerable radiation treatment plan. In STAMPEDE, RT was mandated in all N0 cases and encouraged in N+ cases, which resulted in omission of RT in ≈ 30% of N+ men. Lymph node irradiation (LNI) was encouraged in N+ cases (consistent with current NCCN guidance). It is estimated that approximately 1/3 of N0 patients and 1/2 of N1 patients underwent LNI (Murthy et al., PMID 35907662).

In the modern era, there is some hope of producing a meaningful rate of durable disease control for N+ patients. The Kaplan-Meier estimate of PFS (definition: local progression, nodal progress...