Prostate cancer Lymph node radiotherapy
Started by XRT_doc
All the old trials did.
Yes, but I was trained by Roach. I would also treat LNs in an "unhealthy" patient.
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Yup, also psa >20 or t3b disease on imaging/bx
Nope. Wouldn't even consider it for a second (especially if MRI confirmed T1c disease). Treating pelvic LNs electively is over treatment.
Would definitely treat; didn't know this was at all controversial for high-risk disease, esp G4+4. Long-term morbidity from prostate XRT is generally from structures in the high-dose field (urethra, bladder, rectum, etc), and not the 45 Gy to the pelvis. To me, slightly worse GI symptoms during treatment is not a good enough reason to omit and risk a pelvic nodal failure.
This is definitely a controversial area with several experts I've spoken with being against it unless lymph node positive disease is present (and of course other experts being for it). The problem is that there are no studies showing benefit for pelvic lymph node radiotherapy. The question isn't as much the lack of severe toxicity but the lack of evidence that 45 Gy to the pelvic lymph nodes would do any benefit.
It's unclear what the biological significance of nodal disease actually is. The patient will get long-term hormone therapy regardless which would arguably treat the microscopic disease (if it's even there). It's controversial because there is not good data to guide elective nodal coverage and the approach is very dogmatic depending on treating/training institution.
That said, if Roach were giving oral boards to me, my answer would be an emphatic yes, treat the nodes.
That said, if Roach were giving oral boards to me, my answer would be an emphatic yes, treat the nodes.
Another reason why oral boards are useless! Depending on the examiner, we change our approach.
All of the randomized trials addressing this question have been negative. No evidence that elective pelvic node irradiation changes the natural history of the disease. It is "more" treatment without evidence of benefit. It is also not clear is 2 years of ADT is required as this man does not have locally advanced disease as required by RTOG 9202
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yeah but multiple trials since then have shown the benefit of long term ADT in high risk patients even without locally advanced disease - EORTC 22863 for example
There are some recent data supporting short term ADTfor patients like this
http://www.ncbi.nlm.nih.gov/m/pubmed/26530751/?i=21&from=nguyen prostate
RTOG 9910 also had a subset of these patients and showed no benefit to longer term ADT
http://www.ncbi.nlm.nih.gov/m/pubmed/26530751/?i=21&from=nguyen prostate
RTOG 9910 also had a subset of these patients and showed no benefit to longer term ADT
This is not evidence of anything. Hypothesis generating at best. If you are going to give short term ADT (bar patient refusal to long term) best to do it in the context of a trial. There are interesting intensified short term combination ADT trials (ie abiraterone + lupron) going on to see if escalation can substitute for ADT duration.
Though I must admit - my personal values would favor ST ADT at most if I were the patient in this scenario.
Lol. What about rigor?
EORTC 22863 did not include a STADT arm (and 91% of patients enrolled had T3 or greater disease; 1% had non-palpable disease). EORTC 22961 is more relevant to the question at hand (6 months vs 3 years); this trial did include T1-2a patients (<5%) but they had to have N+ disease. As one poster has already commented there were some high risk patients on 9910 and no difference in 4 versus 9 months were observed. My point is that patients with non-palpable, small volume high grade disease with a low PSA have a different natural history than the typical T3, Gleason 9 PSA 20 patient included in the high risk studies of the late 80s and 90s and they may not need LTADT. In other words there is a "favorable" subgroup of high risk disease see RJ this year PMID 26530751.
We would definitely treat nodes at my institution. Interesting that there is such practice variation. Maybe we'll have an answer in ~5-10 years... https://www.rtog.org/ClinicalTrials/ProtocolTable/StudyDetails.aspx?study=0924
I love this question. Where I was trained we were taught to only treat nodes if they had clinical evidence of nodal spread. ENI in PC was more or less taboo. Now our department has fully embraced brachytherapy boost for HR PC ala the ASCENDE trial...but are still not doing whole pelvis or at least covering nodes like in the trial. Not everyone here has the same opinion but the main prostate guy is very strongly against WP or ENI because of a lack of good historical data. Personally I'm not sure how I feel about the benefit of 45 Gy to involved nodes but practically speaking the results of ASCENDE were pretty good and it's hard to argue at least in that setting the additional coverage might not have been beneficial.
Does anyone still not use imrt to treat nodes? It's really pretty well tolerated imo. The toxicity is going to be less than what was seen in those trials
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I would do unilateral lymph node sparing- it's a new technique I just invented using IMRT-SIB boost with a low risk, int risk and high risk volume followed by SBRT then a proton boost to a total dose of 42.751 Gy. You will definitely need IGRT with daily cone beam CT's.
I haven't used it yet but I bet OS would be the same and we would spare the contralateral LN chain with my dose constraint of 0.772 cc of 32.52 Gy!
I haven't used it yet but I bet OS would be the same and we would spare the contralateral LN chain with my dose constraint of 0.772 cc of 32.52 Gy!
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There just isn't a rationale to treat the nodes, other than the fact that all positive long term ADT trials and ASCENDE-RT trials utilized pelvic fields. But with nobody believing "Mad" Max Roach's study except Max and his disciples, it seems to have fallen to the way side. (shall we say ... it's beyond the Thunder Dome?)
It's really interesting that when JCO had the update showing the trial was negative, the conclusion by Max was that it was still positive. But, you gotta hand it to the guy for sticking to his guns. I respect that. Heard him speak about it at a meeting, and I was shocked at his certainty. He spoke like a surgeon! Man, we need more of that in this field. A bunch of .... Anyway...
At this point, I treat the nodes in these cases (if getting 2-3 years of 'mones or ASCENDE type treatment) simply because I'm a real textualist about this (RIP, Nino, we miss you already). And, it gives me something more to do, other than circling the prostate.
I do remember some people theorized that the increased size of the field led to a higher nut dose, and that additional "hormone" therapy may have led to the initial differences. Interesting theory.
It's really interesting that when JCO had the update showing the trial was negative, the conclusion by Max was that it was still positive. But, you gotta hand it to the guy for sticking to his guns. I respect that. Heard him speak about it at a meeting, and I was shocked at his certainty. He spoke like a surgeon! Man, we need more of that in this field. A bunch of .... Anyway...
At this point, I treat the nodes in these cases (if getting 2-3 years of 'mones or ASCENDE type treatment) simply because I'm a real textualist about this (RIP, Nino, we miss you already). And, it gives me something more to do, other than circling the prostate.
I do remember some people theorized that the increased size of the field led to a higher nut dose, and that additional "hormone" therapy may have led to the initial differences. Interesting theory.
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As others above me have stated.. why is a lymph node dissection justified for a 2% probability per the Roach formula/partin tables if they are not a target volume? I'm sure IMRT can be used to limit toxicity to nodes if there was subclinical disease.
Maybe there is some long-term benefit (20 years) we will see similar to breast.
Maybe there is some long-term benefit (20 years) we will see similar to breast.
