Salvage Nodal Radiotherapy in the PET Era: Long-Term Outcomes

How to cite: Davis BJ. Salvage Nodal Radiotherapy in the PET Era: Long-Term Outcomes. Grand Rounds in Urology. February 2026. Accessed Oct 2026. https://grandroundsinurology.com/salvage-nodal-radiotherapy-in-the-pet-era-long-term-outcomes/

Summary

Brian J. Davis, MD, PhD, FABS, Professor of Radiation Oncology, Mayo Clinic, Rochester, Minnesota, discusses the role of salvage nodal radiotherapy in prostate cancer recurrence, emphasizing how molecular imaging has shifted patterns of disease detection and treatment strategy. He explains that in the pre-positron emission tomography (PET) era, metastatic disease was predominantly identified in bone, whereas modern PET imaging reveals that the majority of recurrences after prostatectomy occur in lymph nodes, often confined to pelvic or para-aortic regions.

Dr. Davis reviews institutional data demonstrating that up to 83 percent of patients with recurrence after prostatectomy and prior radiation have lymph node-only disease, highlighting a shift toward nodal-directed management. He emphasizes that imaging underestimates true disease burden, as pathologic analyses frequently reveal more involved nodes than detected on PET imaging.

He presents long-term outcomes from a retrospective cohort of patients treated with extended nodal radiotherapy combined with androgen deprivation therapy. With a median follow-up of approximately 10 years, prostate cancer–specific survival approaches 96 percent, and a substantial proportion of patients achieve durable disease control with periods free from systemic therapy.

Dr. Davis contrasts extended nodal radiotherapy with metastasis-directed therapy limited to PET-avid lesions. He highlights surgical and clinical trial data demonstrating that treating only visible lesions may miss occult disease, whereas extended field treatment improves regional control and reduces the risk of further metastatic spread.

He also reviews data supporting moderate hypofractionation, which allows shorter treatment courses with comparable toxicity profiles using modern techniques such as intensity-modulated radiation therapy or proton therapy.

Dr. Davis emphasizes that in the PET era, lymph node recurrence is common and potentially curable in selected patients. Extended nodal radiotherapy, including treatment of pelvic and para-aortic regions, represents an effective strategy to improve long-term outcomes when applied in appropriate clinical contexts.

The International Prostate Cancer Update (IPCU), is a multi-day, CME-accredited conference focused on new developments in prostate cancer treatment, diagnosis, and prevention. IPCU 36 featured lectures, interactive discussions, panel roundtables, debates, and case reports. This conference is led by expert physicians and is designed for urologists, medical oncologists, radiation oncologists, and other healthcare professionals involved in the diagnosis and treatment of prostate cancer.

The goal of this educational program is to equip healthcare professionals involved in the diagnosis and treatment of prostate cancer with the up-to-date clinical knowledge and tools they need to best treat their patients. The program will discuss the treatment of prostate cancer from diagnosis to treating advanced and metastatic disease. The conference aims to give physicians exposure to a comprehensive review of treating prostate cancer patients and to give them a chance to discuss the issues with peers and experts.