1. Managing pelvic lymph nodes and related toxicity - Radiation perspective - Thomas Wiegel

3. RT of suspected disease (cNx)

6. RTOG 9413 Roach III M et al., J Clin Oncol 10, 2003

7. RTOG 9413 Roach III M et al., J Clin Oncol 10, 2003

8. RTOG 9413 Roach III M et al., J Clin Oncol 10, 2003

9. RTOG 9413 - Update Lawton CA et al., Int J Radiat Oncol Biol Phys 69, 2007

10. RTOG 9413 – Update - med. FU 6.6 years Lawton CA et al., Int J Radiat Oncol Biol Phys 69, 2007

11. RTOG 9413 - Update Lawton CA et al., Int J Radiat Oncol Biol Phys 69, 2007

12. RTOG 9413 - Update Lawton CA et al., Int J Radiat Oncol Biol Phys 69, 2007

13. RTOG 9413 - Update Lawton CA et al., Int J Radiat Oncol Biol Phys 69, 2007 bNED protocol definition Phoenix definition

14. RTOG 9413 - Update Lawton CA et al., Int J Radiat Oncol Biol Phys 69, 2007

16. GETUG-01: Progression-free survival Pommier P et al., J Clin Oncol 25, 2007 High-risk group Low-risk group 5-year PFS and overall survival similar in the two treatment arms

17. Roach et al., Br. J. Cancer 2005 All major elderly Phase-III-studies with RT pel. LN

18. RT of positive node PCA (pN+)

20. MD-Anderson-trial (retrospective) Zagars et al., Urology 58, 2001 Clear advantage for RT + AA OS PFS

21. Lawton et al., J. Clin. Oncol. 23, 2005 AA + RT versus RT (RTOG 85-31) Retrospective subgroup-analysis

22. Lawton et al., J. Clin. Oncol. 23, 2005 AA + RT versus RT alone (RTOG-trial 85-31) OS

23. Lawton et al., J. Clin. Oncol. 23, 2005 No data from a prospective trial are available. „ So until such data are available, RT and immediate hormonal manipulation clearly remain an effective means to control pN+ PCA in a significant cohort of men with such aggresive disease...“

24. Da. Pozzo et al., Eur. Urol. 55, 2009 Adjuvant RT for LN (+) – pts. after RP Retrospective series N=250 Patients

25. Da. Pozzo et al., Eur. Urol. 55, 2009 Adjuvant RT for LN (+) – pts. after RP

27. Briganti et al., Eur. Urol. 2011, in press OS in the overall matched population 84% vs. 65% 19% better OS

28. Briganti et al., Eur. Urol. 2011, in press OS for pts. with <= two LN 19% better OS

32. Lawton et al., Int. J. Radiat. Oncol. Biol. Phys.74, 2009 Conclusion: Consus urgently needed

33. Periprostatic LN www-rtog.org RTOG consensus for delineation of the target volume

34. Iliac lymph nodes www-rtog.org/ Lawton CA, Int. J. Radiat. Oncol. Biol. Phys. 74, 2009

35. Presacral nodes RT Pelvic Lymphatics (CTV) www-rtog.org

36. IMRT of the pelvic lymphatics - Comparison 3D-planning vs. IMRT - 3-D-RT IMRT

38. „ Fast“ IMRT – Rapid Arc/Volumetric Arc Technique/Tomo Yoo et al., Int J Radiat Oncol Biol Phys 76 (2010) Bladder- and rectum sparing

39. Ashman et al., Int. J. Radiat. Oncol. Biol. Phys.63, 2005 Wang-Chesebro et al., Int. J. Radiat. Oncol. Biol. Phys. 66, 2006 Ganswind et al, Int J. Radiat. Oncol. Biol. Phys. 67, 2007 IMRT of the pelvic lymphatics Reduction of dose and volume to small bowel Mean dose: 33 Gy vs. 26 Gy

40. Side effects

41. RTOG 9413 Roach III M et al., J Clin Oncol 10, 2003 • Neoadj. TAB 2 mo. before/during RT pel. LN + Boost • Neoadj. TAB 2 Mo. before/during RT of prostate • RT pel. LN + prostate + 4 mo. adjuvant HT • RT prostate + 4 mo. adjuvant HT

42. GETUG-01: Acute and late Toxicity Pommier P et al., J Clin Oncol 25, 2007

43. Chung et al., Int. J. Radiat. Oncol. Biol. Phys. 71, 2009 Comparison IMRT vs. IMRT/IGRT RT pelvic lymphatics Significant reduced acute Side effects II (p=0.004) Small prospective series – 10 vs. 15 Pts.

44. Upcoming ARO-study for pN+ after RP (ART-2)

46. ART-2-Study bNED after 5 years for pN+ Bern study – none HT 1 LN+: 24.7% bNED >= 2 LN+: 11.8% 4.9% Schuhmacher et al., Eur. Uro. 54, 2008

47. ART-2-Study Augsburg (unpublished) - pN+ bNED after 3 years – none HT micro metastases (0.2 – 2mm)(20/56): 64% metastases (55/74): 35% 1micro metastasis: undetectable range: 86% 1 metastasis: undetectable range: 56% >1 metastasis: 47% Weckermann et al., Augsburg

48. Flow-Chart ART-2 study No hormonal treatment! RP (</= 2 LK-mets) Central pathologic review PSA Undetectable range (<0.1 ng/ml) R Wait and See RT pelvic lymphatics (50.4 Gy) SM +: 64.8 Gy SM: + or -

51. ART-2-study Stratification Gleason-score <7 vs. >=7 Margin R1 vs. R0 Stage: pT2 vs. >pT2 PSA before R.: <0.03 vs. >0.03<0.1 Metastases: Micromets. vs. 1 Mets. vs. 2 Mets

53. Urologists and Radiation Oncologists are friends!