Elective Regional Nodal Irradiation in Prostate Cancer

Elective nodal radiotherapy (ENRT) targets microscopic pelvic lymph node metastases to improve locoregional control in prostate cancer. Recent randomized trials report improved outcomes, particularly in high-risk cohorts, albeit with modest increases in Grade 2 gastrointestinal (GI) and genitourinary (GU) toxicities. Molecular imaging has markedly refined patient selection, enabling precise identification of occult nodal disease and enhancing application of ENRT beyond traditional clinical parameters. Modern radiation therapy approaches, including image-guided intensity-modulated radiotherapy (IMRT) and stereotactic body radiotherapy (SBRT), have enhanced ENRT efficacy and safety by employing stringent organ-at-risk constraints. Recent evidence supports SBRT-based ENRT (25 Gy in 5 fractions), demonstrating both efficacy and acceptable toxicity profiles. In the postoperative adjuvant context, ENRT shows promise for patients with pathological nodal involvement (pN+), particularly those with ≥3 positive nodes, high-grade disease, or positive surgical margins. In the salvage setting, combining ENRT with short-term androgen deprivation therapy (ADT) may benefit patients with biochemical recurrence and adverse pathological features, even in node-negative cases. Until definitive data emerges from ongoing randomized trials, multidisciplinary evaluation and integration of modern imaging and radiotherapy techniques remain essential for optimal ENRT in prostate cancer.