Techniques of Pelvic Irradiation

Part of the Medical Radiology book series (MEDRAD)


Even if irradiation of pelvic lymph nodes in prostate cancer is still under debate, there is abundant evidence that a well-defined subgroup of prostate cancer patients benefit from such treatment. Thus, the management of high risk and node-positive patients has evolved significantly in the past few years. New imaging tools such as MR, PET, and sentinel procedures now allow surgeons and radiation oncologists to better target lymph nodes or nodal metastasis. Derived from surgical lymphadenectomy series, sentinel lymph node, or PET/MR imaging data, there exist precise guidelines for target volume delineation. In addition, improved radiation technologies such as IMRT and IGRT enable to deliver high-dose conformal radiation to a target volume while minimizing toxicities to normal tissues and allow differentiated dose prescriptions. In this regard, adjuvant regions (suspected microscopic involvement) are most often treated with 45–50 Gy overall dose. In cases of macroscopic lymph node involvement, overall dose on localized lymph node metastasis should be escalated to ≥60 Gy, depending on tumor volume and surrounding normal tissues. Besides conventional fractionation schemes, first series using a moderate hypo-fractionation to the prostate in combination with pelvic node irradiation was reported. The encouraging results must be validated in prospective clinical trials.


Sentinel Node Target Volume Prostate Cancer Patient Pelvic Lymph Node IMRT Technique 
These keywords were added by machine and not by the authors. This process is experimental and the keywords may be updated as the learning algorithm improves.


  1. Abdollah F et al (2014) Predicting survival of patients with node-positive prostate cancer following multimodal treatment. Eur Urol 65(3):554–562PubMedCrossRefGoogle Scholar
  2. Adamczyk M et al (2013) Dosimetric consequences of prostate-based couch shifts on the precision of dose delivery during simultaneous IMRT irradiation of the prostate, seminal vesicles and pelvic lymph nodes. Phys Med 30(2):228–233Google Scholar
  3. Allaf ME et al (2004) Anatomical extent of lymph node dissection: impact on men with clinically localized prostate cancer. J Urol 172(5 Pt 1):1840–1844PubMedCrossRefGoogle Scholar
  4. Al-Mamgani A et al (2009) Role of intensity-modulated radiotherapy in reducing toxicity in dose escalation for localized prostate cancer. Int J Radiat Oncol Biol Phys 73(3):685–691PubMedCrossRefGoogle Scholar
  5. Alongi F et al (2012) Moderate hypofractionation and simultaneous integrated boost with volumetric modulated arc therapy (RapidArc) for prostate cancer. Report of feasibility and acute toxicity. Strahlenther Onkol 188(11):990–996PubMedCrossRefGoogle Scholar
  6. Bader P et al (2002) Is a limited lymph node dissection an adequate staging procedure for prostate cancer? J Urol 168(2):514–518 (discussion 518)Google Scholar
  7. Bader P et al (2003) Disease progression and survival of patients with positive lymph nodes after radical prostatectomy. Is there a chance of cure? J Urol 169(3):849–854PubMedCrossRefGoogle Scholar
  8. Bastide C et al (2009) Radioisotope guided sentinel lymph node dissection in patients with localized prostate cancer: results of the first 100 cases. Eur J Surg Oncol 35(7):751–756PubMedCrossRefGoogle Scholar
  9. Bolla M et al (2002) Long-term results with immediate androgen suppression and external irradiation in patients with locally advanced prostate cancer (an EORTC study): a phase III randomised trial. Lancet 360(9327):103–106PubMedCrossRefGoogle Scholar
  10. Bolla M et al (2010) External irradiation with or without long-term androgen suppression for prostate cancer with high metastatic risk: 10-year results of an EORTC randomised study. Lancet Oncol 11(11):1066–1073PubMedCrossRefGoogle Scholar
  11. Briganti A et al (2006) Validation of a nomogram predicting the probability of lymph node invasion based on the extent of pelvic lymphadenectomy in patients with clinically localized prostate cancer. BJU Int 98(4):788–793PubMedCrossRefGoogle Scholar
  12. Briganti A et al (2007) Critical assessment of ideal nodal yield at pelvic lymphadenectomy to accurately diagnose prostate cancer nodal metastasis in patients undergoing radical retropubic prostatectomy. Urology 69(1):147–151PubMedCrossRefGoogle Scholar
  13. Briganti A et al (2008) Impact of surgical volume on the rate of lymph node metastases in patients undergoing radical prostatectomy and extended pelvic lymph node dissection for clinically localized prostate cancer. Eur Urol 54(4):794–802PubMedCrossRefGoogle Scholar
  14. Briganti A et al (2011) Combination of adjuvant hormonal and radiation therapy significantly prolongs survival of patients with pT2-4 pN+ prostate cancer: results of a matched analysis. Eur Urol 59(5):832–840PubMedCrossRefGoogle Scholar
  15. Budiharto T et al (2011) Prospective evaluation of 11C-choline positron emission tomography/computed tomography and diffusion-weighted magnetic resonance imaging for the nodal staging of prostate cancer with a high risk of lymph node metastases. Eur Urol 60(1):125–130PubMedCrossRefGoogle Scholar
  16. Burkhard FC et al (2002) Reliability of preoperative values to determine the need for lymphadenectomy in patients with prostate cancer and meticulous lymph node dissection. Eur Urol 42(2):84–90 (discussion 90–92)Google Scholar
  17. Burkhard FC et al (2005) Is pelvic lymphadenectomy really necessary in patients with a serum prostate-specific antigen level of <10 ng/ml undergoing radical prostatectomy for prostate cancer? BJU Int 95(3):275–278PubMedCrossRefGoogle Scholar
  18. Cagiannos I et al (2003) A preoperative nomogram identifying decreased risk of positive pelvic lymph nodes in patients with prostate cancer. J Urol 170(5):1798–1803PubMedCrossRefGoogle Scholar
  19. Cheng L et al (2001) Risk of prostate carcinoma death in patients with lymph node metastasis. Cancer 91(1):66–73PubMedCrossRefGoogle Scholar
  20. Crehange G et al (2012) Management of prostate cancer patients with lymph node involvement: a rapidly evolving paradigm. Cancer Treat Rev 38(8):956–967PubMedCentralPubMedCrossRefGoogle Scholar
  21. Da Pozzo LF et al (2009) Long-term follow-up of patients with prostate cancer and nodal metastases treated by pelvic lymphadenectomy and radical prostatectomy: the positive impact of adjuvant radiotherapy. Eur Urol 55(5):1003–1011PubMedCrossRefGoogle Scholar
  22. Eade TN et al (2008) A comparison of acute and chronic toxicity for men with low-risk prostate cancer treated with intensity-modulated radiation therapy or (125)I permanent implant. Int J Radiat Oncol Biol Phys 71(2):338–345PubMedCentralPubMedCrossRefGoogle Scholar
  23. Engels B et al (2009a) Conformal arc radiotherapy for prostate cancer: increased biochemical failure in patients with distended rectum on the planning computed tomogram despite image guidance by implanted markers. Int J Radiat Oncol Biol Phys 74(2):388–391PubMedCrossRefGoogle Scholar
  24. Engels B et al (2009b) Helical tomotherapy with simultaneous integrated boost for high-risk and lymph node-positive prostate cancer: early report on acute and late toxicity. Technol Cancer Res Treat 8(5):353–359PubMedCrossRefGoogle Scholar
  25. Ferjani S et al (2013) Alignment focus of daily image guidance for concurrent treatment of prostate and pelvic lymph nodes. Int J Radiat Oncol Biol Phys 87(2):383–389PubMedCrossRefGoogle Scholar
  26. Ferrari AC et al (2006) Molecular load of pathologically occult metastases in pelvic lymph nodes is an independent prognostic marker of biochemical failure after localized prostate cancer treatment. J Clin Oncol 24(19):3081–3088PubMedCrossRefGoogle Scholar
  27. Fukuda M et al (2007) Detection of sentinel node micrometastasis by step section and immunohistochemistry in patients with prostate cancer. J Urol 177(4):1313–1317 (discussion 1317)Google Scholar
  28. Ganswindt U et al (2005a) 70 Gy or more: which dose for which prostate cancer? J Cancer Res Clin Oncol 131(7):407–419Google Scholar
  29. Ganswindt U et al (2005b) Intensity modulated radiotherapy for high risk prostate cancer based on sentinel node SPECT imaging for target volume definition. BMC Cancer 5:91Google Scholar
  30. Ganswindt U et al (2007) Optimized coverage of high-risk adjuvant lymph node areas in prostate cancer using a sentinel node-based, intensity-modulated radiation therapy technique. Int J Radiat Oncol Biol Phys 67(2):347–355PubMedCrossRefGoogle Scholar
  31. Ganswindt U et al (2011) Distribution of prostate sentinel nodes: a SPECT-derived anatomic atlas. Int J Radiat Oncol Biol Phys 79(5):1364–1372PubMedCrossRefGoogle Scholar
  32. Guckenberger M et al (2008) Does intensity modulated radiation therapy (IMRT) prevent additional toxicity of treating the pelvic lymph nodes compared to treatment of the prostate only? Radiat Oncol 3:3PubMedCentralPubMedCrossRefGoogle Scholar
  33. Guckenberger M, Lawrenz I, Flentje M (2014) Moderately hypofractionated radiotherapy for localized prostate cancer : Long-term outcome using IMRT and volumetric IGRT. Strahlenther Onkol 190(1):48–53PubMedCrossRefGoogle Scholar
  34. Hanks GE et al (1998) Ten-year outcomes for pathologic node-positive patients treated in RTOG 75-06. Int J Radiat Oncol Biol Phys 40(4):765–768PubMedCrossRefGoogle Scholar
  35. Hanks GE et al (2000) Dose selection for prostate cancer patients based on dose comparison and dose response studies. Int J Radiat Oncol Biol Phys 46(4):823–832PubMedCrossRefGoogle Scholar
  36. Hanks GE et al (2003) Phase III trial of long-term adjuvant androgen deprivation after neoadjuvant hormonal cytoreduction and radiotherapy in locally advanced carcinoma of the prostate: the radiation therapy oncology group protocol 92-02. J Clin Oncol 21(21):3972–3978PubMedCrossRefGoogle Scholar
  37. Heemsbergen WD et al (2007) Increased risk of biochemical and clinical failure for prostate patients with a large rectum at radiotherapy planning: results from the Dutch trial of 68 GY versus 78 Gy. Int J Radiat Oncol Biol Phys 67(5):1418–1424PubMedCrossRefGoogle Scholar
  38. Heidenreich A, Varga Z, Von Knobloch R (2002) Extended pelvic lymphadenectomy in patients undergoing radical prostatectomy: high incidence of lymph node metastasis. J Urol 167(4):1681–1686PubMedCrossRefGoogle Scholar
  39. Holl G et al (2009) Validation of sentinel lymph node dissection in prostate cancer: experience in more than 2,000 patients. Eur J Nucl Med Mol Imaging 36(9):1377–1382 Google Scholar
  40. Hull GW et al (2002) Cancer control with radical prostatectomy alone in 1,000 consecutive patients. J Urol 167(2 Pt 1):528–534PubMedCrossRefGoogle Scholar
  41. Iversen P, Roder MA (2008) The early prostate cancer program: bicalutamide in nonmetastatic prostate cancer. Expert Rev Anticancer Ther 8(3):361–369PubMedCrossRefGoogle Scholar
  42. Jackson A et al (2010) The lessons of QUANTEC: recommendations for reporting and gathering data on dose-volume dependencies of treatment outcome. Int J Radiat Oncol Biol Phys 76(3 Suppl):S155–S160PubMedCentralPubMedCrossRefGoogle Scholar
  43. Jain S et al (2012) The effect of radiation technique and bladder filling on the acute toxicity of pelvic radiotherapy for localized high risk prostate cancer. Radiother Oncol 105(2):193–197PubMedCrossRefGoogle Scholar
  44. Jeschke S et al (2008) Laparoscopic radioisotope-guided sentinel lymph node dissection in staging of prostate cancer. Eur Urol 53(1):126–132PubMedCrossRefGoogle Scholar
  45. Jilg CA et al (2012) Salvage lymph node dissection with adjuvant radiotherapy for nodal recurrence of prostate cancer. J Urol 188(6):2190–2197PubMedCrossRefGoogle Scholar
  46. Joslyn SA, Konety BR (2006) Impact of extent of lymphadenectomy on survival after radical prostatectomy for prostate cancer. Urology 68(1):121–125PubMedCrossRefGoogle Scholar
  47. Krause S et al (2012) Hypofractionated helical intensity-modulated radiotherapy of the prostate bed after prostatectomy with or without the pelvic lymph nodes—the PRIAMOS trial. BMC Cancer 12:504PubMedCentralPubMedCrossRefGoogle Scholar
  48. Lawton CA et al (2005) Androgen suppression plus radiation versus radiation alone for patients with stage D1/pathologic node-positive adenocarcinoma of the prostate: updated results based on national prospective randomized trial Radiation Therapy Oncology Group 85-31. J Clin Oncol 23(4):800–807PubMedCrossRefGoogle Scholar
  49. Lawton CA et al (2007) An update of the phase III trial comparing whole pelvic to prostate only radiotherapy and neoadjuvant to adjuvant total androgen suppression: updated analysis of RTOG 94-13, with emphasis on unexpected hormone/radiation interactions. Int J Radiat Oncol Biol Phys 69(3):646–655PubMedCentralPubMedCrossRefGoogle Scholar
  50. Lawton CA et al (2009) RTOG GU Radiation oncology specialists reach consensus on pelvic lymph node volumes for high-risk prostate cancer. Int J Radiat Oncol Biol Phys 74(2):383–387PubMedCentralPubMedCrossRefGoogle Scholar
  51. Luxton G, Hancock SL, Boyer AL (2004) Dosimetry and radiobiologic model comparison of IMRT and 3D conformal radiotherapy in treatment of carcinoma of the prostate. Int J Radiat Oncol Biol Phys 59(1):267–284PubMedCrossRefGoogle Scholar
  52. Meijer HJ et al (2013) Geographical distribution of lymph node metastases on MR lymphography in prostate cancer patients. Radiother Oncol 106(1):59–63PubMedCrossRefGoogle Scholar
  53. Miyake H et al (2007) Quantitative detection of micrometastases in pelvic lymph nodes in patients with clinically localized prostate cancer by real-time reverse transcriptase-PCR. Clin Cancer Res 13(4):1192–1197PubMedCrossRefGoogle Scholar
  54. Muller AC et al (2012) Toxicity and outcome of pelvic IMRT for node-positive prostate cancer. Strahlenther Onkol 188(11):982–989PubMedCrossRefGoogle Scholar
  55. Nguyen PL et al (2009) Predicting the risk of pelvic node involvement among men with prostate cancer in the contemporary era. Int J Radiat Oncol Biol Phys 74(1):104–109PubMedCrossRefGoogle Scholar
  56. Norkus D et al (2013) A randomized hypofractionation dose escalation trial for high risk prostate cancer patients: interim analysis of acute toxicity and quality of life in 124 patients. Radiat Oncol 8(1):206PubMedCentralPubMedCrossRefGoogle Scholar
  57. Nutting CM et al (2000) Reduction of small and large bowel irradiation using an optimized intensity-modulated pelvic radiotherapy technique in patients with prostate cancer. Int J Radiat Oncol Biol Phys 48(3):649–656PubMedCrossRefGoogle Scholar
  58. Pagliarulo V et al (2006) Detection of occult lymph node metastases in locally advanced node-negative prostate cancer. J Clin Oncol 24(18):2735–2742PubMedCrossRefGoogle Scholar
  59. Partin AW et al (1997) Combination of prostate-specific antigen, clinical stage, and Gleason score to predict pathological stage of localized prostate cancer. A multi-institutional update. Jama 277(18):1445–1451PubMedCrossRefGoogle Scholar
  60. Passoni NM et al (2014) Utility of [(11)C]choline PET/CT in guiding lesion-targeted salvage therapies in patients with prostate cancer recurrence localized to a single lymph node at imaging: Results from a pathologically validated series. Urol Oncol 32(1):38e9–38e16Google Scholar
  61. Paul A et al (2010) Oncologic outcome after extraperitoneal laparoscopic radical prostatectomy: midterm follow-up of 1115 procedures. Eur Urol 57(2):267–272PubMedCrossRefGoogle Scholar
  62. Peeters ST et al (2006) Dose-response in radiotherapy for localized prostate cancer: results of the Dutch multicenter randomized phase III trial comparing 68 Gy of radiotherapy with 78 Gy. J Clin Oncol 24(13):1990–1996PubMedCrossRefGoogle Scholar
  63. Picchio M et al (2014) 11C-Choline PET/CT as a guide to radiation treatment planning of lymph-node relapses in prostate cancer patients. Eur J Nucl Med Mol Imaging 41(7):1270–1279Google Scholar
  64. Pollack A et al (2002) Prostate cancer radiation dose response: results of the M. D. Anderson phase III randomized trial. Int J Radiat Oncol Biol Phys 53(5):1097–1105PubMedCrossRefGoogle Scholar
  65. Pommier P et al (2007) Is there a role for pelvic irradiation in localized prostate adenocarcinoma? Preliminary results of GETUG-01. J Clin Oncol 25(34):5366–5373PubMedCrossRefGoogle Scholar
  66. Reddy NM et al (2009) Influence of volumes of prostate, rectum, and bladder on treatment planning CT on interfraction prostate shifts during ultrasound image-guided IMRT. Med Phys 36(12):5604–5611PubMedCrossRefGoogle Scholar
  67. Rinnab L et al (2008) [11C]choline PET/CT for targeted salvage lymph node dissection in patients with biochemical recurrence after primary curative therapy for prostate cancer. Preliminary results of a prospective study. Urol Int 81(2):191–197PubMedCrossRefGoogle Scholar
  68. Roach M 3rd (2009) Targeted radiotherapy against clinically localized prostate cancer: is pelvic radiotherapy the standard of care for high risk prostate cancer? In: 3rd international symposium on cancer metastasis and the lymphovascular system: basis for rational therapy, San Francisco, Abstract book, pp 56–57Google Scholar
  69. Roach M 3rd et al (2003) Phase III trial comparing whole-pelvic versus prostate-only radiotherapy and neoadjuvant versus adjuvant combined androgen suppression: radiation therapy oncology group 9413. J Clin Oncol 21(10):1904–1911PubMedCrossRefGoogle Scholar
  70. Roach M 3rd et al (2006) Whole-pelvis, “mini-pelvis,” or prostate-only external beam radiotherapy after neoadjuvant and concurrent hormonal therapy in patients treated in the Radiation Therapy Oncology Group 9413 trial. Int J Radiat Oncol Biol Phys 66(3):647–653PubMedCrossRefGoogle Scholar
  71. Sands ME, Pollack A, Zagars GK (1995) Influence of radiotherapy on node-positive prostate cancer treated with androgen ablation. Int J Radiat Oncol Biol Phys 31(1):13–19PubMedCrossRefGoogle Scholar
  72. Sanguineti G et al (2006) Is IMRT needed to spare the rectum when pelvic lymph nodes are part of the initial treatment volume for prostate cancer? Int J Radiat Oncol Biol Phys 64(1):151–160PubMedCrossRefGoogle Scholar
  73. Shariat SF et al (2003) Detection of clinically significant, occult prostate cancer metastases in lymph nodes using a splice variant-specific rt-PCR assay for human glandular kallikrein. J Clin Oncol 21(7):1223–1231PubMedCrossRefGoogle Scholar
  74. Sharma NK et al (2011) Intensity-modulated radiotherapy reduces gastrointestinal toxicity in patients treated with androgen deprivation therapy for prostate cancer. Int J Radiat Oncol Biol Phys 80(2):437–444PubMedCrossRefGoogle Scholar
  75. Sheets NC et al (2012) Intensity-modulated radiation therapy, proton therapy, or conformal radiation therapy and morbidity and disease control in localized prostate cancer. JAMA 307(15):1611–1620PubMedCentralPubMedCrossRefGoogle Scholar
  76. Stone NN, Stock RG, Unger P (1997) Laparoscopic pelvic lymph node dissection for prostate cancer: comparison of the extended and modified techniques. J Urol 158(5):1891–1894PubMedCrossRefGoogle Scholar
  77. Suardi N et al (2014) Long-term outcomes of salvage lymph node dissection for clinically recurrent prostate cancer: results of a single-institution series with a minimum follow-up of 5 years. Eur Urol. pii:S0302-2838(14)00130-4Google Scholar
  78. Vora SA et al (2007) Analysis of biochemical control and prognostic factors in patients treated with either low-dose three-dimensional conformal radiation therapy or high-dose intensity-modulated radiotherapy for localized prostate cancer. Int J Radiat Oncol Biol Phys 68(4):1053–1058PubMedCrossRefGoogle Scholar
  79. Wang-Chesebro A et al (2006) Intensity-modulated radiotherapy improves lymph node coverage and dose to critical structures compared with three-dimensional conformal radiation therapy in clinically localized prostate cancer. Int J Radiat Oncol Biol Phys 66(3):654–662PubMedCrossRefGoogle Scholar
  80. Wawroschek F et al (2003) The influence of serial sections, immunohistochemistry, and extension of pelvic lymph node dissection on the lymph node status in clinically localized prostate cancer. Eur Urol 43(2):132–136 (discussion 137)Google Scholar
  81. Weckermann D, Wawroschek F, Harzmann R (2005) Is there a need for pelvic lymph node dissection in low risk prostate cancer patients prior to definitive local therapy? Eur Urol 47(1):45–50 (discussion 50–51)Google Scholar
  82. Weckermann D et al (2006) Incidence of positive pelvic lymph nodes in patients with prostate cancer, a prostate-specific antigen (PSA) level of < or =10 ng/mL and biopsy Gleason score of < or =6, and their influence on PSA progression-free survival after radical prostatectomy. BJU Int 97(6):1173–1178PubMedCrossRefGoogle Scholar
  83. Weckermann D et al (2007) Sentinel lymph node dissection for prostate cancer: experience with more than 1,000 patients. J Urol 177(3):916–920PubMedCrossRefGoogle Scholar
  84. Whittington R et al (1995) Combined hormonal and radiation therapy for lymph node-positive prostate cancer. Urology 46(2):213–219PubMedCrossRefGoogle Scholar
  85. Wiegel T, Bressel M (1995) Stage D1 prostate cancer–is radiotherapy and early hormonal therapy equivalent to radical prostatectomy, radiotherapy, and early hormonal therapy? (regarding Sands et al (1995) IJROBP 31:13–19). Int J Radiat Oncol Biol Phys 32(3):896–897PubMedCrossRefGoogle Scholar
  86. Wurschmidt F et al (2011) [18F]fluoroethylcholine-PET/CT imaging for radiation treatment planning of recurrent and primary prostate cancer with dose escalation to PET/CT-positive lymph nodes. Radiat Oncol 6:44PubMedCentralPubMedCrossRefGoogle Scholar
  87. Xia P et al (2010) Comparison of three strategies in management of independent movement of the prostate and pelvic lymph nodes. Med Phys 37(9):5006–5013PubMedCrossRefGoogle Scholar
  88. Zapatero A et al (2005) Risk-adapted androgen deprivation and escalated three-dimensional conformal radiotherapy for prostate cancer: does radiation dose influence outcome of patients treated with adjuvant androgen deprivation? A GICOR study. J Clin Oncol 23(27):6561–6568PubMedCrossRefGoogle Scholar
  89. Zelefsky MJ et al (2012) Improved clinical outcomes with high-dose image guided radiotherapy compared with non-IGRT for the treatment of clinically localized prostate cancer. Int J Radiat Oncol Biol Phys 84(1):125–129PubMedCrossRefGoogle Scholar

Copyright information

© Springer-Verlag Berlin Heidelberg 2014

Authors and Affiliations

  1. 1.Department of Radiation OncologyLudwig-Maximilians-University (LMU)MunichGermany

Personalised recommendations