Despite these encouraging but preliminary results, the safety and oncological adequacy of stereotactic body radiation therapy (SBRT) in the management of IRPC needs to be confirmed by ongoing phase III trials. Meanwhile, the preliminary results of an ongoing phase III study comparing moderate hypofractionation with SBRT indicate equivalent and overall mild patient-reported changes in bowel and sexual domains. However, an apparently worse deterioration in urinary symptoms is seen in patients treated with moderate hypofractionation.
Another challenging issue is that of the feasibility of and indications for prophylactic whole pelvic nodal irradiation in the context of hypofractionation, in patients with moderate/high risk of lymph node involvement. Several series have reported the feasibility and clinical efficacy of a simultaneous integrated boost (SIB) intensity modulated radiation therapy (IMRT) approach in which both the prostate (± seminal vesicles), and pelvic lymph-nodes can be safely irradiated with daily doses in the range of 2.5-3.2 and 1.8-2 Gy, respectively. 
Lastly, it is important to note that androgen deprivation therapy, which was differently prescribed in all the above mentioned trials, (usually being at the discretion of the referring radiation oncologist), did not seem to significantly improve clinical outcome. In a recent retrospective analysis of over 19,000 patients with favorable IRPC, treated with modern dose-escalated radiotherapy at conventional fractionation ± ADT, no benefit whatsoever emerged from the combined-modality (ADT+RT) treatment.  Therefore, it is safe to assume, that in the near future, patients with IRPC treated with moderate or extreme hypofractionation, could be spared the additional costs and morbidity of ADT.
Speaker: Cesare Cozzarini, MD Department of Radiation Oncology San Raffaele Scientific Institute Milan, Italy.
Written By: Hanan Goldberg, MD, Urologic Oncology Fellow (SUO), University of Toronto, Princess Margaret Cancer Centre @GoldbergHanan at The 15th Meeting of the EAU Section of Oncological Urology ESOU18 - January 26-28, 2018 - Amsterdam, The Netherlands
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