**9. High-risk and very high-risk prostate cancer**

For high- and very-high risk prostate cancer, curative intent treatment is recommended for men with life expectancies >5 years or who are symptomatic, whereas men asymptomatic with <5 years life expectancy may be managed with observation, ADT alone, or EBRT alone [8]. With the publication of the POP-RT study incorporating Pylarify PET/CTs, the authors recommend treating the pelvic lymph nodes, as the arm treating the pelvic lymph nodes had improved 5-year disease-free survival over the prostate-only arm of 89.5% vs. 77.2% (p = 0.002) [32]. The NRG

now recommends that for pelvic lymph node treatments, the superior border starts at L5-S1 and extends to L4-L5 [33]. Long-term ADT for 1.5–3 years is recommended based on an OS benefit demonstrated with long-term ADT over RT alone or shortterm ADT [34–36].

Per the NCCN guidelines, EBRT, proton therapy, SBRT, and combination EBRT/ brachytherapy are potential radiotherapy treatment options for high-risk and very high-risk prostate adenocarcinoma [8]. However, the authors wish to comment that treating the prostate/seminal vesicles with SBRT alone, and not addressing the lymph nodes, may conflict with the results of the POP-RT study, in which addressing the pelvic lymph nodes demonstrated a disease-free survival benefit [32].
