Pelvic Node Radiation for Recurrent Prostate Cancer: PEACE V-STORM

Short answer: For prostate cancer that returned in a small number of pelvic lymph nodes on PET imaging, PEACE V-STORM found better four-year disease control when radiation covered the elective pelvic nodal region rather than only the visible nodes. Both groups also received six months of hormone therapy.

What problem did the trial address?

Modern PET imaging can find one to five recurrent pelvic lymph nodes after prostatectomy or primary prostate radiation. This creates a choice:

1. treat only the visible nodes with SBRT or surgery; or
2. treat the visible disease and the surrounding pelvic lymph-node regions that may contain microscopic cancer.

The first approach is called metastasis-directed therapy (MDT). The broader approach is elective nodal radiotherapy (ENRT).

How was PEACE V-STORM designed?

The international phase 2 trial randomized 196 participants, with 190 included in the main analysis. More than 80% had only one or two positive nodes, and the recurrence had to remain within the pelvis.

The MDT group generally received SBRT to each PET-positive node: 30 Gy in three treatments. The ENRT group received 45 Gy in 25 treatments to the pelvic nodal region with a simultaneous boost to 65 Gy for visible nodes. A small number underwent salvage lymph-node surgery.

Everyone received six months of androgen-deprivation therapy (ADT). The study therefore compared two local-treatment strategies combined with the same temporary systemic treatment.

What were the four-year results?

At a median follow-up of 50 months:

• metastasis-free survival was 76% with ENRT and 63% with MDT;
• biochemical relapse-free survival was 57% with ENRT and 41% with MDT; and
• locoregional control was 85% with ENRT and 62% with MDT.

The primary analysis used an 80% confidence interval and a less stringent significance threshold than a typical phase 3 trial. The investigators therefore described ENRT as a potential standard approach while awaiting phase 3 confirmation.

Did broader radiation cause more side effects?

Four-year rates of grade 2 or worse urinary and gastrointestinal adverse events were broadly comparable between the groups. The most common grade 3 events were urinary incontinence—10% with ENRT and 6% with MDT—and diarrhea—2% and 1%, respectively. No treatment-related deaths occurred.

A 2026 secondary analysis found no consistent clinically meaningful difference in health-related quality of life over four years. Both groups reported temporary hormonal symptoms and reduced sexual activity during ADT, with scores moving back toward baseline by 12 months.

These group averages do not remove individual risk. Prior prostate-bed radiation, baseline urinary function, bowel disease, anatomy, and whether prostate-bed radiation is added can change the expected side-effect profile.

How does this fit with PSMA PET?

Most participants were staged with PSMA PET or choline PET. A PET-positive node identifies visible disease, but imaging may not reveal every microscopic deposit along the pelvic lymphatic pathways. The lower rate of pelvic nodal relapse after ENRT supports the idea that treating at-risk regional tissue can matter.

This does not mean every positive scan requires whole-pelvis radiation. Disease outside the pelvis, many involved nodes, prior radiation dose, PSA kinetics, and other risk features may point toward a different strategy.

Questions to ask after a nodal recurrence

Ask:

1. Is recurrence limited to pelvic nodes?
2. Was PSMA PET used, and could microscopic disease still be present?
3. Can the pelvis be treated safely after prior radiation?
4. Should the prostate bed also be included?
5. What is the expected benefit and burden of six months of ADT?
6. Is a phase 3 trial available?

PEACE V-STORM provides the strongest randomized evidence so far for this specific situation. It favors broader elective nodal treatment, but it does not prove an overall-survival benefit or make node-only SBRT inappropriate for every patient.

Questions patients often ask

What is elective nodal radiation?

It treats the known positive lymph nodes and the surrounding pelvic lymph-node regions considered at risk for microscopic cancer.

Is elective nodal radiation the same as SBRT to a lymph node?

No. Node-directed SBRT treats only lesions visible on imaging. Elective nodal radiation covers a broader regional pathway and usually requires more treatment visits.

Did PEACE V-STORM prove an overall-survival benefit?

No. The phase 2 trial improved metastasis-free and locoregional control at four years, but it has not established a longer overall survival.

Sources and further reading

1. PEACE V-STORM: Salvage Metastasis-Directed Therapy Versus Elective Nodal Radiotherapy. The Lancet Oncology (2025).
2. Health-Related Quality of Life Outcomes of PEACE V-STORM. European Urology Oncology (2026).
3. PEACE V-STORM Clinical Trial Record. ClinicalTrials.gov (2026).