83 patients with histologically confirmed high- very high risk prostate cancer or with nodal or distant metastatic disease were treated at IRCCS – FPO Cancer Institute of Candiolo, Torino, Italy, with definitive IMRT-SIB-IGRT technique using Tomotherapy in association with long-term hormone therapy in all patients excluding three. Cohort median follow-up is 14 months. Pre-treatment diagnostic evaluation was performed by multiparametric-MRI and choline-PET/CT in a high percentage of patients. The treatment consisted of extensive field irradiation of pelvic prophylactic nodes, positive nodes or distant metastasis if apparent, and in some patients also prophylactic lumbar-aortic nodes, in addition to prostate bed. Toxicity is acceptable with acute severe GU and GI toxicities respectively of 8% and 1%, and late severe GU and GI toxicities of 0% and 3%. Regarding the outcome, the median PSA nadir after radiotherapy is 0.03 ng/mL and, on considering the 69 patients with a follow-up for longer than 6 months, 66 patients are free from biochemical relapse, two are in clinical progression confirmed by choline-PET/CT, but none in RT treatment fields, and one is dead by cause other than prostate cancer. Hence in this group of patients we favour a personalized treatment thanks to the present day availability of extensive functional imaging in staging and tailored image-guided irradiation.