Oligometastatic Prostate Cancer Patients Research Articles

Savremeni pristup u lečenju oligometastatskog karcinoma prostate

Oligometastatic disease is defined as an intermediate state between localized and widespread metastatic disease. Oligometastatic prostate cancer is generally defined by the presence of five or fewer metastatic sites on imaging. In the era of precision and personalized cancer care, the introduction of more sensitive imaging technologies and the availability of safe and effective localized non-or minimally invasive treatment options, have led to an increase in the incidence and clinical interest in oligometastatic prostate cancer. In addition, the therapeutic paradigm for oligometastatic prostate cancer is evolving toward a more aggressive approach. Retrospective studies have shown that in the metastatic setting, treatments such as radical prostatectomy and local or metastasis-directed radiation therapy can be performed with minimal risk of toxicity and may enhance clinical outcomes. As there is insufficient data to draw reliable conclusions about their impact on survival, aggressive approaches in the treatment of oligometastatic prostate cancer should be considered only in the context of prospective clinical trials, with the patient informed of the limited evidence of benefit. The current inconsistent approach of detecting and treating oligometastatic prostate cancer patients will need to be standardized in order for future clinical studies to be properly performed and, more importantly, compared. These crucial conditions will reveal if oligometastasis diagnosis and therapy should be included in the standard clinical practice of prostate cancer patients.

Radiotherapy of the Primary Tumor and All Metastatic Lesions in Oligometastatic Prostate Cancer

<h3>Purpose/Objective(s)</h3> The aim of this study was to evaluate the survival in oligometastatic prostate cancer patients treated with radiotherapy (RT) for both primary tumor and all metastatic lesions. <h3>Materials/Methods</h3> This was a single-center cohort study. Oligometastatic prostate cancer patients with RT for both primary tumor and all metastatic lesions were included. Kaplan–Meier method, log rank test and cox regression were used to calculate OS and PFS. PFS included PSA failure, local or distant failure assessed by imaging. <h3>Results</h3> This study analyzed 395 patients from 10/2011 to 1/2022 with median follow-up of 42 months. 264 patients (66.8%) were hormone sensitive (HSPC) and 131patients (33.2%) were castrate resistant (CRPC) at the time of RT. 212 patients (53.7%) were synchronous oligometastatic status, 58 patients (14.7%) were metachronous oligometastatic status, and 105 patients (26.6%) were oligoprogressive status. PSMA-PETCT was used for 238 men (60.3%). Before radiotherapy, 12 patients (3.0%) did not receive androgen deprivation therapy (ADT), 252 patients (63.8%) were treated with luteinizing hormone releasing hormone analogue (LHRHa) with or without bikaluamide. 131 patients (33.2%) were treated with LHRHa combined with novel ADT (abiraterone, enzalutamide, apalutamide, etc.), including 3 patients treated with enzalutamide, 2 patients treated with apalutamine, and the rest treated with abiraterone. The most common fractionation scheme of the primary tumor was 2.8Gy for 25 fractions (81.5%). The median BED₃ was 135.3Gy (IQR:128.3-135.3Gy). A total of 247 (62.5%) patients were treated with whole pelvic RT (WPRT). A total of 718 metastatic lesions were treated with RT. The median BED₃ was 121.3Gy (IQR:113.3-131.3Gy). For the whole cohort, the PFS and OS were 62.5% and 92.7% at 3 year, 53.1% and 81.7% at 5 years. Median PFS for men with HSPC was not reached compared with 10 months in men with CRPC. On univariable analysis, HSPC, shorter interval between diagnosis and RT, lower pre-RT PSA, lower Gleason score, lower metastatic burden/volume, use of WPRT, ADT type, chemotherapy were associated with improved PFS. <h3>Conclusion</h3> Our study suggests that RT for the primary tumor and all metastatic lesions has better survival than clinical studies of prostate radiotherapy alone, especially for patients with HSPC, shorter interval between diagnosis and RT and lower metastatic burden/volume.

Stereotactic ablative radiotherapy for oligometastatic prostate cancer.

The present study assessed clinical outcomes of stereotactic body radiotherapy (SBRT) in oligometastatic prostate cancer patients. Between 2017 and 2020, 37 lesions (12 osseous and 25 nodal targets) detected with conventional and/or functional imaging, were treated in 29 patients (pts), in different clinical settings: de novo oligometastatic (2 pts), oligorecurrent castration-sensitive (19 pts), castration-resistant (6 pts) prostate cancers and oligoprogressive disease during systemic therapy (2 pts). SBRT was delivered with volumetric modulated arc therapy up to a total dose of 21 Gy given in 3 fractions for bone and 30 Gy in 5 fractions for nodal metastases. A total of 34% of pts received hormonal therapy. We evaluated biochemical control [prostate serum antigen (PSA) increase < 10%)], progression free-survival (PFS) (time from SBRT to biochemical progression), local control (LC) (time from SBRT to in-field radiologic progression), hormone/systemic therapy-free survival, acute and late toxicities. At 3 months, biochemical response was observed in 20/29 pts (69%). At a median follow-up of 17 months (range 6-33), 8/20 (40%) of the 3-month responders remained free from progression. Two-year PFS and LC were 37% and 70%, respectively. In-field progression occurred in 3/37 (8%) lesions. Hormone/systemic therapy was delayed by an average of 11.6 months (range 3-28). No significant difference in PFS based on the type of lesion or concomitant endocrine therapy was observed and no toxicity > grade 2 was reported. SBRT for oligometastatic prostate cancer offers a good biochemical/local control and tangible delay of hormone/systemic therapy without major toxicities.

Systemic Therapy Postponement after Stereotactic Body Radiation Therapy for Oligometastatic Prostate Cancer

<h3>Purpose/Objective(s)</h3> To evaluate the oncological outcome after stereotactic body radiation therapy (SBRT) for oligometastatic (OM) prostate cancer (PC) patients. <h3>Materials/Methods</h3> In this retrospective observational multi-institutional study (Health-data-hub N°F20210402112942), patients with OM (≤ 5) PC underwent SBRT. While patients were enrolled irrespective of PC initial treatment, castration sensitive (CS)/resistant (CR) and synchronous (SM)/metachronous (MM) metastatic disease status were taken into account. Primary endpoint was systemic therapy postponement (STP) after SBRT. Oncological outcome was assessed by post-SBRT biochemical response, local (LR; in SBRT field), metastatic (MR), prostatic (PR) and isolated biochemical (iBR) relapses. PSA kinetic (PSAdt; velocity) and prognostic factors for STP were investigated. Toxicity was reported (CTCAE v5). <h3>Results</h3> From 01/07 to 09/19, 169 pts (median age 71.4 y [48.7 – 100.1]) underwent SBRT. At the time of SBRT, 151 pts (89.3%) and 18 pts (10.7%) were MM and SM respectively and 119 pts (70.4%) and 50 pts (29.6%) were CS and CR respectively. Median PSA, PSAdt and velocity were 2.4 ng/ml [0.01 – 277], 5.2 months [0.9 – 45.2] and 2.3 ng/ml/an [0.1 – 25.9] respectively. Median time between initial PC/metastatic disease (TPCMD) and metastatic disease/SBRT were 68.9 months [1.9 – 273.4] and 3.1 months [0.1 – 97.9]. Metastatic anatomic sites were pelvic (PLN) and extra-pelvic lymph nodes (EPLN), bone and brain for 58 pts (34.4%), 15 pts (8.9%), 92 pts (54.4%) and 4 pts (2.4%) respectively. SBRT regimens were 27 Gy/3f (29%), 35 Gy/5f (24.3%), 36 Gy/6f (18.3%) and other (28.4%). With a MFU of 27.5 months [1 – 100.5], median time between SBRT/1^st PSA control was 2 months [0.5 – 29]. PSA decreased in 67.4%, was stable in 9.4% and increased in 23.2%. Eighty-eight pts (52.1%) underwent post-SBRT systemic therapy after a median STP of 15.4 months [2.6 – 86.9]. One hundred and thirty events (LR, MR, PR, iBR) were observed in 106 pts (62.7%), among whom 13 (12.3%) relapsed in the irradiated area (local control rate: 92.3%). MR, PR, iBR were observed in 82 pts (77.4%), 33 pts (31.1 %) and 2 pts (1.9 %) respectively. Prognostic factors for STP after SBRT were: hormonal status (CS vs CR: 20.9 vs 10.8 months; p < 0.001), post-SBRT biochemical response ([declined + stable] PSA vs increased PSA: 21 vs 11 months; p = 0.004) and TPCMD (< 42 vs ≥ 42 months; p < 0.001). G≥3 toxicity occurred in 4 pts: 2 pts with G3 post-SBRT fracture (1 surgery), 1 pt with G3 radiation pneumonitis and 1 pt with G4 intracranial hypertension (emergency surgery). <h3>Conclusion</h3> SBRT for oligometastatic prostate cancer is an option to postpone systemic therapy, mainly for CS and MM patients with an acceptable toxicity profile. Patient selection criteria remain a crucial goal in order to refine SBRT indications, while the impact of combination with systemic therapy remains under investigation.

Oligometastatic Prostate Cancer in the Modern Era: Post-SBRT Chronicle

<h3>Purpose/Objective(s)</h3> Recent randomized phase II trials have demonstrated the clinical benefit of incorporating modern functional radionuclide imaging modalities and stereotactic body radiotherapy (SBRT) in the management of oligometastatic prostate cancers. An improved understanding of the clinical course following metastasis-directed therapy can assist in the role and timing of systemic treatment as a part of complex management decisions. Here, we provide long-term follow-up data for oligometastatic castration-sensitive (CSPC) and resistant (CRPC) prostate cancer following SBRT. <h3>Materials/Methods</h3> We retrospectively evaluated patients with oligometastatic prostate cancer (≤3 lesions) identified on 11C-Choline PET who were treated with SBRT. Outcomes reported were biochemical progression-free (BPFS), local (LPFS), distant (DPFS), and overall (OS) survival. Survival curves were generated by Kaplan-Meier analysis and compared by Cox proportional hazards. <h3>Results</h3> A total of 139 patients were analyzed, 31 (22%) with CSPC and 107 (78%) with CRPC (78%). Median follow-up after SBRT was 49 months (range 6.7 to 143.5 months). 124 patients (89%) were treated with SBRT at multiple sites for their oligometastatic disease and most treated lesions (96.7%) were osseous metastases. In addition, 76% of CRPC and 58% of CSPC patients had previously received chemotherapy (p=0.09) and 82% of CRPC and 48% of CSPC had previously received a second-generation antiandrogen (p<0.001). The median BPFS defined by PCWG-3 was 48.1 months (95% CI 10.5-NR) in CSPC versus 20.5 months (95% CI 17.5-34.4) in CRPC (p=0.2). DPFS and LPFS were very similar, with excellent long-term local control in both CSPC and CRPC (75% LPFS versus 38% DPFS at 2 years, 66% LPFS and 19% DPFS at 4 years). Overall survival was significantly longer in CSPC patients compared to CRPC patients (median OS not reached versus 64.4 months, p=0.016). Overall survival after radiotherapy trended worse among patients with CRPC previously exposed to chemotherapy (death HR 2.32, p=0.075) or second-generation antiandrogen (death HR 2.1, p=0.12) as would be expected; this trend was not present in CSPC. <h3>Conclusion</h3> In our study of oligometastatic prostate cancer patients treated with SBRT to a site of metastatic disease, patients with CSPC had better outcomes for progression-free survival and overall survival compared to CRPC patients. Pre-treatment with chemotherapy or second-generation antiandrogens did not significantly impact overall survival in patients with CSPC. Local control was excellent in both CSPC and CRPC, suggesting that highly sensitive imaging modalities may best select patients for effective SBRT.

Stratification of Oligometastatic Prostate Cancer Patients by Liquid Biopsy: Clinical Insights from a Pilot Study.

We propose a pilot, prospective, translational study with the aim of identifying possible molecular markers underlying metastatic prostate cancer (PC) evolution with the use of liquid biopsy. Twenty-eight castrate sensitive, oligometastatic PC patients undergoing bone and/or nodal stereotactic body radiotherapy (SBRT) were recruited. Peripheral blood samples were collected before the commencement of SBRT, then they were processed for circulating cell free DNA (cfDNA) extraction. Deep targeted sequencing was performed using a custom gene panel. The primary endpoint was to identify differences in the molecular contribution between the oligometastatic and polymetastatic evolution of PC to same-first oligo-recurrent disease presentation. Seventy-seven mutations were detected in 25/28 cfDNA samples: ATM in 14 (50%) cases, BRCA2 11 (39%), BRCA1 6 (21%), AR 13 (46%), ETV4, and ETV6 2 (7%). SBRT failure was associated with an increased risk of harboring the BRCA1 mutation (OR 10.5) (p = 0.043). The median cfDNA concentration was 24.02 ng/mL for ATM mutation carriers vs. 40.04 ng/mL for non-carriers (p = 0.039). Real-time molecular characterization of oligometastatic PC may allow for the identification of a true oligometastatic phenotype, with a stable disease over a long time being more likely to benefit from local, curative treatments or the achievement of long-term disease control. A prospective validation of our promising findings is desirable for a better understanding of the real impact of liquid biopsy in detecting tumor aggressiveness and clonal evolution.

Oligometastatic Prostate Cancer: Is there a Role for Surgery? A Narrative Review.

Oligometastatic prostate cancer is commonly considered a transition between high metastatic and local- ized disease and includes a large spectrum of conditions with a polymorphic clinical behavior. The current management of these patients contemplates systemic therapy (i.e., androgen-deprivation drugs, chemothera- peutic drugs, or both treatments administered simultaneously) which have been shown to improve survival. Radiotherapy has also been introduced, into a multimodal setting, among the therapeutic treatments forpatients who are defined as oligometastatic prostate cancer according to Chemohormonal Therapy Versus Androgen Ablation Randomized Trial for Extensive Disease in Prostate Cancer (CHAARTED) criteria.The role of surgical debulking in patients with oligometastatic prostate cancer has always been considered impracticable, both for a marginal therapeutic role and for the greater risk of sequelae and/or complications related to the procedure itself. Several authors have demonstrated some mechanisms by which the persistence of the primary tumor can facilitate the clinical progression of the disease itself and promote carcinogenesis, differentiation, migration, and angiogenesis in prostate cancer. From these studies emerges the hypothesis of a possible therapeutic advantage in oncological terms also for cytoreductive radical prostatectomy, in a multimodal therapy setting, compared to systemic therapy alone. The present review summarizes the main knowledge regarding the safety, feasibility, and oncological outcomes of cytoreductive radical prostatectomy in oligometastatic prostate cancer patients.

Oligometastatic Prostate Cancer: A Comparison between Multimodality Treatment vs. Androgen Deprivation Therapy Alone.

Simple SummaryData regarding the survival effect of radical prostatectomy in patients with oligometastatic PC (OPC) are sparse and based on small series. Moreover, few studies compared radical prostatectomy with systemic treatment in an OPC setting. We compared multimodality treatment (MMT, defined as robot-assisted radical prostatectomy (RARP) with androgen deprivation therapy (ADT), with or without adjuvant radiotherapy (RT)) vs. ADT alone in oligometastatic prostate cancer (OPC) patients. MMT was associated with lower CSM, mCRPC and second-line therapy rates. A lower rate of treatment-related adverse events was recorded for the MMT group.Background: We compared multimodality treatment (MMT, defined as robot-assisted radical prostatectomy (RARP) with androgen deprivation therapy (ADT), with or without adjuvant radiotherapy (RT)) vs. ADT alone in oligometastatic prostate cancer (OPC) patients. Methods: From 2010 to 2018, we identified 74 patients affected by cM1a-b OPC (≤5 metastases). Kaplan–Meier (KM) plots depicted cancer-specific mortality (CSM), disease progression, metastatic castration-resistant PC (mCRPC), and time to second-line systemic therapy rates. Multivariable Cox regression models (MCRMs) focused on disease progression and mCRPC. Results: Forty (54.0%) MMT and thirty-four (46.0%) ADT patients were identified. On KM plots, higher CSM (5.9 vs. 37.1%; p = 0.02), mCRPC (24.0 vs. 62.5%; p < 0.01), and second-line systemic therapy (33.3 vs. 62.5%; p < 0.01) rates were recorded in the ADT group. No statistically significant difference was recorded for disease progression. ForMCRMs adjusted for the metastatic site and PSA, a higher mCRPC rate was recorded in the ADT group. No statistically significant difference was recorded for disease progression. Treatment-related adverse events occurred in 5 (12.5%) MMT vs. 15 (44.1%) ADT patients (p < 0.01). Conclusions: MMT was associated with lower CSM, mCRPC, and second-line therapy rates. A lower rate of treatment-related adverse events was recorded for the MMT group.

PSMA-guided metastases directed therapy for bone castration sensitive oligometastatic prostate cancer: a multi-institutional study

To assess the outcomes of a cohort of bone oligometastatic prostate cancer patients treated with PSMA-PET guided stereotactic body radiotherapy (SBRT). From April 2017 to January 2021, 40 patients with oligorecurrent prostate cancer detected by PSMA-PET were treated with SBRT for bone oligometastases. Concurrent androgen deprivation therapy was an exclusion criterion. A total of 56 prostate cancer bone oligometastases were included in the present analysis. In 28 patients (70%), oligometastatic disease presented as a single lesion, two lesions in 22.5%, three lesions in 5%, four lesions in 2.5%. 30.3% were spine-metastases, while 69.7% were non-spine metastases. SBRT was delivered for a median dose of 30Gy (24-40Gy) in 3-5 fractions, with a median EQD2 = 85 Gy2 (64.3-138.9Gy2). With a median follow-up of 22months (range 2-48months), local control (LC) 1- and 2-years rates were 96.3% and 93.9%, while distant progression-free survival (DPFS) rates were 45.3% and 27%. At multivariate analysis, the lower PSA nadir value after SBRT remained significantly related to better DPFS rates (p = 0.03). In 7 patients, a second SBRT course was proposed with concurrent ADT, while 11 patients, due to polymetastatic spread, received ADT alone, resulting in 1- and 2-years ADT-free survival rates of 67.5% and 61.8%. At multivariate analysis, a lower number of treated oligometastases maintained a correlation with higher ADT-free survival rates (p = 0.04). In our experience, PSMA-PET guided SBRT resulted in excellent results in terms of clinical outcomes, representing a helpful tool with the aim to delay the start of ADT.

ARTO trial-(NCT03449719): Early results from a phase II randomized trial testing stereotactic body radiation therapy in patients with oligometastatic castration-resistant prostate cancer undergoing I line treatment with abiraterone acetate.

100 Background: ARTO (NCT03449719) is a multicentre, randomized trial started in January 2019 and currently running in 16 Italian centres, testing the benefit of adding stereotactic body radiation therapy (SBRT) to Abiraterone Acetate (AA) in oligometastatic Castrate Resistant Prostate Cancer (CRPC) patients. Seventy-nine per cent of the target accrual population has been currently enrolled. Here we present a report about early efficacy results of SBRT+AA combination. Methods: Data from patients with ≥ 6 months of follow up were reported. All patients were affected by oligometastatic CRPC, defined as ≤ 3 non-visceral metastatic lesions. Patients were randomized 1:1 to receive either AA alone (control arm) or associated with concomitant SBRT on all sites of disease (treatment arm). Primary endpoint of the trial is rate of biochemical response (BR, defined as a PSA decrease ≥ 50% from baseline measured within 6 months from treatment start). Complete biochemical response (CBR, defined as PSA at 6 months ≤ 0.2 ng/ml) is a secondary endpoint of the trial. Results: Overall, 123 patients have been currently enrolled in ARTO trial. To date, 98 patients had ≥ 6 months of follow-up and were evaluable for the present analysis. BR was detected in 75 (76.5%) patients (82.2% vs. 71.7% in treatment vs. control arm, respectively), with an unadjusted odds ratio (OR) equal to 1.83 (95% CI 0.69-4.82, p-value 0.22). After adjustment for baseline PSA and the number of metastatic sites ( &gt; 1 vs. 1), the OR for BR was 2.23 (95% CI 0.74-6.73, p-value 0.15). CBR was detected in 36 (36.7%) patients (46.7% vs. 28.3% in treatment vs. control arm, respectively), with an unadjusted OR of 2.22 (95% CI 0.96-5.12, p-value 0.06), and an adjusted OR of 2.31 (95% CI 0.90-5.92, p-value 0.08). In multivariable models, baseline PSA and the number of metastatic sites &gt; 1 were non-statistically associated with CBR, with OR equal to 0.92 (95% CI 0.85-1.01, p-value 0.06) and 1.20 (95% CI 0.46-3.09, p-value 0.71), respectively. Conclusions: Results showed promising efficacy of SBRT+AA combination if compared to systemic treatment alone for oligometastatic CRPC, OR for BR and CBR were doubled in treatment vs. control arm, even if statistical significance is not yet reached. Interestingly, baseline burden of disease seems to predict increased outcome after SBRT, suggesting that selection criteria for local treatment may be further refined. Complete results for primary endpoint are awaited in 2022, after enrollment and follow-up completion of whole cohort, and may confirm these early outcomes in a larger population. Clinical trial information: NCT03449719.

A0665 - Feasibility of radio-guided lymph node dissection in primary oligometastatic prostate cancer patients: An interim analysis

A0665 - Feasibility of radio-guided lymph node dissection in primary oligometastatic prostate cancer patients: An interim analysis

Radiotherapy treatment modification for prostate cancer patients based on PSMA-PET/CT

BackgroundProstate cancer is the most common cancer among men, and its diagnosis and treatment are improving. Our study evaluated how PSMA-PET/CT prior to treatment planning might improve the optimal management of prostate cancer radiotherapy.MethodsThis retrospective pilot study included 43 prostate cancer (PCa) patients referred to our radiation oncologist department, from the urology department, for radiation therapy. 18F-PSMA-PET/CT was ordered by the radiation oncologists mainly due to the lack of resent image staging. The patients were divided into three different groups according to their initially planned treatments: radical radiation therapy (RT) (newly diagnosed PCa patients), salvage RT (patients with biochemical recurrence after radical prostatectomy), or oligometastatic RT (oligometastatic PCa patients with good response after systemic treatment).ResultsFollowing PSMA-PET/CT, the initially planned RT was changed for 60.5% of the patients due to new findings (metastases and/or recurrent disease). The final treatment choice was effected by PSMA-PET/CT outcome in 60.5% (26/43) of the patients, and in 50% (16/32) of patients, the radiation treatment plan changed following PSMA-PET/CT. Only 39.5% (17/43) of the patients who underwent PSMA-PET/CT were treated according to their initial treatment plans.ConclusionsOur results indicate that PSMA-PET/CT impacts treatment decisions and the selection of RT as well as adjuvant treatment protocols in the management of prostate cancer.

Clinical Significance of Mesenchymal Circulating Tumor Cells in Patients With Oligometastatic Hormone-Sensitive Prostate Cancer Who Underwent Cytoreductive Radical Prostatectomy.

PurposeGrowing evidence shows that circulating tumor cells (CTCs) become more aggressive after the epithelial–mesenchymal transition (EMT), though the clinical significance of CTCs undergoing EMT in oligometastatic hormone-sensitive prostate cancer (omHSPC) patients has not yet been reported. Accordingly, the aim of this study was to detect the CTC level and investigate the clinical significance of mesenchymal CTCs in omHSPC patients who underwent cytoreductive radical prostatectomy (CRP).Materials and MethodsBlood samples were drawn from 54 omHSPC patients who underwent CRP. The CanPatrol CTC enrichment technique was applied to isolate and identify different phenotypes of CTCs, which were classified as epithelial (E-CTCs), mesenchymal (M-CTCs), or biphenotypic epithelial/mesenchymal (Bi-CTCs). Univariable and multivariable Cox regression analyses were employed to investigate potential prognostic factors for metastatic castration-resistant prostate cancer (mCRPC)-free survival and cancer-specific survival (CSS). The prognostic value of CTCs for CSS and mCRPC-free survival was assessed using time-dependent receiver operating characteristic (ROC) curves and Kaplan–Meier analysis.ResultsCTCs were detected in 51 of 54 patients (94%). E-CTC, M-CTC, and Bi-CTC detection rates were 56%, 67%, and 85%, respectively. A positive correlation was found between the M-CTC count and number of bone metastases (p = 0.012). Time-dependent ROC analysis showed that the M-CTC count had higher predictive power than E-CTC or Bi-CTC for mCRPC-free survival (3-year area under the curve [AUC] values: 0.64, 0.60, and 0.61) and CSS (3-year AUC: 0.86, 0.58, and 0.67). Additionally, time-dependent ROC analysis revealed total CTCs (T-CTCs) ≥5 and M-CTCs ≥2 to be the cutoff points with optimal specificity and sensitivity. Based on multivariable Cox regression, T-CTC and M-CTC counts were both independently associated with CSS and mCRPC-free survival (all p < 0.05), though E-CTCs and Bi-CTCs had no significant prognostic value (all p > 0.05). Patients with T-CTC ≥5 or M-CTC ≥2 had significantly worse mCRPC-free survival and CSS than those with T-CTC<5 or M-CTC<2 (all p < 0.05) after CRP.ConclusionCTC quantification and phenotype characterization provide prognostic information, and M-CTCs can be used as a novel biomarker for omHSPC patients who undergo CRP. The results need to be validated in prospective studies.

Radiating the prostate bed in relapsed oligometastatic prostate cancer: How comprehensive should we be?

A subset of patients with high-risk pathological features at radical prostatectomy recur with oligometastatic disease. The aim of this study is to investigate the rate of prostate bed recurrence, with or without history of prostate bed irradiation (PBRT), in oligometastatic prostate cancer (OMPC) patients after metastasis-directed therapy (MDT). We performed a retrospective analysis of hormone-sensitive OMPC patients treated initially with curative-intent radical prostatectomy followed by disease recurrence and metastasis-directed stereotactic ablative radiotherapy (SABR) at our institution. Prostate bed recurrence rates were compared between patients who had PBRT at any point (i.e., before oligometastatic diagnosis or concurrently with MDT) versus those with no history of PBRT. Seventy-seven patients were included, and 68.8% had received PBRT. There were no significant differences in baseline characteristics between those who had received and had not received PBRT. There were five prostate bed recurrences following MDT, specifically with a 24-month cumulative incidence of 30.4% in patients who did not have PBRT and 2.4% in those who did (p = 0.03). Three of the five recurrences were isolated to the prostate bed at time of recurrence. Relapsed oligometastatic prostate cancer patients who have not received maximal local consolidative therapy to the prostate bed may have higher rates of local failure. Prospective studies are warranted investigating when prostate bed irradiation should be considered for patients after radical prostatectomy who ultimately have oligometastatic prostate cancer.

Recent Advances in the Management of Hormone-Sensitive Oligometastatic Prostate Cancer.

After primary treatment for prostate cancer with either radical prostatectomy or radiotherapy, a significant proportion of patients are at risk of developing metastases. In recent years, a deeper understanding of the underlying biology together with improved imaging techniques and the advent of new therapeutic options including metastases-directed therapies and new drugs have revolutionized the management of low-burden metastatic disease, also known as oligometastatic state. The purpose of this narrative review is to report the recent developments in the management of hormone-sensitive oligometastatic prostate cancer patients.

Radiotherapy of the Primary Tumor and All Metastatic Lesions in Synchronous Oligometastatic Prostate Cancer

The aim of this study was to evaluate the survival in synchronous oligometastatic prostate cancer patients treated with radiotherapy (RT) for both primary tumor and all metastatic lesions.This was a single-center cohort study. Synchronous oligometastatic (≤5) prostate cancer patients with RT for both primary tumor and all metastatic lesions were included. Kaplan-Meier method, log rank test and cox regression were used to calculate OS and PFS. PFS included PSA failure, local or distant failure assessed by imaging.This study analyzed 60 patients from 10/2011 to 12/2017 with median follow-up of 48 months. All patients had metastatic disease at the time of initial diagnosis and all patients received androgen deprivation therapy (ADT). Forty-four (73%) patients were hormone sensitive (HSPC) and 16 (27%) patients were castrate resistant (CRPC) at the time of RT. PSMA PET/CT was used for 7 (12%) men. The most common fractionation schemes of the primary tumor were 2 Gy for 35-38 fractions (67%) and 2.7-2.8 Gy for 13 fractions (22%). The median BED3 was 126 Gy (range, 100-128 Gy). A total of 37 (62%) patients were treated with whole pelvic RT (WPRT). A total of 87 metastatic lesions were treated with RT. The median BED3 was 120 Gy for metastatic lesions (range, 63-139 Gy). For the whole cohort, the PFS and OS were 51.4% and 47.4% at 4 years. Median PFS for men with HSPC was 78 months compared with 11 months in men with CRPC. Median OS for men was 45 months in men with CRPC. On univariable analysis, HSPC, shorter interval between diagnosis and RT, lower pre-RT PSA, lower Gleason score, lower metastatic burden/volume, use of WPRT were associated with improved PFS.Our study suggests that RT for the primary tumor and all metastatic lesions plus systemic therapy has better survival than clinical studies of prostate radiotherapy alone, especially for patients with HSPC, shorter interval between diagnosis and RT and lower metastatic burden/volume.

Current usage of stereotactic body radiotherapy for oligometastatic prostate cancer in Korea: patterns of care survey (KROG 19-08).

BackgroundGrowing evidence suggests that metastasis-directed therapy and/or prostate-directed therapy may benefit patients with oligometastatic prostate cancer (OMPC). Stereotactic body radiotherapy (SBRT) is increasingly used to treat oligometastases in various cancers. The purpose of this study was to investigate the current patterns of curative-intent SBRT for OMPC in Korea.MethodsA 20-item questionnaire was sent to 326 radiation oncologists in 93 institutions in Korea. Only 1 physician per institution was required to complete the survey. Subsequently, the second survey consisting of 3 clinical scenarios was sent to 64 physicians with clinical experience in SBRT: case 1, cT4N0M1 (direct invasion to two pelvic bones); case 2, cT2N0M1 (three bone metastases); and case 3, solitary spine metastasis after radical prostatectomy.ResultsSeventy-six physicians from 93 institutions (82%) answered the first survey. The multidisciplinary team approach was practiced in 16 institutions (21%). Most physicians (75%) agreed on the definition of oligometastases as limited lesions and/or organs ≤5: 25% agreed with low-volume disease according to CHAARTED trial. During the last year, 49 physicians (64%) treated OMPC patients with curative intent. Sixty four physicians (84%) had a clinical experience with SBRT: 48 (75%) stated that both dose and fraction number should be considered when defining SBRT, whereas others (25%) stated that only fraction size should be considered. Fifty-five faculties (86%) answered the second survey. Physicians agreed with oligometastases in 89% for case 1, in 80% for case 2, and in 100% for case 3. The rate of SBRT application was the highest in case 3 (70%).ConclusionsThere was diversity in the patterns of SBRT for OMPC in Korea. Additional prospective studies are necessary to strengthen evidence regarding role of SBRT in OMPC.

IJU this issue

In this issue, one Review Article, seven Original Articles, two Urological Notes and nine Editorial Comments (total 19 manuscripts) are published. Shigemura and Fujisawa (Hyogo, Japan) reviewed the prevention and management of infectious complications in prostate biopsy. Miyamoto et al. (Nara, Japan) reported on the clinical outcomes after intravesical bacillus Calmette–Guérin for the highest-risk non-muscle-invasive bladder cancer newly defined in the Japanese Urological Association Guidelines 2019. Tabei et al. (Kanagawa, Japan) investigated the efficacy of re-do urethroplasty for post-traumatic urethral stricture in terms of anatomical and functional outcomes to show a high success rate and beneficial effects on both anatomical and functional outcomes. Taoka et al. (Kagawa, Japan) showed the therapeutic benefits of a surgical checklist in improving the quality of resection during transurethral resection and reducing the recurrence rate in patients with non-muscle-invasive bladder cancer. Hata et al. (Fukushima, Japan) identified the preoperative low bladder contractile index as the predictor of postoperative detrusor underactivity during the early postoperative period after robot-assisted radical prostatectomy. Shin and Mimata (Oita, Japan) described the “early pull-out” technique for intracorporeal ileal conduit urinary diversion after robot-assisted radical cystectomy. Aizawa et al. (Kyoto, Japan) reported that prostate-targeted treatment plus metastasis-directed therapy through external beam radiation therapy can result in favorable long-term disease-free and survival outcomes with acceptable morbidities among synchronous oligometastatic prostate cancer patients. Iguchi et al. (Osaka, Japan) reported that enzalutamide plus androgen deprivation therapy has clinical benefit with a tolerable safety profile in Japanese men with metastatic hormone-sensitive prostate cancer, consistent with the overall population. Yamashita et al. (Wakayama, Japan) evaluated the prognostic impact of sarcopenia and myosteatosis on survival after radical cystectomy for bladder cancer. Unfortunately, the limited space does not allow me to introduce all the papers. However, all the articles in this issue are very informative and interesting, so please enjoy it by all means. None declared.

P0925 - Radio-guided lymph node dissection in primary oligometastatic prostate cancer patients

P0925 - Radio-guided lymph node dissection in primary oligometastatic prostate cancer patients

Does surgery benefit patients with oligometastatic or metastatic prostate cancer? -Aretrospective cohort study and meta-analysis.

To evaluate long-term oncological outcomes of radical prostatectomy (RP) plus androgen deprivation therapy (ADT) in oligometastatic prostate cancer (PCa) patients. Our study included oligometastatic PCa patients hospitalized between January 1, 2010 and December 31, 2015, who received ADT with or without RP. We evaluated survival by employing Kaplan-Meier methods, with log-rank tests and univariate and multivariate Cox regression analyses. A meta-analysis of previously published studies was additionally performed. The median follow-up times of both groups were 68.4 months (interquartile range = 56.5-85.0). In this cohort study, significant statistical difference in preoperative total prostate-specific antigen(tPSA;p = .121), clinical T stage (p = .115), and N stage (p = .394) were not found between the two groups. Meanwhile, the difference in overall survival (OS) between the two groups did not reach statistical significance (p = .649). A significant difference was not observed in castration-resistant prostate cancer (CRPC)-free survival between two groups as well (p = .183). Numbers of metastases might be an independent prognosis factor (p = .05) for OS, and postoperative tPSA is a risk predictor for CRPC-free survival (p = .032). A meta-analysis of four relevant studies demonstrated significant statistical difference in clinical improvement with RP plus ADT over ADT alone in OS survival (p < .001;hazard ratio [HR] = 0.51; 95% confidence interval [CI] = 0.38-0.69) instead of CRPC-free survival (p = .42; HR = 0.86; 95% CI = 0.59-1.24). The addition of RP to ADT for the treatment of oligometastatic PCawas associated with an improved OS instead of CRPC-free survival.