The Role of Local Therapy for Oligometastatic Prostate Cancer: Should We Expect a Cure?

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Key points

  • There are data to suggest that an oligometastatic state may confer a better outcome than higher-volume metastases.

  • Such patients may be considered for aggressive approaches, including radical treatment of the primary cancer.

  • The definition of oligometastatic state remains contentious, and superior imaging is challenging the traditional paradigm based on conventional imaging.

  • Nonrandomized data suggest a survival benefit for patients who undergo treatment of the primary despite metastatic disease

Defining oligometastatic prostate cancer

Most studies and trials have defined oligometastasis in prostate cancer according to the number of metastatic lesions. Most vary between 3 and 5 metastases,2, 3, 4, 5, 6, 7, 8, 9, 11 although 1 study included patients with 10 or fewer lesions.12 Other studies have defined the oligometastatic state according to site of lesions, with lymph node, bone, and extrapelvic metastases commonly used as site-specific criteria.21 In addition, 1 previous study used the size of the metastases as part of

Surgical Treatment of Oligometastatic Prostate Cancer

It is important to remember that there is no level 1 evidence with respect to treatment of the primary in metastatic prostate cancer, and guidelines uniformly recommend systemic treatment as the standard of care. Data on treatment are drawn largely from nonrandomized trials, retrospective cohorts, and post-hoc analyses of prospective studies, all of which carry inherent bias, and should be interpreted with caution.

Nevertheless, there are some data that support the role of cytoreductive

Limitations of the evidence for treating the primary in oligometastatic disease

Although, at face value, the evidence for treatment of the primary in oligometastatic prostate cancer may be convincing, it must be interpreted with caution. There is currently no level 1 evidence from randomized trials suggesting that local treatment of the primary tumor in metastatic prostate cancer improves survival. Many of the studies are epidemiologic or are nonrandomized and therefore have significant methodological limitations (selection bias in particular), which limits the scope of

Imaging techniques in redefining metastatic disease

Traditional curative treatment of localized prostate cancer has only been advocated in the nonmetastatic setting.11 At present, the standard for staging prostate cancer, in order to determine eligibility for potentially curative treatment, is cross-sectional imaging (CT or MRI and technetium-99m [99mTc] bone scan or single-photon emission CT [SPECT]). However, over the past few years, significant advancements in imaging techniques have been made, specifically in PET imaging.45, 46, 47 Emerging

End points in oligometastatic prostate cancer: is a cure really expected?

Patients presenting with advanced prostate cancer account for approximately one-third of prostate cancer deaths in the United States, with an average age of 73 years and a median survival of approximately 3 years.55 However, most patients who die from prostate cancer are those who recur after radical treatment. Men with oligometastatic disease belong to both groups and accordingly, discussion of a cure may not adequately represent the complexity of the disease. It may be more appropriate to

Imaging in Oligometastatic Prostate Cancer

PSMA-targeted imaging is gaining interest, with data showing high sensitivity to small-volume sites of prostate cancer that are not detectable on conventional imaging.62 The ongoing proPSMA (Prospective Evaluation of 68Ga-PSMA–PET/CT for Recurrence Detection of Prostate Cancer and Its Impact on Patient Management) study, a single-arm, phase III imaging trial, is designed to prospectively evaluate the impact of 68Ga-PSMA–PET/CT on the therapeutic management of patients with biological recurrent

Summary

The widespread use of local and ablative treatment of oligometastatic prostate cancer outside the setting of clinical trials remains uncertain. Although there is a promising and growing bank of evidence, current standard of care has not been sufficiently challenged. There remain insufficient conclusions regarding cancer-specific and overall survival and the outcomes of the prospective trials are eagerly awaited.

Standardization in the definition of oligometastasis must extend beyond the number

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