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

The prognostic significance of additional localized treatment to primary lesion in patients undergoing hormone therapy for metastatic hormone-sensitive prostate cancer: A systematic review and meta-analysis

BACKGROUND

We aimed to compare the prognostic values of 'localized treatment to the primary lesion (LT) plus hormone therapy (HT)' versus 'HT alone' in metastatic hormone-sensitive prostate cancer (mHSPC).

METHODS

We conducted a systematic search through the databases of PubMed®, Web of Science®, and Cochrane library® in April 2023 based on the PRISMA (Preferred Reporting Items for Systemic Reviews and Meta-Analyses) statement. A pooled meta-analysis was performed to assess the prognostic differences between LT + HT and HT alone according to randomized and non-randomized controlled studies (RCTs and NRCTs, respectively).

RESULTS

The search identified three RCTs and eight NRCTs. In RCTs, LT did not show prognostic benefits regarding biochemical-failure free rate nor overall survival (OS), although in patients with low tumor burdens, the LT + HT group showed better OS (HR: 0.68, 95% CI: 0.54-0.86). In the NRCTs, the LT+HT group showed superior progression-free survival (hazard ratio (HR): 0.42, 95% confidence interval (CI): 0.21-0.87), cancer-specific survival (HR: 0.39, 95% CI: 0.20-0.76), and OS (HR: 0.63, 95% CI: 0.57-0.69) to the HT alone group. In addition, better OS was observed in the LT +HT group regardless of the type of treatment modality for LT; radical prostatectomy (HR: 0.52, 95% CI: 0.39-0.69), radiotherapy (HR: 0.63, 95% CI: 0.56-0.71) in NRCTs.

CONCLUSIONS

LT to the primary lesion in metastatic hormone-sensitive prostate cancer may provide prognostic benefits and especially in patients with low tumor burden.

Is there a role for radical prostatectomy in the management of oligometastatic prostate cancer? A systematic review

CONTEXT

There is a growing interest about the role of radical prostatectomy (RP) in local cancer control in oligometastatic prostate cancer (PCa).

PURPOSE

To evaluate the oncological and functional outcomes of RP in the management of oligometastatic PCa through a systematic review.

METHODS

A systematic review search was performed and the following bibliographic databases were accessed: PubMed, Scopus, Embase and the Cochrane central register of controlled trials were searched from January 2000 to November 2022. This was carried out by the Preferred Reporting Items for Systematic reviews and Meta-analyses (PRISMA) guidelines.

RESULTS

Based on the literature search of 384 articles, 11 (511 patients) met the inclusion criteria (mean age: 65.5 yr.). Positive surgical margins were 59%. Median follow-up ranged from 13 to 64 months. Clinical progression-free survival ranged from 56% at 3 years to 45% at 7 years. Specific and overall survival rates ranged from 60 to 80.5% and 78 to 80% at 5 years, respectively. Clavien ≥3 complications ranged from 0 to 21%. The urinary incontinence rate was 14.5%.

CONCLUSIONS

Similar to published studies, RP of oligometastatic PCa appears to be safe with acceptable morbidity in selected patients. The lack of a consensual definition, the low level of evidence and the bias of the comparative and retrospective studies available do not allow practical recommendations to be made. There is currently no place for metastatic surgery outside of participation in a clinical trial.

Local Therapeutics for the Treatment of Oligo Metastatic Prostate Cancer

PURPOSE OF REVIEW

Metastatic prostate cancer remains universally lethal. Although de-novo metastatic prostate cancer was historically managed with systemic therapy alone, local therapies are increasingly utilized in the early treatment of the disease, particularly in patients with oligometastatic prostate cancer (OMPC). OMPC represents an intermediate stage between clinically localized and widespread metastatic disease. Diseases classified within this stage present an opportunity for localized targeting of the disease prior to progression to widespread metastases. The purpose of this review is to discuss the contemporary and emerging local therapies for the treatment of OMPC.

RECENT FINDINGS

To date, there are three utilized forms of local therapy for OMPC: cryoablation, radiation therapy, and cytoreductive prostatectomy. Cryoablation can be utilized for the total ablation of the prostate and has shown promising results in patients with OMPC either in combination with ADT or with ADT and systemic chemotherapy. Radiation therapy along with ADT has demonstrated improvement in progression-free survival. The STAMPEDE Arm G, PEACE-1, and the HORRAD clinical trials have investigated radiation therapy for mPCa compared to standard of care versus systemic therapy with varying results. Cytoreductive radical prostatectomy (CRP) in conjunction with ADT has also been proposed in the management of OPMC with promising results from case-control and retrospective studies. Currently there are larger controlled trials investigating CRP for OPMC including the SIMCAP, LoMP, TRoMbone, SWOG 1802, IP2-ATLANTA, g-RAMPP, and FUSCC-OMPCa trials. Given the novel nature of local treatments for OPMC, treatment selection is still controversial and requires long-term follow-up and randomized clinical trials to aid patient and clinician decision making.

Cytoreductive prostatectomy may improve oncological outcomes in patients with oligometastatic prostate cancer: An updated systematic review and meta-analysis

The oncologic outcomes of cytoreductive prostatectomy (CRP) in oligometastatic prostate cancer (OmPCa) are still controversial. Therefore, we conducted a systematic review and meta-analysis on the oncologic outcome of CRP in OmPCa. OVID-Medline, OVID-Embase, and Cochrane Library databases were searched to identify eligible studies published before January 2023. A total of 11 studies (929 patients), 1 randomized controlled trial (RCT) and 10 non-RCT studies, were included in the final analysis. RCT and non-RCT were further analyzed separately. End points were progression-free-survival (PFS), time to castration-resistant prostate cancer (CRPCa), cancer-specific-survival (CSS) and overall-survival (OS). It was analyzed using hazard ratio (HR) and 95% confidence intervals (CIs). In PFS, in RCT, HR=0.43 (CIs=0.27-0.69) was shown statistically significant, but in non-RCTs, HR=0.50 (CIs=0.20-1.25), there was no statistical difference. And, in time to CRPCa was statistically significant in the CRP group in all analyses (RCT; HR=0.44; CIs=0.29-0.67) (non-RCTs; HR=0.64; CIs=0.47-0.88). Next, CSS was not statistically different between the two groups (HR=0.63; CIs=0.37-1.05). Finally, OS showed better results in the CRP group in all analyses (RCT; HR=0.44; CIs=0.26-0.76) (non-RCTs; HR=0.59; CIs=0.37-0.93). Patients who received CRP in OmPCa showed better oncologic outcomes compared to controls. Notably, time to CRPC and OS showed significantly improved compared with control. We recommend that experienced urologists who are capable of managing complications consider CRP as a strategy to achieve good oncological outcomes in OmPCa. However, since most of the included studies are non-RCT studies, caution should be exercised in interpreting the results.

Cytoreductive radical prostatectomy: who benefits from the surgical approach?

PURPOSE OF REVIEW

Local treatment in oligometastatic prostate cancer patients is associated with improved survival. Nevertheless, in term of surgery, cytoreductive radical prostatectomy has no level of evidence 1 and is an individual treatment approach. We reviewed the recent literature to highlight parameters for selecting patients for a surgical approach.

RECENT FINDINGS

Retrospective data on oncologic outcome for cytoreductive prostatectomy are confirmed. We identified several parameters that help to select patients for surgery. Patients with a favorable prostate-specific antigen (PSA) decline after androgen deprivation therapy (ADT) have excellent oncologic long-term control. Circulating tumor cells (CTC's) are frequently analyzed in more advanced prostate cancer. In case of C-reactive protein (CRP) at least a longer interval to develop castration resistant prostate cancer (CRPC) is shown in case of low CTC count at time of surgery. Nutrition status analyzed as the hemoglobin, albumin, lymphocyte, and platelet (HALP)-score is of significant value in demonstrating an effect of CRP.

SUMMARY

From retrospective findings we have several clinical and basic science parameters to select patients for CRP. PSA at the time of surgery is the most frequently analyzed one, whereas CTC and HALP-score are promising tools to select patients that need to be validated.

Current Controversy and Developments Regarding the Cytoreductive Prostatectomy for Oligometastatic Prostate Cancer

Oligometastatic prostate cancer is a term that is most often used to refer to limited sites of disseminated tumor growth following primary radical prostatectomy (RP) or radiotherapy (RT), while de novo oligometastatic is a term that is used to refer to prostate tumors that have disseminated to limited sites before definitive treatment. In patients with de novo oligometastatic prostate cancer, treatment planning must thus consider the need to manage the primary tumor and the associated distant lesions. Traditionally, resectioning primary metastatic tumors is not thought to offer significant benefits to affected patients while increasing their risk of surgery-related complications. Recent clinical evidence indicates that patients undergoing cytoreductive prostatectomy (CRP) may observe substantial enhancements in overall survival rates while not experiencing a noticeable decline in their quality of life. Nevertheless, based on the current body of evidence, it is deemed inadequate to justify revising clinical guidelines. Consequently, it is not advisable to propose CRP for patients with oligometastatic prostate cancer. The present review was compiled to summarize available data regarding the indications, functional outcomes, and oncological outcomes associated with cytoreductive radical prostatectomy to provide a robust and objective foundation that can be used to better assess the value of this interventional strategy from a clinical perspective.

Cytoreductive radical prostatectomy or radiation therapy for metastases prostate cancer: Evidence from meta-analysis

BACKGROUND

Cytoreductive radical prostatectomy (RP), transurethral resection of the prostate, and radiation therapy were the main local treatments for oligometastatic prostate cancer (PCa). An optimal local treatment for metastases PCa was not consensus. The purpose of this study was to evaluate the effect on these local treatments for patients with metastases PCa.

METHODS

All relevant studies were systematically searched through PubMed, Web of Science through November 1, 2021. Studies were screened by inclusion and exclusion criteria. Progression-free survival (PFS), cancer-specific survival (CSS), and overall survival (OS) were evaluated by this meta-analysis.

RESULTS

Eleven studies were identified that met the inclusion criteria. 644 patients received cytoreductive surgery, 8556 patients received no surgery or radiation therapy (RT), and 461 patients received RP + androgen deprivation therapy compared with 746 patients who received RT. Pooled data indicated that cytoreductive surgery significantly prolonged the PFS (OR = 0.65, 95% CI 0.53-0.80, P < .0001), CSS and OS (OR = 0.49, 95% CI 0.43-0.56, P < .00001; and OR = 0.80, 95% CI 0.72-0.88, P < .00001; respectively). Comparing cytoreductive surgery with RT, CSS, and OS were similar (OR = 0.82, 95% CI 0.67-1.01, P = .06; and OR = 0.93, 95% CI 0.79-1.09, P = .39; respectively).

CONCLUSIONS

Cytoreductive radical prostatectomy significantly prolonged the PFS for metastatic PCa. Although OS was considered a-not-so significant difference between cytoreductive surgery and non-local therapy, non-local treatment was not recommended.

Cytoreductive prostatectomy improves survival outcomes in patients with oligometastases: a systematic meta-analysis

BACKGROUND

Whether cytoreductive prostatectomy (CRP) should be performed in patients with oligometastatic prostate cancer (OPC) remains controversial. The goal of this systematic meta-analysis was to assess the efficacy of CRP as a treatment for OPC.

METHODS

This systematic review and meta-analysis was conducted in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analysis statement. Data sources included publications in the PubMed, Embase, the Cochrane Library, EBSCO, and Web of Science (SCI) databases as of May 2022. Eligible articles included prospective studies comparing the efficacy of CRP to a lack of CRP in patients with OPC.

RESULTS

In total, 10 publications incorporating 888 patients were analyzed. Tumor-reducing prostatectomy was found to have no significant effect on long-term or short-term OS [OR = 2.26, 95% CI (0.97, 5.28), P = 0.06] and [OR = 1.73, 95% CI (0.83, 3.58), P = 0.14], but it significantly improved patient long-term or short-term CSS [OR = 1.77, 95% CI (1.01, 310), P = 0.04] and [OR = 2.71, 95% CI (1.72, 4.29), P < 0.0001] and PFS [OR = 1.93, 95% CI (1.25, 2.97), P = 0.003].

CONCLUSION

These results suggest that cytoreductive prostatectomy can confer survival benefits to OPC patients.

TRIAL REGISTRATION

INPLASY protocol 202260017 https://doi.org/10.37766/inplasy2022.6.0017 .