Role of radical prostatectomy in metastatic prostate cancer: data from the Munich Cancer Registry

A Personalized Approach for Oligometastatic Prostate Cancer: Current Understanding and Future Directions

Oligometastatic prostate cancer (OMPC) represents an intermediate state in the progression from localized disease to widespread metastasis when the radiographically significant sites are limited in number and location. With no clear consensus on a definition, its diagnostic significance and associated optimal therapeutic approach remain controversial, posing a significant challenge for clinicians. The current standard of care for metastatic disease is to start systemic therapy; however, active surveillance and targeted radiotherapy have become attractive options to mitigate the long-term effects of androgen deprivation therapy (ADT). Furthermore, evolving biomarker methodologies may further define optimal treatment selection. In this review, we summarize the current understanding that guides the treatment of OMPC, with a focus on how host response can be an important contributing factor. Evolving scientific understanding and clinical development will continue to shape the landscape of treatment strategies for this distinct disease state.

Cost-effectiveness analysis of additional local prostate radio therapy in metastatic prostate cancer from a medicare perspective

BACKGROUND

Metastatic prostate cancer remains a therapeutic challenge. Based on data of the STAMPEDE trial, patients with a low metastatic burden showed prolonged failure-free and overall survival when treated with prostate radio therapy (RT) in addition to standard of care (SOC). The objective of this study was to determine the cost-effectiveness of additional prostate RT compared to SOC alone for following subgroups: non-regional lymph node (NRLN) metastases, up to three bone metastases and four or more bone metastases.

METHODS

A partitioned survival model was implemented with clinical data from STAMPEDE trial. Analyses were performed from a United States healthcare system perspective. Costs for treatment and adverse events were derived from Medicare coverage. Utilities for health states were derived from public databases and literature. Outcome measurements included incremental costs, effectiveness, and cost-effectiveness ratio. The willingness-to-pay threshold was set to USD 100,000 per quality-adjusted life year (QALY).

RESULTS

Additional RT led to 0.92 incremental QALYs with increased costs of USD 26,098 with an incremental cost-effectiveness ratio (ICER) of USD 28,452/QALY for patients with only NRLN metastases and 3.83 incremental QALYs with increased costs of USD 153,490 with an ICER of USD 40,032/QALY for patients with up to three bone metastases. Sensitivity analysis showed robustness of the model regarding various parameters. In probabilistic sensitivity analysis using Monte Carlo simulation with 10,000 iterations, additional RT was found as the cost-effective strategy in over 96% for both subgroups iterations at a willingness-to-pay threshold of USD 100,000/QALYs.

CONCLUSIONS

Additional RT is cost-effective in patients with only NRLN metastases and up to three metastases compared to SOC.

[Local therapies for oligometastatic hormone-sensitive prostate cancer]

BACKGROUND

Oligometastatic, hormone-sensitive prostate cancer (omHSPC) is increasingly diagnosed due to the implementation of molecular imaging. OmHSPC is mostly defined as a maximum of four bone metastases without visceral metastases on conventional imaging.

OBJECTIVES

This study highlights the existing evidence regarding local treatment of omHSPC, taking into account molecular imaging and modern therapies.

MATERIALS AND METHODS

Narrative review article based on expert consensus and national/international guideline recommendations, supported by a nonsystematic literature search in PubMed (MEDLINE). The authors consider the cited studies as the most significant works in this regard and these were selected to illustrate developments and fundamental concepts, without claiming completeness.

RESULTS

Initially, the STAMPEDE study prospectively demonstrated an oncologic benefit of radiotherapy (RT) to the prostate in addition to androgen deprivation therapy for omHSPC. At 3 years, overall survival (OS) was 81% with RT versus 73% without RT (hazard ratio [HR] 0.68; 95% confidence interval [CI] 0.52-0.90; p = 0.007). However, this benefit was not observed in polymetastatic HSPC (HR 1.07; 95% CI 0.90-1.28; p = 0.4). In a study by Dai et al., local therapy for omHSPC was performed surgically in 85% of cases, also demonstrating an OS advantage (HR 0.44; 95% CI 0.24-0.81; p = 0.008).

CONCLUSION

OmHSPC should be treated using adjunctive RT. Preliminary prospective evidence shows comparable efficacy with prostatectomy. Modern systemic combination therapies challenge the role of local therapy.

Does Radical Local Treatment in Oligometastatic Prostate Cancer Improve Overall Survival: A Systematic Review and Meta-analysis

OBJECTIVE

To determine the impact of radical local treatment (RLT) on overall survival (OS) and other survival outcomes in patients with OligoMetastatic Prostate Cancer (OMPC).

METHODS

We performed a meta-analysis of randomized controlled trials (RCTs) published in the MEDLINE and CENTRAL databases until May 2023. We included RCTs that randomized patients to RLT (either radical prostatectomy [RP] or external beam radiotherapy [EBRT]) and standard of care and reported on OMPC. Our primary objective was to analyze OS with a minimum median follow-up of 4years (PROSPERO-CRD42023422736).

RESULTS

We analyzed 3 RCTs, presenting data across 5 papers. OS was significantly higher in the RLT group (HR - 0.643, 95%CI 0.514-0.8, P-value <.001). The data on EBRT was drawn from 520 patients and that of RP was from 85. The post-hoc power analysis showed 81% power to detect a difference of 10% with an alpha error of 0.01. Pooled prevalence of grade 3-4 bowel and bladder toxicity was 4.5%. Health-Related Quality of Life was similar in both groups (mean difference - 1.54, 95%CI -0.625 -3.705, P-value .163). The risk of bias as per the RoB2 tool was low for all domains and overall bias. As per GRADE criteria, the certainty of evidence was high.

CONCLUSION

Our meta-analysis underscores the evidence-based significance of RLT, particularly emphasizing the benefits of EBRT in patients with OMPC. However, the findings should be interpreted with caution due to the limited number of studies and the relatively small sample sizes, especially in the RP subgroup. Future investigations in OMPC should consider incorporating EBRT in their standard treatment approach.

Local Treatment and Treatment-Related Adverse Effects Among Patients With Advanced Prostate Cancer

Importance

Recent data suggest that local treatment with radical prostatectomy or radiation may improve survival outcomes in men with advanced prostate cancer. However, evidence is lacking on treatment-related adverse effects among men with advanced prostate cancer.

Objective

To assess the association of local treatment on treatment-related adverse effects among men diagnosed with advanced prostate cancer.

Design, Setting, and Participants

This cohort study assessed men diagnosed with advanced prostate cancer (defined as T4, N1, and/or M1 prostate cancer) between January 1, 1999, and December 31, 2013, with follow-up through December 31, 2021, who were treated at Veterans Health Administration medical centers.

Exposure

Local treatment with radical prostatectomy or radiation.

Main Outcomes and Measures

Main outcomes were treatment-related adverse effects, including constitutional, gastrointestinal, pain, sexual function, and urinary function conditions, at 3 intervals after initial treatment (≤1 year, >1 to ≤2 years, and >2 to ≤5 years) after initial treatment.

Results

This cohort study consisted of 5502 men (mean [SD] age, 68.7 [10.3] years) diagnosed with advanced prostate cancer. Of the cohort, 1705 men (31.0%) received local treatment. There was a high prevalence of adverse conditions in men receiving both local and nonlocal treatment, and these adverse conditions persisted for more than 2 years to 5 years or less after initial treatment. A total of 916 men (75.2%) with initial local treatment and 897 men (67.1%) with initial nonlocal treatment reported the presence of at least 1 adverse condition for more than 2 years to 5 years or less after initial treatment. In the first year, local treatment (vs nonlocal) was associated with adverse gastrointestinal (multivariable-adjusted odds ratio [AOR], 4.08; 95% CI, 3.06-5.45), pain (AOR, 1.57; 95% CI, 1.35-1.83), sexual (AOR, 2.96; 95% CI, 2.42-3.62), and urinary (AOR, 2.25; 95% CI, 1.90-2.66) conditions. Local treatment (without secondary treatment) remained significantly associated with adverse gastrointestinal (AOR, 2.39; 95% CI, 1.52-3.77), sexual (AOR, 3.36; 95% CI, 2.56-4.41), and urinary (AOR, 1.39; 95% CI, 1.09-1.78) conditions at more than 2 years to 5 years or less after treatment.

Conclusions and Relevance

In this cohort study of men with advanced prostate cancer, local treatment was associated with persistent treatment-related adverse effects across multiple domains. These results suggest that patients and clinicians should consider the adverse effects of local treatment when making treatment decisions in the setting of advanced prostate cancer.

The role of cytoreductive radical prostatectomy and lymph node dissection in bone-metastatic prostate cancer: A population-based study

BACKGROUNDS

The role of cytoreductive radical prostatectomy (cRP) for bone-metastatic prostate cancer (bmPCa) remains controversial. We aimed to figure out whether cRP and lymph node dissection (LND) can benefit bmPCa.

METHODS

11,271 PCa patients with bone metastatic burden from 2010 to 2019 were identified using SEER-Medicare. Overall survival (OS) and cancer-specific survival (CSS) rates were visualized using Kaplan-Meier plots. Multivariable Cox regression analyses were constructed to examine the effects of cRP and LND on survival, after stratifying to age, prostate specific antigen (PSA), clinical stages, Gleason score, metastatic burden, radiotherapy, and chemotherapy status.

RESULTS

317 PCa patients underwent cRP and cRP was increasingly performed for bmPCa from 2010 (2.2%) to 2019 (3.0%) (p < 0.05). In multi analyses, cRP was predisposed to a better OS or CSS in patients with age < 75, PSA < 98 ng/mL, bone-only metastatic sites or patients not receiving chemotherapy (all p < 0.05). For the patients undergoing cRP, LND especially extended LND was associated with a better OS or CSS (all p < 0.05).

CONCLUSIONS

cRP might benefit OS or CSS in young patients with low PSA and bone-only metastatic sites not receiving chemotherapy. And a clear OS or CSS benefit of LND especially extended LND was observed in patients undergoing cRP.

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.

Unravelling oligometastatic disease from the perspective of radiation and medical oncology. Part II: prostate cancer and colorectal cancer

Oligometastatic disease (OMD) defines a status of cancer that is intermediate between localized and widely spread metastatic disease, and can be treated with curative intent. While imaging diagnostic tools have considerably improved in recent years, unidentified micrometastases can still escape from current detection techniques allowing disease to progress. The variety of OMD scenarios are mainly defined by the number of metastases, the biological and molecular tumour profiles, and the timing of the development of metastases. Increasing knowledge has contributed to the earlier and improved detection of OMD, underlining the importance of an early disease control. Based on increasing detection rates of OMD in the current real clinical practice and the lack of standardized evidence-based guidelines to treat this cancer status, a board of experts from the Spanish Societies of Radiation Oncology (SEOR) and Medical Oncology (SEOM) organized a series of sessions to update the current state-of-the-art on OMD from a multidisciplinary perspective, and to discuss how results from clinical studies may translate into promising treatment options. This experts' review series summarizes what is known and what it is pending clarification in the context of OMD in the scenarios of Non-Small Cell Lung Cancer and Breast Cancer (Part I), and Prostate Cancer and Colorectal Cancer (Part II), aiming to offer specialists a pragmatic framework that might contribute to the improved management of patients.

Definitive treatment and risk of death among men diagnosed with metastatic prostate cancer at the Veterans Health Administration

PURPOSE

To assess the potential survival benefit associated with receipt of definitive treatment (radical prostatectomy or radiation), compared to non-definitive treatment (hormonal therapy or chemotherapy) among men with metastatic prostate cancer.

METHODS

A cohort of men diagnosed with metastatic (T4/M1/N1 or T4/M1) prostate cancer from 1999 to 2013 in the Veterans Health Administration were identified and followed to December 28, 2014. All-cause and prostate cancer-specific mortality were evaluated at 10 years for the T4/M1/N1 cohort and 8 years for the T4/M1/ cohort. The association of definitive treatment (radical prostatectomy or radiation), compared to non-definitive (hormonal therapy or chemotherapy) with both all-cause and prostate cancer-specific mortality was assessed using inverse probability of treatment weighted (IPTW) multivariable survival analyses.

RESULTS

The cohort included 2919 with T4/M1/N1 disease and 1479 men with T4/M1 disease. Receipt of definitive treatment was associated with a reduced risk of 10-year all-cause (Hazard Ratio (HR): 0.61; 95% Confidence Interval (CI): 0.57-0.65) and prostate cancer-specific mortality (HR: 0.50; 95% CI: 0.46-0.55) among men diagnosed with T4/M1/N1 met-astatic disease. Definitive treatment was similarly associated with a reduced risk of all-cause (HR: 0.84; 95% CI: 0.77-0.91) and prostate cancer-specific (HR: 0.81; 95% CI: 0.73-0.90) mortality among men diagnosed with T4/M1 only metastatic disease.

CONCLUSIONS

Definitive treatment may improve survival in men diagnosed with metastatic prostate cancer.

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.

An Updated Systematic and Comprehensive Review of Cytoreductive Prostatectomy for Metastatic Prostate Cancer

(1) Background: Local therapy is highly promising in a multimodal approach strategy for patients with low-volume metastatic prostate cancer (mPCa). We aimed to systematically assess and summarize the safety, oncologic, and functional outcomes of cytoreductive prostatectomy (cRP) in mPCa. (2) Methods: Three databases were queried in September 2022 for publications that analyzed mPCa patients treated with cytoreductive prostatectomy without restrictions. The outcomes of interest were progression-free survival (PFS), cancer-specific survival (CSS), overall survival (OS), perioperative complication rates, and functional outcomes following cRP. (3) Results: Overall, 26 studies were included in this systematic review. Among eight population-based studies, cRP was associated with a reduced risk of CSS and OS compared with no local therapy (NLT) after adjusting for the effects of possible confounders. Furthermore, one population-based study showed that cRP reduced the risk of CSS even when compared with radiotherapy (RT) of the prostate after adjusting for the effects of possible confounders. In addition, one randomized controlled trial (RCT) demonstrated that local therapy (comprising 85% of cRP) significantly improved the prostate-specific antigen (PSA)-PFS and OS. Overall, cRP had acceptable perioperative complication rates and functional outcomes. (4) Conclusions: Mounting evidence suggests that cRP offers promising oncological and functional outcomes and technical feasibility and that it is associated with limited complications. Well-designed RCTs that limit selection bias in patients treated with cRP are warranted.

Assessment of oligometastasis status of prostate cancer following combined robot-assisted radical prostatectomy and androgen deprivation versus androgen deprivation therapy alone using PSA percentage decline rate

Objective

To compare the tumor control in prostate cancer patients with oligo-metastasis following combined robot-assisted radical prostatectomy and androgen deprivation versus androgen deprivation therapy alone based on total prostate-specific antigen (tPSA) assessment.

Methods

Medical data of a total of 18 prostate cancer patients with oligometastasis administered in The First Affiliated Hospital of Nanchang University from March 2017 to March 2018 were prospectively collected. 10 patients received a combined therapy of robot-assisted radical prostatectomy and pharmaceutical androgen deprivation (RARP+ADT group), while 8 patients received pharmaceutical androgen deprivation therapy alone (ADT group). Then demographic characteristics, prostate volume, tumor characteristics and tPSA data were analysised and compared. Statistical analysis was performed using t-test for continuous variables and Pearson chi-square test or Fisher's exact test for categorical variables.

Results

No significant difference was found in patients' age (p = 0.075), prostate volume (p = 0.134) and number of bone metastasis (p = 0.342). Pre-treatment Gleason score was significantly lower in RA group (p = 0.003). Patients in RARP+ADT group had significantly lower pre-treatment tPSA (p = 0.014), while no statistical difference was noted in reexamined tPSA (p = 0.140) on follow-up. No statistical difference was noted in tPSA decline rates (declined tPSA value per day) in RARP+ADT and ADT group (8.1 ± 4.7 verse 7.5 ± 8.0 ng/ml/d, p = 0.853). However, tPSA percentage decline rate (declined tPSA percentage per day) was significantly higher in RARP+ADT group (11.6 ± 1.5%/d verses 2.9 ± 2.2%/d, p< 0.001). Immediate urinary continence was achieved in 9 patients (90%) upon removal of urethral catheter on post-operative day 7 in RARP+ADT group.

Conclusion

ADT alone and in combination with RARP both provide effective tumor control in patients suffering from prostate cancer with oligometastasis. ADT combined with RARP exhibited significant advantage in PSA percentage decline rate without compromising patients' urinary continence. Long-term tumor control requires further follow-up.

Prostate and metastasis-directed focal therapy in prostate cancer: hype or hope?

INTRODUCTION

The paradigm of focal therapy's role in metastatic patients is being challenged by evolving attitudes and emerging data. At the current time, specifically regarding prostate cancer, does the evidence indicate this is more hype or hope?

AREAS COVERED

We searched the literature via PubMed, MEDLINE, and Embase for studies from 2014 to the present addressing focal therapy with non-palliative intent in metastatic prostate cancer patients, emphasizing prospective trials when available. We sought to address all common clinical scenarios: de novo synchronous diagnosis, oligorecurrence, oligoprogression, and mCRPC disease.

EXPERT OPINION

Current evidence is strongest, and in our opinion practice-changing, for prostate-directed RT in de novo metastatic patients with low metastatic burden. Metastasis-directed therapy with SBRT is consistently shown to have low rates of toxicity, and promising rates of ADT-free survival and progression-free survival. These can be utilized on a patient-by-patient basis with these endpoints in mind, but do not yet show sufficient benefit to be standard of care. This is a rich area of ongoing research, and many trials should publish in the coming years to shed light on many unanswered questions, including the role of cytoreductive prostatectomy, systemic therapy combined with MDT, and the integration of modern PET imaging.

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.

Overall survival and cancer-specific survival were improved in local treatment of metastatic prostate cancer

Background

For metastatic prostate cancer (mPCa), radical prostatectomy (RP) and radiation therapy (RT) may improve overall survival (OS) and cancer-specific survival (CSS). Compared with RT, RP shows significant advantages in improving patient outcomes. External beam radiation therapy (EBRT) even slightly elevates CSM with no statistical difference in OS compared with no local treatment (NLT).

Objective

To evaluate OS and CSS after local treatment (LT) (including RP and RT) versus NLT in mPCa. Design, setting, and participants Within the Surveillance, Epidemiology and End Results (SEER) database (2000-2018), 20098 patients with metastatic prostate cancer were selected in this study, of which 19433 patients had no local treatment, 377 patients with radical prostate treatment, and 288 patients with RT.

Outcome measurements and statistical analysis

Multivariable competing risks regression analysis after propensity score matching (PSM) was used to calculate CSM. Multivariable Cox regression analysis was used to identify the risk factors. Kaplan-Meier methods were used to calculate OS.

Results and limitations

A total of 20098 patients were included: NLT (n = 19433), RP (n=377) and RT (n=288). In a competing risk regression analysis after PSM (ratio 1:1), RP resulted in a significantly lower CSM (hazard ratio [HR] 0.36, 95% confidence interval [CI] 0.29-0.45) than NLT, while RT showed a slightly lower CSM (HR 0.77, 95% CI 0.63-0.95). In a competing risk regression analysis after PSM (ratio 1:1), RP led to a lower CSM (HR 0.56, 95% CI 0.41-0.76) versus RT. As for all-cause mortality (ACM), RP (HR 0.37, 95% CI 0.31-0.45) and RT (HR 0.66, 95% CI 0.56-0.79). also showed a downward trend. In terms of OS, RP and RT significantly improved the survival probability compared with NLT, with the effect of RP being more pronounced. Obviously, older age, Gleason scores ≥8, AJCC T3-T4 stage, AJCC N1, AJCC M1b-M1c were all associated with higher CSM (P <0.05). The same results held true for ACM. The limitation of this article is that it is not possible to assess the effect of differences in systemic therapy on CSM in mPCa patients and clinical trials are needed to verify the results.

Conclusions

For patients with mPCa, both RP and RT are beneficial to patients, and the efficacy of RP is better than RT from the perspective of CSM and ACM. Older age, higher gleason scores and the more advanced AJCC TNM stage all put patients at higher risk of dying.

Patient summary

A large population-based cancer database showed that in addition to first-line therapy (hormonal treatment), RP and radiotherapy can also benefit patients with mPCa.

Imaging of prostate cancer: optimizing affinity to prostate specific membrane antigen by spacer modifications in a tumor spheroid model

Early diagnosis of prostate cancer (PCa) is crucial for staging, treatment and management of patients. Prostate specific membrane antigen (PSMA), highly over-expressed on PCa cells, is an excellent target for selective imaging of PCa. In recent years, various scaffolds have been explored as potential carriers to target diagnostic and therapeutic agents to PSMA⁺ tumour cells. Numerous fluorescent or radioisotope probes linked via a peptide linker have been developed that selectively binds to PCa cells. However, there are very few reports that examine the effects of chemical modifications in the peptide linker of an imaging probe on its affinity to PSMA protein. This report systematically investigates the impact of hydrophobic aromatic moieties in the peptide linker on PSMA affinity and in vitro performance. For this, a series of fluorescent bioconjugates 12-17 with different aromatic spacers were designed, synthesized, and their interactions within the PSMA pocket were first analysed in silico. Cell uptake studies were then performed for 12-17 in PSMA⁺ cell lines and 3D tumour models in vitro. Binding affinity values of 12-17 were found to be in the range of 36 to 157.9 nM, and 12 with three aromatic groups in the spacer exhibit highest affinity (K_D = 36 nM) compared to 17 which is devoid of aromatic groups. These studies suggest that aromatic groups in the spacer region can significantly affect deep tissue imaging of fluorescent bioconjugates. Bioconjugate 12 can be a promising diagnostic tool, and conjugation to near-infrared agents would further its applications in deep-tissue imaging and surgery. Communicated by Ramaswamy H. Sarma.

The current role of precision surgery in oligometastatic prostate cancer

Oligometastatic prostate cancer (omPCa) is a novel intermediate disease state characterized by a limited volume of metastatic cells and specific locations. Accurate staging is paramount to unmask oligometastatic disease, as provided by prostate-specific membrane antigen-positron emission tomography. Driven by the results of prospective trials employing conventional and/or modern staging modalities, the treatment landscape of omPCa has rapidly evolved over the last years. Several treatment-related questions comprising the concept of precision strikes are under development. For example, beyond systemic therapy, cohort studies have found that cytoreductive radical prostatectomy (CRP) can confer a survival benefit in select patients with omPCa. More importantly, CRP has been consistently shown to improve long-term local symptoms when the tumor progresses across disease states due to resistance to systemic therapies. Metastasis-directed treatments have also emerged as a promising treatment option due to the visibility of oligometastatic disease and new technologies as well as treatment strategies to target the novel PCa colonies. Whether metastases are present at primary cancer diagnosis or detected upon biochemical recurrence after treatment with curative intent, targeted yet decisive elimination of disseminated tumor cell hotspots is thought to improve survival outcomes. One such strategy is salvage lymph node dissection in oligorecurrent PCa which can alter the natural history of progressive PCa. In this review, we will highlight how refinements in modern staging modalities change the classification and treatment of (oligo-)metastatic PCa. Further, we will also discuss the current role and future directions of precision surgery in omPCa.

Current status and future perspective on the management of metastatic castration-sensitive prostate cancer

Since 1941, the standard treatment for metastatic castration-sensitive prostate cancer (mCSPC) was androgen deprivation therapy (ADT) by surgical or medical castration with or without first-generation antiandrogen. However, the efficacy of ADT does not last in most cases. In the 2010s, de-intensification by intermittent ADT was evaluated by RCTs for mCSPC to mitigate the treatment-emerged burdens. However, intermittent ADT failed to show non-inferiority in OS for mCSPC and is an optional treatment for selected patients with mCSPC. The treatment for patients with mCSPC has improved in the last years. Currently, based on the evidence from RCTs, intensification treatment by adding docetaxel, novel androgen receptor pathway inhibitors and multimodal treatment using radiotherapy to the primary have become new standard treatments for mCSPC. Furthermore, ongoing RCTs have been investigating the clinical values of more intensified treatments by combining multiple effective treatment for mCSPC. In addition, novel treatment using immunotherapeutics such as anti-PD-1 antibody and precision medicine approach using novel imaging and genomic marker has been investigated vigorously. Thus, we review current treatment evidence obtained by RCTs that included patients with mCSPC. The future key to mCSPC treatment could be personalized medicine including translational and clinical medicine aspects, with molecular testing to assess the biological tumor behavior to optimize clinical decision-making.

Combination of Androgen Deprivation Therapy with Radical Local Therapy Versus Androgen Deprivation Therapy Alone for Newly Diagnosed Oligometastatic Prostate Cancer: A Phase II Randomized Controlled Trial

BACKGROUND

Previous studies suggested that men with metastatic prostate cancer might benefit from local treatment of the primary tumor.

OBJECTIVE

To determine whether radical local therapy (RLT) improves survival for men with oligometastatic prostate cancer (OMPCa).

DESIGN, SETTING, AND PARTICIPANTS

This open-label randomized controlled trial included patients with newly diagnosed OMPCa defined as five or fewer bone or extrapelvic lymph node metastases and no visceral metastases.

INTERVENTION

Patients were randomly allocated to androgen deprivation therapy (ADT) or ADT and RLT. Men allocated RLT received either cytoreductive radical prostatectomy (RP) or prostate radiation therapy (RT) with a radical dose schedule.

OUTCOME MEASUREMENTS AND STATISTICAL ANALYSIS

The primary outcome was radiographic progression-free survival (rPFS). Secondary outcomes were overall survival (OS) and prostate-specific antigen (PSA) progression-free survival.

RESULTS AND LIMITATIONS

Between September 2015 and March 2019, 200 patients were randomized, with 100 men allocated to each group. The median age was 68 yr and the median PSA at diagnosis was 99 ng/ml. In the study group, 96 patients underwent RLT (85 RP and 11 RT). In the control group, 17 patients eventually received RLT (15 RP and two RT). All patients were included for an intention-to-treat analysis. After a median follow-up of -48 mo, the median rPFS was not reached in the study group and was 40 mo in the control group (hazard ratio [HR] 0.43, 95% confidence interval [CI] 0.27-0.70; p = 0.001). The 3-yr OS rate was 88% for the study group and 70% for the control group (HR 0.44, 95% CI 0.24-0.81; p = 0.008).

CONCLUSIONS

Men with newly diagnosed OMPCa who received ADT plus RLT (mainly prostatectomy) had significantly higher rates of rPFS and OS than those who received ADT alone.

PATIENT SUMMARY

This study investigated the effect of radical local therapy (RLT) of the primary tumor on survival in patents with oligometastatic prostate cancer. In our group, RLT improved radiographic progression-free and overall survival.

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

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.

Einfluss von lokalen Therapiemaßnahmen auf die Biologie des fortschreitenden Prostatakarzinoms

Hintergrund

In den letzten 15 Jahren zeigt sich ein Trend hin zu einem längeren Überleben beim metastasierten Prostatakarzinom. Neben dem durch neue Medikamente bedingten Fortschritt deuten retrospektive Daten auch auf einen möglichen positiven Effekt einer früheren Primärtumorbehandlung hin.

Fragestellung

Kann eine Primärtumorbehandlung im Falle einer späteren Metastasierung die Prognose der betroffenen Patienten verbessern und wenn ja, über welche Mechanismen?

Material und Methode

Wir werteten die klinischen Langzeitergebnisse von 115 Patienten aus, die bei T4-Prostatakarzinomen nach induktiver Hormontherapie an unserer Klinik prostatektomiert worden waren. Weiterhin erfolgte eine kritische Durchsicht und Diskussion der zur oben genannten Fragestellung vorhandenen Literatur.

Ergebnisse

Von den 115 Patienten hatten 84 im weiteren Verlauf ein biochemisches Rezidiv erlitten, waren also definitiv durch die radikale Prostatektomie nicht geheilt. Das tumorspezifische und das Gesamtüberleben dieser 84 Patienten lag nach 150 Monaten bei 61 % bzw. 44 %. Bemerkenswert war die Beobachtung, dass diese Patienten ein überraschend gutes und langes Ansprechen auf eine Hormontherapie zeigten. Von den 84 Patienten waren nach durchschnittlich 95 Monaten Nachbeobachtungszeit noch 47 am Leben. 31 von ihnen, also ungefähr zwei Drittel, standen immer noch unter einer Standardhormontherapie. Nur 13 hatten eine Resistenz gegen die primäre Hormontherapie entwickelt und entsprechend eine tertiäre Hormontherapie erhalten, auf die sie teilweise aber auch wieder langfristig sensibel blieben.

Schlussfolgerungen

Die Primärtumorentfernung, zumindest unter den beschriebenen Begleitumständen, scheint die Entwicklung einer Hormonresistenz beim metastasierten Prostatakarzinom hinauszögern und in Einzelfällen sogar ganz verhindern zu können.

Comparing the Survival Outcomes of Radical Prostatectomy Versus Radiotherapy for Patients With De Novo Metastasis Prostate Cancer: A Population-Based Study

Purpose

The efficacy of local treatments (LTs) in selected patients with metastatic prostate cancer (mPCa) had been demonstrated. However, the comparative effectiveness between LTs is unclear. Here, we compared the impact of radical prostatectomy (RP) and brachytherapy (RT) on the survival outcomes of mPCa patients.

Materials and Methods

mPCa patients who received RT or RP between 2004 and 2016 were identified from the Surveillance, Epidemiology, and End Results (SEER) database. Multivariable Cox proportional hazards analysis was used to evaluate the comparative risk of prostate cancer-specific mortality (CSM) and all-cause mortality (ACM) between LTs. A 1:1 propensity score matching (PSM) and adjusted standardized mortality ratio weighting (SMRW) were performed to balance the clinicopathological characteristics of the groups.

Results

Of 684 mPCa patients, 481 underwent RP and 203 received RT. After PSM, both groups included 148 cases, and RT resulted in comparable CSM versus RP [CSM: hazard ratio (HR) = 0.77, p = 0.325; ACM: HR = 0.73, p = 0.138], which was consistent with the SMRW model [CSM: HR = 0.83, p = 0.138; overall survival (OS): HR = 0.75, p = 0.132]. However, RP was associated with a lower CSM in the T_1–2 subgroup (HR = 0.42, p = 0.048) and a lower ACM in the T_1–2 (HR = 0.55, p = 0.031) and prostate-specific antigen (PSA) ≤20ng/ml (HR = 0.48, p = 0.022) subgroups. Besides, the results showed that the mortality risk was similar between the two groups in the T_3–4, Gleason score (GS) >7, PSA >20 ng/ml, and all metastatic subgroups (all p > 0.100).

Conclusions

RP could confer better survival outcomes than could RT in mPCa patients with favorable primary tumor features, but not in those with advanced primary tumor features. Moreover, the metastatic substage has limited impact on the comparative effectiveness between RP and RT. Further clinical trials are necessary to confirm the present results.

Health-Related Quality of Life following Cytoreductive Radical Prostatectomy in Patients with De-Novo Oligometastatic Prostate Cancer

Simple Summary

Recent retrospective data indicate a survival benefit of surgical removal of the prostate in patients with oligometastatic prostate cancer as part of a multimodal therapeutic regime. However, the impact of radical prostatectomy (RP) on patient’s health-related quality of life (HRQOL) in this scenario has not been evaluated yet. In a contemporary and well-balanced cohort, we compared the self-assessed HRQOL of patients with oligometastatic prostate cancer with patients with locally confined prostate cancer two years postoperatively. In multivariate analysis, we found no significant difference in postoperative HRQOL and urinary continence recovery in patients with de-novo oligo-metastatic compared to patients with locally confined prostate cancer.

Abstract

(1) Background: local treatment of the primary tumor has become a valid therapeutic option in de-novo oligo-metastatic prostate cancer (PC). However, evidence regarding radical prostatectomy (RP) in this setting is still subpar, and the effect of cytoreductive RP on postoperative health-related quality of life (HRQOL) is still unclear. (2) Methods: for the current study, patients with de-novo oligo-metastatic PC (cM1-oligo), defined as ≤5 bone lesions in the preoperative staging, were included, and matched cohorts using the variables age, body-mass index (BMI), and pT-stage were generated. Patient-reported outcome measures (PROMS) were assessed pre- and postoperatively using the validated EORTC-QLQ-C30, IIEF-5, and ICIQ-SF questionnaires. The primary endpoint for univariate and multivariable analysis was good general HRQOL defined by previously validated cut-off values. (3) Results: in total, 1268 patients (n = 84 (7%) cM1-oligo) underwent RP between 2012 and 2020 at one tertiary care center. A matched cohort of 411 patients (n = 79 with oligo-metastatic bone disease (cM1-oligo) and n = 332 patients without clinical indication of metastatic disease (cM0)) was created. The median follow-up was 25mo. There was no significant difference in good general HRQOL rates between cM1-oligo-patients and cM0-patients before RP (45.6% vs. 55.2%, p = 0.186), and at time of follow-up (44% vs. 56%, p = 0.811). Global health status (GHS) worsened significantly in cM0-patients compared to baseline (−5, p = 0.001), whereas GHS did not change significantly in cM1-oligo-patients (+3.2, p = 0.381). In multivariate analysis stratified for good erectile function (IIEF5 > 18; OR 5.722, 95% CI 1.89–17.36, p = 0.002) and continence recovery (OR 1.671, 95% CI 1.03–2.70, p = 0.036), cM1-oligo was not an independent predictive feature for general HRQOL (OR 0.821, 95% CI 0.44–1.53, p = 0.536). (4) Conclusions: in this large contemporary retrospective analysis, we observed no significant difference in HRQOL in patients with the oligometastatic bone disease after cytoreductive radical prostatectomy, when compared to patients with localized disease at time of surgery.

Can local treatment prolong the sensitivity of metastatic prostate cancer to androgen deprivation or even prevent castration resistance?

PURPOSE

A number of observational clinical studies suggest that prior primary tumor treatment favorably influences the course of metastatic prostate cancer (PCa), but its mechanisms of action are still speculative. Here, we describe the long-lasting sensitivity to various forms of androgen deprivation in patients after radical prostatectomy (RP) for locally advanced PCa as one potential mechanism.

METHODS

A consecutive series of 115 radical prostatectomies after inductive therapy for T4 prostate cancer was re-analyzed, and long-term survival, as well as recurrence patterns and responses to different forms of hormonal manipulation, were assessed.

RESULTS

The estimated biochemical response-free, PCa-specific, and overall survival rates after 200 months were 20%, 65%, and 47% with a median overall survival of 156 months. The majority of patients, although not cured of locally advanced PCa (84/115), showed long-term survival after RP. PCa-specific and overall survival rates of these 84 patients with biochemical recurrence were 61% and 44% at 150 months. Long-term sensitivity to ADT was found to be the main reason for the favorable tumor-specific survival in spite of biochemical recurrence.

CONCLUSIONS

Sensitivity to primary or secondary hormonal manipulation was the main reason for the long-term survival of patients who had not been cured by surgery only. The results suggest that treatment of the primary tumor-bearing prostate delays castration-resistant PCa and enhances the effect of hormonal therapies in a previously unknown manner. The underlying cellular and molecular mechanisms need to be explored in more detailed analyses, which could profoundly impact treatment concepts of locally advanced and metastatic PCa.

Oligometastatic prostate cancer: definition and the role of local and systemic therapy: a narrative review

The definition of oligometastatic prostate cancer (OMPC) includes a heterogenous group of disease states, mostly defined by the number and site of metastases, which seems to be biologically different to widespread tumors. Evidence suggests a substantial survival benefit for this subgroup of limited metastatic burden which is currently seen as a potentially curable disease and therefore with an increasing interest in the scientific community. As there is still no consensus on the definition of OMPC, commonly used criteria are based on the CHAARTED and LATITUDE trials. The management algorithms for these patients were rapidly changing in the past decade due to recent data with a paradigm shift to a multimodal intensification of the treatment by the availability of combinations of hormonal therapy with taxane-based chemotherapy and androgen-receptor-targeted agents leading to significant improvement of clinical outcomes. In addition, radiotherapy of the primary tumor is associated with significant survival benefit in patients with OMPC establishing a new arm in the multimodal treatment concept. Recent data on metastases directed therapy and cytoreductive prostatectomy showed promising results, while there is still a lack of prospective trials and therefore should be limited to experimental settings. The purpose of this review is to summarize and discuss the existing data on treatment of OMPC.

Cytoreductive radical prostatectomy versus systemic therapy and radiation therapy in metastatic prostate cancer: A systematic review and meta-analysis

Cytoreductive prostatectomy had gained a lot of interest in treatment of metastatic prostate cancer (mPCa) but this treatment approach is still in the experimental phase. This systematic review and meta-analysis was conducted to shed light on the merits of cytoreductive radical prostatectomy compared to systemic and radiation therapy in treatment of mPCa. In February 2021, summary data from 12 original research papers covering 100,973 patients is abstracted. PubMed/Medline, Scopus, Google Scholar, EMBASE, and the Cochrane Library were all reviewed and 12 publications were chosen for inclusion. The evaluated outcomes were 1-, 3-, and 5-year Cancer-Specific (CSS) and overall survival (OS) rates. Cytoreductive radical prostatectomy had significantly higher survival rate for 1-year (OR: 3.03; 95% CI: 2.30-3.98; p < 0.001), 3-year (OR: 2.47; 95% CI: 2.14-3.51; p < 0.001), and 5-year CSS rates (OR: 2.90; 95% CI: 2.10-4.01; p < 0.001) than systemic therapy in mPCa. Higher significant rates of 1-year (OR: 2.35; 95% CI: 1.65-3.36; p < 0.001), three-year (OR: 2.25; 95% CI: 1.96-2.60; p < 0.001), and 5-year OS rates (OR: 2.54; 95% CI: 2.10-3.08; p < 0.001) were also detected for cytoreductive radical prostatectomy compared to systemic therapy. There were no significant differences in 1-year (OR: 1.21; 95% CI: 0.88-1.66; p = 0.25), 3-year (OR: 1.21; 95% CI: 0.92-1.59; p = 0.18), and 5-year CSS rates (OR: 0.91; 95% CI: 0.58-1.42; p = 0.67) between cytoreductive radical prostatectomy and radiation in mPCa patients. Also, no significant differences in 1-year (OR: 1.06; 95% CI: 0.77-1.47; p = 0.71), 3-year (OR: 0.83; 95% CI: 0.60-1.14; p = 0.25), and 5-year OS rates (OR: 1.84; 95% CI: 0.76-4.45; p = 0.18) were detected between cytoreductive radical prostatectomy and radiation therapy. Cytoreductive radical prostatectomy had significantly higher 1-, 3-, and 5-year CSS and OS rates compared to systemic therapy. Comparable CSS and OS rates were found between cytoreductive radical prostatectomy and radiation therapy.

Multicentre, prospective study on local treatment of metastatic prostate cancer (LoMP study)

OBJECTIVES

To investigate the role of cytoreductive radical prostatectomy in addition to standard of care for patients with newly diagnosed metastatic prostate cancer.

MATERIALS AND METHODS

This multicentre, prospective study included asymptomatic patients from 2014 to 2018 (NCT02138721). Cytoreductive radical prostatectomy was offered to all fit patients with resectable tumours, resulting in 40 patients. Standard of care was administered to 40 patients who were ineligible or unwilling to undergo surgery. The primary endpoint was castration resistant cancer-free survival at the time point of ≥50% events. The secondary endpoint was local event-free survival. Kaplan-Meier and Cox regression analyses with propensity-score analysis were applied.

RESULTS

After a median (quartiles) follow-up of 35 (24-47) months, 42 patients became castration-resistant or died. The median castration resistant cancer-free survival was 53 (95% confidence interval [CI] 14-92) vs 21 (95% CI 15-27) months for cytoreductive radical prostatectomy compared to standard of care (P = 0.017). The 3-year estimates for local event-free survival were 83% (95% CI 71-95) vs 59% (95% CI 51-67) for cytoreductive radical prostatectomy compared to standard of care (P = 0.012). However, treatment group showed no significance in the multivariable models for castration resistant cancer-free survival (P = 0.5) or local event-free survival (P = 0.3), adjusted for propensity-score analysis. Complications were similar to the non-metastatic setting. Patients undergoing surgery were younger, with lower baseline prostate-specific antigen levels, alkaline phosphatase levels and metastatic burden.

CONCLUSION

The present LoMP study was unable to show a difference between the two inclusion groups regarding castration resistant cancer-free survival for asymptomatic patients with newly diagnosed metastatic prostate cancer. These results validate previous evidence that, in well-selected and informed patients, cytoreductive radical prostatectomy is feasible and safe, with corresponding continence rates compared to the non-metastatic, high-risk setting. Whether cytoreductive radical prostatectomy could be a valuable option to achieve good local palliation needs to be further researched. Overall, the role of cytoreductive radical prostatectomy needs to be further explored in randomized studies to correct for potential bias.

Radical prostatectomy improves survival in selected metastatic prostate cancer patients: A North American population-based study

OBJECTIVE

To test whether radical prostatectomy might result in better survival than external beam radiation therapy in metastatic prostate cancer patients.

METHODS

Newly diagnosed metastatic prostate cancer patients with M1a/b substages, treated with radical prostatectomy or external beam radiation therapy were abstracted from the Surveillance, Epidemiology and End Results database (2004-2016). Temporal trend analyses, propensity score matching, cumulative incidence plots, multivariate competing risks regression models and landmark analyses were used.

RESULTS

Of 4280 patients, 954 (22.3%) were treated with radical prostatectomy. After propensity score matching, 5-year cancer-specific mortality was 47.0 versus 53.0% in radical prostatectomy versus external beam radiation therapy patients (P = 0.003). In propensity score matched competing risks regression models, radical prostatectomy was associated with lower cancer-specific mortality versus external beam radiation therapy (hazard ratio 0.79, 95% confidence interval 0.79-0.90; P = 0.001). Finally, landmark analyses rejected the bias favoring radical prostatectomy. Finally, in subgroup analyses, we relied on selection criteria that most closely resembled the STAMPEDE criteria and a similar hazard ratio of 0.8 (P < 0.001) was recorded.

CONCLUSION

In metastatic prostate cancer, radical prostatectomy results in lower cancer-specific mortality relative to external beam radiation therapy. Even after adjustment for age at diagnosis, prostate-specific antigen and biopsy Gleason grade grouping, lower cancer-specific mortality rates are recorded in radical prostatectomy patients than in external beam radiation therapy patients. As a result, radical prostatectomy should be considered as a treatment option in selected metastatic prostate cancer patients. However, further validation will be provided by ongoing clinical trials.

Contemporary outcomes following robotic prostatectomy for locally advanced and metastatic prostate cancer

While radical prostatectomy (RP) plays a prominent role in the management of localized prostate cancer, its role in high risk or metastatic disease is less clear. Due to changes in prostate cancer screening patterns, particularly those made by the United States Preventive Services Task Force, data is suggesting increasing incidences of high risk and metastatic disease, underlying the importance of continued research in this area. While past approaches to management may have discouraged surgical intervention, more contemporary approaches have attempted to evaluate its effectiveness and utility. The purpose of this review is an updated discussion of the current literature regarding surgical approaches to high risk prostate cancer. The PubMed and Medline databases were queried for English language articles related to the surgical management of high-risk prostate adenocarcinoma. In this review, we examine the utility of surgery as a single or multimodal approach to management with patients with high risk, locally advanced, and metastatic prostate cancer. Outcomes measures are reviewed including data on survival and recurrence rates. Functional outcomes are an important consideration in prostate cancer management and while data is more limited, this review examines some of the key findings. Finally, a discussion regarding surgical complication rates and ongoing clinical trials is addressed. While surgery appears to be promising in this patient cohort, there remains significant heterogeneity in the data that ongoing trials may be able to address. At its current level of understanding, surgery should be considered as a potential tool in patient management, but may play a more prominent role in a multi-modality setting for optimal outcomes.

[Local and metastasis-directed therapy for oligometastatic prostate cancer]

New developments of systemic therapy concepts for metastatic prostate carcinoma have led to a significant improvement in the prognosis in the recent past. It has long been unclear to what extent local and/or metastasis-directed therapies have an additional oncologic benefit in addition to palliation, local control and functional maintenance. For local therapy of the prostate, the highest evidence currently exists for radiotherapy and shows a significantly increased overall survival in "low- burden" oligometastatic patients. Metastasis-directed surgical or radio-oncological concepts may also improve prognosis but have not yet been sufficiently investigated and should therefore be discussed, documented and established on an individual and interdisciplinary basis.

Cytoreductive radical prostatectomy after chemohormonal therapy in patients with primary metastatic prostate cancer

Objective

Methods

Results

Conclusion

Nomogram predicting survival to assist decision-making of radical prostatectomy in patients with metastatic prostate cancer

Background

Radical prostatectomy (RP) has heterogeneous effects on survival of patients with metastatic prostate cancer (mPCa). A reliable model to predict risk of cancer-specific mortality (CSM) and the potential benefit derived from RP is needed.

Methods

Patients diagnosed with mPCa were identified using the Surveillance, Epidemiology, and End Results database (2004–2015) and categorized in RP versus nonlocal treatment (NLT). Based on the Fine and Gray competing risks model in 8,463 NLT patients, a nomogram was created to predict CSM in mPCa patients. Decision tree analysis was then utilized for patient stratification. The effect of RP was evaluated among 3 different subgroups.

Results

A total of 8,863 patients were identified for analysis. Four hundred (4.5%) patients received RP. The 5-year cumulative incidence of CSM was 52.4% for the entire patients. Based on nomogram scores, patients were sorted into three risk groups using decision tree analysis. In the low- and intermediate-risk group, RP was found to be significantly correlated with a 21.7% risk reduction of 5-year CSM, and 25.0% risk reduction of 5-year CSM, respectively, whereas RP was not associated with CSM in high-risk group (hazard ratio =0.748, 95% confidence interval 0.485–1.150; P=0.190).

Conclusions

We developed a novel nomogram and corresponding patient stratification predicting CSM in mPCa patients. A newly identified patient subgroup with low-, and intermediate-risk of CSM might benefit more from RP. These results should be further validated and improved by ongoing prospective trials.

Treatment of the primary in metastatic prostate cancer

PURPOSE OF REVIEW

The standard treatment in metastatic prostate cancer (mPCa) is systemic, based on androgen deprivation therapy recommended in different forms, alone or combined with abiraterone acetate or docetaxel. The aim of this review is to synthesize the available data from literature regarding the optimal treatment of the primary in patients diagnosed with metastatic prostate cancer.

RECENT FINDINGS

Multimodal treatments offer the best chance for survival for these patients, but the optimal strategy lacks consensus. Using retrospective studies as an argument, recent articles sustain the clinical and oncological benefits of local therapies in hormone-naïve metastatic prostate cancer, represented by radical prostatectomy or radiotherapy. Through these procedures, local control of disease can be achieved, thus avoiding potential complications and further surgical interventions. Even if the current results are not evenly relevant, the treatment of the primary along with metastasis-directed therapy could improve survival and even cure-selected patients.

SUMMARY

This article emphasizes important aspects regarding a feasible management of mPCa, with possible impact on subsequent guidelines. The expected results from ongoing trials may provide another perspective in treatment of these cases.

Metastasis-directed therapy and prostate-targeted therapy in oligometastatic prostate cancer: a systematic review

INTRODUCTION

The aim of this review was to summarize the available evidence on the role of metastasis-directed therapy (MDT) and/or prostate-targeted therapy (PTT) in the setting of oligometastatic prostate cancer (PCa).

EVIDENCE ACQUISITION

We searched PubMed, the Web of Science, and the Cochrane Library databases. The following keywords were used: ("prostate cancer" OR "prostate carcinoma" OR "prostate neoplasm" OR "prostate tumor") AND ("oligometastatic" OR "oligometastasis" OR "PSMA") AND ("surgery" OR "prostatectomy" OR "radical prostatectomy" OR "cytoreductive" OR "local treatment" OR "radiotherapy" OR "stereotactic" OR "stereotaxic") AND ("survival" OR "mortality").

EVIDENCE SYNTHESIS

After evaluating the selection criteria, 81 studies were evaluated for our endpoints. We included 22 studies for PTT of synchronous mPCa. There have been no randomized studies on cytoreductive prostatectomy (cRP). Four prospective studies showed that cRP was feasible but did not contribute to a positive effect on overall survival (OS). Regarding PTT-radiotherapy, two randomized controlled phase 3 trials showed that OS was improved in men with a low metastatic burden. Regarding MDT of metachronous lymph node recurrence, we included 29 retrospective studies. For MDT of oligometastases, we included 30 studies. One randomized phase 2 trial showed that androgen deprivation therapy-free survival improved with stereotactic body radiation therapy compared to that with surveillance; however, benefits on OS remain unclear.

CONCLUSIONS

We performed a comprehensive overview of the current literature on MDT and PTT. The feasibility of MDT and PTT is supported by several retrospective studies. Nevertheless, there remains a lack of high-quality trials to prove its survival benefits. Results from ongoing prospective trials data are awaited.

[Treatment concepts for primary oligometastatic prostate cancer]

BACKGROUND

About 5% of prostate cancer patients have distant metastases at diagnosis. In these metastatic hormone-sensitive prostate cancers (mHSPC), systemic therapy is recommended, according to the guidelines. Moreover, metastasis-directed therapy (MDT) is discussed to prolong survival.

OBJECTIVES

The contemporary literature concerning local therapy and MDT in patients with mHSPC is summarized.

METHODS

Selective literature search.

RESULTS

In 2018, randomized controlled data on local therapy in mHSPC patients were published by the authors of the STAMPEDE study. Here, patients were randomized between standard of care (SOC) ± radiotherapy to the prostate (RT). Within the overall cohort, no difference regarding 3‑year overall survival (OS) was observed. Within a prespecified subgroup of patients with low metastatic burden. Similar results were observed in numerous retrospective studies analyzing radical prostatectomy; prospective randomized studies are pending. For MDT, there are no sufficient data in mHSPC patients yet.

CONCLUSIONS

In the current guidelines, systematic therapy is standard of care in mHSPC patients. In patients with low metastatic burden, a survival benefit was observed when adding percutaneous RT to the prostate. Retrospective studies also suggest a benefit when adding RP. However, whether MDT prolongs survival is still unknown.

Metastatic hormone sensitive prostate cancer: local treatment strategies

PURPOSE

The landscape of the management of metastatic prostate cancer is changing rapidly and there is growing interest in the local treatment of the primary in these patients. The effect of local treatment on the outcome of metastatic prostate cancer patients was addressed based on retrospective analysis but now also based on prospective randomized trials. This article provides an overview of the currently available literature in this field.

METHODS

A literature review was done searching the Medline database for English language articles using the keywords "metastatic prostate cancer", and "local treatment", "radiotherapy", "prostatectomy". The data of prospective randomized studies and the data of case-control studies or retrospective analysis were summarized in a narrative fashion.

RESULTS

Data from two prospective randomized trials exploring the effect of local treatment of the prostate in hormone-sensitive metastatic prostate cancer showed no improvement of overall survival in the individual overall cohorts as well as in the pooled analysis (HR 0.92, 95% CI 0.81-1.04). There was an improvement of failure-free survival (pooled analysis HR 0.76, 95% CI 0.69-0.0.84). There was also an improved overall survival associated with radiotherapy in patients with < 5 metastases and with low volume disease. Data from prospective non-randomized or retrospective studies are inconclusive and underlies major selection biases.

CONCLUSION

Based on prospective randomized trials, local treatment by radiotherapy does not improve the overall survival in unselected metastatic prostate cancer patients. An effect can be seen in low volume patients or patients with < 5 metastases.

Multidisciplinary total eradication therapy (TET) in men with newly diagnosed oligometastatic prostate cancer

To evaluate the outcomes of total eradication therapy (TET), designed to eradicate all sites of visible cancer and micrometastases, in men with newly diagnosed oligometastatic prostate cancer (OMPCa). Men with ≤ 5 sites of metastases were enrolled in a prospective registry study, underwent neoadjuvant chemohormonal therapy, followed by radical prostatectomy, adjuvant radiation (RT) to prostate bed/pelvis, stereotactic body radiation therapy (SBRT) to oligometastases, and adjuvant hormonal therapy (HT). When possible, the prostate-specific membrane antigen targeted ¹⁸F-DCFPyL PET/CT (¹⁸F-DCFPyL) scan was obtained, and abiraterone was added to neoadjuvant HT. Twelve men, median 55 years, ECOG 0, median PSA 14.7 ng/dL, clinical stages M0—1/12 (8%), M1a—3/12 (25%) and M1b—8/12 (67%), were treated. ¹⁸F-DCFPyL scan was utilized in 58% of cases. Therapies included prostatectomy 12/12 (100%), neoadjuvant [docetaxel 11/12 (92%), LHRH agonist 12/12 (100%), abiraterone + prednisone 6/12 (50%)], adjuvant radiation [RT 2/12 (17%), RT + SBRT 4/12 (33%), SBRT 6/12 (50%)], and LHRH agonist 12/12 (100%)]. 2/5 (40%) initial patients developed neutropenic fever (NF), while 0/6 (0%) subsequent patients given modified docetaxel dosing developed NF. Otherwise, TET resulted in no additive toxicities. Median follow-up was 48.8 months. Overall survival was 12/12 (100%). 1-, 2-, and 3-year undetectable PSA’s were 12/12 (100%), 10/12 (83%) and 8/12 (67%), respectively. Median time to biochemical recurrence was not reached. The outcomes suggest TET in men with newly diagnosed OMPCa is safe, does not appear to cause additive toxicities, and may result in an extended interval of undetectable PSA.

Metastasis-directed therapy for oligometastatic urological tumours: still no second-hand news

For patients presenting with limited metastatic disease burden, known as the oligometastatic state of disease, a more aggressive treatment approach targeting the new or progressive metastatic lesions might improve patient outcome, with no or only limited toxicity to be expected from the treatment. This review provides an overview of the existing evidence and on-going trials on oligometastatic disease and metastasis-directed therapy in the field of renal, bladder and prostate cancer.

The cytoreductive prostatectomy in metastatic prostate cancer: what the individual trials are hoping to answer

OBJECTIVE

To review the ongoing randomised trials of cytoreductive prostatectomy (CRP) in de novo hormone-sensitive metastatic prostate cancer (HSPC) in order to identify their goals and assess their strengths and weaknesses.

METHODS

PubMed, MEDLINE and clinical trials websites searches were performed to identify currently ongoing trials of CRP in de novo HSPC.

RESULTS

Nine randomised clinical trials in CRP were identified and included: Southwest Oncology Group (SWOG) 1802, Surgery in Metastatic Carcinoma of Prostate (SIMCAP), Adjuvant Treatments to the Local Tumour for Metastatic Prostate Cancer: Assessment of Novel Treatment Algorithms (IP2-ATLANTA), Testing Radical prostatectomy in men with prostate cancer and oligoMetastases to the bone (TRoMbone), Impact of Radical Prostatectomy as Primary Treatment in Patients with Prostate Cancer with Limited Bone Metastases (g-RAMPP), Cytoreductive Prostatectomy vs Cytoreductive Prostate Irradiation as a Local Treatment Option for Metastatic Prostate Cancer: a Multicentric Feasibility Trial (LoMP II), Androgen-Deprivation Therapy or Androgen-Deprivation Therapy Plus Definitive Treatment (Radiation or Surgery) (FUSCC-OMPCa), and the Testing Radical Prostatectomy in Chinese Men with Prostate Cancer and oligoMetastases to the Bone study. Each study was different; assessing various primary outcome measures including overall survival (OS), progression-free survival and feasibility to randomise between standard therapy and CRP or between radiation therapy and CRP in the metastatic setting. In the oligometastatic setting, the trials assess OS, feasibility to randomise and time to castration resistance. Similarly, a number of secondary endpoints ranging from cancer-specific outcomes to quality-of-life outcomes are being investigated. The inclusion criteria in these trials also varied in terms of volume of metastatic disease (oligometastatic to high-volume metastatic disease), diagnosis of metastases (imaging based vs biopsy confirmed), imaging modalities used (conventional to newer modalities), as well as outcomes and follow-up regimes.

CONCLUSION

While there are differences in each protocol, each trial aims to address different aspects of CRP in de novo HSPC. Therefore, the specific goals of each study and the limitations have to be taken into consideration when interpreting the results of these trials.

Techniques of robotic radical prostatectomy for the management of prostate cancer: which one, when and why

The advent of robotic assistance in surgery has completely revolutionized the surgical management of prostate cancer. It enables precise dissection and reconstruction in order to maximize oncological and functional outcomes. In many parts of the world, robot-assisted laparoscopic radical prostatectomy has evolved to become the surgical standard of care for localized disease, including in appropriately selected patients with high risk prostate cancer. Its role has also been expanded to encompass cytoreductive prostatectomy and salvage radical prostatectomy. As surgical expertise grows with robotic assistance, several novel and non-radical approaches have been developed to further mitigate treatment side effects. Patient characteristics, disease factors and surgeon expertise are important metrics for consideration when selecting the most appropriate technique for any given patient.

The Emerging Role of Local Therapy in Metastatic Prostate Cancer

PURPOSE OF REVIEW

This review summarizes the prospective clinical evidence regarding local therapy in metastatic prostate cancer.

RECENT FINDINGS

The phase 3 STAMPEDE trial showed that prostate radiotherapy confers a survival benefit for newly diagnosed patients with low volume metastatic hormone-sensitive prostate cancer (HSPC). No survival benefit was noted for those with high volume disease. A subsequent meta-analysis combining the data of the STAMPEDE trial with that of the HORRAD trial corroborated these findings. The phase 2 randomized STOMP trial investigated local treatment of metastases in patients with oligometastatic HSPC, and showed an improvement in hormone therapy-free survival. Local prostate radiotherapy should be offered to patients with newly diagnosed low volume metastatic HSPC. Early clinical evidence suggests that local treatment to metastatic disease might be beneficial for patients with oligometastatic HSPC, but larger trials are awaited.

[Changes in the treatment of metastatic prostate cancer-new data and open questions]

The availability of taxane-based chemotherapy and androgen-receptor-targeted agents (ARTAs) have significantly broadened the therapeutic options for patients with metastatic prostate cancer and may also result in longer patient survival. The therapeutic sequence of ARTAs and taxanes may influence outcome and therefore decisions should be made on an individual basis. This article provides guidance for therapeutic decision-making in daily clinical practice by working out criteria that can be used to support individual therapeutic decisions. The focus is on metastatic castration-naive prostate cancer, oligometastatic disease as well as non-metastatic and metastatic castration-resistant prostate cancer.

Cytoreductive treatment strategies for de novo metastatic prostate cancer

In the past decade, a revolution in the treatment of metastatic prostate cancer has occurred with the advent of novel hormonal agents and life-prolonging chemotherapy regimens in combination with standard androgen-deprivation therapy. Notwithstanding, the use of systemic therapy alone can result in a castrate-resistant state; therefore, increasing focus is being placed on the additional survival benefits that could potentially be achieved with local cytoreductive and/or metastasis-directed therapies. Local treatment of the primary tumour with the established modalities of radiotherapy and radical prostatectomy has been explored in this context, and the use of novel minimally invasive ablative therapies has been proposed. In addition, evidence of the potential clinical benefits of metastasis-directed therapy with ionizing radiation (primarily stereotactic ablative radiotherapy) is accumulating. Herein, we summarize the pathobiological rationale for local cytoreduction and the potentially systemic immunological responses to radiotherapy and ablative therapies in patients with metastatic prostate cancer. We also discuss the current evidence base for a cytoreductive strategy, including metastasis-directed therapy, in the current era of sequential multimodal therapy incorporating novel treatments. Finally, we outline further research questions relating to this complex and evolving treatment landscape.

Comparison of Open Versus Robotically Assisted Cytoreductive Radical Prostatectomy for Metastatic Prostate Cancer

INTRODUCTION

Cytoreductive radical prostatectomy (CRP) may offer a survival advantage, according to several retrospective analyses. However, no direct comparisons are available regarding the type of surgical approach (open vs. robotic) in the metastatic setting. To address intraoperative and postoperative complications of robotically assisted CRP relative to open CRP in patients with metastatic prostate cancer.

PATIENTS AND METHODS

Within the National Inpatient Sample database (2008-2013), we identified patients with metastatic prostate cancer who underwent robotically assisted versus open CRP. Multivariable logistic regression, multivariable Poisson regression models, and linear regression models were used.

RESULTS

Of 874 patients who underwent CRP, 412 (47.1%) versus 462 (52.9%) underwent open versus robotically assisted CRP, respectively. Between 2008 and 2013, robotically assisted CRP rates increased from 7.6% to 50.0% (P = .5). In multivariable logistic regression models, robotically assisted CRP resulted in lower rates of overall (odds ratio [OR], 0.42; P < .001), miscellaneous medical (OR, 0.47; P = .02), and miscellaneous surgical complications (OR, 0.40; P = .04), as well as in lower rates of blood transfusions (OR, 0.19; P < .001). In multivariable Poisson regression models, robotically assisted CRP was associated with shorter stay (OR, 0.72; P < .001) and higher total hospital charges ($2483 more for each robotic surgery; P < .001). Similar results were recorded after adjustment for clustering.

CONCLUSION

The intraoperative and postoperative complications associated with robotically assisted CRP are lower than those of open CRP. Similarly, robotically assisted CRP is associated with shorter stay. Conversely, an increase in total hospital charges is associated with robotically assisted CRP. Nonetheless, the complication profile of robotically assisted CRP validates its safety and feasibility.

[Oligometastatic prostate cancer management]

OBJECTIVE

To review biology and management of oligometastatic prostate cancer.

MATERIAL AND METHODS

Relevant publications were identified through Medline (www. ncbi.nlm.nih.gov), Embase (www.embase.com) and the US National Library of Medicine (www.clinicaltrials.org) databases using the following keywords, alone or in association, «prostate cancer; metastasis; oligo-metastasis». Articles were selected according to methods, language of publication and relevance. After careful selection 99 publications were eligible for our review.

RESULTS

Oligometastatic prostate cancer is a new entity including prostate cancer with a limited number of metastasis. This particular state becomes more frequent with the imaging progresses especially with the common use of new PET imaging with Choline or PSMA. There is no consensus about a strict definition of oligometastatic prostate cancer, number and sites of metastasis vary widely in the literature. Moreover, oligometastatic state can be observed de novo at the time of prostate cancer diagnosis as well as in case of recurrence after a primary treatment. There is actually an important lack of evidence-based medicine and no guidelines regarding treatment can be found. In de novo oligo-metatastatic prostate cancer, treatment of the primary tumor in association with androgen deprivation therapy seems to increase survival in selected patients but this needs to be confirmed by ongoing prospective clinical trials. In recurrent prostate cancer, metastasis directed therapy with or without androgen deprivation therapy is now routinely performed but its impact needs also to be analyzed.

CONCLUSION

In absence of consensus or guidelines, management of prostate cancer should be an individualized, patient-based management taking into account primary tumor stage and grade, number and types of metastasis and patient characteristics.

Management of Metastatic Hormone-Sensitive Prostate Cancer (mHSPC): an Evolving Treatment Paradigm

OPINION STATEMENT

Combination systemic therapy is now standard of care for all men with metastatic, hormone-sensitive prostate cancer (mHSPC). Patients with mHSPC should be treated with standard androgen deprivation therapy (ADT) and abiraterone acetate with prednisone or docetaxel (chemohormoanl therapy) unless there are contraindications to combination therapy. Based on the Chemohormonal Therapy Versus Androgen Ablation Randomized Trial for Extensive Disease in Prostate Cancer (CHAARTED) study subgroup analysis, chemohormonal therapy may be most beneficial in men with high-volume disease burden, as men with low-volume metastatic disease do not appear to experience a survival benefit with chemohormonal therapy, while abiraterone in combination with ADT appears to be beneficial across both disease volume subgroups. Decisions regarding whether to use chemohormonal therapy or abiraterone and ADT for men with mHSPC should integrate consideration of volume of disease burden, quality of life effects, duration of therapy, and patient preferences for treatment as there is no formally powered prospective head-to-head comparison of these options demonstrating superiority of one approach over the other. Treatment of the primary tumor with radiation should be considered in men with de novo low-volume metastatic disease as radiation is associated with prolonged survival and a tolerable toxicity profile. Men with de novo high-volume metastatic disease do not appear to have improved survival with radiation of the primary tumor. Numerous clinical trials are ongoing to evaluate treatment approaches that may benefit men with mHSPC. Radical prostatectomy in men with mHSPC in combination with optimal systemic therapy is currently being assessed in a clinical trial, but should not be considered outside of a clinical trial. Metastasis-directed therapy with radiotherapy directed at metastatic lesions is still investigational, but can be considered in clinical trials in men with oligometastatic disease. Multiple studies are enrolling worldwide for men with mHSPC, and these should be considered for all interested patients.

Treatment of the Primary Tumor in Metastatic Hormone-sensitive Prostate Cancer: Not Yet Ready for Prime Time as the Standard of Care

Retrospective studies in selected patients have demonstrated a survival benefit with prostatectomy or radiotherapy (RT) of the primary tumor in metastatic hormone-sensitive prostate cancer (mHSPC). However, there is currently not enough evidence to recommend RT to the primary tumor as the standard of care for patients treated with androgen deprivation therapy plus abiraterone or docetaxel for low-volume mHSPC.