Identifying optimal candidates for local treatment of the primary tumor among patients diagnosed with metastatic prostate cancer: a SEER-based study

Front-Line Therapeutic Strategy in Metastatic Hormone Sensitive Prostate Cancer: An Updated Therapeutic Algorithm

Prostate carcinoma (PC), the second most diagnosed cancer globally, saw approximately 1,414,000 new cases in 2020, with 17% being de novo metastatic. In these cases, the 5-year relative survival rate is 32%. Metastatic hormone-sensitive prostate cancer (mHSPC) includes those with metastatic disease at initial diagnosis or after initial therapy without long-term androgen deprivation therapy (ADT), eventually progressing to castration-resistant prostate cancer (CRPC). The established therapeutic principle of ADT has persisted for 80 years, with luteinizing hormone-releasing hormone (LHRH) agonists like leuprorelin being commonly used. LHRH antagonists, such as degarelix, have also emerged. Recent advances in mHSPC treatment involve combination strategies with drugs proven effective in CRPC, considering prognostic factors like disease volume and presentation. This review outlines pivotal trials leading to drug approvals in mHSPC and proposes a treatment decision algorithm for the same, based on statement from the Tuscan Interdisciplinary Uro-Oncological Group. A multidisciplinary approach is crucial to tailor treatment intensity and weigh risks and benefits effectively.

99mTcPSMA-radioguided surgery in oligorecurrent prostate cancer: the randomised TRACE-II trial

OBJECTIVE

To investigate whether combination treatment of prostate-specific membrane antigen (PSMA)-based radioguided surgery (RGS) with short-term androgen deprivation therapy (ADT) improves oncological outcomes in men with oligorecurrent prostate cancer (PCa) as compared to treatment with short-term ADT only.

METHODS

The TRACE-II study is an investigator-initiated, prospective, randomised controlled clinical trial. Patients (aged >18 years) with hormone-sensitive recurrent PCa after radical prostatectomy or radiotherapy (brachytherapy or external beam radiotherapy), with involvement of ≤2 lymph nodes or local oligorecurrent disease within the pelvis as determined by PSMA positron emission tomography (PET)/computed tomography (CT) are randomly assigned in a 1:1 ratio between 6-month ADT (Arm A) or 6-month ADT plus RGS (Arm B). The primary objective is to determine clinical progression-free survival (CPFS) at 24 months. After PSMA-RGS, CPFS is defined as the time between the start of treatment and the appearance of a re-recurrence (any N1 or M1) as suggested by PSMA-PET/CT or symptoms related to progressive PCa, or death from any cause. The secondary objectives include metastasis-free survival at 2, 5 and 10 years, biochemical progression-free survival at 2 years, and patient-reported quality of life at 2, 5 and 10 years. A total of 60 patients, 30 per arm, will be included. The trial is powered (80%) to detect at least a 30% absolute difference in CPFS between the two study arms in the period 2 years after randomisation. We expect to enrol the required participants in 3 years. The study has an expected duration of 5 years in total.

CONCLUSIONS

Combining RGS with short-term ADT might be oncologically beneficial for patients with oligorecurrent PCa. In this first randomised controlled trial, we are investigating the potential oncological benefits of this combined treatment, while also focusing on maintaining quality of life.

Efficacy of cytoreductive radical cystectomy in metastatic urothelial bladder cancer based on site and number of metastases

BACKGROUND

Recent studies have highlighted the overall survival (OS) benefit of cytoreductive radical cystectomy (CRC) in metastatic bladder cancer (mBCa). Cytoreductive surgery has been established in other urologic cancers. However, the efficacy of CRC and optimal criteria for patient selection in mBCa is unclear. This study investigated the oncologic efficacy of CRC, particularly emphasizing the location and number of metastasis sites as a predictor of survival and treatment response.

METHODS

A retrospective analysis of cT2-4N0-3M1 mBCa patients treated with multiagent chemotherapy between 2004 and 2019 was conducted using the National Cancer Database. Patients were classified by additional treatment with CRC or conservative local treatment (CLT), consisting of transurethral resection of bladder tumor, radiation, or no local treatment and propensity score (PS) matched. Kaplan-Meier analysis and multivariate Cox Proportional Hazards model assessed the effect of CRC or CLT on OS within the matched cohort and in four subgroups (1) patients with only distant lymph node (LN) metastasis vs. any organ metastasis, (2) patients with single metastasis vs. multiple metastases. Sensitivity analysis estimated the influence of unmeasured confounders on CRC OS benefit.

RESULTS

Propensity matching yielded 247 and 251 patients treated with CRC and CLT, respectively. Median OS in patients who received CRC was greater than that of patients treated with CLT (20.4 months vs. 12.0 months, P < 0.001). CRC was associated with reduced mortality risk in patients with only distant LN metastases (HR = 0.545, P = 0.039), any organ metastasis (HR = 0.421, P < 0.001), and single visceral metastasis (HR = 0.483, P = 0.002). However, CRC did not significantly improve OS in patients with multiple metastases (HR = 0.501, P = 0.064).

CONCLUSION

These findings demonstrate an OS benefit of CRC with multiagent chemotherapy and pinpoint multiple visceral metastases as a potential contraindication for CRC. Although limited by the influence of unmeasured confounders, these findings may inform future prospective investigations into CRC.

Identifying Optimal Candidates for Primary Tumor Resection Among Metastatic Pancreatic Cancer Patients: A Population-Based Predictive Model

BACKGROUND

There is a controversy about whether surgery should proceed among metastatic pancreatic cancer (mPC) patients. A survival benefit was observed in mPC patients who underwent primary tumor resection; however, determining which patients would benefit from surgery is complex. For this purpose, we created a model to identify mPC patients who may benefit from primary tumor excision.

METHODS

Patients with mPC were extracted from the Surveillance, Epidemiology, and End Results database, and separated into surgery and nonsurgery groups based on whether the primary tumor was resected. Propensity score matching (PSM) was applied to balance confounding factors between the two groups. A nomogram was developed using multivariable logistic regression to estimate surgical benefit. Our model is evaluated using multiple methods.

RESULTS

About 662 of 14,183 mPC patients had primary tumor surgery. Kaplan-Meier analyses showed that the surgery group had a better prognosis. After PSM, a survival benefit was still observed in the surgery group. Among the surgery cohort, 202 patients survived longer than 4 months (surgery-beneficial group). The nomogram discriminated better in training and validation sets under the receiver operating characteristic (ROC) curve (AUC), and calibration curves were consistent. Decision curve analysis (DCA) revealed that it was clinically valuable. This model is better at identifying candidates for primary tumor excision.

CONCLUSION

A helpful prediction model was developed and validated to identify ideal candidates who may benefit from primary tumor resection in mPC.

[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.

Evodiamine impairs HIF1A histone lactylation to inhibit Sema3A-mediated angiogenesis and PD-L1 by inducing ferroptosis in prostate cancer

Prostate cancer (PCa) is among the most commonly diagnosed solid cancers in male adults. However, most anti-angiogenic therapies and immunotherapies fail to achieve durable remission in advanced PCa. Integrative analysis indicated that Sema3A was negatively correlated with the pathological malignancy and was involved in angiogenesis, cell adhesion, and immune infiltrates in PCa. Sema3A significantly inhibited vascular endothelial growth factor (VEGFA)-induced colony formation, cell proliferation, and PD-L1 expression in PCa cells. Network pharmacological analysis demonstrated that evodiamine, a natural alkaloid compound derived from Evodiae fructus fruits, might regulate Sema3A, lipid metabolism, and monocarboxylic acid transport signaling of PCa. Evodiamine evidently inhibited PCa cell viability in a time-dose-dependent manner. Furthermore, evodiamine impaired angiogenesis by increasing Sema3A expression, and induced ferroptosis by reducing glutathione peroxidase 4 (GPX4) expression, which could be reversed by the ferroptosis blocker ferrostatin-1. Lactate treatment increased hypoxia-inducible factor (HIF)-1α and PD-L1 expressions while restricting Sema3A expression in PCa cells, which could be reversed by silencing monocarboxylate transporter 4 (MCT4) expression. Moreover, evodiamine markedly blocked lactate-induced angiogenesis by restricting histone lactylation and expression of HIF1A in PCa cells, further enhancing Sema3A transcription while inhibiting that of PD-L1. In vivo, evodiamine remarkably inhibited PCa xenograft growth in nude mice, repressing expressions of HIF1α, H3K18la, GPX4, PD-L1, and proliferation, while hindering angiogenesis by increasing Sema3A expression. Therefore, Sema3A represents an essential antineoplastic biomarker, while evodiamine may act as a metabolic-epigenetic modulator, as well as a promising agent in either PCa anti-angiogenic therapy or immunotherapy.

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.

A nomogram model for determining optimal patients for local therapy in metastatic prostate cancer: a SEER database-based study

BACKGROUND

Numerous studies have shown that local therapy can improve long-term survival in patients with metastatic prostate cancer. However, it is unclear which patients are the potential beneficiaries.

METHODS

We obtained information on prostate cancer patients from the Surveillance, Epidemiology, and End Results database and divided eligible patients into the local treatment group and non-local treatment group. Propensity score matching (PSM) was used to reduce the influence of confounding factors. In the matched local treatment (LT) group, if the median overall survival time (OS) was longer than the Nonlocal treatment (NLT) group, it was defined as a benefit group, otherwise, it was a non-benefit group. Then, univariate and multivariate logistic regression were used to screen out predictors associated with benefits, and a nomogram model was constructed based on these factors. The accuracy and clinical value of the models were assessed through calibration plots and decision curve analysis.

RESULTS

The study enrolled 7255 eligible patients, and after PSM, each component included 1923 patients. After matching, the median OS was still higher in the LT group than in the NLT group [42 (95% confidence interval: 39-45) months vs 40 (95% confidence interval: 38-42) months, p = 0.03]. The independent predictors associated with benefit were age, PSA, Gleason score, T stage, N stage, and M stage. The nomogram model has high accuracy and clinical application value in both the training set (C-index = 0.725) and the validation set (C-index = 0.664).

CONCLUSIONS

The nomogram model we constructed can help clinicians identify patients with potential benefits from LT and formulate a reasonable treatment plan.

Local treatment Associated With Prognosis among Men With Metastatic Prostate Cancer: A SEER-Based Study

INTRODUCTION

In order to identify the impact of local treatment on overall survival (OS) and cancer-specific survival(CSS) in men with mPCa.

MATERIALS AND METHODS

Men with mPCa undergoing local treatment by radical prostatectomy (RP), radiotherapy (RT) including beam radiation and brachytherapy or no local treatment identified from Surveillance, Epidemiology, and End Results (SEER) database (2010-2015). To evaluate local therapy impact on OS and CSS in relation to baseline characteristics, univariate and multivariable Cox regression analysis was used to predict the prognostic value of local therapy in OS and CSS.

RESULTS

A total of 902 (25.8%) patients received local treatment and 2598 (74.2%) patients did not receive local treatment in this study. The Kaplan-Meier curves showed that there was significant difference in OS between patients underwent local treatment and patients without local treatment (P = .013) but not in CSS (P = .068). While multivariate Cox regression analysis showed that local treatment may not significantly improve OS(P = .724). In subgroup analysis, Among patients with prostate-specific antigent (PSA)<10ng/ml, local treatment could significantly improve OS and CSS (all P < .05). Multivariate Cox regression analysis showed that local treatment could be used as an independent prognostic factor to improve OS in mPCa patients with PSA<10ng/ml (P = .031). Another multivariate Cox regression analysis demonstrated that patients with mPCa undergoing RP had better OS and CSS (all P < .05).

CONCLUSIONS

Our results showed that local salvage therapy did not seem to be an independent prognostic factor in all mPCa patients, but we found that local therapy can show a better prognosis in patients with lower PSA levels. Compared with RT, patients who had experienced RP may have better prognosis. We still need prospective research to further study the application value of local treatment in mPCa patients.

Cohort Study of Oligorecurrent Prostate Cancer Patients: Oncological Outcomes of Patients Treated with Salvage Lymph Node Dissection via Prostate-specific Membrane Antigen-radioguided Surgery

BACKGROUND

In a subset of patients with recurrent oligometastatic prostate cancer (PCa) salvage surgery with prostate-specific membrane antigen (PSMA)-targeted radioguidance (PSMA-RGS) might be of value.

OBJECTIVE

To evaluate the oncological outcomes of salvage PSMA-RGS and determine the predictive preoperative factors of improved outcomes.

DESIGN, SETTING, AND PARTICIPANTS

A cohort study of oligorecurrent PCa patients with biochemical recurrence (BCR) after radical prostatectomy and imaging with PSMA positron emission tomography (PET), treated with PSMA-RGS in two tertiary care centers (2014-2020), was conducted.

INTERVENTION

PSMA-RGS.

OUTCOME MEASUREMENTS AND STATISTICAL ANALYSIS

Kaplan-Meier and multivariable Cox regression models were used to assess BCR-free (BFS) and therapy-free (TFS) survival. Postoperative complications were classified according to Clavien-Dindo.

RESULTS AND LIMITATIONS

Overall, 364 patients without concomitant treatment were assessed. At PSMA-RGS, metastatic soft-tissue PCa lesions were removed in 343 (94%) patients. At 2-16 wk after PSMA-RGS, 165 patients reached a prostate-specific antigen (PSA) level of <0.2 ng/ml. Within 3 mo, 24 (6.6%) patients suffered from Clavien-Dindo complications grade III-IV. At 2 yr, BFS and TFS rates were 32% and 58%, respectively. In multivariable analyses, higher preoperative PSA (hazard ratio [HR]: 1.07, 95% confidence interval [CI]: 1.02-1.12), higher number of PSMA-avid lesions (HR: 1.23, CI: 1.08-1.40), multiple (pelvic plus retroperitoneal) localizations (HR: 1.90, CI: 1.23-2.95), and retroperitoneal localization (HR: 2.04, CI: 1.31-3.18) of lesions in preoperative imaging were independent predictors of BCR after PSMA-RGS. The main limitation is the lack of a control group.

CONCLUSIONS

As salvage surgery in oligorecurrent PCa currently constitutes an experimental treatment approach, careful patient selection is mandatory based on life expectancy, low PSA values, and low number of PSMA PET-avid lesions located in the pelvis.

PATIENT SUMMARY

We looked at the outcomes from prostate cancer patients with recurrent disease after radical prostatectomy. We found that surgery may be an opportunity to prolong treatment-free survival, but patient selection criteria need to be very narrow.

Radiotherapy of the Primary Disease for Synchronous Metastatic Cancer: A Systematic Review

In the case of synchronous metastatic disease, the local treatment of primary tumors by radiotherapy has long been reserved for palliative indications. The emergence of the concept of oligometastatic and oligopersistent diseases, the advent of new systemic therapies enabling longer overall survival with an enhanced quality of life, a better understanding of the biologic history of metastatic spread, and technical advances in radiation therapy are revolutionizing the management of patients with de novo metastatic cancer. The prognosis of these patients has been markedly improved and many studies have investigated the survival benefits from the local treatment of various primary tumors in cases of advanced disease at the time of diagnosis or in the case of oligopersistence. This article provides an update on the place of irradiation of the primary tumor in cancer with synchronous metastases, and discusses its interest through published or ongoing trials.

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.

Narrative review of local prostate and metastasis-directed radiotherapy in the treatment of metastatic prostate cancer

The role of local treatment in patients with de novo metastatic prostate cancer is controversial. In population-based retrospective studies, metastatic prostate cancer patients who received local treatment with prostate radiotherapy showed a better prognosis than those who did not. In addition, several prospective randomized studies demonstrated that prostate radiotherapy achieves a survival benefit for patients with oligo-metastasis. Moreover, the efficacy of metastasis-directed radiotherapy was evaluated, revealing a potential benefit for patients with oligo-metastasis. Importantly, these radiotherapies may reduce the occurrence of symptomatic local events. In this review, the rationale, efficacy and future perspectives for local prostate and metastasis-directed radiotherapy in the treatment of metastatic prostate cancer were described and summarized.

A Model for Identifying Optimal Patients for Primary Tumor Resection in Patients With Metastatic Bladder Cancer

Background

A survival benefit was observed in metastatic bladder cancer patients who underwent primary tumor resection, but it was still confusing which patients are suitable for the surgery. For this purpose, we developed a model to screen stage M1 patients who would benefit from primary tumor resection.

Methods

Patients with metastatic bladder cancer were screened from the Surveillance, Epidemiology, and End Results database (2004–2016) and then were divided into surgery (partial or complete cystectomy) group and non-surgery group. To balance the characteristics between them, a 1:1 propensity score matching analysis was applied. A hypothesis was proposed that the received primary tumor resection group has a more optimistic prognosis than the other group. The multivariable Cox model was used to explore the independent factors of survival time in two groups (beneficial and non-beneficial groups). Logistic regression was used to build a nomogram based on the significant predictive factors. Finally, a variety of methods are used to evaluate our model.

Results

A total of 7,965 patients with metastatic bladder cancer were included. And 3,314 patients met filtering standards, of which 545 (16.4%) received partial or complete cystectomy. Plots of the Kaplan–Meier and subgroup analyses confirmed our hypothesis. After propensity score matching analysis, a survival benefit was still observed that the surgery group has a longer median overall survival time (11.0 vs. 6.0 months, p < 0.001). Among the surgery cohort, 303 (65.8%) patients lived longer than 6 months (beneficial group). Differentiated characteristics included age, gender, TNM stage, histologic type, differentiation grade, and therapy, which were integrated as predictors to build a nomogram. The nomogram showed good discrimination in both training and validation cohorts (area under the receiver operating characteristic curve (AUC): 0.806 and 0.742, respectively), and the calibration curves demonstrated good consistency. Decision curve analysis showed that the nomogram was clinically useful. Compared with TNM staging, our model shows a better predictive value in identifying optimal patients for primary tumor resection.

Conclusions

A practical predictive model was created and verified, which might be used to identify the optimal candidates for the partial or complete cystectomy group of the primary tumor among metastatic bladder cancer.

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.

High-intensity local treatment of clinical node-positive urothelial carcinoma of the bladder alongside systemic chemotherapy improves overall survival

PURPOSE

Clinical node-positive urothelial carcinoma of the bladder (cN+UCaB) is a rapidly fatal disease with limited information on comparative-effectiveness of available treatment options. We sought to examine the impact of high-intensity vs. conservative local treatment (LT) regimens in management of these patients alongside systemic chemotherapy.

MATERIALS AND METHODS

We identified 3,227 patients within the National Cancer Data Base who underwent multiagent systemic chemotherapy along with either high-intensity or conservative LT for primary cN+UCaB between 2004-2016. Patients who received no LT, TURBT alone, or <50 Gy radiation therapy to the bladder were included in the conservative group, while patients that received radical cystectomy with pelvic lymphadenectomy or ≥50 Gy radiation therapy with TURBT were included in the high-intensity group. Inverse probability of treatment weighting (IPTW) adjusted Kaplan-Meier and Cox regression analyses were used to assess overall survival (OS). Additionally, to assess whether the benefit of high-intensity LT differs by baseline mortality risk, we tested an interaction between 5-year predicted life-expectancy and the LT type.

RESULTS

Overall, 784 (24.3%) and 2,443 (75.7%) cN+UCaB patients underwent high-intensity and conservative LT, respectively. IPTW-adjusted Kaplan-Meier analysis demonstrated OS to be significantly higher in the high-intensity group compared to the conservative group: 5-year OS 28.4% vs. 18.3%, respectively (Log-rank P<0.001). IPTW-adjusted multivariable Cox regression analysis confirmed the benefit of high-intensity LT in prolonging OS (HR 0.63, P<0.001). Interaction analysis showed that high-intensity LT approach was associated with longer OS in all patients regardless of their baseline 5-year life-expectancy (P_interaction=0.79).

CONCLUSION

Eligible patients with cN+UCaB should be considered for aggressive local treatment alongside multiagent systemic chemotherapy. Prospective trials are needed to validate these preliminary findings.

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.

Local Therapies in Oligometastatic and Oligoprogressive Prostate Cancer

Oligometastatic disease was originally defined by Hellman and Weichselbaum as an intermediate-state existing between locally confined and widely disseminated malignancy, whose natural history could be positively impacted with systemic and importantly local therapies such as radiation. Currently oligometastatic prostate cancer (OPCa) is defined clinically by lesion enumeration and several subgroups exist: de novo (synchronous) oligometastatic disease present at initial diagnosis, oligorecurrent (metachronous) disease arising after definitive therapy to the prostate, and oligoprogressive disease where isolated lesions progress in a background of otherwise stable disease. In this review we highlight current knowledge and the potential future of local therapies, such as radiation to the primary prostate and metastasis-directed therapy (MDT), in the disease management of OPCa for all 3 subgroups. In addition, we examine more recent studies classifying the patterns of failure and natural history of OPCa following treatment with local therapies. Finally, while current clinical definitions of OPCa dominate, we introduce studies attempting to elucidate a more biological definition of OPCa to allow for improved selection of patients to treat with local therapies and to better inform precision combination approaches with systemic therapy.

Exploring miRNA Signature and Other Potential Biomarkers for Oligometastatic Prostate Cancer Characterization: The Biological Challenge behind Clinical Practice. A Narrative Review

Simple Summary

The oligometastatic prostate cancer state is defined as the presence of a number of lesions ≤ 5 and has been significantly correlated with better survival if compared to a number of metastases > 5. In particular, patients in an oligometastatic setting could benefit from a metastates directed therapy, which could control the disease delaying the start of systemic therapies. For this reason, the selection of true-oligometastatic patients who could benefit from such approach is particularly important in this setting. The aim of the present narrative review is to report the current state of the art on the liquid biopsy-derived analytes and their reliability as biomarkers in the clinics for the identification of true-oligometastatic patients. This kind of molecular profiling could refine current developments in the era of precision oncology allowing patients’ stratification and leading to more refined therapeutic strategies.

Abstract

In recent years, a growing interest has been directed towards oligometastatic prostate cancer (OMPC), as patients with three to five metastatic lesions have shown a significantly better survival as compared with those harboring a higher number of lesions. The efficacy of local ablative treatments directed on metastatic lesions (metastases-directed treatments) was extensively investigated, with the aim of preventing further disease progression and delaying the start of systemic androgen deprivation therapies. Definitive diagnosis of prostate cancer is traditionally based on histopathological analysis. Nevertheless, a bioptic sample—static in nature—inevitably fails to reflect the dynamics of the tumor and its biological response due to the dynamic selective pressure of cancer therapies, which can profoundly influence spatio-temporal heterogeneity. Furthermore, even with new imaging technologies allowing an increasingly early detection, the diagnosis of oligometastasis is currently based exclusively on radiological investigations. Given these premises, the development of minimally-invasive liquid biopsies was recently promoted and implemented as predictive biomarkers both for clinical decision-making at pre-treatment (baseline assessment) and for monitoring treatment response during the clinical course of the disease. Through liquid biopsy, different biomarkers, commonly extracted from blood, urine or saliva, can be characterized and implemented in clinical routine to select targeted therapies and assess treatment response. Moreover, this approach has the potential to act as a tissue substitute and to accelerate the identification of novel and consistent predictive analytes cost-efficiently. However, the utility of tumor profiling is currently limited in OMPC due to the lack of clinically validated predictive biomarkers. In this scenario, different ongoing trials, such as the RADIOSA trial, might provide additional insights into the biology of the oligometastatic state and on the identification of novel biomarkers for the outlining of true oligometastatic patients, paving the way towards a wider ideal approach of personalized medicine. The aim of the present narrative review is to report the current state of the art on the solidity of liquid biopsy-related analytes such as CTCs, cfDNA, miRNA and epi-miRNA, and to provide a benchmark for their further clinical implementation. Arguably, this kind of molecular profiling could refine current developments in the era of precision oncology and lead to more refined therapeutic strategies in this subset of oligometastatic patients.

Oligometastatic and Oligoprogression Disease and Local Therapies in Prostate Cancer

Our understanding of metastatic disease is rapidly advancing, with recent evidence supporting an oligometastatic state currently defined by patients having a limited (typically ≤5) number of metastatic deposits. The optimal management of these patients is also shifting toward increased integration of local therapies, with emerging evidence suggesting metastasis-directed therapy can improve overall survival. Additionally, the use of stereotactic ablative radiation therapy within castration-sensitive oligometastatic prostate cancer cohorts appears to forestall the need to initiate systemic therapy, which has unfavorable side effect profiles, such as androgen deprivation therapy, while itself being associated with little toxicity. We review the literature surrounding the use of metastasis-directed therapy in the treatment of oligometastatic prostate cancer by reviewing the evidence for its use within 3 subgroups: de novo synchronous, oligorecurrent, and oligoprogressive disease.

[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.

Clinical features and prognostic factors of elderly patients with metastatic pancreatic cancer: a population-based study

The aim of this study was to evaluate the clinical features and prognostic factors of elderly patients with metastatic pancreatic cancer. Patients diagnosed with metastatic pancreatic cancer between 2004 and 2014 were identified from the Surveillance Epidemiology and End Results database. Clinical characteristics and prognostic factors in elderly patients with metastatic pancreatic cancer were examined. A total of 10784 metastatic pancreatic cancer patients between 65 and 80 years old were included and divided into three age groups. Elderly metastatic pancreatic cancer patients differed from younger patients in many aspects, including marital status, race, sex, T stage, N stage, treatment regimen, prognosis, cause of death, and metastatic characteristics (P<0.001). An analysis of prognostic factors showed that chemotherapy, as the main treatment for elderly patients, can significantly improve prognosis, while surgery can improve the prognosis of patients between 65 and 80 years old. Other factors, including sex, marital status, T stage, and site of metastasis, had different effects on patients in different age groups. Elderly patients with metastatic pancreatic cancer are a special group of individuals whose clinical characteristics and prognostic factors are different from those of younger patients, and these patients require special treatment and attention.

Metastatic hormone-sensitive prostate cancer: How should it be treated?

The number of treatment options for metastatic hormone-sensitive prostate cancer has increased substantially in recent years. The classic treatment approach for these patients—androgen-deprivation therapy alone—is now considered suboptimal. Several randomized phase III clinical trials have demonstrated significant clinical benefits—including significantly better overall survival and quality of life—for treatments that combine androgen-deprivation therapy with docetaxel, abiraterone acetate, enzalutamide, apalutamide, and/or radiotherapy to the primary tumour. As a result, these approaches are now included in treatment guidelines and considered standard of care. However, the different treatment strategies have not been directly compared, and thus treatment selection remains at the discretion of the individual physician or, ideally, a multidisciplinary team. Given the range of available treatment approaches with varying toxicity profiles, treatment selection should be individualized based on the patient’s clinical characteristics and preferences, which implies active patient participation in the decision-making process. In the present document, we discuss the changing landscape of the management of patients with metastatic hormone-sensitive prostate cancer in the context of several recently-published landmark randomized trials. In addition, we discuss several unresolved issues, including the optimal sequencing of systemic treatments and the incorporation of local treatment of the primary tumour and metastases.

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.

Impact of Radiotherapy on Prognosis in Patients Diagnosed with Metastatic Prostate Cancer: A Systematic Review and Meta-Analysis

BACKGROUND

It has been reported that compared with no local therapy (NLT), patients treated with local therapy (LT) using radiotherapy (RT) possess higher survival rate in metastatic prostate cancer (mPCa). The aim of this meta-analysis was to evaluate the impact of RT on prognosis in patients with mPCa.

METHODS

We retrieved the literature in PubMed, Embase, and Cochrane Library databases until June 2019 using structured search terms. Several studies were included, which evaluated patients with mPCa who received RT versus NLT.

RESULTS

A total of 14,542 patients were analyzed in 7 included papers (2 randomized controlled trials [RCTs] and 5 cohort retrospective studies [CRS]), and 2,232 mPCa patients were treated with RT and 12,310 with NLT. The data of RCTs and CRS were analyzed separately. In RCTs, RT was associated with no significant difference in overall survival (OS) (pooled hazard ratio [HR] = 0.96; 95% confidence interval [CI]: 0.85-1.09; p = 0.55; I2 = 42%) relative to NLT, while survival benefit was observed in the low-metastatic burden group (pooled HR = 0.68; 95% CI: 0.54-0.86; p = 0.001; I2 = 0%), and no survival benefit was observed in the high-metastatic burden group (pooled HR = 1.07; 95% CI: 0.92-1.24; p = 0.39; I2 = 0%). In CRS, RT results in lower cancer-specific mortality (CSM) (pooled HR = 0.49; 95% CI: 0.34-0.75; p < 0.00001; I2 = 0%) and higher OS (pooled HR = 0.61; 95% CI: 0.55-0.68; p < 0.00001; I2 = 0%) relative to NLT. Subsequent analysis demonstrated that high level of M-stage or N-stage was associated with increased CSM (pooled HR = 2.08; 95% CI: 1.69-2.55; p < 0.00001; I2 = 0% and pooled HR = 1.16; 95% CI: 1.03-1.30; p < 0.00001; I2 = 0%; respectively).

CONCLUSIONS

Our observations in aggregate indicated that RT at least does not appear to be harmful and may be beneficial for low-metastatic burden patients and better condition patients. More prospective and randomized studies evaluating RT for mPCa are warranted.

Prognostic Value of Local Treatment in Prostate Cancer Patients With Different Metastatic Sites: A Population Based Retrospective Study

PURPOSE

Our study aims to examine the impact of definitive local therapy in prostate cancer patients with different metastatic sites.

METHODS

Totally, 5,849 patients diagnosed with metastatic prostate carcinoma from 2010 to 2014 were selected from Surveillance, Epidemiology, and End Results (SEER). Log-rank analyses, multivariable regression analysis, and Kaplan-Meier methods were used to assess prognostic impact of local treatment in patients with different metastatic sites. Survival curves and forest plots were also plotted to describe the prognostic value of definitive local therapy.

RESULTS

In our study, 159 patients received radical prostatectomy, and 62 received brachytherapy, while 5,628 did not receive local definitive local therapy. Survival analysis revealed that patients who received definitive local therapy had a better 5-year overall survival (OS) (P = 0.011) and cancer-specific survival (CSS) (P = 0.012). Multivariate regression analyses demonstrated that type of treatment was an independent prognostic indicator for OS (P = 0.011) and CSS (P = 0.012), along with age at diagnosis, chemotherapy, PSA level, and Gleason score. According to subgroup analysis, patients with bone metastasis or distant lymph node (LN) metastasis were significantly more likely to benefit from definitive local therapy. In addition, forest plots demonstrated that RP group had significant favorable OS and CSS in subgroups of younger age at diagnosis, T2-3 stage, N0-1 stage, Gleason score =7 or ≥8, bone metastasis, and distant LN metastasis.

CONCLUSIONS

Our study suggested that local therapy improved survival in prostate cancer patients with bone or distant LN metastasis. Furthermore, patients who were at T2-3 stage or Gleason score ≥7 also significantly benefit from definitive local therapy.

Impact of Time to Castration Resistance on Cytoreductive Radiotherapy in Metastatic Castration-Resistant Prostate Cancer

Background

The role of local radiotherapy in metastatic castration-resistant prostate cancer (mCRPC) remains undefined. This study aimed to identify the value of local radiotherapy and potential candidates for mCRPC.

Methods

A total of 215 patients with mCRPC treated with or without cytoreductive radiotherapy (CRT) between June 2011 and February 2019 were analyzed. Overall survival (OS) was calculated from the onset of mCRPC. The receiver-operating characteristic (ROC) curve was used to find the cutoff point for time to castration resistance (TCR).

Results

One-hundred and fifty-five (72.1%) patients received abiraterone after mCRPC, and 54 (25.1%) patients received CRT. The median TCR was 14.9 months. After a median follow-up of 31.7 months, the median OS was 33.3 months. The Eastern Cooperative Oncology Group (ECOG) performance scores 0-1, oligometastases, abiraterone after mCRPC, CRT, and TCR ≥9 months were independent prognostic factors for better OS. Stratified analyses showed improved survival when CRT was applied to patients treated with abiraterone (HR 0.44; 95% CI 0.23-0.83; P = 0.012) and TCR ≥9 months (HR 0.39; 95% CI 0.21-0.74; P = 0.004). The percentage of PSA response after radiotherapy was higher in patients with TCR ≥9 months compared to those with TCR <9 months. No grade 3 or worse adverse events after radiotherapy were reported.

Conclusions

ECOG performance score, oligometastases, abiraterone application, TCR and CRT were independent prognostic factors for OS in patients with mCRPC. Patients with a short duration of response to primary androgen deprivation therapy were less likely to benefit from CRT.

Potential effectiveness of local radiotherapy for extending survival and reducing symptomatic local events in patients with de novo metastatic prostate cancer

Objectives

To evaluate the association between the use of local radiotherapy (RT) with the survival of patients with de novo metastatic prostate cancer and symptomatic local events (SLEs).

Patients and methods

Patients were initially diagnosed with metastatic prostate cancer between 2008 and 2017 at 30 institutes in Japan. Prostate‐specific antigen (PSA) progression‐free survival (PSA‐PFS) under initial androgen deprivation therapy and overall survival (OS) was compared between patients receiving local RT (RT group) and no RT (no‐RT group) by multivariate Cox proportional hazard analyses. The occurrence rate of grade ≥2 SLEs was compared by multivariate logistic regression analyses. Propensity score matching (PSM) analyses were performed to compare PSA‐PFS and OS of the groups in the high and low metastatic burden cohort.

Results

Two hundred and five (7%) of 2829 patients received RT before PSA progression. Median PSA‐PFS and OS were significantly longer in the RT group than in the no‐RT group and the difference was significant in multivariate analyses (HR = 0.44, 95% CI = 0.33‐0.57 and HR = 0.40, 95% CI = 0.27‐0.60, respectively). The occurrence rate of grade ≥2 SLEs was significantly lower in the RT group (2%) than the no‐RT group (9%) and the difference was significant in multivariate analyses (HR = 0.28, 95% CI = 0.10‐0.76). Using PSM analyses, PSA‐PFS and OS remained significantly different (HR = 0.64, 95% CI = 0.46‐0.89 and HR = 0.47, 95% CI = 0.30‐0.72, respectively), between the RT (n = 182) and the no‐RT (n = 182) groups. The difference in OS was significant in the high metastatic burden cohort (HR = 0.55, 95% CI = 0.37‐0.81).

Conclusions

Addition of local RT to standard treatment for de novo metastatic prostate cancer patients tends to have the potential to extend survival, even in patients with high metastatic burden, and to reduce SLEs.

Metastatic pancreatic adenocarcinomas could be classified into M1a and M1b category by the number of metastatic organs

Background

With the improvement of treatment and prognosis for patients with late malignant diseases, certain malignancies with distant metastasis (M1 category) have been further classified into M1a (single metastatic site) and M1b (multiple metastatic sites) category in the staging system. We aimed to assess the feasibility of sub-classifying metastatic pancreatic adenocarcinoma (mPA) into M1a and M1b category depending on the number of metastatic organs.

Methods

Patient records were collected from the Surveillance, Epidemiology, and End Results (SEER) database (2010–2015). Univariable and multivariable analyses were performed using the Cox regression model. Then survival analysis was determined using the Kaplan–Meier method.

Results

A total of 11,885 patients were included in this analysis, including 9425 patients with single metastasis and 2460 patients with multiple metastases. Multivariable analysis showed that gender, age, marital status, grade, surgery, chemotherapy, and radiotherapy were independent prognostic factors for patients with single metastasis; gender, age, marital status, grade, chemotherapy and radiotherapy were independent prognostic factors for patients with multiple metastases. Notably, surgery was an independent prognostic factor for patients with single metastasis (P < 0.001) but not for patients with multiple metastases (P = 0.134). Kaplan–Meier analysis showed that patients with single metastasis (M1a) had better survival outcomes than patients with multiple metastases (M1b) (P < 0.001).

Conclusions

PA patients with M1 diseases could be divided into M1a (single metastasis) category and M1b (multiple metastases) category by the number of metastatic organs. The subclassification would facilitate individualized treatment for late PA patients. Surgery was associated with lower mortality in M1a patients but not significantly in M1b patients.

[Treatment of primary disease for synchronous metastatic prostate cancer]

The management of early metastatic prostate cancer is based on systemic treatment by androgen deprivation therapy with or without chemotherapy or next-generation anti-androgen therapies. Local treatment of the prostate was initially used only to alleviate local symptoms. However, local radiotherapy of the prostate has been the subject of retrospective and prospective studies in patients with better prognostic factors, particularly in oligometastatic status. The results of these studies support that prostate radiotherapy can prolong the survival of patients with a low metastatic burden. This article states the biological bases, the main published and future published studies aimed to embed this strategy to optimize therapeutic management.

Survival Outcomes for Metastatic Prostate Cancer Patients Treated With Radical Prostatectomy or Radiation Therapy: A SEER-based Study

BACKGROUND

Patients with metastatic prostate cancer (mPCa) have a very low 5-year survival rate. How to choose proper treatment of mPCa remains controversial.

METHOD

Within the Surveillance, Epidemiology, and End Results (SEER) database (2004-2015), we performed analyses of cancer-specific mortality (CSM) and overall mortality (OM) in the comparisons of local treatment (LT) versus no local treatment (NLT) and radical prostatectomy (RP) versus radiation therapy (RT). To balance the characteristics between 2 treatment groups, propensity score matching was performed. Considering the selection bias, we additionally used an instrument variate (IVA) to calculate the unmeasured confounders.

RESULT

Multivariate regression showed that patients receiving LT had the lower risks of OM and CSM after adjustment of covariates (hazard ratio [HR] 0.39, 95% confidence interval [CI] 0.35-0.44 and HR 0.39, 95% CI 0.34-0.45). In the IVA-adjusted model, LT showed more survival benefits compared with NLT, with HR of 0.57 (95% CI 0.50-0.65) and cancer-specific HR of 0.59 (95% CI 0.51-0.68), respectively. For those receiving LT, adjusted multivariate regression indicated that RP is superior to RT (HR 0.60; 95% CI 0.43-0.83 for OM and HR 0.61; 95% CI 0.42-0.91 for CSM). The IVA-adjusted model also showed that RP presented with potentially better survival outcome compared with RT, although the effect was not statistically significant (HR 0.63; 95% CI 0.26-1.54 for OM and HR 0.47; 95% CI 0.16-1.35 for CSM).

CONCLUSION

Among patients with metastatic prostate cancer, LT might bring better survival benefits in decreasing CSM and all-cause mortality compared with NLT. For those receiving LT, RP showed better survival outcomes than RT.

[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.

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.

Safety and Feasibility of Radiation Therapy to the Primary Tumor in Patients With Metastatic Castration-resistant Prostate Cancer

INTRODUCTION

The objective of this study was to evaluate the safety and feasibility of radiation therapy (RT) to the primary tumor in patients with metastatic castration-resistant prostate cancer (mCRPC).

PATIENTS AND METHODS

This retrospective study included 105 patients with mCRPC who were treated between April 2004 and May 2019. We divided the patients into 2 groups: patients treated with RT to the primary tumor after they developed CRPC (RT group) and without (non-RT group). The primary purpose was safety assessed using the Common Terminology Criteria for Adverse Events. The secondary purpose included prostate-specific antigen (PSA) response, cancer-specific survival (CSS), and overall survival (OS). Background-adjusted multivariate analyses, with the inverse probability of treatment weighting (IPTW) method, were performed to evaluate impact of RT on CSS and OS.

RESULTS

The median age at CRPC diagnosis was 75 years, and the median follow-up period after CRPC diagnosis was 21 months. The adverse events rates related to RT in any grade and grade ≥ 3 were 55% and 23%, respectively. Nine (29%) patients achieved ≥ 30% PSA decline with RT. In multivariate analyses with the IPTW method, the CSS and OS in the RT group were significantly longer than those in the non-RT group. In subgroup analyses with the IPTW method, RT was significantly associated with improved OS in patients aged ≥ 75 years and patients with initial PSA ≥ 500 ng/mL, cT4, Gleason score ≥ 8, and high-volume metastatic burden.

CONCLUSIONS

RT to the primary tumor is safe and feasible, and it has potential benefits on oncologic outcomes in patients with mCRPC.

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.

[Oligometastases and oligoprogressions: Concepts and natural history]

The oligometastatic paradigm refers to an intermediate biologic state of cancer with restricted metastatic capacity. Its phenotype is characterized by a limited number of metastases and a slow tumor growth. Various clinical and pre-clinical studies associated this state to alterations of the biological mechanisms involved in metastatic diffusion. Eventually, this transitional state leads to a wide metastatic dissemination. However, there is a period during which the patient could benefit from local ablative treatment. Depending on several prognostic factors and the treatment provided, long survival or even healing can sometimes be achieved. The selection of patients eligible for such a curative strategy may be adapted following clinical, radiological or biological markers. Recent improvement of therapeutic and imaging are changing the clinical definition of oligometastatic cancer, which should be adapted to evidence from recent clinical and preclinical data.

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.

Revealing hemodynamic heterogeneity of gliomas based on signal profile features of dynamic susceptibility contrast-enhanced MRI

Dynamic susceptibility contrast enhanced magnetic resonance imaging (DSC MRI) is widely used for studying blood perfusion in brain tumors. While the time-dependent change of MRI signals related to the concentration of the tracer is used to derive the hemodynamic parameters such as regional blood volume and flow into tumors, the tissue-specific information associated with variations in profiles of signal time course is often overlooked. We report a new approach of combining model free independent component analysis (ICA) identification of specific signal profiles of DSC MRI time course data and extraction of the features from those time course profiles to interrogate time course data followed by calculating the region specific blood volume based on selected individual time courses. Based on the retrospective analysis of DSC MRI data from 38 patients with pathology confirmed low (n = 18) and high (n = 20) grade gliomas, the results reveal the spatially defined intra-tumoral hemodynamic heterogeneity of brain tumors based on features of time course profiles. The hemodynamic heterogeneity as measured by the number of independent components of time course data is associated with the tumor grade. Using 8 selected signal profile features, machine-learning trained algorithm, e.g., logistic regression, was able to differentiate pathology confirmed low intra-tumoral and high grade gliomas with an accuracy of 86.7%. Furthermore, the new method can potentially extract more tumor physiological information from DSC MRI comparing to the traditional model-based analysis and morphological analysis of tumor heterogeneity, thus may improve the characterizations of gliomas for better diagnosis and treatment decisions.

•

Signal profiles of dynamic susceptibility contrast MRI data of brain tumors reflect hemodynamic properties of tumor tissue.

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Features in signal profiles extracted by machine learning methods revealed the hemodynamic heterogeneity of the gliomas.

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The reported approach is a new strategy to characterize the intra-tumor heterogeneity and physiological properties of gliomas.