Cytoreductive surgery for men with metastatic prostate cancer

Cytoreductive surgery in patients with oligometastatic prostate cancer. Systematic review of the scientific literature

INTRODUCTION

Interest in oligometastatic prostate cancer has spiked due to the emergence of new evidence regarding more specific and accurate imaging, and the wider use of minimally invasive techniques. Nevertheless, the optimal management of this pathology is yet to be determined.

OBJECTIVE

Assess the efficacy and safety of cytoreductive surgery in patients suffering from oligometastatic prostate cancer.

EVIDENCE GATHERING

Systematic review of the scientific literature (01/01/2010-31/12/2021) within the MedLine, Embase, Cochrane Library, Cinahl, Scopus, Spanish Healthcare Technology Assessment Agencies (AETS, Agencias de Evaluación de Tecnologías Sanitarias) and ClinicalTrials.gov databases. The keywords used were prostatectomy, prostatic neoplasm, radical prostatectomy; the free search terms were prostatectomy and oligometastatic prostate. The inclusion criteria comprised studies on patients with oligometastatic prostate cancer who had been operated on using radical cytoreductive prostatectomy.

EVIDENCE SYNTHESIS

The systematic review included 4 observational studies, 2 clinical trials, and 2 case series, of moderate quality. The results observed suggest that oligometastatic prostate cancer patients who had undergone cytoreductive prostate surgery obtained a benefit in terms of efficacy. Conversely, the majority of these studies showed a reduction in the number of localized complications, when compared to the best systemic treatments.

CONCLUSIONS

Cytoreductive surgery in this group of patients is a safe procedure that reduces the incidence of localized complications and that presents promising results with regard to survival rates. To date, the lack of prospective trials limits the use of this therapeutic option to experimental environments.

Oncological Outcome of Combining Cytoreductive Prostatectomy and Metastasis-Directed Radiotherapy in Patients with Prostate Cancer and Bone Oligometastases: A Retrospective Cohort Study

Background

The current standard of care for metastatic prostate cancer (mPCa) is androgen deprivation therapy (ADT) with or without anti-androgen and chemotherapy. The aim of this study was to evaluate the efficacy and safety of a multimodal approach including local primary tumor therapy, metastasis-directed therapy (MDT), and hormonal therapy in patients with oligometastatic prostate cancer (PCa).

Methods

We reviewed data of patients with PCa and bone oligometastases at diagnosis treated in three institutions with ADT followed by cytoreductive surgery with or without metastases-directed radiotherapy. Oligometastases were defined as the presence of five or fewer metastatic lesions with the absence of visceral metastases. In this retrospective cohort study, 58 patients underwent cytoreductive radical prostatectomy and ADT. Of these, 26 patients (45%) received stereotactic body radiation therapy (SBRT) to all metastatic sites as a MDT. Oncological outcomes were analyzed using the Kaplan–Meier method.

Results

The median follow-up period was 46.2 months. Of the 58 patients, the 3-year castration-resistant prostate cancer (CRPC)-free survival and cancer-specific survival was 75.9% and 91.4%, respectively. Pre- or post-treatment predictive factors for progression to CRPC, including prostate-specific antigen (PSA) level at diagnosis ≥20 ng/mL, Gleason grade groups 5, clinical T stage cT3b-4, PSA nadir level of ≥0.05 ng/mL, and no MDT with SBRT, were significantly associated with progression to CRPC. Subgroup analysis showed that the MDT group had significantly better CRPC-free survival than the non-MDT group with Gleason grade groups 1–4 (HR=0.228; 95% CI= 0.056–0.926). A total of 3.4% of the patients had grade 2 acute genitourinary toxicities and 5.2% had grade 2 acute gastrointestinal toxicities. No late grade >2 adverse events were observed.

Conclusion

This multi-center, retrospective cohort study revealed the feasibility of combining cytoreductive prostatectomy and metastasis-directed radiotherapy for newly-diagnosed oligometastatic PCa. This treatment strategy has the potential to delay the progression to CRPC.

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.

Oncological Outcome of Cytoreductive Radical Prostatectomy in Prostate Cancer Patients With Bone Oligometastases

OBJECTIVE

To explore the role of cytoreductive radical prostatectomy (CRP) for locally resectable and distant oligometastatic prostate cancer (CaP).

PATIENTS AND METHODS

Oligometastases were defined as the presence of 5 or fewer metastatic lesions detected on 99mTc bone scan and no suspicious visceral involvement at pretreatment imaging. Clinical data on 111 consecutive patients who were diagnosed as oligometastatic CaP in our center from 2005 to 2016 was retrospectively collected. In this retrospective cohort study, 35 patients underwent CRP and androgen deprivation therapy, and 76 patients underwent androgen deprivation therapy alone. Oncological outcomes were analyzed by employing Kaplan-Meier method.

RESULTS

The median follow-up of both groups was 35 months. In whole cohort analyses, prostate-specific antigen (PSA) decrease velocity (P = .167), PSA half-time (P = .263), and PSA nadir (P = .196) were not significantly different between 2 groups. Meanwhile, the differences in oncological outcomes between 2 groups did not reach statistical significance with regard to PSA relapse-free survival (P = .184), clinical progression-free survival (P = .118), and cancer-specific survival (P = .773). In addition, similar results were also observed in prespecified subgroup analyses (lower PSA group [0-100 ng/mL, P = .543], lower Gleason score group [6-7, P = .266], lower clinical T stage group [2-3 stage, P = .962], lower radiological N stage group [0 stage, P = .364]).

CONCLUSION

In our study, significant benefit from CRP has not been detected in patients with oligometastatic CaP. Facing current trend, it demands deliberate consideration to select candidates for cytoreductive surgery, and the selection criteria should be further refined by incorporating additional prognostic factors.

Impact of tumor cytoreduction in metastatic prostate cancer

Objective: To assess the impact of tumor cytoreduction on cancer outcomes and patient survival in metastatic prostate cancer. Patients and methods: It is a prospective study spanning a two-year period between October 1st 2015 and March 31st 2017. We enrolled 102 cases of metastatic hormone-sensitive prostate cancer. Fifty-seven (57) patients had exclusively androgen deprivation therapy (ADT) (group 1) and 45 had, in addition, an open prostatectomy or Transurethral resection of the Prostate (group 2). We compared both groups using the total PSA nadir, the time to PSA nadir, the overall survival (OS), and the progression-free survival (PFS). Results: The average nadir PSA was lower for the tumor cytoreduction group (16.8±1.6 ng/mL (0.01-193.5) versus 110.7±17.9 ng/mL (0.01-1379)). Median time to PSA nadir was shorter in patients in the ADT only group (8 months vs 3 months (p=0.025)). The OS was shorter in patients treated with ADT only compared to the tumor cytoreduction group (median 14 months vs 24 months, respectively (p=0.03)). Similarly, tumor cytoreduction had a positive impact on patient progression (median PFS 20 months (group 1) vs 43 months (group 2)). Conclusion: Tumor cytoreduction has a positive impact on the oncological results and the survival of patients under ADT.

Radium-223 for primary bone metastases in patients with hormone-sensitive prostate cancer after radical prostatectomy

Radium-223 dichloride (Ra-223) is the first bone-targeting agent showing improvement in overall survival in patients with castration-resistant prostate cancer (CRPC) and bone metastases. We aimed to assess feasibility of Ra-223 treatment in patients with metastatic hormone-sensitive prostate cancer (mHSPC). Ten patients with primary bone metastases received Ra-223 following radical prostatectomy (RP). Changes in alkaline phosphatase (ALP) and prostate-specific antigen (PSA) were recorded, while pain intensity was evaluated using the self-reporting Brief Pain Inventory (BPI) questionnaire. Bone scintigraphy (BS) was performed to assess treatment response. Seven patients completed six cycles of Ra-223. Discontinuation was due to leuko- and lymphopenia, progressive lymph node metastasis or newly diagnosed liver metastasis. Treatment-related adverse events occurred in three patients and included leuko- and lymphopenia, fatigue, abdominal discomfort and nausea. Overall, a median decrease of 28% in ALP and a median decrease of 83% in PSA were noted at follow-up. However, PSA progressed in five patients at follow-up. Improvement of pain was observed in all patients (median decrease of 36% after 3 cycles and of 40% at the end of therapy). On BS, three patients showed remission, four had stable disease, and one showed progressive disease at follow-up. Our results suggest that Ra-223 for primary bone metastases in patients with mHSPC after RP is feasible and alleviates pain. ALP, rather than PSA, may be a good marker for assessing treatment response. Ra-223 could therefore be taken into consideration as part of a multimodal approach for carefully selected patients with advanced prostate cancer.