OLIGOPELVIS GETUG P07, a Multicenter Phase II Trial of Combined High-dose Salvage Radiotherapy and Hormone Therapy in Oligorecurrent Pelvic Node Relapses in Prostate Cancer

Debate 3: Metastasis Directed Therapy in Oligometastatic Prostate Cancer

Oligometastatic prostate cancer (OMPC), characterized by limited metastatic burden (≤5 lesions), encompasses 3 major subtypes: de novo synchronous oligometastatic hormone-sensitive prostate cancer (om-HSPC), metachronous oligorecurrent HSPC (or-HSPC), and oligoprogressive castrate-resistant prostate cancer (op-CRPC). Metastasis-directed therapy (MDT), particularly stereotactic body radiotherapy (SBRT), has been widely adopted and offers a noninvasive approach for delaying disease progression and achieving durable local control while maintaining the quality of life (QoL). This review examines the evolving evidence supporting MDT across OMPC spectrum. In de novo om-HSPC, early prospective studies suggest benefit when combining MDT with systemic therapy and local prostate radiation therapy (RT). However, conclusive randomized evidence for benefit of MDT in de-novo om-HSPC is lacking. For or-HSPC, randomized trials (STOMP, ORIOLE) demonstrate that SBRT-MDT safely delays systemic therapy initiation and prolongs progression-free survival (PFS). In nodal or-HSPC, the PEACE V-STORM trial has shown superior biochemical and locoregional control with elective nodal radiotherapy (ENRT) compared to SBRT alone. For well selected patients with OMPC, systemically augmented MDT (SBRT with short-course ADT±ARPI) is an attractive strategy to improve outcomes with no added QoL detriment and has shown more durable responses than either modality alone (EXTEND, RADIOSA trials). The recent WOLVERINE meta-analysis has shown that MDT improves PFS and overall survival across OMPC subtypes. Patient selection remains crucial, with PSA kinetics, PSMA-PET findings, and genomic factors emerging as potential biomarkers for personalizing the OMPC therapeutic landscape. While several phase III trials are ongoing, current evidence supports MDT integration into clinical practice for appropriately selected OMPC patients.

18F-FDG PET/CT guided salvage radiotherapy strategies for lymph-nodal relapses in gynecological cancers: SBRT vs ENRT

OBJECTIVE

To identify outcome differences between extended nodal radiotherapy (ENRT) with simultaneous integrated boost (SIB) and stereotactic body radiotherapy (SBRT), performed with advanced radiotherapy techniques, both of which were 18F-Fluoro-Deoxy-Glucose (FDG) PET/CT guided, for lymph-node (LN) relapses of gynecological tumors, and to identify the most important determining factors.

METHODS

Records of gynecologic patients treated in a single-institution with FDG PET/CT guided intensity-modulated radiotherapy (IMRT), image-guided radiotherapy (IGRT), or SBRT, were reviewed, and only patients at first salvage radiotherapy for LN relapses were considered. Local relapse-free- (LRFS), regional relapse-free- (RRFS), distant metastasis-free- (DMFS), disease-free-(DFS) and overall-survival (OS), as well as acute and late toxicity (with CTCAE v5.0 score), were determined.

RESULTS

Fifty-eight patients (23 ENRT+SIB; 35 SBRT) treated for 178 LNs from February 2007-April 2023, were identified. Median biological equivalent dose (BED10) delivered to PET-positive LNs was 76.5 Gy (Interquartile range-IQR- 74.4;78.7) for ENRT, and 72 Gy (IQR 59.5;75.6) for SBRT. Median follow-up was 81.1(IQR 48.5; 117.2) and 37.0 (IQR 21.3; 58.4) months for ENRT and SBRT, respectively. Thirty-six-month estimated LRFS was 90.2% for ENRT and 82.6% for SBRT; RRFS was 69% and 63.4%, DMFS 26.1% and 44.3%, and OS 73.7% and 60.4%; no statistically significant differences were found between the two groups (logrank test, p= 0.29). ENRT recorded more acute (p⩽0.033), but not late, toxicities.

CONCLUSIONS

ENRT+SIB and SBRT for gynecological LN tumor relapses obtain similar results in terms of disease-free and OS, with fair toxicity. Prospective studies with higher patient numbers are needed.

Current role of salvage radiotherapy in oligometastatic prostate cancer at the time of recurrence

PURPOSE OF REVIEW

To review the evidence for metastasis-directed therapy (MDT) in oligometastatic (OM) prostate cancer (PC) and future directions in this clinical setting.

RECENT FINDINGS

The indications for radiotherapy in PC have significantly increased over the last decade. The treatment of OM disease has been gaining popularity thanks to new molecular imaging techniques that allow more accurate identification of OM patients who may benefit from MDT. stereotactic body radiation therapy can offer potentially curative treatment with low toxicity rates. Although most published MDT studies focus on hormone-sensitive (HS) PC in the setting of recurrence, promising results have emerged in recent years even in patients with castration resistance.

SUMMARY

MDT has emerged as an effective treatment option for OM PC patients with favorable oncological outcomes and a low toxicity profile. Evidence suggests that MDT can be used to delay androgen deprivation therapy or in combination with systemic therapy to potentially improve efficacy outcomes. Molecular stratification is needed to determine who will benefit from treatment intensification with MDT +/- systemic therapies.

Metastasis-Directed Therapy in Oligometastatic Prostate Cancer: Biological Rationale and Systematic Review of Published Data

INTRODUCTION

Metastasis-directed therapy (MDT) alone may be effective in preventing disease progression and positively affecting overall survival (OS) in oligometastatic prostate cancer (OMPC).

OBJECTIVE

We systematically reviewed the current literature to analyse the biological rationale for integrating MDT into treatment strategies for OMPC and investigate the current evidence on its role in OMPC.

EVIDENCE ACQUISITION

MEDLINE/PUBMED and the EMBASE Database were systematically searched to identify eligible reports published up to January 2024. The proceedings of the European Society for Radiotherapy and Oncology, European Society of Medical Oncology, American Society for Radiation Oncology, American Society of Clinical Oncology, European Uro-Oncology Group, and American Urological Association annual meetings were analysed.

RESULTS

Eighteen studies published between 2014 and 2024 were selected for the analysis. The studies included 1058 patients treated with metastasis-directed radiotherapy. No statistically significant differences were found in terms of treatment-escalation-free survival between hormone-naïve patients treated with MDT alone and those treated with MDT and hormonal manipulation. By contrast, the combination treatment significantly increased both 2 year and 4 year disease-progression-free survival (DPFS) rates (p-values < 0.00001 and 0.006, respectively). In patients with castration-sensitive disease treated with MDT alone, the estimated 2 year and 4 year OS rates were 96.4% (95% confidence interval [CI], 92.9-100%) and 89.1% (95% CI, 82.3-96.5%), respectively. The estimated 2 year and 4 year overall survival rates in the combination treatment group were 86.1% (95% CI 79.2-93.7%) and 74.8% (95% CI 64.6.3-86.5%), respectively.

CONCLUSIONS

MDT alone is associated with promising outcomes in OMPC and represents a valuable, valid, and often preferable strategy. Combined with ADT improves significantly disease-progression-free survival, but its impact on overall survival remains uncertain. Given these findings, the decision to incorporate ADT should be tailored to individual patient characteristics and clinical context. Future research should integrate biomarker-based approaches to optimise MDT use and select the best candidates for a multimodal approach.

Bilateral atypical femur fracture in a patient with breast cancer taking zoledronic acid and denosumab: A case report

A 54-year-old woman developed stage IV breast cancer 8 years prior. Chemotherapy was administered, and she was started on zoledronic acid treatment for her bone metastases. Her chemotherapy regimen was then switched, owing to disease progression. Fifty-seven months after starting treatment with zoledronic acid, the patient suffered an atypical femoral fracture of her right femur, for which she underwent surgery. Twenty months later, she developed another atypical femoral fracture in her left femur and underwent intramedullary nail fixation. Zoledronic acid and denosumab use in patients with metastatic bone tumours caused by breast cancer should be done cautiously, considering atypical femoral fracture risk.

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.

Long-term Outcomes and Patterns of Relapse Following High-dose Elective Salvage Radiotherapy and Hormone Therapy in Oligorecurrent Pelvic Nodes in Prostate Cancer: OLIGOPELVIS (GETUG-P07)

BACKGROUND AND OBJECTIVE

Androgen deprivation therapy (ADT) is a mainstay in metastatic prostate cancer, while additional salvage radiotherapy may offer prolonged remission for patients with regional node relapses. We performed an open-label, phase II trial to assess the long-term outcomes and patterns of relapse of 6-months ADT and elective pelvic radiotherapy in men with oligorecurrent (<6) pelvic nodes in prostate cancer (Oligopelvis GETUG-P07).

METHODS

We analyzed the 5-yr outcomes. Progression was defined as two consecutive prostate-specific antigen levels above the level at inclusion and/or clinical progression as per RECIST 1.1 and/or death from any cause.

KEY FINDINGS AND LIMITATIONS

Sixty-seven patients were recruited. The median follow-up was 6.1 yr (95%CI: 5.9-6.3). Grade 2+ 3-yr, 4-yr and 5-yr genito-urinary and gastro-intestinal toxicities affected 15%, 9%, 4% and 2%, 3%, 4% of non-progressive patients, respectively. 5-yr progression-free, biochemical relapse-free and ADT-free survivals were 39%, 31% and 64%, respectively. In total, 45 patients had progression and 38 had the following clinical progression: local (18%), N1 (29%), M1a (50%), M1b (32%) and M1c (11%).

CONCLUSIONS AND CLINICAL IMPLICATIONS

Finally, combined elective pelvic radiotherapy and ADT appeared to prolong tumor control with limited toxicity. At 5 years, one third of patients had not relapsed biochemically. The major site of relapse was para-aortic lymph nodes.

Avoiding prostate bed radiation for the PSMA-PET detected nodal recurrence patient post prostatectomy

Background

Nodal only recurrence post radical prostatectomy (RP) is increasingly recognised in the PSMA scan era. Management is controversial with a curative approach usually incorporating prostate bed and nodal irradiation (PB + NRT) in combination with long-term hormonal therapy. It is unknown whether omitting prostate-bed irradiation (PBRT) is safe in a subgroup of these patients.

Purpose

To document the outcomes for pelvic nodal only salvage radiation therapy (NRT) plus concurrent androgen deprivation therapy (ADT) for patients with PSMA PET documented nodal relapses.

Methods and materials

Eligible patients included PSMA PET documented nodal only relapses post RP who received NRT with or without PBRT at Royal North Shore Hospital (NSCC), Gosford Hospital (CCCC) or Genesis Care (GC) between January 2015 and December 2021. Baseline demographics, surgical pathology, radiation details, ADT use and outcomes were documented.

Results

Forty-six patients were identified, 22 in the PB + NRT cohort and 24 in the NRT cohort. Compared to the PBRT + NRT group, the NRT cohort had lower stage disease (pT2 = 7 (29 %), pT3a = 15 (63 %), pT3b = 1 (4 %) vs pT2 = 0, pT3a = 10 (45 %), pT3b = 12 (55 %)) (p=<0.001) and lower rates of R1 resection (0 % vs 63.6 % (n = 14)) (p < 0.001) respectively. The median follow-up from radiotherapy was 3.9 years.Four-year biochemical failure- free survival (BFFS) was 64 % in the NRT group vs 67 % in the PB + NRT group. Of the ten (41.6 %) failures in the NRT group, 1 (4 %) was a biochemical failure only, 2 (8 %) recurred in the PB and received further salvage treatment, 4 (17 %) had nodal failure outside the pelvis and 3 (13 %) had distant metastases.One patient (4 %) in the NRT group recorded late grade ≥2 GU toxicity compared with 7 (32 %) in the PB + NRT. No patients in the NRT group recorded late grade ≥2 GI toxicity compared with 2 (9 %) in the PB + NRT cohort.

Conclusion

This study provides early evidence for the feasibility of PBRT sparing to avoid local toxicity. Most patients in this cohort failed distantly. This data suggests that for selected men PB-avoidance may be considered given informed consent.

Early and repetitive novel-tracer PET-guided stereotactic body radiotherapy for nodal oligorecurrent prostate cancer after definitive first-line therapy

BACKGROUND

Prostate-specific membrane antigen (PSMA) positron-emission tomography (PET) imaging can detect prostate cancer (PCa) nodal oligorecurrences (NOR) at very low prostate-specific antigen (PSA) levels. Prospective studies on oligorecurrent (OR) PCa have been hampered by either dated diagnostics or inhomogeneous cohorts and/or treatment approaches. We hypothesized that early and-if necessary and feasible-repetitive PSMA-PET-based metastasis-directed therapy (MDT) using stereotactic body radiotherapy (SBRT) would improve freedom from palliative (systemic) therapy at low toxicity.

METHODS

This study is a retrospective analysis of patients treated for OR PCa after definitive first-line therapy using PSMA-PET/CT-based SBRT. Endpoints were biochemical progression-free survival (bPFS), SBRT-free survival (SBRT-FS), androgen deprivation therapy (ADT)-free survival (ADT-FS), and toxicity.

RESULTS

A total of 67 patients and 248 metastases (211 nodal) were treated. Patients on concurrent ADT were excluded. Median PSA at inclusion was 2.175 ng/ml. bPFS, SBRT-FS, and ADT-FS for multiple-course SBRT were 9.5, 19.5, and 35.0 months, respectively; 32 patients had ≥ 1 course of SBRT. Median PSA nadir was 0.585 ng/ml. There was no ≥ grade 2 toxicity.

CONCLUSION

Modern-tracer PET/CT-based early and repetitive focal SBRT yields promising results with regard to bPFS, SBRT-FS, and ADT-FS with low toxicity. The ability of this approach to postpone initiation of palliative treatment with low toxicity should be re-evaluated prospectively.

French AFU Cancer Committee Guidelines - Update 2024-2026: Prostate cancer - Management of metastatic disease and castration resistance

PURPOSE OF THIS DOCUMENT

The Oncology Committee of the French Urology Association is proposing updated recommendations for the management of recurrent and/or metastatic prostate cancer (PCa).

METHODS

A systematic review of the literature from 2022 to 2024 was conducted by the CCAFU on the therapeutic management of recurrent PCa following local or metastatic treatment, assessing the references based on their level of evidence.

RESULTS

Molecular imaging is the standard approach for assessing recurrence after local treatment and should not delay early salvage treatment. Androgen deprivation therapy (ADT) is the primary treatment option for metastatic PCa. Intensification of ADT, now cononsidered standard care for metastatic PCa, involves incorporating at least one new-generation hormone therapy (ARPI). For patients with high-volume metastatic disease at diagnosis, adding docetaxel to ADT+ARPI may be considered for eligible patients. In castration-resistant PCa (CRPC) patients, poly(ADP) ribose polymerase (PARP) inhibitors and PSMA radioligand therapy are new treatment options. The combination and sequencing of treatmentsare influenced by several factors, including patient and disease characteristics, prior therapies, genomic status, and molecular imaging findings.

CONCLUSION

This update of French recommendations should help to improve the management recurrent or metastatic PCa patients.

PSMA PET/CT patterns of recurrence after mono-brachytherapy in men with low and intermediate prostate cancer and subsequent management

PURPOSE

Brachytherapy as monotherapy is a recommended treatment option for men with low to intermediate risk prostate cancer. Local recurrence is difficult to identify. This study investigated PSMA PET/CT for recurrence after brachytherapy, as well as their subsequent management when recurrence occurred only within the prostate.

METHODS

We performed a retrospective single-center analysis for patients who were treated with brachytherapy as monotherapy for prostate cancer from May 2002 to May 2021 and who underwent a PSMA PET/CT for BCR. We report the findings on PSMA PET/CT, quantitative parameters, as well as the later management of the patients.

RESULTS

Forty patients were identified, who underwent PSMA PET/CT to investigate a rising PSA at a median (IQR) of 7 years (3.0-10.8) after initial therapy. Median (IQR) PSA at time of PSMA PET/CT was 6.54 ng/mL (3.9-15.5). On PSMA PET/CT, 20/40 (50%) men had prostate-only recurrence. Of the 20 patients with prostate-only recurrence, 8/20 (40%) had recurrence in a high-dose radiation zone, versus 7/20 (35%) in an under-covered zone. On PSMA PET/CT, recurrence within the prostate had median (IQR) SUVmax 10.4 (5.1-15.7) and volume 2.9 mL (2.0-11.2). Subsequent management of these patients with local recurrence included surveillance followed by ADT (9/20, 45%). For those with surveillance followed by ADT, the mean time before introduction of ADT was 4.1 years (range 1-8 years).

Nodal radiotherapy for prostate adenocarcinoma recurrence: predictive factors for efficacy

Background

Nodes are the second site for prostate cancer recurrence. Whole-pelvic radiotherapy (WPRT) has shown superiority over nodal stereotactic body radiotherapy (SBRT) in two retrospective cohorts. We aimed to compare both modalities and assess factors associated with treatment outcomes.

Materials and methods

This retrospective multicentric cohort study included patients from five institutions spanning from 2010 to 2022. Patients had a history of prostatic adenocarcinoma classified as N0 M0 at diagnosis with a first nodal-only pelvic castration-sensitive recurrence. Failure-free survival (FFS) was defined as the time from the end of RT to the first failure event-biochemical or imaging recurrence, or death.

Results

A total of 147 patients (pts) were analyzed, mainly treated for a recurrence after initial prostatectomy (87%), with 64 (43.5%) undergoing SBRT and 83 (56.5%) undergoing WPRT. SBRT was chosen mainly for dosimetric constraints (67%) and was associated with a lower rate of concomitant androgen deprivation therapy (ADT) prescription. With a median follow-up of 68 months [inter-quartile range (IQR) = 51], FFS was significantly lower in the SBRT group (p < 0.0001). In multivariable analysis, WPRT and ADT were associated with a longer FFS. Factors associated with a longer FFS after SBRT included associated ADT, lower prostate-specific antigen (PSA) levels, a PSA doubling time >6 months, and a Gleason score <8. SBRT was associated with a lower rate of genitourinary and gastrointestinal grade ≥2 complications.

Discussion

For an isolated pelvic nodal prostate cancer recurrence, SBRT is associated with a shorter FFS compared to WPRT. SBRT is often more convenient for patients and leaves further pelvic salvage options available, so it can be explored as an option for well-informed patients.

Stereotactic ablative radiotherapy (SABR) for pelvic nodal oligorecurrence in prostate cancer

Background

This study evaluated the clinical outcomes of stereotactic ablative radiotherapy (SABR) in the treatment of oligometastatic pelvic node prostate cancer to delay androgen deprivation therapy (ADT).

Materials and methods

Pelvic lymph node metastases were identified by 11C-choline positron emission tomography (PET)-computed tomography (CT), and patients were not receiving ADT. SABR was administered using linear accelerators with intensity-modulated and image-guided radiotherapy, at a prescribed dose of 35 Gy in 5 fractions over 2 weeks. Response was assessed using Response Evaluation Criteria in Solid Tumours (RECIST) v1.1 criteria, and prostate-specific antigen (PSA) levels were monitored post-SABR. Toxicity and quality of life were assessed by the Common Terminology Criteria for Adverse Events Toxicity (CTCAE) v.5.0 and European Organisation for Research and Treatment of Cancer (EORTC) quality of life questionnaires QLQ-C30/QLQ-PR25, respectively. Kaplan-Meier and T-test were used for statistical analysis.

Results

Between June 2015 and November 2023, 56 patients with 85 lesions were treated at our institution. Median follow-up was 30 months [95% confidence interval (CI): 24-33.6]. Prostatectomy was the radical treatment in 85.7% of patients, and radiotherapy in 14.3%. Response rates were 67.1% for complete response, 27.4% for partial response, and 1.4% for stable disease. In-field progression was observed in only 3 lesions (3.5%). The median time to biochemical relapse post-SABR was 15 months (95% CI: 11.4-18.6). Three-year pelvic nodal and distant progression-free survival were 62.5% and 80%, respectively. There was a significant decrease in PSA levels after SABR compared to pretreatment levels (0.77 vs. 2.16 ng/mL respectively, p = 0.001). No grade ≥ 2 genitourinary or gastrointestinal toxicities. The median global health status score was 83.33 points at both time points analysed.

Conclusion

SABR can delay the ADT and provide excellent local control while preserving quality of life.

Whole pelvis vs. hemi pelvis elective nodal radiotherapy in patients with PSMA-positive nodal recurrence after radical prostatectomy - a retrospective multi-institutional propensity score analysis

PURPOSE

Despite growing evidence for bilateral pelvic radiotherapy (whole pelvis RT, WPRT) there is almost no data on unilateral RT (hemi pelvis RT, HPRT) in patients with nodal recurrent prostate cancer after prostatectomy. Nevertheless, in clinical practice HPRT is sometimes used with the intention to reduce side effects compared to WPRT. Prostate-specific membrane antigen positron emission tomography / computed tomography (PSMA-PET/CT) is currently the best imaging modality in this clinical situation. This analysis compares PSMA-PET/CT based WPRT and HPRT.

METHODS

A propensity score matching was performed in a multi-institutional retrospective dataset of 273 patients treated with pelvic RT due to nodal recurrence (214 WPRT, 59 HPRT). In total, 102 patients (51 in each group) were included in the final analysis. Biochemical recurrence-free survival (BRFS) defined as prostate specific antigen (PSA) < post-RT nadir + 0.2ng/ml, metastasis-free survival (MFS) and nodal recurrence-free survival (NRFS) were calculated using the Kaplan-Meier method and compared using the log rank test.

RESULTS

Median follow-up was 29 months. After propensity matching, both groups were mostly well balanced. However, in the WPRT group there were still significantly more patients with additional local recurrences and biochemical persistence after prostatectomy. There were no significant differences between both groups in BRFS (p = .97), MFS (p = .43) and NRFS (p = .43). After two years, BRFS, MFS and NRFS were 61%, 86% and 88% in the WPRT group and 57%, 90% and 82% in the HPRT group, respectively. Application of a boost to lymph node metastases, a higher RT dose to the lymphatic pathways (> 50 Gy EQD2α/β=1.5 Gy) and concomitant androgen deprivation therapy (ADT) were significantly associated with longer BRFS in uni- and multivariate analysis.

CONCLUSIONS

Overall, this analysis presents the outcome of HPRT in nodal recurrent prostate cancer patients and shows that it can result in a similar oncologic outcome compared to WPRT. Nevertheless, patients in the WPRT may have been at a higher risk for progression due to some persistent imbalances between the groups. Therefore, further research should prospectively evaluate which subgroups of patients are suitable for HPRT and if HPRT leads to a clinically significant reduction in toxicity.

The expanding role of radiation oncology across the prostate cancer continuum

Radiotherapy is used in the treatment of prostate cancer in a variety of disease states with significant reliance on imaging to guide clinical decision-making and radiation delivery. In the definitive setting, the choice of radiotherapy treatment modality, dose, and fractionation for localized prostate cancer is determined by the patient's initial risk stratification and other clinical considerations. Radiation is also an option as salvage therapy in patients with locoregionally recurrent disease after prior definitive radiation or surgery. In recent years, the role of radiation has expanded for patients with metastatic disease, including prostate-directed radiotherapy in de novo low volume metastatic disease, metastasis-directed therapy for oligorecurrent disease, and palliative management of symptomatic metastases in the advanced setting. Here we review the expanding role of radiation in the treatment of prostate cancer in the definitive, locoregionally recurrent, and metastatic settings, as well as highlight the role of imaging in clinical reasoning, radiation planning, and treatment delivery.

EAU-EANM-ESTRO-ESUR-ISUP-SIOG Guidelines on Prostate Cancer. Part II-2024 Update: Treatment of Relapsing and Metastatic Prostate Cancer

BACKGROUND AND OBJECTIVE

The European Association of Urology (EAU)-European Association of Nuclear Medicine (EANM)-European Society for Radiotherapy and Oncology (ESTRO)-European Society of Urogenital Radiology (ESUR)-International Society of Urological Pathology (ISUP)-International Society of Geriatric Oncology (SIOG) guidelines on the treatment of relapsing, metastatic, and castration-resistant prostate cancer (PCa) have been updated. Here we provide a summary of the 2024 guidelines.

METHODS

The panel performed a literature review of new data, covering the time frame between 2020 and 2023. The guidelines were updated and a strength rating for each recommendation was added on the basis of a systematic review of the evidence.

KEY FINDINGS AND LIMITATIONS

Risk stratification for relapsing PCa after primary therapy may guide salvage therapy decisions. New treatment options, such as androgen receptor-targeted agents (ARTAs), ARTA + chemotherapy combinations, PARP inhibitors and their combinations, and prostate-specific membrane antigen-based therapy have become available for men with metastatic PCa.

CONCLUSIONS AND CLINICAL IMPLICATIONS

Evidence for relapsing, metastatic, and castration-resistant PCa is evolving rapidly. These guidelines reflect the multidisciplinary nature of PCa management. The full version is available online (http://uroweb.org/guideline/ prostate-cancer/).

PATIENT SUMMARY

This article summarises the 2024 guidelines for the treatment of relapsing, metastatic, and castration-resistant prostate cancer. These guidelines are based on evidence and guide doctors in discussing treatment decisions with their patients. The guidelines are updated every year.

PEACE V-Salvage Treatment of OligoRecurrent nodal prostate cancer Metastases (STORM): Acute Toxicity of a Randomized Phase 2 Trial

BACKGROUND

Treatment recommendations for patients with limited nodal recurrences are lacking, and different locoregional treatment approaches are currently being used.

OBJECTIVE

The aim of this trial is to compare metastasis-directed therapy (MDT) with or without elective nodal pelvic radiotherapy (ENRT).

DESIGN, SETTING, AND PARTICIPANTS

PEACE V-Salvage Treatment of OligoRecurrent nodal prostate cancer Metastases (STORM) is an international, phase 2, open-label, randomized, superiority trial (ClinicalTrials.gov identifier: NCT03569241). Patients diagnosed with positron emission tomography-detected pelvic nodal oligorecurrence (five or fewer nodes) following radical local treatment for prostate cancer were randomized in a 1:1 ratio between arm A (MDT and 6 mo of androgen deprivation therapy [ADT]) and arm B (ENRT [25 × 1.8 Gy] with MDT and 6 mo of ADT).

OUTCOME MEASUREMENTS AND STATISTICAL ANALYSIS

We report the secondary endpoint acute toxicity, defined as worst grade ≥2 Common Terminology Criteria for Adverse Events v4.0 gastrointestinal (GI) or genitourinary (GU) toxicity within 3 mo of treatment. The chi-square test was used to compare toxicity between treatment arms. We also compare the quality of life (QoL) using the European Organisation for Research and Treatment of Cancer QLQ C30 and PR25 questionnaires.

RESULTS AND LIMITATIONS

Between June 2018 and April 2021, 196 patients were assigned randomly to MDT or ENRT. Ninety-seven of 99 patients allocated to MDT and 93 of 97 allocated to ENRT received per-protocol treatment. Worst acute GI toxicity proportions were as follows: grade ≥2 events in three (3%) in the MDT group versus four (4%) in the ENRT group (p = 0.11). Worst acute GU toxicity proportions were as follows: grade ≥2 events in eight (8%) in the MDT group versus 12 (13%) in the ENRT group (p = 0.95). We observed no significant difference between the study groups in the proportion of patients with a clinically significant QoL reduction from baseline for any subdomain score area.

CONCLUSIONS

No clinically meaningful differences were observed in worst grade ≥2 acute GI or GU toxicity or in QoL subdomains between MDT and ENRT.

PATIENT SUMMARY

We found no evidence of differential acute bowel or urinary side effects using metastasis-directed therapy and elective nodal radiotherapy for the treatment of patients with a pelvic lymph node recurrence.

Optimal systemic therapy in men with low-volume prostate cancer

PURPOSE OF REVIEW

Low-volume prostate cancer is an established prognostic category of metastatic hormone-sensitive prostate cancer. However, the term is often loosely used to reflect the low burden of disease across different prostate cancer states. This review explores the definitions of low-volume prostate cancer, biology, and current evidence for treatment. We also explore future directions, including the impact of advanced imaging modalities, particularly prostate-specific membrane antigen (PSMA) positron emission tomography (PET) scans, on refining patient subgroups and treatment strategies for patients with low-volume prostate cancer.

RECENT FINDINGS

Recent investigations have attempted to redefine low-volume disease, incorporating factors beyond metastatic burden. Advanced imaging, especially PSMA PET, offers enhanced accuracy in detecting metastases, potentially challenging the conventional definition of low volume. The prognosis and treatment of low-volume prostate cancer may vary by the timing of metastatic presentation. Biomarker-directed consolidative therapy, metastases-directed therapy, and de-escalation of systemic therapies will be increasingly important, especially in patients with metachronous low-volume disease.

SUMMARY

In the absence of validated biomarkers, the management of low-volume prostate cancer as defined by CHAARTED criteria may be guided by the timing of metastatic presentation. For metachronous low-volume disease, we recommend novel hormonal therapy (NHT) doublets with or without consolidative metastasis-directed therapy (MDT), and for synchronous low-volume disease, NHT doublets with or without consolidative MDT and prostate-directed radiation. Docetaxel triplets may be a reasonable alternative in some patients with synchronous presentation. There is no clear role of docetaxel doublets in patients with low-volume disease. In the future, a small subset of low-volume diseases with oligometastases selected by genomics and advanced imaging like PSMA PET may achieve long-term remission with MDT with no systemic therapy.

Metastases-directed radiotherapy in castration resistant oligo metastatic prostate cancer: A multicentric retrospective study from the French group COLib

Oligometastases are defined as a number of detectable metastases less or equal to 5. In castrate-resistant oligo metastatic prostate Cancer (CR oligoM PC), Metastases-Directed Ablative radiotherapy (MDRT) is poorly investigated. Our study retrospectively reviewed the cases of CR oligoM PC treated with MDRT in 8 French high-volume radiotherapy centers. OS and PFS are defined as the delay between the first day of MDRT and death (OS) or progression according to PCWG criteria (PFS). OS and PFS are evaluated according to Kaplan Meyer, curves are compared with log rank test. Logistic regression was used to identify predictive factors for outcome: bone versus node metastasis, ISUP grade, PSA doubling Time (PSADT) at the time of MDRT, time to castration resistance. 107 patients were included in the study, among those 197 metastases received MDRT. For the overall population, the median follow-up was 25.2 months (1,4-145). OS was 93 % at 2 years and 81,4% at 3 years. At 2 years, 100 % of patients with node-only metastasis were alive versus 88,7% among those who have bone metastases (p = 0,72). The median PFS was 12,6 months (IC 95 % [9,6; 17]), with no difference among patients with node only disease versus the rest of the cohort. The PFS was 18,2 months (10,0; 32,4) in patients with PSADT >6 months versus 10,7 months (8,9; 14,3) when PSADT was inferior to 6 months. However, this difference did not reach significant. We did not find a correlation neither between ISUP grade (1-2 versus 3-4-5) and PFS, nor between hormone-sensitivity duration and PFS. Patients receiving MDRT for CR oligoM PC have a good prognosis with 81,6% OS at 3 years. PSA DT longer than 6 months could be related to better PFS. MDRT strategy could postpone the onset of new systemic treatment with median PFS >1 year.

[Metastasis-directed therapy in prostate cancer]

BACKGROUND

Metastasis-directed therapy (MDT) in oligometastatic prostate cancer (omHSPC) is playing an increasingly important role in therapy with the aim of delaying disease progression, the start of systemic treatment or switching systemic treatment to improve the patient's overall prognosis. Molecular imaging as prostate-specific membrane antigen positron emission tomography (PSMA-PET) imaging allows metastases to be detected with a higher sensitivity and specificity. This means that they can be detected early and made accessible for treatment.

RESULTS

The standard therapy for oligo-mHSPC is androgen deprivation (ADT), which is supplemented by novel hormonal therapeutics (NHT). A few small prospective trials have shown an extension of the ADT-free interval and progression-free survival (PFS), particularly in metachronous oligo-mHSPC, by MDT, usually radiotherapy. Additional ADT can further extend the PFS in particular. There are hardly any prospective data for synchronous oligo-mHSPC.

CONCLUSION

Despite the currently still poor evidence, MDT is playing an increasingly important role. The still unclear definition of oligometastasis and the large number of influencing factors make it difficult to compare current data. Large multicenter prospective data are still pending. It is also important to clarify the effect of limited ADT in combination with NHT in the treatment of synchronous and metachronous oligo-mHSPC with MDT. In synchronous oligo-mHSPC in particular, further benefit of additional local therapy of the primary in combination with MDT should also be investigated.

The Potential Contribution of Radiopharmaceutical Therapies in Managing Oligometastatic Disease

There is a growing understanding of the oligometastatic disease state, characterized by the presence of 5 or fewer lesions. Advanced molecular imaging techniques, such as prostate-specific membrane antigen PET, refines the ability to detect oligometastatic recurrences (oligorecurrences) early. These developments have led to the exploration of metastasis-directed therapy (MDT) in oligorecurrent disease as an alternative to or as a means of delaying systemic therapy. Unfortunately, MDT often does not provide a durable cure, and progression-particularly progression in multiple new areas-remains a concern. Simultaneously, developments in radioligand therapy (RLT) have led to studies showing overall survival benefits with α-emitting and β-emitting RLT in advanced, high-volume, metastatic castration-resistant prostate cancer. The success of RLT in late-stage disease suggests that earlier use in the disease spectrum may be impactful. Specifically, integration of RLT with MDT might reduce progression, including polymetastatic progression, in the setting of oligorecurrent disease.

The Efficacy and Safety of Metastasis-directed Therapy in Patients with Prostate Cancer: A Systematic Review and Meta-analysis of Prospective Studies

CONTEXT

Despite the lack of level 1 evidence, metastasis-directed therapy (MDT) is used widely in the management of metastatic prostate cancer (mPCa) patients. Data are continuously emerging from well-designed prospective studies.

OBJECTIVE

To summarise and report the evidence on oncological and safety outcomes of MDT in the management of mPCa patients.

EVIDENCE ACQUISITION

We searched the PubMed, Scopus, and Web of Science databases for prospective studies assessing progression-free survival (PFS), local control (LC), androgen deprivation therapy (ADT)-free survival (ADT-FS), overall survival (OS), and/or adverse events (AEs) in mPCa patients treated with MDT. A meta-analysis was performed for 1- and 2-yr PFS, LC, ADT-FS, OS, and rate of AEs. Meta-regression and sensitivity analysis were performed to account for heterogeneity and identify moderators.

EVIDENCE SYNTHESIS

We identified 22 prospective studies (n = 1137), including two randomised controlled trials (n = 116). Two studies were excluded from the meta-analysis (n = 120). The estimated 2-yr PFS was 46% (95% confidence interval [CI]: 36-56%) or 42% (95% CI: 33-52%) after excluding studies using biochemical or ADT-related endpoints. The estimated 2-yr LC, ADT-FS, and OS were 97% (95% CI: 94-98%), 55% (95% CI: 44-65%), and 97% (95% CI: 95-98%), respectively. Rates of treatment-related grade 2 and ≥3 AEs were 2.4% (95% CI: 0.2-7%) and 0.3% (95% CI: 0-1%), respectively.

CONCLUSIONS

MDT is a promising treatment strategy associated with favourable PFS, excellent LC, and a low toxicity profile that allows oligorecurrent hormone-sensitive patients to avoid or defer ADT-related toxicity. Integration of MDT with other therapies offers a promising research direction, in particular, in conjunction with systemic treatments and as a component of definitive care for oligometastatic PCa. However, in the absence of randomised trials, using MDT for treatment intensification remains an experimental approach, and the impact on OS is uncertain.

PATIENT SUMMARY

Direct treatment of metastases is a promising option for selected prostate cancer patients. It can delay hormone therapy and is being investigated as a way of intensifying treatment at the expense of manageable toxicity.

Progress in Oligometastatic Prostate Cancer: Emerging Imaging Innovations and Therapeutic Approaches

Prostate cancer (PCa) exhibits a spectrum of heterogeneity, from indolent to highly aggressive forms, with approximately 10-20% of patients experiencing metastatic PCa. Oligometastatic PCa, characterized by a limited number of metastatic lesions in specific anatomical locations, has gained attention due to advanced imaging modalities. Although patients with metastatic PCa typically receive systemic therapy, personalized treatment approaches for oligometastatic PCa are emerging, including surgical and radiotherapeutic interventions. This comprehensive review explores the latest developments in the field of oligometastatic PCa, including its biological mechanisms, advanced imaging techniques, and relevant clinical studies. Oligometastatic PCa is distinct from widespread metastases and presents challenges in patient classification. Imaging plays a crucial role in identifying and characterizing oligometastatic lesions, with new techniques such as prostate-specific membrane antigen positron emission tomography demonstrating a remarkable efficacy. The management strategies encompass cytoreductive surgery, radiotherapy targeting the primary tumor, and metastasis-directed therapy for recurrent lesions. Ongoing clinical trials are evaluating the effectiveness of these approaches. Oligometastatic PCa occupies a unique position between locally advanced and high-volume metastatic diseases. While a universally accepted definition and standardized diagnostic criteria are still evolving, emerging imaging technologies and therapeutic strategies hold promise for improving the patient outcomes in this intermediate stage of PCa.

Application of Advanced Imaging to Prostate Cancer Diagnosis and Management: A Narrative Review of Current Practice and Unanswered Questions

Major advances in prostate cancer diagnosis, staging, and management have occurred over the past decade, largely due to our improved understanding of the technical aspects and clinical applications of advanced imaging, specifically magnetic resonance imaging (MRI) and prostate-cancer-specific positron emission tomography (PET). Herein, we review the established utility of these important and exciting technologies, as well as areas of controversy and uncertainty that remain important areas for future study. There is strong evidence supporting the utility of MRI in guiding initial biopsy and assessing local disease. There is debate, however, regarding how to best use the imaging modality in risk stratification, treatment planning, and assessment of biochemical failure. Prostate-cancer-specific PET is a relatively new technology that provides great value to the evaluation of newly diagnosed, treated, and recurrent prostate cancer. However, its ideal use in treatment decision making, staging, recurrence detection, and surveillance necessitates further research. Continued study of both imaging modalities will allow for an improved understanding of their best utilization in improving cancer care.

De-Escalation of Therapy for Prostate Cancer

Prostate cancer (PCa) is the second most commonly diagnosed cancer in men with around 1.4 million new cases every year. In patients with localized disease, management options include active surveillance (AS), radical prostatectomy (RP; with or without pelvic lymph node dissection), or radiotherapy to the prostate (with or without pelvic irradiation) with or without hormonotherapy. In advanced disease, treatment options include systemic treatment(s) and/or treatment to primary tumour and/or metastasis-directed therapies (MDTs). Specifically, in advanced stage, the current trend is earlier intensification of treatment such as dual or triple combination systemic treatments or adding treatment to primary and MDT to systemic treatment. However, earlier treatment intensification comes with the cost of increased morbidity and mortality resulting from drug-/treatment-related side effects. The main goal is and should be to provide the best possible care and oncologic outcomes with minimum possible side effects. This chapter will explore emerging possibilities to de-escalate treatment in PCa driven by enhanced insights into disease biology and the natural course of PCa such as AS in intermediate-risk disease or salvage versus adjuvant radiotherapy in post-RP patients. Considerations arising from advancements in PCa imaging and technological advancements in surgical and radiation therapy techniques including omitting pelvic lymph node dissection in the era of prostate-specific membrane antigen positron emitting tomography, the potential of MDT to delay/omit systemic treatment in metachronous oligorecurrence, and the efficacy of hypofractionation schemes compared with conventional fractionated radiotherapy will be discussed.

Genitourinary cancer neoadjuvant therapies: current and future approaches

Neoadjuvant therapies can improve tolerability, reduce tumor volume to facilitate surgery, and assess subsequent treatment response. Therefore, there is much enthusiasm for expanding the benefits of cancer therapies to the neoadjuvant setting to reduce recurrence and improve survival in patients with localized or locally advanced genitourinary (GU) cancer. This approach is clinically pertinent because these treatments are administered primarily to treatment-naive patients and can elicit the greatest drug response. In addition, the results are not impacted by other anticancer treatments. While neoadjuvant therapies have been the standard treatment for bladder cancer in the past, they are presently restricted to clinical trials for renal and prostate cancer (PCa); however, changes are imminent. Precision neoadjuvant therapies will be ushered in by biomarker-stratified neoadjuvant trials with appropriate survival endpoints and comprehensive correlative and imaging studies. This review discusses neoadjuvant studies in GU malignancies and how they inform future study design considerations.

Node Oligorecurrence in Prostate Cancer: A Challenge

Within the oligometastatic state, oligorecurrent lymph node disease in prostate cancer represents an interesting clinical entity characterized by a relatively indolent biology that makes it unique: it can be treated radically, and its treatment is usually associated with a long period of control and excellent survival. Additionally, it is an emergent situation that we are facing more frequently mainly due to (a) the incorporation into clinical practice of the PSMA-PET that provides strikingly increased superior images in comparison to conventional imaging, with higher sensitivity and specificity; (b) the higher detection rates of bone and node disease with extremely low levels of PSA; and (c) the availability of high-precision technology in radiotherapy treatments with the incorporation of stereotaxic body radiotherapy (SBRT) or stereotaxic ablative radiotherapy (SABR) technology that allows the safe administration of high doses of radiation in a very limited number of fractions with low toxicity and excellent tolerance. This approach of new image-guided patient management is compelling for doctors and patients since it can potentially contribute to improving the clinical outcome. In this work, we discuss the available evidence, areas of debate, and potential future directions concerning the utilization of new imaging-guided SBRT for the treatment of nodal recurrence in prostate cancer.

Stereotactic Body Radiotherapy for Lymph-Nodal Oligometastatic Prostate Cancer: A Multicenter Retrospective Experience

Background: The favorable role of SBRT for lymph-nodal oligometastases from prostate cancer has been reported by several retrospective and prospective experiences, suggesting a more indolent natural history of disease when compared to patients with bone oligometastases. This retrospective multicenter study evaluates the outcomes of a cohort of patients treated with stereotactic body radiotherapy for lymph-nodal oligometastases. Methods: Inclusion criteria were up to five lymph-nodal oligometastases detected either with Choline-PET or PSMA-PET in patients naïve for ADT or already ongoing with systemic therapy and at least 6 Gy per fraction for SBRT. Only patients with exclusive lymph-nodal disease were included. The primary endpoint of the study was LC; a toxicity assessment was retrospectively performed following CTCAE v4.0. Results: A total of 100 lymph-nodal oligometastases in 69 patients have been treated with SBRT between April 2015 and November 2022. The median age was 73 years (range, 60-85). Oligometastatic disease was mainly detected with Choline-PET in 47 cases, while the remaining were diagnosed using PSMA-PET, with most of the patients treated to a single lymph-nodal metastasis (48/69 cases), two in 14 cases, and three in the remaining cases. The median PSA prior to SBRT was 1.35 ng/mL (range, 0.3-23.7 ng/mL). Patients received SBRT with a median total dose of 35 Gy (range, 30-40 Gy) in a median number of 5 (range, 3-6) fractions. With a median follow-up of 16 months (range, 7-59 months), our LC rates were 95.8% and 86.3% at 1 and 2 years. DPFS rates were 90.4% and 53.4%, respectively, at 1 and 2 years, with nine patients developing a sequential oligometastatic disease treated with a second course of SBRT. Polymetastatic disease-free survival (PMFS) at 1 and 2 years was 98% and 96%. Six patients needed ADT after SBRT for a median time of ADT-free survival of 15 months (range, 6-22 months). The median OS was 16 months (range, 7-59) with 1- and 2-year rates of both 98%. In multivariate analysis, higher LC rates and the use of PSMA-PET were related to improved DPFS rates, and OS was significantly related to a lower incidence of distant progression. No G3 or higher adverse events were reported. Conclusions: In our experience, lymph-nodal SBRT for oligometastatic prostate cancer is a safe and effective option for ADT delay with no severe toxicity.

Oligometastatic Hormone-Sensitive Prostate Cancer. Why Radiotherapy?

Androgen deprivation therapy (ADT) has been considered for years the standard initial treatment for patients with metastatic prostate cancer (mPC). Recently published results support the use of taxanes, second-generation antiandrogens or radiotherapy to the primary tumor as part of the treatment in these patients, considering ADT alone as suboptimal. Metastasis-directed therapy (MDT) is used as part of the treatment for oligometastatic patients in different tumor types. In oligometastatic hormone-sensitive prostate cancer the role of MDT is being studied with promising results. In the present review we assess the available evidence for radiotherapy to the primary tumor in newly diagnosed mPC and for MDT in oligometastatic prostate cancer, as well as future directions in this clinical setting.

Comparison of Hormone-Sensitive Oligorecurrent Prostate Cancer Patients Based on Routine Use of Choline and/or PSMA PET/CT to Guide Metastasis-Directed Therapy

BACKGROUND

In hormone-sensitive oligorecurrent prostate cancer (PC), the literature showed [68Ga]Ga-PSMA (PSMA) and [18F]F-choline (FCH) PET/CT can successfully guide metastasis-directed therapies (MDT). This observational retrospective study aimed to explore, in routine use, the impact of FCH or PSMA PET/CT in guiding MDT for hormone-sensitive oligometastatic PC at different recurrences.

METHODS

In 2017-2020, patients initially treated with radical prostatectomy but, in biochemical recurrence (with PSA ≤ 2 ng/mL), diagnosed as oligometastatic based on FCH or PSMA PET/CT, were identified. MDT was stereotactic body radiotherapy (SBRT), elective nodal or prostate bed radiotherapy ± boost and ± androgen deprivation therapy (ADT). The primary endpoint was biochemical relapse-free survival (BR-FS), defined as a PSA increase ≥ 0.2 ng/mL above the nadir and increasing over two successive samples and the secondaries were ADT-free survival (ADT-FS).

RESULTS

123 patients (70 PSMA and 53 FCH) were included. The median follow-up was 42.2 months. The median BR-FS was 24.7 months in the PSMA group versus 13.0 months in the FCH group (p = 0.008). Similarly, ADT-FS (p = 0.001) was longer in patients in the PSMA group. In multivariate analysis, a short PSA doubling time before imaging (p = 0.005) and MDT with SBRT (p = 0.001) were poor prognostic factors for BR-FS.

CONCLUSIONS

Routine use of FCH or PSMA PET/CT in hormone-sensitive PC showed an advantage for using PSMA PET/CT to guide MDT in terms of BR-FS and ADT-FS in patients with low PSA value. Prospective studies are needed to confirm these hypotheses.

Management of Patients with Advanced Prostate Cancer. Part I: Intermediate-/High-risk and Locally Advanced Disease, Biochemical Relapse, and Side Effects of Hormonal Treatment: Report of the Advanced Prostate Cancer Consensus Conference 2022

BACKGROUND

Innovations in imaging and molecular characterisation and the evolution of new therapies have improved outcomes in advanced prostate cancer. Nonetheless, we continue to lack high-level evidence on a variety of clinical topics that greatly impact daily practice. To supplement evidence-based guidelines, the 2022 Advanced Prostate Cancer Consensus Conference (APCCC 2022) surveyed experts about key dilemmas in clinical management.

OBJECTIVE

To present consensus voting results for select questions from APCCC 2022.

DESIGN, SETTING, AND PARTICIPANTS

Before the conference, a panel of 117 international prostate cancer experts used a modified Delphi process to develop 198 multiple-choice consensus questions on (1) intermediate- and high-risk and locally advanced prostate cancer, (2) biochemical recurrence after local treatment, (3) side effects from hormonal therapies, (4) metastatic hormone-sensitive prostate cancer, (5) nonmetastatic castration-resistant prostate cancer, (6) metastatic castration-resistant prostate cancer, and (7) oligometastatic and oligoprogressive prostate cancer. Before the conference, these questions were administered via a web-based survey to the 105 physician panel members ("panellists") who directly engage in prostate cancer treatment decision-making. Herein, we present results for the 82 questions on topics 1-3.

OUTCOME MEASUREMENTS AND STATISTICAL ANALYSIS

Consensus was defined as ≥75% agreement, with strong consensus defined as ≥90% agreement.

RESULTS AND LIMITATIONS

The voting results reveal varying degrees of consensus, as is discussed in this article and shown in the detailed results in the Supplementary material. The findings reflect the opinions of an international panel of experts and did not incorporate a formal literature review and meta-analysis.

CONCLUSIONS

These voting results by a panel of international experts in advanced prostate cancer can help physicians and patients navigate controversial areas of clinical management for which high-level evidence is scant or conflicting. The findings can also help funders and policymakers prioritise areas for future research. Diagnostic and treatment decisions should always be individualised based on patient and cancer characteristics (disease extent and location, treatment history, comorbidities, and patient preferences) and should incorporate current and emerging clinical evidence, therapeutic guidelines, and logistic and economic factors. Enrolment in clinical trials is always strongly encouraged. Importantly, APCCC 2022 once again identified important gaps (areas of nonconsensus) that merit evaluation in specifically designed trials.

PATIENT SUMMARY

The Advanced Prostate Cancer Consensus Conference (APCCC) provides a forum to discuss and debate current diagnostic and treatment options for patients with advanced prostate cancer. The conference aims to share the knowledge of international experts in prostate cancer with health care providers and patients worldwide. At each APCCC, a panel of physician experts vote in response to multiple-choice questions about their clinical opinions and approaches to managing advanced prostate cancer. This report presents voting results for the subset of questions pertaining to intermediate- and high-risk and locally advanced prostate cancer, biochemical relapse after definitive treatment, advanced (next-generation) imaging, and management of side effects caused by hormonal therapies. The results provide a practical guide to help clinicians and patients discuss treatment options as part of shared multidisciplinary decision-making. The findings may be especially useful when there is little or no high-level evidence to guide treatment decisions.

LUNAR: a randomized Phase 2 study of 177 Lutetium-PSMA Neoadjuvant to Ablative Radiotherapy for Oligorecurrent Prostate Cancer (clinical trial protocol)

OBJECTIVE

To assess the efficacy of ¹⁷⁷ Lu-PNT2002, a novel radiolabelled small molecule that binds with high affinity to prostate-specific membrane antigen (PSMA), in combination with stereotactic body radiotherapy (SBRT) to all sites of metastasis, vs SBRT alone, in men with oligorecurrent metastatic hormone-sensitive prostate cancer (mHSPC).

PATIENTS AND METHODS

The ¹⁷⁷ Lutetium-PSMA Neoadjuvant to Ablative Radiotherapy for Oligorecurrent Prostate Cancer (LUNAR) trial is an open-label, randomized, stratified, two-arm, single-centre, Phase 2 trial to compare the efficacy and safety of neoadjuvant ¹⁷⁷ Lu-PNT2002 plus SBRT vs SBRT alone in men with oligorecurrent mHSPC. Key eligibility criteria include one to five lesions identified on a PSMA positron emission tomography (PET)/computed tomography (CT) scan centrally reviewed by a board-certified nuclear medicine physician. Key exclusion criteria include castrate-resistant disease, de novo oligometastatic disease and receipt of androgen deprivation therapy (ADT) within 6 months of trial enrolment. The trial aims to enrol 100 patients who will be centrally randomized to one of the two treatment arms, in a 1:1 ratio. Patients in the control arm receive SBRT to all sites of disease. Patients in the experimental arm receive two cycles of neoadjuvant ¹⁷⁷ Lu-PNT2002 (6.8 GBq) 6-8 weeks apart, followed by an interval PSMA PET/CT in 4-6 weeks and dose-adapted SBRT to all sites of disease 1-2 weeks later. The primary endpoint is progression-free survival. Secondary endpoints are radiographic and prostate-specific antigen-based progression, acute and late physician-scored toxicity, patient-reported quality of life, ADT-free survival, time to progression, overall survival, locoregional control, and duration of response. Enrolment in the study commenced in September 2022.

RESULTS AND CONCLUSIONS

The addition of ¹⁷⁷ Lu-PNT2002 to metastasis-directed therapy alone may potentially further forestall disease progression. The results of this Phase 2 trial will determine, for the first time in a randomized fashion, the added benefit of ¹⁷⁷ Lu-PNT2002 to SBRT in patients with oligorecurrent mHSPC.

Review of Prospective Trials Assessing the Role of Stereotactic Body Radiation Therapy for Metastasis-directed Treatment in Oligometastatic Genitourinary Cancers

CONTEXT

Emerging evidence supports the use of stereotactic body radiation therapy (SBRT) as metastatic-directed therapy (MDT) for oligometastatic genitourinary cancers; however, the prospective data to guide its application as an alternative standard of care remain limited.

OBJECTIVE

To review prospective trials that assess the role of SBRT for patients with genitourinary cancers within a modern framework of oligometastatic disease (OMD) and to highlight clinical scenarios where SBRT may offer a benefit to patients with metastatic cancer.

EVIDENCE ACQUISITION

We performed a critical review of PubMed and clinicaltrials.gov in April 2022 according to the Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) statement, combined with expert input to identify prospective studies investigating the role of SBRT for oligometastatic prostate, renal, or bladder cancer.

EVIDENCE SYNTHESIS

The most commonly studied application of SBRT has been for metachronous oligorecurrent hormone-sensitive prostate cancer (HSPC). Further prospective study is needed to define the role of SBRT in delaying time to next therapy or inducing synergy with other systemic therapies.

CONCLUSIONS

SBRT has been associated with high rates of local control and minimal risk of toxicity with multiple trials assessing an MDT-alone approach for oligorecurrent HSPC. From a tumor-agnostic perspective, the clinical benefit of SBRT for OMD has been associated with the ability to extend overall survival. As methods of cancer detection and treatment evolve, expansion of studies that prospectively evaluate SBRT MDT, stratifying by tumor histology and oligometastatic state, is needed to inform optimal patient selection and treatment strategy.

PATIENT SUMMARY

We review outcomes from prospective trials assessing the role of stereotactic body radiation therapy (SBRT) for oligometastatic genitourinary cancers, which have predominantly investigated SBRT for oligorecurrent prostate cancer. Much work remains to define how SBRT alone compares with other standard of care treatments for prostate cancer or the role of SBRT in tumor control or delaying time to next therapy in oligometastatic renal and bladder cancer.

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.

Using PSMA imaging for prognostication in localized and advanced prostate cancer

The use of prostate-specific membrane antigen (PSMA)-directed applications in modern prostate cancer management has evolved rapidly over the past few years, helping to establish new treatment pathways and provide further insights into prostate cancer biology. However, the prognostic implications of PSMA-PET have not been studied systematically, owing to rapid clinical implementation without long follow-up periods to determine intermediate-term and long-term oncological outcomes. Currently available data suggest that traditional prognostic factors and survival outcomes are associated with high PSMA expression (both according to immunohistochemistry and PET uptake) in men with localized and biochemically recurrent disease. Treatment with curative intent (primary and/or salvage) often fails when PSMA-positive metastases are present; however, the sensitivity of PSMA-PET in detecting all metastases is poor. Low PSMA-PET uptake in recurrent disease is a favourable prognostic factor; however, it can be associated with poor prognosis in conjunction with high ¹⁸F-fluorodeoxyglucose uptake in metastatic castration-resistant prostate cancer. Clinical trials embedding PSMA-PET for guiding management with reliable oncological outcomes are needed to support ongoing clinical use.

Elective nodal radiotherapy with a gapless radiation field junction for oligorecurrent prostate cancer after previous radiotherapy

Purpose

To evaluate the feasibility of subsequent elective nodal radiotherapy (ENRT) for nodal recurrences after previous radiotherapy with a defined planning approach for a gapless radiation field junction.

Methods

Patients with 1) previous radiotherapy of prostate or prostatic fossa and subsequent pelvic ENRT or 2) previous pelvic radiotherapy and subsequent ENRT to paraaortic lymph nodes (LN) and gapless junction of both radiation fields were analyzed. The cumulative maximum dose (D_max-cum) and the maximum cumulative dose in 1 cc (D_1cc-cum) were estimated. Absolute toxicity and the toxicity exceeding baseline were evaluated.

Results

Twenty-two patients with PSMA-PET/CT-staged nodal oligorecurrence after prior radiotherapy were treated with pelvic (14 patients) or paraaortic ENRT (9 patients). One patient was treated sequentially at both locations. Median time between first and second RT was 20.2 months. Median doses to the lymphatic pathways and to PET-positive LN were 47.5 Gy and 64.8 Gy, respectively. The planning constraint of an estimated D_max-cum ≤ 95 Gy and of D_1cc-cum < 90 Gy were achieved in 23/23 cases and 22/23 cases, respectively. Median follow-up was 33.5 months. There was no additional acute or late toxicity ≥ grade 3. Worst acute toxicity exceeding baseline was grade 1 in 68.2% and grade 2 in 22.7% of patients. Worst late toxicity exceeding baseline was grade 1 in 31.8% and grade 2 in 18.2% of patients.

Conclusion

ENRT for nodal recurrences after a previous radiotherapy with gapless junction of radiation fields seems to be feasible, applying the dose constraints D_max-cum ≤ 95 Gy and D_1cc-cum < 90 Gy without grade 3 acute or late toxicities exceeding baseline.

Androgen Metabolism and Response in Prostate Cancer Anti-Androgen Therapy Resistance

All aspects of prostate cancer evolution are closely related to androgen levels and the status of the androgen receptor (AR). Almost all treatments target androgen metabolism pathways and AR, from castration-sensitive prostate cancer (CSPC) to castration-resistant prostate cancer (CRPC). Alterations in androgen metabolism and its response are one of the main reasons for prostate cancer drug resistance. In this review, we will introduce androgen metabolism, including how the androgen was synthesized, consumed, and responded to in healthy people and prostate cancer patients, and discuss how these alterations in androgen metabolism contribute to the resistance to anti-androgen therapy.

Incorporating Prostate-specific Membrane Antigen Positron Emission Tomography in Management Decisions for Men with Newly Diagnosed or Biochemically Recurrent Prostate Cancer

CONTEXT

Prostate-specific membrane antigen (PSMA) is a promising molecular target for prostate cancer (PCa) that has allowed the development of a novel diagnostic approach to PCA in the primary and recurrent settings.

OBJECTIVE

To summarize available data and recommendations regarding the use of PSMA in newly diagnosed and recurrent PCa via a narrative review.

EVIDENCE ACQUISITION

A literature review was conducted using MEDLINE (via PubMed) and Scopus. The search strategy included meta-analyses, reviews, and original studies on staging and restaging with ⁶⁸Ga-PSMA positron emission tomography (PET)/computed tomography (CT).

EVIDENCE SYNTHESIS

Studies comparing PSMA-targeted imaging and conventional imaging suggest superior performance of PSMA-targeted imaging in primary and recurrent PCa, albeit with several clinically relevant limitations. Pretreatment ⁶⁸Ga-PSMA PET/CT allowed more accurate PCa staging in compared to routine practice for high-risk cases, and identified a number of otherwise unknown metastatic lesions. In biochemically recurrent PCa, PSMA PET can reveal sites of recurrence with greater sensitivity and specificity than conventional imaging, potentially detecting a major proportion of occult disease. This review will help providers in applying the most up-to-date and relevant literature to (1) determine which patients truly have oligometastatic disease and (2) ascertain who is most likely to experience a meaningful response to local consolidation in the biochemical recurrence setting.

CONCLUSIONS

Data on PSMA diagnostic studies in primary and recurrent PCa highlight the accuracy and clinical application of PSMA PET. While this review and the evidence to date might lead to a perception of superiority in metastasis directed therapy, fundamental lack of phase III clinical trials with clinically meaningful outcomes are yet to be determined.

PATIENT SUMMARY

PSMA (prostate-specific membrane antigen) scans have shown great promise for initial evaluation of prostate cancer (PCa) and in detection of PCa recurrence. The benefits are more apparent for initial staging of PCa. There are more limited clinical trial results for PCa recurrence on how best to use this new technique to guide cancer treatment.

Recommendations for radiation therapy in oligometastatic prostate cancer: An ESTRO-ACROP Delphi consensus

BACKGROUND AND PURPOSE

Oligometastatic prostate cancer is a new and emerging treatment field with only few prospective randomized studies published so far. Despite the lack of strong level I evidence, metastasis-directed therapies (MDT) are widely used in clinical practice, mainly based on retrospective and small phase 2 studies and with a large difference across centers. Pending results of ongoing prospective randomized trials, there is a clear need for more consistent treatment indications and radiotherapy practices.

MATERIAL AND METHODS

A European Society for Radiotherapy and Oncology (ESTRO) Guidelines Committee consisting of radiation oncologists' experts in prostate cancer was asked to answer a dedicated questionnaire, including 41 questions on the main controversial issues with regard to oligometastatic prostate cancer.

RESULTS

The panel achieved consensus on patient selection and routine use of prostate-specific membrane antigen positron emission tomography (PSMA PET) imaging as preferred staging and restaging imaging. MDT strategies are recommended in the de novo oligometastatic, oligorecurrent and oligoprogressive disease setting for nodal, bone and visceral metastases. Radiation therapy doses, volumes and techniques were discussed and commented.

CONCLUSION

These recommendations have the purpose of providing standardization and consensus to optimize the radiotherapy treatment of oligometastatic prostate cancer until mature results of randomized trials are available.

Dose-escalation in prostate cancer: Results of randomized trials

In 1998, an editorial from the International Journal of Radiation Oncology - Biology - Physics (IJROBP) on the occasion of the publication of Phase I by Zelefsky et al. on 3D radiotherapy dose escalation asked the question: "will more prove better?". More than 20 years later, several prospective studies have supported the authors' conclusions, making dose escalation a new standard in prostate cancer. The data from prospective randomized studies were ultimately disappointing in that they failed to show an overall survival benefit from dose escalation. However, there is a clear and consistent benefit in biochemical recurrence-free survival, which must be weighed on an individual patient basis against the potential additional toxicity of dose escalation. Techniques and concepts have become more and more precise, such as intensity modulated irradiation, simultaneous integrated boost, hypofractionated dose-escalation, pelvic irradiation with involved node boost or focal dose-escalation on gross recurrence after prostatectomy. The objective here was to summarize the prospective data on dose escalation in prostate cancer and in particular on recent advances in the field. In 2022, can we finally say that more has proven better?

Systematic review of adjuvant external beam radiotherapy for hepatocellular carcinoma following radical hepatectomy

BACKGROUND AND AIM

Recurrence remains the main bottleneck hindering outcomes of hepatectomy for hepatocellular carcinoma (HCC). Owing to technological advances, external beam radiotherapy (EBRT) is being increasingly used in the management of HCC; however, there is no consensus on the role of adjuvant EBRT following hepatectomy.

METHODS

A systematic review was conducted according to the guidelines of the Preferred Reporting Items for Systematic Reviews and Meta-Analysis. PubMed, MedLine, Embase, the Cochrane Library, Web of Knowledge were used to screen eligible studies (published as of May 1st, 2022) that evaluated the clinical safety and efficacy of EBRT for HCC receiving hepatectomy. The endpoints were disease-free survival (DFS), overall survival (OS), and adverse events (AEs).

RESULTS

A total of ten studies were eligible (three randomized controlled trials, one phase II trial, and six retrospective comparative studies). The pooled hazard ratio (HR) for median DFS and OS were both in favor of adjuvant EBRT compared with surgery alone (all P<0.05), and the advantage of adjuvant EBRT was also confirmed in subgroups stratified by different populations (narrow margin, P<0.05; microvascular invasion, P<0.05; portal vein tumor thrombus, P<0.05) and study designs (prospective studies, P<0.05; retrospective studies, P<0.05). Adjuvant EBRT was also found to be superior to adjuvant TACE (P<0.05). Pooled rates of overall AEs and severe AEs were 65.3% and 12.2%, but no fatal AEs were reported.

CONCLUSION

Adjuvant EBRT can be considered for HCC patients, especially those with a high risk of recurrence. Further studies are required for validation of these findings.

Salvage Nodal Radiotherapy as Metastasis-Directed Therapy for Oligorecurrent Prostate Cancer Detected by Positron Emission Tomography Shows Favorable Outcome in Long-Term Follow-Up

Simple Summary

Patients, who suffer from oligorecurrent prostate cancer with limited nodal involvement, may be offered positron emission tomography (PET)-directed salvage nodal radiotherapy to delay disease progression. This current analysis aimed to access salvage radiotherapy for nodal oligorecurrent prostate cancer with simultaneous integrated boost to PET-involved lymph nodes as metastasis-directed therapy. A long-term oncological outcome was favorable after salvage nodal radiotherapy and severe toxicity rates were low. Androgen deprivation therapy plays a major role in recurrent prostate cancer management and demonstrates a positive influence on the rate of biochemical progression in patients receiving salvage nodal radiotherapy. The present long-term analysis may help clinicians identify patients who would benefit from salvage nodal radiotherapy and androgen deprivation therapy, as a multimodal treatment strategy for oligorecurrent prostate cancer.

Abstract

Background: The study aimed to access the long-term outcome of salvage nodal radiotherapy (SNRT) in oligorecurrent prostate cancer. Methods: A total of 95 consecutive patients received SNRT for pelvic and/or extrapelvic nodal recurrence after prostate-specific membrane antigen (PSMA) or choline PET from 2010 to 2021. SNRT was applied as external beam radiotherapy with simultaneous integrated boost up to a median total dose of 62.9 Gy (EQD2_1.5Gy) to the recurrent lymph node metastases. The outcome was analyzed by cumulative incidence functions with death as the competing risk. Fine–Gray regression analyses were performed to estimate the relative hazards of the outcome parameters. Genitourinary (GU)/gastrointestinal (GI) toxicity evaluation utilized Common Toxicity Criteria for Adverse Events (v5.0). The results are as follows: the median follow-up was 47.1 months. The five-year biochemical progression rate (95% CI) was 50.1% (35.7–62.9%). Concomitant androgen deprivation therapy (ADT) was adminstered in 60.0% of the patients. The five-year biochemical progression rate was 75.0% (42.0–90.9%) without ADT versus 35.3% (19.6–51.4%) with ADT (p = 0.003). The cumulative five-year late grade 3 GU toxicity rate was 2.1%. No late grade 3 GI toxicity occured. Conclusions: Metastasis-directed therapy through SNRT for PET-staged oligorecurrent prostate cancer demonstrated a favorable long-term oncologic outcome. Omittance of ADT led to an increased biochemical progression.

Radiotherapy in Oligometastatic Prostate Cancer

Prostate cancer ranges from localized, low risk to metastatic, morbid disease. While radiotherapy is commonly incorporated in the treatment of early disease or for palliation of symptomatic lesions, its role in extending survival in metastatic disease is less well-established. Here, we review the available evidence surrounding localized radiotherapy in the presence of oligometastatic disease and metastasis-directed therapy in both hormone-sensitive and hormone-resistant prostate cancer. We further outline potential future incorporation of radiotherapy as an immune-sensitizing therapy and the importance of highly sensitive imaging modalities in considering radiotherapy in metastatic disease.

Oligorecurrent nodal prostate cancer: Radiotherapy quality assurance of the randomized PEACE V-STORM phase II trial

PURPOSE

Aim of this study is to report the results of the radiotherapy quality assurance program of the PEACE V-STORM randomized phase II trial for pelvic nodal oligorecurrent prostate cancer (PCa).

MATERIAL AND METHODS

A benchmark case (BC) consisting of a postoperative case with 2 nodal recurrences was used for both stereotactic body radiotherapy (SBRT, 30 Gy/3 fx) and whole pelvic radiotherapy (WPRT, 45 Gy/25 fx + SIB boost to 65 Gy).

RESULTS

BC of 24 centers were analyzed. The overall grading for delineation variation of the 1st BC was rated as 'UV' (Unacceptable Variation) or 'AV' (Acceptable Variation) for 1 and 7 centers for SBRT (33%), and 3 and 8 centers for WPRT (46%), respectively. An inadequate upper limit of the WPRT CTV (n = 2), a missing delineation of the prostate bed (n = 1), and a missing nodal target volume (n = 1 for SBRT and WPRT) constituted the observed 'UV'. With the 2nd BC (n = 11), the overall delineation review showed 2 and 8 'AV' for SBRT and WPRT, respectively, with no 'UV'. For the plan review of the 2nd BC, all treatment plans were per protocol for WPRT. SBRT plans showed variability in dose normalization (Median D90% = 30.1 Gy, range 22.9-33.2 Gy and 30.6 Gy, range 26.8-34.2 Gy for nodes 1 and 2 respectively).

CONCLUSIONS

Up to 46% of protocol deviations were observed in delineation of WPRT for nodal oligorecurrent PCa, while dosimetric results of SBRT showed the greatest disparities between centers. Repeated BC resulted in an improved adherence to the protocol, translating in an overall acceptable contouring and planning compliance rate among participating centers.

Para-Aortic Radiation Therapy for Oligorecurrent Prostate Cancer

PURPOSE

Oligorecurrent prostate cancer limited to the pelvic lymph nodes (LNs) can be treated with whole pelvis radiotherapy. Radiotherapy may also be beneficial for oligorecurrent prostate cancer in the para-aortic (PA) LNs.

METHODS

We identified a sequential cohort of patients with oligorecurrent prostate cancer to the PA LNs (≤5) treated with elective, conventionally fractionated PA radiotherapy (PA-RT) plus simultaneous integrated boost (SIB) to LN+ disease at our institution from 2015 to 2021. The primary endpoint was progression-free survival (PFS) at 2 years using Kaplan-Meier estimation. PFS was defined as the time from PA-RT to the first event: biochemical failure (PSA 50% above post-treatment nadir and at least 4 ng/mL), escalation of therapy, radiological progression, or death. Secondary endpoints included 2-year biochemical failure-free survival (BFFS), 2-year overall survival (OS) and treatment-related toxicity.

RESULTS

Thirty-four patients were included (median age 66 years), and 82.4% were status post-prostatectomy. The median time from diagnosis to PA-RT was 5.7 years. The median PSA at PA-RT was 3.15 ng/mL (IQR 1.30-5.90). All patients were treated to the PA region with 45-50 Gy in 25 daily fractions. LN+ disease received a SIB to a median dose of 62.5 Gy (range 60-65 Gy). Most received photon-based RT, while 21.1% were treated with proton therapy. Nearly all (97.1%) patients had androgen deprivation therapy (ADT) and 52.9% abiraterone. The median follow-up time from PA-RT was 21.5 months. PFS at 2-years was 83.4% (95% CI: 68.6-100%). Two-year BFFS was 90.4% and OS 100%. There were no grade 3 or higher acute toxicities. There were 10 (29.4%) grade 2 acute toxicities. There were two (5.9%) grade 3 chronic toxicities and 4 (11.8%) chronic grade 2 toxicities.

CONCLUSION

PA-RT for oligorecurrent prostate cancer has low toxicity with very encouraging early disease control. These preliminary results require validation in prospective studies.