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Kwon DH, Shakhnazaryan N, Shui D, Hong JC, Mohamad O, de Kouchkovsky I, Borno HT, Bose R, Chou J, Desai A, Fong L, Friedlander TW, Koshkin VS, Aggarwal RR, Feng FY, Hope TA, Small EJ. Serial stereotactic body radiation therapy for oligometastatic prostate cancer detected by novel PET-based radiotracers. Urol Oncol 2023; 41:145.e7-145.e15. [PMID: 36435709 DOI: 10.1016/j.urolonc.2022.10.025] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/15/2022] [Revised: 10/21/2022] [Accepted: 10/28/2022] [Indexed: 11/25/2022]
Abstract
BACKGROUND Radiopharmaceuticals, including Ga-68-prostate specific membrane antigen (PSMA)-11 and F-18-Fluciclovine, are increasingly used to inform therapies for prostate cancer (CaP). Stereotactic body radiation therapy (SBRT) to PET-detected oligometastatic CaP has been shown to improve progression free survival (PFS) and delay androgen deprivation therapy (ADT) compared to observation. For men who subsequently develop oligorecurrent CaP, outcomes following second SBRT are unknown. METHODS A retrospective cohort study was conducted. Eligibility criteria included patients with oligometastatic (1-5 lesions) CaP detected on PSMA or Fluciclovine PET who underwent 2 consecutive SBRT courses to tracer-avid sites. Data on stage, tracer type, concurrent systemic therapy, and prostate-specific antigen (PSA) responses for first SBRT (SBRT1) and second SBRT (SBRT2) were collected. Outcomes included PSA decline ≥50% (PSA50), PFS after SBRT2, and ADT initiation or intensification-free survival after SBRT2. Factors potentially associated with PSA50 after SBRT2 was evaluated with multivariable logistic regression. Factors potentially associated with PFS and ADT initiation/intensification-free survival after SBRT2 were evaluated with separate multivariable Cox proportional-hazards models. RESULTS Twenty-five patients were identified. At SBRT2, oligorecurrence was detected on PSMA and Fluciclovine PET in 17 (68%) and 8 (32%) patients, respectively. Fifteen (60%) patients had castration-sensitive disease and 10 (40%) had castration-resistant disease. After SBRT2, 16 (64%) achieved a PSA50 response, median PFS was 11.0mo, and median ADT initiation/intensification-free survival was 23.2mo. On multivariable analysis, maximum percent change in PSA after SBRT1 (OR 0.94, 95%CI 0.88-0.99, P = 0.046) and concurrent change in systemic therapy (OR 21.61, 95%CI 1.12-417.9, P = 0.042) were associated with PSA50 responses after SBRT2. PSA50 response after SBRT1 was associated with improved PFS (HR 0.36, 95%CI 0.00-0.42, P = 0.008) and ADT initiation/intensification-free survival (HR 0.07, 95%CI 0.01-0.68, P = 0.021) after SBRT2. From SBRT1 to last follow-up (median 48 months), 7 (28%) patients remained ADT-free. CONCLUSIONS Serial SBRT for oligometastatic CaP detected on PSMA or Fluciclovine PET is feasible and can achieve PSA declines, with or without systemic therapy. Degree of biochemical response to first SBRT warrants further study as a potential predictor of PSA response, PFS, and ADT initiation/intensification-free survival following a subsequent SBRT course. This preliminary evidence provides rationale for larger, prospective studies of this strategy.
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Affiliation(s)
- Daniel H Kwon
- Division of Hematology/Oncology, Department of Medicine, University of California, San Francisco, CA; Helen Diller Family Comprehensive Cancer Center, University of California, San Francisco, CA.
| | - Nonna Shakhnazaryan
- Helen Diller Family Comprehensive Cancer Center, University of California, San Francisco, CA
| | - David Shui
- Helen Diller Family Comprehensive Cancer Center, University of California, San Francisco, CA
| | - Julian C Hong
- Helen Diller Family Comprehensive Cancer Center, University of California, San Francisco, CA; Department of Radiation Oncology, University of California, San Francisco, CA; Bakar Computational Health Sciences Institute, University of California, San Francisco, CA
| | - Osama Mohamad
- Helen Diller Family Comprehensive Cancer Center, University of California, San Francisco, CA; Department of Radiation Oncology, University of California, San Francisco, CA; Department of Urology, University of California, San Francisco, CA
| | - Ivan de Kouchkovsky
- Division of Hematology/Oncology, Department of Medicine, University of California, San Francisco, CA; Helen Diller Family Comprehensive Cancer Center, University of California, San Francisco, CA
| | - Hala T Borno
- Division of Hematology/Oncology, Department of Medicine, University of California, San Francisco, CA; Helen Diller Family Comprehensive Cancer Center, University of California, San Francisco, CA
| | - Rohit Bose
- Division of Hematology/Oncology, Department of Medicine, University of California, San Francisco, CA; Helen Diller Family Comprehensive Cancer Center, University of California, San Francisco, CA
| | - Jonathan Chou
- Division of Hematology/Oncology, Department of Medicine, University of California, San Francisco, CA; Helen Diller Family Comprehensive Cancer Center, University of California, San Francisco, CA
| | - Arpita Desai
- Division of Hematology/Oncology, Department of Medicine, University of California, San Francisco, CA; Helen Diller Family Comprehensive Cancer Center, University of California, San Francisco, CA
| | - Lawrence Fong
- Division of Hematology/Oncology, Department of Medicine, University of California, San Francisco, CA; Helen Diller Family Comprehensive Cancer Center, University of California, San Francisco, CA
| | - Terence W Friedlander
- Division of Hematology/Oncology, Department of Medicine, University of California, San Francisco, CA; Helen Diller Family Comprehensive Cancer Center, University of California, San Francisco, CA
| | - Vadim S Koshkin
- Division of Hematology/Oncology, Department of Medicine, University of California, San Francisco, CA; Helen Diller Family Comprehensive Cancer Center, University of California, San Francisco, CA
| | - Rahul R Aggarwal
- Division of Hematology/Oncology, Department of Medicine, University of California, San Francisco, CA; Helen Diller Family Comprehensive Cancer Center, University of California, San Francisco, CA
| | - Felix Y Feng
- Helen Diller Family Comprehensive Cancer Center, University of California, San Francisco, CA; Department of Radiation Oncology, University of California, San Francisco, CA
| | - Thomas A Hope
- Helen Diller Family Comprehensive Cancer Center, University of California, San Francisco, CA; Department of Radiology and Biomedical Imaging, University of California, San Francisco, CA
| | - Eric J Small
- Division of Hematology/Oncology, Department of Medicine, University of California, San Francisco, CA; Helen Diller Family Comprehensive Cancer Center, University of California, San Francisco, CA
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Willmann J, Vlaskou Badra E, Adilovic S, Christ SM, Ahmadsei M, Mayinger M, Guckenberger M, Andratschke N. Stereotactic body radiotherapy to defer systemic therapy in patients with oligorecurrent disease. Clin Transl Radiat Oncol 2022; 37:12-18. [PMID: 36046333 PMCID: PMC9421088 DOI: 10.1016/j.ctro.2022.08.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/27/2022] [Revised: 08/15/2022] [Accepted: 08/16/2022] [Indexed: 11/26/2022] Open
Abstract
SBRT may be used to defer systemic therapy in patients with oligorecurrence. Low rates of systemic therapy after SBRT for all oligorecurrent lesions were observed. Patients had favorable OS and few treatment-related toxicities. New metastases were treated with repeat SBRT in 33.8% of patients. Fewer lines of systemic therapy and a low baseline tumor volume were associated with longer systemic therapy-free interval.
Background Patients who develop oligorecurrent disease may be treated with metastasis-directed stereotactic body radiotherapy (SBRT) to defer the start of systemic therapy and delay its potential side effects. We report oncological outcomes and patterns of failure in patients with oligorecurrent disease treated with SBRT and determine which factors impact the interval to initiation of systemic therapy. Material/Methods This retrospective study included patients with oligorecurrent disease (≤5 lesions) from any solid organ malignancy, treated with SBRT to all metastases and no systemic therapy for a minimum one month after SBRT between 01/2014 and 12/2019. The Kaplan-Meier method was used to analyze overall survival (OS) and progression-free survival (PFS), and the cumulative incidence of initiation of systemic therapy was analyzed assuming death without systemic therapy as a competing risk. Univariable and multivariable analyses are used to assess predictors of the systemic therapy-free interval. Results Among 545 patients treated with SBRT for oligometastatic disease, 142 patients were treated with SBRT only for oligorecurrent disease. The most common primary tumors were lung and gastrointestinal cancer in 47 (33.1 %) and 28 (19.7 %) patients, respectively. After a median follow-up of 25 months, the median PFS and OS was 6.1 months and 48.9 months, respectively. Distant metastases were the most common first failure, and oligometastatic distant failure occured in 86 patients (60.6 %). New metastases were treated with repeat SBRT in 48 patients (33.8 %). The 1- and 2-year cumulative incidence of initiation of systemic therapy was 24.6 % and 36.8 %, respectively. In multivariable analysis, the number of previous lines of systemic therapy and the cumulative volume of metastases were significantly associated with the interval to initiation of systemic therapy. Conclusion Selected patients with oligorecurrence achieved favorable OS and low cumulative incidence of initiation of systemic therapy. Prospective studies are warranted to determine how the deferral of systemic therapy impacts OS compared with immediate systemic therapy in combination with SBRT.
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Affiliation(s)
- Jonas Willmann
- Department of Radiation Oncology, University Hospital Zurich, University of Zurich, Rämistrasse 100, 8091 Zurich, Switzerland
| | - Eugenia Vlaskou Badra
- Department of Radiation Oncology, University Hospital Zurich, University of Zurich, Rämistrasse 100, 8091 Zurich, Switzerland
| | - Selma Adilovic
- Department of Radiation Oncology, University Hospital Zurich, University of Zurich, Rämistrasse 100, 8091 Zurich, Switzerland
| | - Sebastian M Christ
- Department of Radiation Oncology, University Hospital Zurich, University of Zurich, Rämistrasse 100, 8091 Zurich, Switzerland
| | - Maiwand Ahmadsei
- Department of Radiation Oncology, University Hospital Zurich, University of Zurich, Rämistrasse 100, 8091 Zurich, Switzerland
| | - Michael Mayinger
- Department of Radiation Oncology, University Hospital Zurich, University of Zurich, Rämistrasse 100, 8091 Zurich, Switzerland
| | - Matthias Guckenberger
- Department of Radiation Oncology, University Hospital Zurich, University of Zurich, Rämistrasse 100, 8091 Zurich, Switzerland
| | - Nicolaus Andratschke
- Department of Radiation Oncology, University Hospital Zurich, University of Zurich, Rämistrasse 100, 8091 Zurich, Switzerland
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Zhao X, Wang T, Ye Y, Li J, Gao X, Zhang H. Stereotactic body radiotherapy (SBRT) versus androgen deprivation therapy (ADT) for oligometastatic prostate cancer: protocol for a prospective randomised control clinical trial. BMJ Open 2022; 12:e051371. [PMID: 36180115 PMCID: PMC9528669 DOI: 10.1136/bmjopen-2021-051371] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/18/2022] Open
Abstract
INTRODUCTION The systemic therapy, especially androgen deprivation therapy (ADT), is currently recommended for patients with oligometastatic prostate cancer (PCa). However, the results have not been satisfactory including adverse reactions and castration resistance. Therefore, it is necessary to explore more effective treatment to prolong biochemical progression-free survival (bPFS) and delay the start of hormonal therapy for treating oligometastatic PCa. Stereotactic body radiotherapy (SBRT) is an emerging treatment alternative for patients with oligometastases with high local control rates and minimal toxic effects. This prospective trial aims to demonstrate whether SBRT for the oligometastases of hormone-sensitive PCa can delay the start of ADT and prolong the time from inception of the study to castration-resistant prostate cancer (CRPC). METHODS AND ANALYSIS Patients with ≤3 oligometastatic recurrences, diagnosed on Ga-68 prostate-specific membrane antigen PET/CT, will be randomised in a 1:1 ratio between arm A (ADT only) and arm B (SBRT for oligometastases only). SBRT is conducted by CyberKnife with prescription dose 30-50 Gy in 3-5 fractions. One of the primary endpoints is ADT-free survival of arm B, the other is the time from inception of the study to CRPC. The secondary endpoints include radiotherapy-related toxicity, ADT-related toxicity, bPFS, local PFS and overall survival. Toxicity will be assessed using the National Cancer Institute Common Toxicity Criteria V.5.0. ETHICS AND DISSEMINATION This protocol was approved by the institutional review board of Shanghai Changhai Hospital (CHEC2020-101). This is a randomised control clinical trial comparing SBRT to ADT for men with oligometastatic PCa. The study will be performed in compliance with applicable local legislation and in accordance with the ethical principles developed by the World Medical Association in the Declaration of Helsinki 2013. Study results will be disseminated through conferences and peer-reviewed scientific journals. TRIAL REGISTRATION NUMBER Clinicaltrials.gov identifier:NCT04599686.
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Affiliation(s)
- Xianzhi Zhao
- Department of Radiation Oncology, Changhai Hospital, Naval Medical University, Shanghai, China
| | - Tao Wang
- Department of Urology, the First Affiliated Hospital of Zhengzhou University, Zhengzhou, Henan, China
| | - Yusheng Ye
- Department of Radiation Oncology, Changhai Hospital, Naval Medical University, Shanghai, China
| | - Jing Li
- Department of Bioinformatics,Center for Translational Medicine, Naval Medical University, Shanghai, China
| | - Xu Gao
- Department of Urology, Changhai Hospital, Naval Medical University, Shanghai, China
| | - Huojun Zhang
- Department of Radiation Oncology, Changhai Hospital, Naval Medical University, Shanghai, China
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Nicholls L, Chapman E, Khoo V, Suh YE, Tunariu N, Wang Y, van As N. Metastasis-directed Therapy in Prostate Cancer: Prognostic Significance of the ESTRO/EORTC Classification in Oligometastatic Bone Disease. Clin Oncol (R Coll Radiol) 2021; 34:63-69. [PMID: 34756755 DOI: 10.1016/j.clon.2021.10.004] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/10/2021] [Revised: 09/15/2021] [Accepted: 10/11/2021] [Indexed: 12/11/2022]
Abstract
AIMS Oligometastatic disease (OMD) represents a spectrum of clinical scenarios and various classification systems have been proposed. Bone-only OMD can occur in patients with advanced prostate cancer and validated decision-making tools are needed to assist patient selection for metastasis-directed therapy. The aim of the present study was to determine the prognostic utility of a classification system for OMD. MATERIALS AND METHODS A retrospective review was conducted of all patients with bone-only oligometastatic prostate cancer treated with stereotactic body radiotherapy (SBRT) since November 2011. SBRT was delivered using CyberKnife® and gantry-based linear accelerator platforms. All patients were classified into oligometastatic states based on the European Society for Radiotherapy and Oncology/European Organisation for Research and Treatment of Cancer (ESTRO/EORTC) classification system. Kaplan-Meier and Cox regression analyses were carried out to determine the prognostic utility of this classification system. RESULTS In total, 105 patients with 145 osseous metastases were treated over 119 sessions. The median follow-up after SBRT was 23 months (interquartile range 10-39.8). Twelve patients had died after a median time of 31 months. The 3-year metastatic progression-free survival was 23% (95% confidence interval 13-32) and the 3-year overall survival was 88% (95% confidence interval 80-96). Patients in a metachronous oligometastatic state were 4.50 (95% confidence interval 1.19-17.10, P = 0.03) times more likely to experience metastatic progression compared with those with synchronous oligometastases, and 6.69 (95% confidence interval 1.05-42.50, P = 0.04) times more likely to experience any failure. Hazard ratio magnitudes increased for patients in a repeat oligometastatic state. The multivariate model for both metastatic progression-free survival and failure-free survival found prostate-specific antigen doubling time <4 months (P = 0.002; P = 0.05) to independently predict for progression. CONCLUSION The ESTRO/EORTC classification of OMD predicts for progression in patients treated with SBRT for bone-only oligometastatic prostate cancer at our institution. Further validation in prospective series over multiple tumour sites is needed. These characterisation factors should be assessed in patients considered for metastasis-directed therapy together with established prognostic features.
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Affiliation(s)
- L Nicholls
- Royal Marsden NHS Foundation Trust, London, UK; Faculty of Medicine, University of Queensland, Brisbane, Australia.
| | - E Chapman
- Royal Marsden NHS Foundation Trust, London, UK; Institute of Cancer Research, Chelsea, London, UK
| | - V Khoo
- Royal Marsden NHS Foundation Trust, London, UK; Institute of Cancer Research, Chelsea, London, UK
| | - Y-E Suh
- Royal Marsden NHS Foundation Trust, London, UK
| | - N Tunariu
- Royal Marsden NHS Foundation Trust, London, UK; Institute of Cancer Research, Chelsea, London, UK
| | - Y Wang
- Faculty of Health and Behavioural Sciences, University of Queensland, Brisbane, Australia
| | - N van As
- Royal Marsden NHS Foundation Trust, London, UK; Institute of Cancer Research, Chelsea, London, UK
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Werensteijn-Honingh AM, Wevers AFJ, Peters M, Kroon PS, Intven M, Eppinga WSC, Jürgenliemk-Schulz IM. Progression-free survival in patients with 68Ga-PSMA-PET-directed SBRT for lymph node oligometastases. Acta Oncol 2021; 60:1342-1351. [PMID: 34323648 DOI: 10.1080/0284186x.2021.1955970] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
Abstract
BACKGROUND Prostate cancer oligometastatic disease can be treated using stereotactic body radiotherapy (SBRT) in order to postpone start of systemic treatments such as androgen deprivation therapy (ADT). 68Ga-PSMA-PET/CT imaging allows for diagnosis of oligometastases at lower PSA values. We analysed a cohort of patients with prostate cancer lymph node oligometastases detected on PSMA-PET/CT. MATERIALS AND METHODS Ninety patients with metachronous oligometastatic prostate cancer received SBRT for 1-3 lymph node metastases diagnosed on 68Ga-PSMA-PET/CT. The primary end point was progression free survival (PFS), with disease progression defined as occurrence of either target lesion progression, new metastatic lesion or biochemical progression. Secondary outcomes were biochemical PFS (BPFS), ADT-free survival (ADT-FS), toxicity and quality of life (QoL). Baseline patient characteristics were tested for association with PFS and a preliminary risk score was created. RESULTS Median follow-up was 21 months (interquartile range 10-31 months). Median PFS and BPFS were 16 and 21 months, respectively. Median ADT-FS was not reached (73% (95%-CI 62-86%) at 24 months). In multivariable analysis, younger age, higher PSA prior to SBRT and extrapelvic location were associated with shorter PFS. Grade 1 fatigue was the most predominant acute toxicity (34%). Highest grade toxicity was grade 2 for acute and late events. QoL analysis showed mild, transient increase in fatigue at 1-4 weeks after SBRT. CONCLUSION A median PFS of 16 months was attained after SBRT for patients with PSMA-PET positive oligometastatic lymph nodes from prostate cancer. Higher pre-SBRT PSA, younger age and extrapelvic location were found to be predictors of shorter PFS.
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Affiliation(s)
| | - Anne F. J. Wevers
- Department of Radiotherapy, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Max Peters
- Department of Radiotherapy, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Petra S. Kroon
- Department of Radiotherapy, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Martijn Intven
- Department of Radiotherapy, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Wietse S. C. Eppinga
- Department of Radiotherapy, University Medical Center Utrecht, Utrecht, The Netherlands
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