Treatment Options in Oligometastatic Disease in Prostate Cancer: Thinking Outside the Box
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Genitourinary Cancers (S Gupta, Section Editor)
Treatment Options in Oligometastatic Disease in Prostate Cancer: Thinking Outside the Box Christopher W Fleming, MD* James R Broughman, MD Rahul D Tendulkar, MD Address * Department of Radiation Oncology, Cleveland Clinic Foundation, Taussig Cancer Institute, 9500 Euclid Avenue/CA-50, Cleveland, OH, 44195, USA Email: [email protected]
* Springer Science+Business Media, LLC, part of Springer Nature 2020
This article is part of the Topical Collection on Genitourinary Cancers Keywords Oligometastatic I Metastatic I Prostate cancer I Metastasis-directed therapy I MDT I SBRT I Review
Opinion statement Due to its relatively indolent disease course, the sensitivity of PSA testing, and the emergence of novel PET imaging, metastatic prostate cancer is particularly likely to present with a limited volume of disease. Patients with up to five metastatic lesions should be considered for an oligometastatic treatment approach. Systemic therapy remains the cornerstone of treatment for these patients. The optimal type and duration are unknown; however, the addition of a second agent to ADT appears to be beneficial. Multiple recent studies have found significant benefits to the integration of systemic therapy and local metastasis-directed therapies (MDT), including radiation and surgery, to the prostate and metastatic sites. MDT may also be used in select patients wishing to delay the initiation of systemic therapy. For patients with isolated regional nodal recurrences, whole pelvic radiotherapy or extensive lymphadenectomy is preferred, in combination with ADT.
Introduction Treatment paradigms for oligometastatic disease are rapidly evolving. Historically, a limited number of
metastases was known to portend a relatively favorable prognosis, but was still considered a marker of incurable
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disease. More than two decades ago, Hellman and Weichselbaum proposed the idea that those patients with limited volume of metastatic cancer may instead lie on a spectrum between locally confined and widely metastatic, allowing for the possibility of cure with the integration of local metastasis-directed therapies (MDT) [1]. Interest has increased rapidly over recent years after the publication of multiple phase II trials finding benefit to overall survival (OS) with the addition of MDT, most commonly stereotactic body radiotherapy (SBRT) [2•, 3•, 4]. Prostate cancer is the most common non-cutaneous malignancy in men, with approximately 190,000 new diagnoses per year in the USA [5]. Of those, nearly 20% have metastatic disease at the time of diagnosis [6]. Contributing to the number of new diagnoses per year is the abundant use of prostate-specific antigen (PSA) screening, increasing the likelihood of diagnosis earlier in the disease course. Relative to other cancers, prostate cancer is comparatively indolent, evidenced by an
(2021) 22:2
accepted active surveillance paradigm for appropriately selected patients with early stage disease [7]. Despite
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