Cytoreductive Radical Prostatectomy cRP in men with hormone-naive, metastatic prostate cancer (mPCA) | EAU 2017:

London, England (UroToday.com) The surgical management of oligometastatic prostate cancer is a hot topic within prostate cancer management. The authors, based on recent reports of cancer-specific outcome benefit from radiation or surgery to the prostate primary, evaluated the role of cytoreductive radical prostatectomy (cRP) in the largest contemporary cohort of mPCa patients treated with cRP. 

A total of 114 patients from 4 tertiary referral centres in the US and Europe underwent cRP for oligometastatic mPCa, with low and high volume defined as such by the CHAARTED criteria. Specific outcomes assessed were overall survival, relapse-free survival, and functional outcomes (continence). Majority of the cases were open RP (92%). LND extent was at the discretion of the surgeon, though 89.4% were reported to have ePLND. Of note, however, 70% underwent neoadjuvant ADT therapy with LHRH analogues; 86.8% went on to receive adjuvant therapy. Of the cohort, 81.6% had low-volume oligometastatic disease.

As can be expected, pN+ disease and positive surgical margin rates were high – 61.6 and 36.8%, respectively. With a mean and median follow-up of 39.7 (7-75) and 40 (28-96) months, respectively, 110 (96.5%) are alive and 66.7% are relapse-free. In terms of safety, while the majority did not experience any surgery related complications, 15 (13.1%) experienced Grade IIIb/IV complications and underwent surgical reintervention. Amongst other factors, pre-operative / pre-ADT PSA < 8 and post-ADT PSA nadir < 1 predicted longer PSA-free recurrence, and may help select patients for treatment.

Continence, a small portion of this paper in terms of functional outcome assessment, was noted to be inferior to traditional RP for curative intent. Up to 14% had severe incontinence following the surgery.

Overall, this was one of 3 abstracts on this topic, though by far the most robust. Of the other two, one looked at the feasibility of robotic surgery in this setting while the other looked at perioperative outcomes. Both suggested technical feasibility and perioperative outcomes similar to RP.

Limitations / Discussion / Future Directions:

1. Ongoing prospective clinical trial in Germany and US will help solidify mamagement in this disease state.
2. Key going forward will be how to best identify the best responders!
3. Is there a role for PSMA PE

- Authors note that PSMA PET likely to pick up microscopic disease

- As all prior studies for oligometastatic diagnosis and treatment have been done with traditional CT scan and bone scan, these should be the standards for initial assessment.

Presented by: Axel Heidenreich

Co-Authors: Briganti A., Karnes J., Fossati N., Gandaglia G., Montorsi F., Suardi N., Colicchia M., Shariat S., Pfister D.