The Current Role of Precision Surgery in Oligometastatic Prostate Cancer - Beyond the Abstract

Metastatic prostate cancer (PCa) comprises a spectrum of metastatic volume and locations, reflecting the multistep polyclonal nature of cancer spread, colonization, growth, and continuous interplay1. Within this, oligometastatic PCa (omPCa) has gained increasing attention, partly as a result of more accurate staging modalities such as the prostate-specific membrane antigen (PSMA)-PET. Based on its superior accuracy, the growing use of PSMA-PET resulted in a patient shift with a significant number of patients previously thought to have high-risk nonmetastatic PCa being unmasked as having omPCa.1

These findings challenge current treatment paradigms and open a window of opportunity for modern and innovative treatment approaches. However, despite a consensus recommendation to classify oligometastatic disease in general, there is no uniform definition yet of omPCa to guide decision-making.2 It is generally accepted that the number and location of metastases have an impact on oncological outcomes. Indeed, most studies on omPCa employed the Chemohormonal Therapy Versus Androgen Ablation Randomized Trial for Extensive Disease in Prostate Cancer (CHAARTED)’s definition to classify omPCa.3 According to this definition, all patients with visceral metastases and/or at least four bone lesions with at least one lesion outside of the vertebral column and/or pelvis are classified as high-volume metastatic disease, whereas all other patterns are considered as low-volume metastatic disease.3 Merely based on the timing of the presentation, omPCa may also be subdivided into de novo (metastases were detected at the time of PCa diagnosis) or recurrent/metachronous (metastases were detected after a local disease state).

In this review, we highlight the impact of modern staging technologies on disease classification and survival outcomes as well as the clinical challenges related to that. In brief, PSMA-PET is more accurate for the staging of lymph nodes compared to conventional imaging, however, existing treatment recommendations are based on studies that largely employed conventional imaging. Modern imaging can lead to a change in treatment recommendations and is of prognostic importance, as shown in the ORIOLE trial.4 Given the current challenges regarding the clinical implications of the more accurate staging and imaging-induced patient shift towards omPCa, the optimal management of these patients warrants further evaluation in well-designed prospective trials to ultimately avoid under- or overtreatment.

Moreover, we dissect the available evidence on surgical precision strikes in de novo and recurrent metastatic PCa. While the standard of care for de novo low-volume hormone-sensitive omPCa is still radiotherapy, several ongoing prospective trials assess the oncological outcomes of cytoreductive radical prostatectomy (CRP) in this setting. According to retrospective studies, CRP does not only improve survival outcomes but also reduces long-term local symptoms caused by local tumor progression. In addition, metastasis-directed surgery (and/or radiotherapy) has become increasingly central to the treatment diversification of oligorecurrent hormone-sensitive PCa. In this setting, salvage lymph node dissection (SLND) conferred a survival benefit in several retrospective studies and PSMA-radio-guided surgery may further improve outcomes. On the contrary, the resection of distant metastases in metastatic PCa is currently considered an experimental approach without high-quality data supporting it.

In this review we provide evidence for novel surgical treatment approaches in omPCa, which will become a more prevalent disease entity thanks to the PSMA-PET. We discuss novel concepts, their clinical implications and pitfalls, and address future directions in the management of omPCa.

Written by: Markus von Deimling1,2 and Shahrokh F. Shariat2-8

  1. Department of Urology, Comprehensive Cancer Center, Medical University of Vienna, Vienna, Austria
  2. Department of Urology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
  3. Hourani Center for Applied Scientific Research, Al-Ahliyya Amman University, Amman, Jordan
  4. Karl Landsteiner Institute of Urology and Andrology, Vienna, Austria
  5. Department of Urology, Weill Cornell Medical College, New York, New York, NY
  6. Department of Urology, University of Texas Southwestern, Dallas, TX
  7. Department of Urology, Second Faculty of Medicine, Charles University, Prague, Czech Republic
  8. Institute for Urology and Reproductive Health, Sechenov University, Moscow, Russia
References:

  1. von Deimling M, Rajwa P, Tilki D, et al: The current role of precision surgery in oligometastatic prostate cancer. ESMO Open 2022; 7: 1–14. Available at: https://doi.org/10.1016/j.esmoop.2022.100597.
  2. Guckenberger M, Lievens Y, Bouma AB, et al: Characterisation and classification of oligometastatic disease: a European Society for Radiotherapy and Oncology and European Organisation for Research and Treatment of Cancer consensus recommendation. Lancet Oncol. 2020; 21: e18–e28. Available at: http://dx.doi.org/10.1016/S1470-2045(19)30718-1.
  3. Kyriakopoulos CE, Chen YH, Carducci MA, et al: Chemohormonal therapy in metastatic hormone-sensitive prostate cancer: long-term survival analysis of the randomized phase III E3805 chaarted trial. J. Clin. Oncol. 2018; 36: 1080–1087.
  4. Phillips R, Shi WY, Deek M, et al: Outcomes of Observation vs Stereotactic Ablative Radiation for Oligometastatic Prostate Cancer: The ORIOLE Phase 2 Randomized Clinical Trial. JAMA Oncol. 2020; 6: 650–659.
Read the Abstract