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The 2026 European Association of Urology (EAU) Annual Meeting
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| Optimal Management of De-Novo Oligometastatic Disease: Can't Say We Always Need PSMA PET/CT Imaging in This Setting!
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| Renu Eapen, MBBS, FRACS
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| Renu Eapen argued that in de‑novo oligometastatic prostate cancer, highly sensitive staging with PSMA PET/CT is critical because the very definition of “oligometastatic” depends on how well we can see all disease sites. Drawing on data such as the proPSMA trial—which showed markedly higher accuracy, sensitivity, and specificity for PSMA PET/CT versus conventional CT/bone scan—Dr. Eapen contended that advanced imaging more reliably distinguishes polymetastatic, truly oligometastatic, and actually localized patients, allowing better selection for systemic therapy, metastasis‑directed treatment, or definitive local surgery/radiation.
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| Optimal Management of De-Novo Oligometastatic Disease: Surgery Is Still an Option in 2026
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| Markus Graefen, MD
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| Data from RAMPP and other studies indicate that radical prostatectomy is a safe option for carefully selected men with de‑novo oligometastatic hormone‑sensitive prostate cancer, especially younger patients with low metastatic burden and resectable primary tumors. Although radiotherapy has stronger evidence, surgery can be part of an “all‑in” strategy with systemic and metastasis‑directed therapies to reduce local events and may modestly improve cancer‑specific outcomes.
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| Optimal Management of De-Novo Oligometastatic Disease: Radiotherapy – Treat All You Can See
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| Amar Kishan, MD
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| Radiotherapy to the primary tumor in de‑novo oligometastatic or even high‑volume mHSPC has level 1 evidence from PEACE‑1 for improving castration‑resistance–free survival and delaying serious GU events. In carefully selected young, fit patients, adding metastasis‑directed radiotherapy to all visible sites on top of standard systemic therapy is a reasonable, increasingly studied strategy to maximize disease control and potentially allow future de‑escalation.
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| Optimal Management of De-Novo Oligometastatic Disease: Intensified Systemic Therapy Is Still Mandatory
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| Jozefina Casuscelli, MD, FEBU
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| Intensified systemic therapy remains the cornerstone for de‑novo oligometastatic mHSPC. Dr. Casuscelli argued that what looks “oligometastatic” on conventional imaging is still biologically systemic disease, so patients should receive immediate ADT plus an androgen‑receptor pathway inhibitor, ideally guided by PSMA PET and germline/somatic testing and, when possible, enrollment on dedicated oligometastatic trials.
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| The Road to Cure: Does Intensification Matter?
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| Bertrand Tombal, MD, PhD
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| Dr. Tombal reviewed data showing that intensifying systemic therapy clearly improves survival for patients with low-volume metastatic or high‑risk biochemically recurrent prostate cancer, particularly when ADT is combined with a modern AR pathway inhibitor. He emphasized tailoring intensification by disease setting and risk—using continuous ADT+ARPI in metachronous low‑burden mHSPC, reserving systemic treatment for high‑risk biochemical recurrence, and favoring intermittent approaches in good PSA responders—while recognizing that many low‑risk BCR patients gain little from early systemic therapy.
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| Who Can Really Benefit from Metastasis Directed Therapies?
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| Barbara Jereczek-Fossa, MD, PhD
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| Metastasis-directed therapy offers clear benefits in carefully selected men with oligorecurrent, hormone-sensitive prostate cancer—particularly those with ≤3–5 PSMA-detected lesions, slow PSA kinetics, and no visceral disease—by improving progression-free and castration-resistance–free survival in pooled phase II data while delaying systemic therapy.
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| Optimal Management of Oligorecurrent Disease: Take Them Out! Radioguided Surgery
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| Henk G. van der Poel, MD
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| Radioguided, PSMA‑guided salvage lymph node dissection is a viable option for well‑selected men with oligorecurrent node‑only prostate cancer after prostatectomy, achieving about 50–60% 5‑year treatment‑free survival when PSA falls below 0.1 ng/mL and with generally manageable toxicity. This approach can postpone long‑term ADT, outperforms template dissections, and preserves radiotherapy and systemic therapy as future options if needed.
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| Optimal Management of Oligorecurrent Disease: Irradiate Them!
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| Giulia Marvaso, MD
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| Giulia Marvaso argued that, in carefully selected patients with a small number of PSMA‑positive lesions, irradiating all visible metastases—often combined with short-course ADT—can delay long-term systemic therapy and support future de‑escalation strategies, even as phase III radiotherapy trials and optimal integration with intensified systemic therapy remain open questions.
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| Optimal Management of Oligorecurrent Disease: Too Late! Systemic Treatment
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| Ursula Vogl, MD
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| For oligorecurrent, high‑risk prostate cancer like this case, Dr. Vogl argued that systemic therapy is essential, not optional. She recommended treating these patients along EMBARK or STAMPEDE lines—initiating intensified systemic therapy with ADT plus an androgen‑receptor pathway inhibitor, potentially in an intermittent fashion, and then individualizing nodal radiotherapy in a multidisciplinary discussion.
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| Optimal Management of Oligorecurrent Disease: Is There a Role for Lutetium PSMA?
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| Wolfgang Fendler, MD
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| Lutetium-PSMA radioligand therapy for oligorecurrent hormone‑sensitive prostate cancer clearly improves progression‑free outcomes and delays castration in high‑risk, fast‑progressing patients, but it is still considered investigational and not ready for routine use in nodal oligo‑recurrence outside trials. Current data from phase II trials like LUNAR and BULLSEYE show that adding Lu‑PSMA to SBRT or using it alone can markedly prolong progression‑free survival and postpone ADT with good tolerability.
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