The index patient in the debate was a 68-year-old gentleman with a PSA of 9.2. His biopsy revealed 3 cores of Gleason 4+3=7 prostate adenocarcinoma in ~40% of the biopsy volume. He underwent a nerve-sparing radical prostatectomy with final pathology showing Gleason 4+4=8 disease with negative surgical margins. Unfortunately, the patient is noted to have a PSA of 8.2ng/mL 18 months postoperatively. He undergoes a bone scan and CT which reveal metastatic bone lesions of the iliac wing and the sacrum, which are 1.2cm and 1.4cm in size.
Francesco began the debate by noting that our definition of oligometastatic disease has changed over time, and with newer imaging modalities, we continue to become more precise at detecting low volume metastatic prostate cancer. The two main metastatic-directed treatment options include regional lymphadenectomy for nodal disease and stereotactic radiotherapy for bony lesions. He referenced studies showing that patients who undergo radiotherapy for oligometastatic disease have prolonged progression-free survival over patients on observation alone. Those patients who were treated with stereotactic radiotherapy also were noted to have an 18-month median time to starting ADT. At a median follow-up of 70 months, these patients were found to have an improved cancer-specific survival over observation alone. Furthermore, he presented data suggesting that salvage lymphadenectomy for patients with nodal disease delays biochemical recurrence and progression.
Jeanny Aragon-Ching highlighted the goals of metastates-directed therapies (MDT) which include delaying ADT, improving disease-free of PSA progression, prolonging overall survival, and providing maximal cytoreduction in those who can achieve remission. She does note that MDT is most likely to be effective in the goal of delaying ADT and the negative side effects associated with ADT. She highlighted some of the issues that she sees with the STAMPEDE and LATITUDE trials, in which many of the men did not have oligometastatic disease. She also showed data to suggest that de novo and progressive metastases behave rather differently, with de novo lesions being more aggressive. She concluded that in the CHAARTED trial, men with low-volume metastatic disease did not have an overall survival benefit with upfront ADT and docetaxel. She further argued that the combination of ADT and abiraterone can have significant toxicity in some men and that by avoiding or delaying this treatment, there can be a quality of life benefit for some men. She concluded that focal ablation of oligometastatic lesions can be considered in carefully selected, motivated patients, only after careful counseling about the potential risks and benefits of this treatment.
Debater - Pro(s):
Francesco Montorsi, MD, FRCS, Vita Salute San Raffaele University, Milan, Italy
Jeanny Aragon-Ching, MD, Inova Medical Group - Hematology Oncology, Fairfax, VA
Read the Opposing Debate: A Crossfire Debate: Controversies in Prostate Cancer (Con) – ADT + Abiraterone is Key To Prolonging Survival in Oligometastatic Prostate Cancer