EAU 2020: Metastases-directed Therapy with Surgery

(UroToday.com) As part of a plenary presentation at the European Association of Urology (EAU) Virtual 2020 meeting assessing “Modern prostate cancer imaging in daily practice,” Tobias Maurer, MD, followed Annika Herlemann, MD's presentation by suggesting we start with metastasis directed therapy with surgery for patients with biochemical recurrence following initial local therapy.

In support of his thesis for surgical metastasis-directed therapy, he relied on two case examples.

First, a gentleman who underwent radical prostatectomy (RP) in 2019 for pT3a pN1 R0 Gleason score 4+3 prostate cancer with a prostate-specific antigen (PSA) at the time of diagnosis of 5.6 ng/mL. Post-operatively, this gentleman had a persistent and then subsequently rising PSA, up to 10.4 ng/mL. Prostate membrane antigen (PSMA) Positron Emission Tomography - Computed Tomography (PET/CT) identified a solitary large lymph node metastasis.

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A salvage lymph node dissection performed less than 6 months following initial surgery. Pathologic examination revealed a solitary metastasis (1 of 26 submitted lymph nodes) and PSA fell to <0.02 ng/mL 4 weeks following surgery.

Second, a gentleman underwent RP in 2016 for pT3a pN0 R0 Gleason score 4+5 prostate cancer with a PSA at the time of diagnosis of 8.9ng/mL. After a period with undetectable PSA, he experienced biochemical recurrence and PSA rose to 0.21 ng/mL. Again, PSMA PET/CT confirmed a solitary nodal metastasis for which he underwent surgery nearly 3 years following his initial operation.

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Again, histological analysis demonstrated nodal disease, this time involving 2 of 18 lymph nodes and PSA nadired at undetectable levels 4 weeks after surgery. A year later, he has had a subsequent biochemical recurrence and PSA is now 0.18 ng/mL highlighting that the durability of this approach is limited due to micrometastatic disease.

In Dr. Maurer’s approach, the goal of metastases-directed therapy (MDT) is to primarily prevent local complications and delay systemic therapy acknowledging that permanent cure may only be possible in a subset.

Presented by: Tobias Maurer, MD, University of Hamburg-Eppendorf, Martini-Klinik Prostate Cancer Center, Germany

Written by: Christopher J.D. Wallis, Urologic Oncology Fellow, Vanderbilt University Medical Center, Nashville, TN, Twitter: @WallisCJD, at the 35th Annual EAU Congress, 2020 Virtual Program #EAU20, July 17-19, 2020.