Management of Node-Positive and Oligometastatic Prostate Cancer

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Historically, stage IV prostate cancer was considered incurable. Although node-positive and oligometastatic prostate cancers are both classified as stage IV, these likely represent distinct clinical groups, and some patients may be curable with aggressive multimodality treatments. There is a lack of randomized evidence, but retrospective studies suggest that radical prostatectomy or radiotherapy may improve survival in these patients. This is an area of great current research interest and prospective randomized trials are needed to help define the optimal treatments for these patients.

Introduction

Prostate cancer is the most common nonskin cancer and the second leading cause of cancer death among American men.1 Of the 180,000 new prostate cancer cases diagnosed each year in the United States, 80% of patients have localized disease, 12% have regional disease, and 4% have distant metastatic spread.2 Patients with nodal or distant metastatic prostate cancer are classified as “Stage IV.” Historically, metastatic prostate cancer was thought to be incurable and treatment mainly consisted of palliative efforts. This paradigm is shifting, however, and there are active research efforts to examine whether aggressive treatments can cure a proportion of patients with limited stage IV disease. The goal of this article is to review the currently available evidence on the treatment and outcomes of patients with node-positive and oligometastatic prostate cancers.

Section snippets

ADT Alone

Androgen deprivation therapy (ADT) alone does not seem to be effective as a primary treatment for node-positive prostate cancer. The European Organisation for the Research and Treatment of Cancer (EORTC) 30846 trial randomized 234 treatment-naïve patients with node-positive disease to receive immediate ADT (administered at initial diagnosis) vs delayed ADT (administered following clinical progression) (Table 1).3, 4 The ADT consisted of surgical castration or luteinizing hormone-releasing

Rationale for Aggressive Treatment

Traditionally, metastatic cancer has been considered to be an incurable disease. This perception is shifting because of growing evidence of an intermediate “oligometastatic” state which portends favorable survival outcomes compared with widespread metastatic disease. Oligometastatic cancer refers to a state where metastases are limited both in number and organ site.24 Though there is no consensus regarding the number of metastases needed to constitute oligometastatic disease, most studies use

Conclusion

Although node-positive disease represents 12% of new prostate cancer diagnoses, there is little randomized evidence to guide the optimal treatment selection for these patients.2 Retrospective studies which suggest that curative-intent treatment may improve survival in node-positive prostate cancer patients compared with conservative management, and a hypothesis that some patients with oligometastatic disease may benefit from aggressive treatment to the prostate and metastatic sites, have

References (50)

  • E.M. Messing et al.

    Immediate versus deferred androgen deprivation treatment in patients with node-positive prostate cancer after radical prostatectomy and pelvic lymphadenectomy

    Lancet Oncol

    (2006)
  • A. Briganti et al.

    Combination of adjuvant hormonal and radiation therapy significantly prolongs survival of patients with pT2–4pN+ prostate cancer: Results of a matched analysis

    Eur Urol

    (2011)
  • K. Fizazi et al.

    Androgen deprivation therapy plus docetaxel and estramustine versus androgen deprivation therapy alone for high-risk localised prostate cancer (GETUG 12): A phase 3 randomised controlled trial

    Lancet Oncol

    (2015)
  • D. Singh et al.

    Is there a favorable subset of patients with prostate cancer who develop oligometastases?

    (2004)
  • A.C. Tree et al.

    Stereotactic body radiotherapy for oligometastases

    Lancet Oncol

    (2013)
  • S.H. Culp et al.

    Might men diagnosed with metastatic prostate cancer benefit from definitive treatment of the primary tumor? A SEER-based study

    Eur Urol

    (2014)
  • N. Fossati et al.

    Identifying optimal candidates for local treatment of the primary tumor among patients diagnosed with metastatic prostate cancer: A SEER-based study

    Eur Urol

    (2015)
  • C. Gratzke et al.

    Role of radical prostatectomy in metastatic prostate cancer: Data from the Munich Cancer Registry

    Eur Urol

    (2014)
  • M.T. Milano et al.

    Oligometastases treated with stereotactic body radiotherapy: Long-term follow-up of prospective study

    Int J Radiat Oncol Biol Phys

    (2012)
  • A. Muacevic et al.

    Safety and feasibility of image-guided robotic radiosurgery for patients with limited bone metastases of prostate cancer

    Urol Oncol

    (2013)
  • P. Berkovic et al.

    Salvage stereotactic body radiotherapy for patients with limited prostate cancer metastases: Deferring androgen deprivation therapy

    Clin GU Can

    (2013)
  • R.L. Siegel et al.

    Cancer statistics, 2015

    CA Cancer J Clin

    (2015)
  • Fast Stats: An Interactive Tool for Access to SEER Cancer Statistics. Available at: www.seer.cancer.gov/faststats....
  • C.C. Lin et al.

    Androgen deprivation with or without radiation therapy for clinically node-positive prostate cancer

    J Natl Cancer Inst

    (2015)
  • N.D. James et al.

    Failure-free survival and radiotherapy in patients with newly diagnosed nonmetastatic prostate cancer: Data from patients in the control arm of the STAMPEDE trial

    JAMA Oncol

    (2016)

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    Conflict of Interest: Dr. Chen served as a paid consulatnt for Astellas/Medivation, and received a research grant from Accuray, Inc. Mr. Broughman has no conflict of interest to disclose.

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