GU Cancers 2019 | The role of the Urologist in oligometastatic PC management

Oligometastatic prostate cancer is something that we have been seeing more and more often in our offices. These are patients who come in with not only prostate cancer but with a limited dissemination at a certain distance from the gland. That is the definition of oligometastatic, which means that typically no more than 5 metastases are seen around. Historically, these patients were considered treatable only by hormonal therapy, which is a form of palliation. Today, things are different, and we believe that there is a way to be curative with these patients, which means dealing with the disease in the prostate and also around the prostate.

Essentially, we presented a real case that came to us in 2015, where we found initially high-grade prostate cancer with metastases at pelvic lymph nodes. The final plan that was discussed with the patient and approved by the patient was to do radical surgery that was done robotically. So the prostate and lymph nodes were removed, and as it always, it almost always happens, we found a pathology that was worse than what the biopsies were suggesting, so confirming high-risk disease, Gleason 8, and it was confirmed also the presence of metastases in the pelvic lymph nodes.

Typically, these patients would be seen three months following the procedure with a second PSA to see what is the, that special outcome. In this patient, the PSA was completely zero. So there was yesterday a lot of discussion about what to do. Options are just to look at the patient and wait, while on the contrary one could use some form of adjuvant therapy, where radiation is the classic approach that would be used more frequently. This is what we actually did in this patient.

The role of radiation therapy was discussed yesterday, and it was very clear that it should be given in these patients who are starting with a very bad pathology. The issue of concomitant hormonal therapy was also discussed. There have been a quite number of publications over the last 12 months on this topic, and we did a couple also ourselves, suggesting that if the final pathology is bad and radiation therapy is considered, adjuvant therapy also with hormones should be given. So the combination of hormonal and the radiation therapy is giving better results.

So this is what the patient received, and then, unfortunately, after a couple of years he developed further metastases, which is something quite typical in these patients. There were further lymph nodes in another area and one tiny bone lesion. So, the concept on how to approach these further distant lesion was discussed during the symposium, and in that specific case, we showed that we did another surgery, which is called salvage lymphadenectomy. So you go back in and remove these further lymph nodes that becomes apparent, and then the bone metastases was treated with stereotactic radiation therapy, which is a new form using a technology called CyberKnife, which is very efficient with low morbidity. After this treatment, the patient showed a PSA that went back to zero.

The case was used as to create the clinical scenario of something that is seen in our everyday practice showing essentially that multimodal treatment is the way to go for these patients, and that surgeons should be working together with the radiation oncologist and medical oncologist to get best that we can obtain from the available treatments.