Topic: Oligometastatic Prostate Cancer

Future Directions (FD) in Molecular Targeted Imaging (MTI) and Theranostics Discussion

Future Directions (FD) in Molecular Targeted Imaging (MTI) and Theranostics Discussion

by | Jan 2025

Robert E. Reiter, MD, MBA, highlights advances in molecular targeting and imaging in prostate cancer, with a focus on PSMA PET imaging. PSMA PET is expanding its role, particularly in identifying primary or secondary tumors when MRI results are negative or ambiguous. This application, under investigation in the Primary Two study, could reduce unnecessary biopsies and improve tumor detection.

In this 7-minute presentation, Dr. Reiter reviews PSMA-guided surgical resection using fluorescence or radioguidance to enhance precision. He asserts that this approach could reduce positive margins, optimize node removal, and support nerve-sparing techniques when appropriate, improving functional outcomes.

Reiter also discusses PSMA PET in oligometastatic disease, specifically the optimal treatment approach when few metastases are present. In addition, PSMA imaging is being explored in focal and radiation therapies, where it could provide a more accurate assessment of recurrence and treatment response; in advanced prostate cancer, PET could help identify resistant lesions for targeted radiotherapy.

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Oligometastatic Prostate Cancer

Oligometastatic Prostate Cancer

by | Dec 2024

Daniel Song, MD, explores the evolving role of metastasis-directed therapy (MDT) and androgen deprivation therapy (ADT) in oligometastatic prostate cancer. Initial studies, including SABR-COMET and STOMP, demonstrate that MDT, through approaches like stereotactic body radiotherapy (SBRT) or surgery, improves progression-free and ADT-free survival compared to observation alone. Recent trials also evaluate the combination of MDT and short-term ADT, such as the EXTEND trial, which shows significantly prolonged progression-free survival.

The 9-minute presentation highlights how advanced imaging, particularly PSMA PET scans, outperforms conventional imaging in detecting and targeting metastases, enhancing MDT’s efficacy. Comparisons of PSMA-guided versus choline-guided SBRT reveal superior outcomes in disease-free survival. Furthermore, ongoing research seeks to clarify whether systemic hormone therapy is necessary alongside MDT, with trials like DART exploring novel ADT strategies.

Dr. Song asserts that MDT improves survival metrics in oligometastatic prostate cancer, particularly when informed by advanced imaging. Combining MDT with prostate radiation or systemic ADT offers additional survival benefits.

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The Role of Radiotherapy in Oligometastatic Prostate Cancer and How to Treat the Primary in De Novo Oligometastatic Disease

The Role of Radiotherapy in Oligometastatic Prostate Cancer and How to Treat the Primary in De Novo Oligometastatic Disease

by | Dec 2023

Daniel A. Hamstra, MD, PhD, FASTRO, FASCO, discusses the use of radiotherapy in oligometastatic prostate cancer treatment and how to approach treating the primary in de novo oligometastatic disease. In this presentation, Dr. Hamstra covers:

The history and definition of oligometastatic disease.
The history of radiation therapy in localized and metastatic prostate cancer.
Results from the STAMPEDE, PEACE-1, and STOMP and ORIOLE trials.
The Pros and Cons of including radiation therapy in systemic therapy.
Progression to Survival and Overall Survival rates in radiation therapy patients.

Dr. Hamstra concludes by highlighting the need for more data on low-volume versus high-volume patients, and he recommends enrolling eligible patients in the ongoing SWOG S1802 trial.

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Treatment of Oligometastatic Disease

Treatment of Oligometastatic Disease

by | Oct 2023

Juanita M. Crook, MD, FRCPC defines the clinical criteria for oligometastatic prostate cancer, highlighting the significance of accurate staging and advanced imaging techniques in identifying patients who may benefit from targeted treatments. She emphasizes new evidence suggesting that aggressive local and systemic therapies can achieve prolonged disease control and possibly cure in select patients.
Dr. Crook presents various treatment modalities, including stereotactic body radiotherapy (SBRT), surgery, and systemic therapies such as androgen deprivation therapy (ADT) and novel hormonal agents. She presents data from recent clinical trials demonstrating the efficacy of SBRT in controlling metastatic lesions. Additionally, she explores the role of metastasis-directed therapy (MDT) in delaying the initiation of systemic treatments and reducing treatment-related side effects.

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PSA Screening in 2023

PSA Screening in 2023

by | Jun 2023

Gerald L. Andriole, Jr., reviews evidence supporting a more comprehensive family history and biomarkers in screening and treating prostate cancer. Andriole underscores the power of a well-taken family history. He suggests doctors counsel patients on their hereditary risk of prostate cancer, emphasizing the importance of one diagnosed high risk family member, to reduce the rate of mortality.

Describing the Germline Mutations in Metastatic PCa, Andriole recommends all patients with prostate cancer who have certain characteristics be encouraged to speak to their physicians about whether they may need genetic testing for an inherited mutation. When looking in detail at polygenic risk scores (GRS,) knowledge of high GRS decreased mortality rate.

Andriole highlights the Prompt Test, the direct to consumer, poly-genomic test in the US. In comparison, the UK Biobank data compares prevalence and hazard ratio to show the frequency is higher, some predict cancer aggressiveness. He expects to hear a lot about the prompt test in future.

Dr. Andriole recommends identifying patients with clinically significant PCa earlier through a lower PSA cutpoint. He suggests using image guided Micro US or MRI, or a transperineal biopsy to show potentially indicative biomarkers.

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PSMA: Current State of the Art and Future Vision

by | Feb 2022

Phillip J. Koo, MD, Division Chief of Diagnostic Imaging and Northwest Region Oncology Physician Executive at the Banner MD Anderson Cancer Center in Phoenix, Arizona, discusses current and possible future applications for prostate-specific membrane antigen (PSMA) as both a diagnostic and a theranostic radiopharmaceutical for prostate cancer. He begins by considering PSMA in the diagnostic setting and explains that its current state-of-the art use is in the area of detection of metastatic disease. Dr. Koo particularly highlights its role in detecting oligometastatic disease in cases of biochemical recurrence. He also notes that PSMA currently has a role in initial staging, and that this role is likely to expand in the future. He predicts that other future diagnostic applications of PSMA will include restaging/treatment response, primary lesion characterization, and potentially prognosis. Dr. Koo then moves to discussing PSMA in the theranostic setting, mentioning the current role of Lu-177 PSMA on the “thera-” side and looking at PSMA, FDG, and PSMA plus FDG on the “-nostic” patient selection side. He also considers the question of whether imaging is even needed considering the large percentage of patients who are PSMA-positive, though he argues for the benefits of imaging. Dr. Koo lists some potential future therapeutic applications of PSMA, such as in earlier treatment, retreatment, combination therapy, dosimetry, and with alpha particles. He concludes that there are many unanswered questions, that conventional wisdom and anecdotes are not evidence-based, and that there is a need for more clinical trials and more disease site specialization within nuclear medicine.

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