Consensus statements on ablative radiotherapy for oligometastatic prostate cancer: A position paper of Italian Association of Radiotherapy and Clinical Oncology (AIRO)
Introduction
The ‘oligometastatic’ concept was initially proposed by Hellman and Weichselbaum in 1995 (Hellman and Weichselbaum, 1995), to identify patients with an intermediate stage of cancer disease, between localized and widespread metastatic. More recently, the same authors (Weichselbaum and Hellman, 2011) underlined the promising role of local treatments as potentially curative in strictly selected subgroups of patients with limited burden of metastatic disease. This supported the assumption that oligometastatic disease could be defined as a distinct clinical entity.
Since 2015, more than 600 papers have been published about oligometastatic cancer, and one out of five specifically focused on prostate cancer patients. In 2015, the St Gallen Advanced Prostate Cancer Consensus Conference (APCCC) (Gillessen et al., 2015) stated that ‘the presence of ≤3 synchronous metastases (bone and/or lymph nodes) is the most meaningful definition of oligometastatic prostate cancer’. However, in 2017 the APCCC (Gillessen et al., 2018) thoroughly explored the oligometastatic concept highlighting several topics of debate, including number and site of lesions, castration-sensitive or castration-resistant setting, synchronous versus metachronous metastases and imaging modality used to identify metastases.
Indeed, oligometastatic prostate cancer comprises a spectrum of numerous conditions, ranging from de novo oligometastatic cancer at diagnosis to oligometastatic castration-resistant disease, which differ widely. These distinct settings entail wide variations in terms of biology, benefit from treatments and prognosis (Francini et al., 2018; Gravis et al., 2018).
The emerging interest for oligometastatic prostate cancer, the increasing adoption of metastasis direct therapy (MDT, either surgery or ablative radiotherapy [RT]) (Ost et al., 2015), and the recent availability of prospective studies (Ost et al., 2018; Palma et al., 2012; Siva et al., 2018) even in the absence of data from randomized phase III trials encouraged the Italian Association of Radiotherapy and Clinical Oncology (AIRO) to form an expert panel to review the current literature and develop a formal consensus about the use of ablative RT in oligometastatic patients.
We herein report the results of this expert-opinion consensus from AIRO.
Section snippets
Methods
The statements formulated refer to four clinical scenarios: metastatic castration-sensitive disease at diagnosis and metastatic castration-sensitive disease after primary treatment (controlled primary), newly diagnosed metastatic castration-resistant disease (mCRPC) and, finally, mCRPC on therapy. In all cases, the sites of metastases are lymph nodes outside pelvis or bone; visceral metastasis are excluded for their poor prognosis (Gandaglia et al., 2015). The number of metastases was defined
First clinical scenario: oligometastatic prostate cancer at diagnosis
In this scenario, patients have been diagnosed with de novo oligometastatic disease and have not yet received any treatment for their prostate cancer.
The treatment of metastatic disease at diagnosis has suddenly changed in recent years: indeed, the STAMPEDE (James et al., 2016, 2017), CHAARTED (Kyriakopoulos et al., 2018) and LATITUDE (Fizazi et al., 2017) trials have recorded impressive survival benefit adding docetaxel (DOC) or abiraterone acetate + prednisone (AAP) to standard androgen
Discussion
In the absence of high-quality, level I evidence, two possibilities are available to meet clinical needs: phase III randomized trials or expert opinions. Randomized trials are the best way to evaluate the impact, and its magnitude, of a treatment or diagnostic intervention. However, this approach is not always feasible, especially in a widely heterogeneous population, such as oligometastatic prostate cancer patients.
Besides, if conflicting data, or their controversial interpretation, are
Funding
The preparation of the present article was supported by an unconditioned contribution from Janssen-Cilag SpA. The funding source had no role in study design, collection, analysis and interpretation of data, in writing of the report or in the decision to submit the article for publication.
Conflict of interest statement
Authors declared no conflict of interest.
Acknowledgement
Editorial assistance was provided by EDRA SpA (Milan, Italy)
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