12 De novo (synchronous) oligometastatic disease represents patients found to have metastatic disease at the time of initial diagnosis. Oligorecurrent (metachronous) disease are patients initially treated with denitive therapy to cure their malignancy who subsequently develop limited metastatic disease recurrence. The use of close PSA monitoring after primary treatment together with active incorporation of more sensitive and specic molecular imaging modalities such as PSMA-PET for local and systemic staging, has emerged as a crucial approach for early detection of oligorecurrence. Finally, oligoprogressive disease represents patients with known metastatic disease who exhibit few isolated areas of progression in a background of otherwise stable disease. This oligometastatic state may be an apparent turning point between stillcontrollable regional disease that might be managed with local intervention, and diffuse disease for which systemic therapies are the mainstay. Oligorecurrent prostate cancer is now the preferred term for designating such relapses after primary curative-intent 2 treatments. Metastasis-directed therapy for oligometastatic disease Although promising, additional data from prospective studies are required to determine the role of metastasis-directed therapy (MDT) for males with oligometastatic disease, especially how it should be integrated with androgen deprivation therapy (ADT) and novel agents like androgen receptor pathway inhibitors. Decisions regarding treatment must be individualized, taking into account a wide range of factors (eg, site of metastasis, disease-free interval, patient age, PSA kinetics, patient comorbidities etc). After prior denitive therapy, patients will occasionally present with metachronous oligometastatic disease, which most of the time is diagnosed using positron emission tomography (PET CT) with more sensitive prostate-specic radiotracers. The following data are available regarding the benet of metastasis-directed therapy for males with oligometastatic prostate cancer: • In an early phase II trial (STOMP), 62 asymptomatic patients with a biochemical recurrence after primary denitive treatment, one to three metastases on conventional (not PET-based) imaging, and a serum testosterone >50 ng/mL were randomly assigned to observation alone or to metastasis-directed therapy . In the latest analysis, presented at the 2020 American Society of Clinical Oncology (ASCO) Genitourinary Cancers Symposium, the time to initiation of ADT based on progression of symptoms, progression to more than three metastases, or progression of known lesions was signicantly longer in patients who received initial metastasis-directed therapy (ve-year ADT-free survival 34 versus 8 percent, HR 0.57, 95% CI 0.380.84), although ve-year overall survival was 8 similarly high in both groups (85 percent) Systemic Therapy Oligometastasis Oligorecurrence MDT to all disease MDT to recurrent disease MDT to progressive disease MDT to symptomatic disease Oligiprogression Widely Matastatic Disease PET CT imaging shows right sacroiliac bone metastasis corresponding to the small focus of increased radiotracer uptake. (B) Metastasis-directed stereotactic body radiotherapy was administered at 40 Gy in 5 fractions; isodoses of 95%, 90%, 50%, and 30% (yellow, green, light blue, and violet lines, respectively) indicate the small irradiated volume (isodose of 95%) and the rapid fall of dose outside the target (isodose of 30%). (C) PET CT imaging showing no radiotracer uptake to the right sacroiliac bone metastasis after irradiation UROLOGY, URO-ONCOLOGY AND SEXOLOGY UPDATE
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