14 Genetic and genomic classication, DNA biomarkers and circulating tumor DNA may add to the management pathway of oligometastatic prostate carcinoma. A sub-analysis was conducted on pooled data from STOMP and ORIOLE trials to assess the effectiveness of a high-risk mutational signature in stratifying outcomes after MDT, which was dened as the presence of pathogenic somatic mutations within ATM, BRCA1/2, Rb1, and TP53. Long-term results showed that metastasis directed therapy (MDT) benetted both patients with and without a high-risk mutation, although those individuals without a high-risk mutation treated with MDT had superior outcomes (median PFS 13.4 11 months versus 7.5 months. These ndings suggest that selected patients with oligometastatic or oligorecurrent disease lacking a high-risk mutation could potentially de-escalate treatment using MDT alone. Conversely, patients with high-risk mutations should be contemplated for an intensied targeted approach. Currently, several phase II and phase III studies recruit patients with recurrent OMPC to assess combinations of MDT and systemic therapy options, 12 such as ADT plus abiraterone + apalutamide. POSTCARD will determine the effect of durvalumab 13 in addition to MDT and Stereotactic Body Radiotherapy with or without darolutamide for OligoRecurrent Prostate Cancer (DART), which will 14 study the combination of darolutamide with SBRT. A phase III trial will test the role of apalutamide alone or in combination with MDT in patients with recurrent 15 hormone sensitive prostate cancer. Common SBRT recommended fractionations used are 35 Gy in 5 fractions for spinal lesions and 30 Gy in 3 fractions for extra spinal bone metastases. For the treatment of nodal disease, elective nodal irradiation (45 Gy in 25 fractions ) with a boost to suspicious lymph nodes ( 2.2-2.7Gy per fraction) or SBRT doses of 35 Gy in 5 fractions are 16-17 recommended. Study STOMP ORIOLE SABECOMET N 62 54 16 Nodal Recurrence Number of mets Treatment arms Type of treatment Type of imaging Media follow-up Results 55% <3 extracranial Observation vs. metastasesdirected therapies SBRT (n=25) sLND (n=6) Choline PET/CT 5.3 years Improved ADT-free survival (HR: 0.53: p,0.05) 61% Observation vs. metastasesdirected therapies SBRT Conventional imaging (for study includion) = PSMA PET/CT 18.8 months SBRT improved progression -free survival 4 1-5 SOC vs. SOC+ SABR SBRT Conventional imaging + PET 51 months SBRT improved overall survival <3 Example of (A) a patient with solitary oligorecurrent pelvic nodal relapse detected via PSMA-PET and (B) the corresponding imaging matched SBRT plan capture (30 Gy in 3 fractions) C) a patient with multiple (3) oligorecurrent pelvic and low paraaortic nodal disease in PSMA-PET and (D) the matched radiotherapy to the extended eld pelvic nodes (45 Gy in 25 fractions) with a simultaneous integrated boost to 65 Gy UROLOGY, URO-ONCOLOGY AND SEXOLOGY UPDATE
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