The Optimal Management of Patients with Prostate Cancer with Oligometastatic Disease and Low Metastatic Burden in the PSMA-PET Era

Historically, systemic therapy has been the primary treatment for metastatic prostate cancer (MPC), with radiotherapy and surgery reserved for palliation. The recent literature suggests that adding local therapy (i.e., radiotherapy or surgery) to systemic therapy may improve survival for MPC patients with low metastatic burden (LMB). While some evidence supports the use of early intervention with local therapy targeting both the primary tumor and limited metastatic sites, the definition of LMB disease requires further clarification. Prostate-specific membrane antigen (PSMA) positron emission tomography (PET) scans play a vital role in staging MPC because they offer superior sensitivity and specificity compared to conventional imaging. PSMA PET thus improves patient selection and helps direct treatment planning. Local therapy in MPC can be separated into the treatment of primary and metastatic tumors. Furthermore, treatment of both the primary tumor and metastases can be managed using either radiotherapy or surgical intervention. Studies exploring the use of local therapy for both the primary tumor and oligometastatic sites have demonstrated promising clinical outcomes in patients with LMB or oligometastatic disease. This review provides a detailed description of the current optimal management of patients with metastatic prostate cancer with limited disease.