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Optimal management of oligometastatic prostate cancer: current state and future directions
Michael K Rooney1, Paul G Corn2, Phuoc T Tran1
1Department of Genitourinary Radiation Oncology.
Purpose:
Oligometastatic prostate cancer (oligoPCa) represents a clinical state of limited metastatic spread in which metastasis-directed therapy (MDT) may offer meaningful disease control either alone or with systemic therapy. As imaging, systemic therapy, and biologic characterization evolve, management strategies for both synchronous and metachronous presentations continue to undergo significant refinement.
Recent Findings:
Randomized trials such as STOMP and ORIOLE have demonstrated improved progression-free and androgen deprivation therapy (ADT)-free survival with MDT in metachronous oligometastatic disease. More recent studies, including EXTEND and RADIOSA, suggest that combining MDT with short-course systemic therapy may further enhance disease control, while ongoing trials continue to evaluate MDT in synchronous disease. In parallel, the systemic therapy landscape has expanded with early adoption of second-generation androgen receptor pathway inhibitors (ARPIs), PARP inhibitors for selected biomarker-defined populations, and radioligand therapies such as lutetium-177. Emerging evidence also suggests that molecular imaging with PSMA PET, genomic classifiers (e.g., Decipher), multimodal digital pathology tools (e.g., ArteraAI), and machine learning-based predictive models may help identify patients most likely to benefit from MDT. Additionally, novel immuno-oncology and bispecific antibody-based strategies are under active investigation.
Summary:
The integration of MDT with modern systemic and biologically informed strategies holds promise for personalized management of oligoPCa. Future efforts should prioritize biomarker- driven patient selection and rational treatment sequencing to optimize long-term outcomes.
Insights
Metastasis-directed therapy (MDT) shows promise for oligometastatic prostate cancer (oligoPCa). Combining MDT with advanced systemic therapies and biomarker selection can personalize treatment and improve outcomes for oligoPCa patients.
Area of Science:
- Oncology
- Urology
- Medical Imaging
Background:
- Oligometastatic prostate cancer (oligoPCa) is a clinical state with limited metastatic spread.
- Management strategies for oligoPCa are evolving with advances in imaging, systemic therapy, and biologic characterization.
Purpose of the Study:
- To review the current role and evolving strategies of metastasis-directed therapy (MDT) in the management of oligometastatic prostate cancer (oligoPCa).
- To discuss the integration of MDT with modern systemic therapies and biomarker-driven approaches for personalized oligoPCa treatment.
Main Methods:
- Review of randomized trials (STOMP, ORIOLE, EXTEND, RADIOSA) evaluating MDT in oligoPCa.
- Discussion of emerging systemic therapies including ARPIs, PARP inhibitors, and radioligand therapies.
- Exploration of advanced diagnostic tools such as PSMA PET, genomic classifiers, digital pathology, and predictive models for patient selection.
Main Results:
- MDT has demonstrated improved progression-free and ADT-free survival in metachronous oligoPCa.
- Combining MDT with short-course systemic therapy may further enhance disease control.
- Ongoing trials are evaluating MDT in synchronous oligoPCa and novel systemic/immuno-oncology strategies.
Conclusions:
- Integration of MDT with advanced systemic and biologically informed strategies offers personalized management for oligoPCa.
- Biomarker-driven patient selection and rational treatment sequencing are crucial for optimizing long-term outcomes in oligoPCa.
