stereotactic radiosurgery for bone metastases in oligometastatic prostate cancer patients: DESTROY-2 clinical trial subanalysis
Francesco Deodato, Donato Pezzulla, Savino Cilla, Milena Ferro, C Romano, P Bonome, Milly Buwenge, A Zamagni, L Strigari, Vincenzo Valentini, Alessio Giuseppe Morganti, Gabriella Macchia
Clinical and Translational Oncology 24 (6), 1177-1183, 2022
Introduction
Aim of this analysis was to report toxicity and clinical outcomes in oligorecurrent prostate cancer (PCa) patients treated with single fraction stereotactic radiosurgery (SRS) for bone metastases.
Methods
We separately analyzed clinical data of PCa patients with bone oligometastases enrolled in a prospective phase I trial (DESTROY-2). DESTROY-2 was based on SRS delivered using volumetric modulated arc therapy in patients with primary or metastatic tumors in several extra-cranial body sites. Acute and late toxicity, biochemical tumor response, local control (LC), distant metastases-free (DPFS), progression-free (PFS), time to next-line systemic treatment-free (NEST-FS), and overall survival (OS) were calculated.
Results
Data on 37 PCa patients, carrying out 50 bone metastases, candidates for curative-intent treatment and treated with SRS at our Institution were collected. SRS dose ranged between 12 and 24 Gy. One grade 1 acute skin toxicity in one patient treated on the hip (24 Gy) and one grade 1 late skin toxicity in a patient with a scapular lesion (24 Gy) were recorded. No cases of bone fracture were registered in the treated population. With a median follow-up of 25 months (range 3–72 months) 2-year actuarial LC, DPFS, PFS, and OS were 96.7%, 58.1%, 58.1%, and 95.8%, respectively. Median and 2-year NEST-FS were 30 months (range 1–69 months) and 51.2%, respectively.
Conclusions
Data analysis showed few toxicity events, high local control rate and prolonged NEST-FS after linear accelerator-based radiosurgery of bone oligometastases from PCa. The possibility of postponing systemic treatments in patients with oligometastatic PCa by means of SRS should be taken into account. Further prospective studies on larger series are needed to confirm the reported results.
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Graham49
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"Conclusions: This first report on single session, image-guided robotic SRS documents a safe, feasible, and patient-friendly treatment option in selected patients with bone metastases of prostate cancer. "
There are lot of conflicting reports about using SBRT in Oligometastatic bone mets. My Onco told me that unless one has painful bone met..there is no rationale in using SBRT.SBRT is only to get rid of the pain. Do others have other take on SBRT for couple of small painless spots on pelvic bone ?
I think the article dealt with oligo men who had a PSA between 5 and 6, which suggests to me the Mets were not found earlier by means of a PSMA pet scan. My met was found when my PSA was .54. I had SBRT to it. I am no expert but I noticed the psa of the men involved. Also not sure if the men were oligo recurrent or oligo de novo.
Graham, I am Oligometastatic, and had SBRT/SABR to T5, and Primary Prostate Gland at 15 months after Dx (I was told inoperable). My PSA has dropped every test to new lows 7 months later. Now .022 this week.Stampede Trial (I believe Arm H) proved that there was extension of time to advancement of disease. I like the idea that you are taking out hard tumors, and letting the ADT work on the Micro Mets.
The longer we live, the greater our shot at a cure coming along!
This is a summary quote from Stampede Trial Arm H using 1,850 Men with low metastatic Burden. Gleeson 8-10 and definition of Oligometastic same as 2 previous Trials :
“In summary, radiotherapy to the prostate did not improve survival for unselected patients with newly diagnosed metastatic prostate cancer, but, in a prespecified subgroup analysis, overall survival did improve in men with a low metastatic burden. Therefore, prostate radiotherapy should be a standard treatment option for men with a low metastatic burden. These findings also raise the possibility that local treatment to the primary tumour should be explored for patients with small-volume metastatic disease from other malignant disease”
This week coffee is bad for us. Last week Great
This week 81mg Aspiri is bad for us. Last week great
Yes my RO immediately took ‘stampede trial type’ scans when my PSMA PET scan showed 2 mets to the bone ( third rib and T1)
She did SBRT to them both which did not stop new ones cropping up 6 months later ( pre ADT). She said I fit the subtype for stampede type radiation to the prostate once ADT was established. This was all approved by the University College London Hospital ( UCLH) Multi Disciplinary Team.
However I had this in Finland so I could add Lu-177 to my systemic treatments early whilst hormone sensitive ( off SOC) and they recommended 20x radiation to prostate and wider pelvic area which London were also OK with. They did a third SBRT to T9 which had been the largest of my second group of bone mets. London would not have done that.
Then most controversially Finland added 2 x Brachi boost internal radiation to my prostate. London MDT did not approve of this!
I also had 3 early Docetaxel infusions after the Lu-177 x 3 to focus on non PSMA expressing cells as the Lu-177 only deal with PSMA positive cancer cells. London we’re happy to give me 6x Docetaxels or none at my choice. I opted for the SOC plus 3 x Lu-177 3 plus 3 Docetaxel.
But all agreed I was in the stampede subgroup for prostate radiation
Double HT for me of Degarelix and Apa so now PSA undetectable and no idea what did what!
Sorry about the delay in replying, I had an IT problem. Every time I tried to reply I got the "be nice" popup which would not go away.
You need to get a PSMA Pet scan. If there are 5 or less metastases, this is generally termed oligometastases. This paper may interest you.
Safety and Efficacy Study of Neoadjuvant Radiohormonal Therapy for Oligometastatic Prostate Cancer: Protocol of an Open-Label, Dose-Escalation, Single-Centre Phase I/II …
The optimal treatment for oligometastatic prostate cancer (OMPC) is still on its way. Accumulating evidence has proven the safety and feasibility of radical prostatectomy and local or metastasis-directed radiotherapy for oligometastatic patients. The aim of this trial is to demonstrate the safety and feasibility outcomes of metastasis-directed neoadjuvant radiotherapy (naRT) and neoadjuvant androgen deprivation therapy (naADT) followed by robotic-assisted radical prostatectomy (RARP) for treating OMPC.
Methods
The present study will be conducted as a prospective, open-label, dose-escalation, phase I/II clinical trial. The patients with oligometastatic PCa will receive 1 month of naADT, followed by metastasis-directed radiation and abdominal or pelvic radiotherapy. Then, radical prostatectomy will be performed at intervals of 4-8 weeks after radiotherapy, and ADT will be continued for 2 years. The primary endpoints of the study are safety profiles, assessed by the Common Terminology Criteria for Adverse Events (CTCAE) 5.0 grading scale, and perioperativemorbidities, assessed by the Clavien-Dindo classification system. The secondary endpoints include positive surgical margin (pSM), biochemical recurrence-free survival (bPFS), radiological progression-free survival (RPFS), postoperative continence, and quality of life (QoL) parameters.
Discussion
The optimal treatment for OMPC is still on its way, prompting investigation for novel multimodality treatment protocol for this patient population. Traditionally, radical prostatectomy has been recommended as one of the standard therapies for localized prostate cancer, but indications have expanded over the years as recommended by NCCN and EAU guidelines. RP has been carried out in some centres for OMPC patients, but its value has been inconclusive, showing elevated complication risks and limited survival benefit. Neoadjuvant radiotherapy has been proven safe and effective in colorectal cancer, breast cancer and other various types of malignant tumors, showing potential advantages in terms of reducing metastatic stem-cell activity, providing clinical downstaging, and reducing potential intraoperative risks. Existing trials have shown that naRT is well tolerated for high-risk and locally-advanced prostate cancer. In this study, we hope to further determine the optimal irradiation dose and patient tolerance for genitourinary, gastrointestinal and systemic toxicities with the design of 3+3 dose escalation; also, final pathology can be obtained following RP to further determine treatment response and follow-up treatment plans.
PSMA-guided metastases directed therapy for bone castration sensitive oligometastatic prostate cancer: a multi-institutional study
Rosario Mazzola, Francesco Cuccia, Edoardo Pastorello, Matteo Salgarello, Giulio Francolini, Lorenzo Livi, Luca Triggiani, Stefano Maria Magrini, Gianluca Ingrosso, Cynthia Aristei, Ciro Franzese, Marta Scorsetti, Filippo Alongi
Clinical & Experimental Metastasis, 1-6, 2022
To assess the outcomes of a cohort of bone oligometastatic prostate cancer patients treated with PSMA-PET guided stereotactic body radiotherapy (SBRT). From April 2017 to January 2021, 40 patients with oligorecurrent prostate cancer detected by PSMA-PET were treated with SBRT for bone oligometastases. Concurrent androgen deprivation therapy was an exclusion criterion. A total of 56 prostate cancer bone oligometastases were included in the present analysis. In 28 patients (70%), oligometastatic disease presented as a single lesion, two lesions in 22.5%, three lesions in 5%, four lesions in 2.5%. 30.3% were spine-metastases, while 69.7% were non-spine metastases. SBRT was delivered for a median dose of 30 Gy (24–40 Gy) in 3–5 fractions, with a median EQD2 = 85 Gy2 (64.3—138.9Gy2). With a median follow-up of 22 months (range 2–48 months), local control (LC) 1- and 2-years rates were 96.3% and 93.9%, while distant progression-free survival (DPFS) rates were 45.3% and 27%. At multivariate analysis, the lower PSA nadir value after SBRT remained significantly related to better DPFS rates (p = 0.03). In 7 patients, a second SBRT course was proposed with concurrent ADT, while 11 patients, due to polymetastatic spread, received ADT alone, resulting in 1- and 2-years ADT-free survival rates of 67.5% and 61.8%. At multivariate analysis, a lower number of treated oligometastases maintained a correlation with higher ADT-free survival rates (p = 0.04). In our experience, PSMA-PET guided SBRT resulted in excellent results in terms of clinical outcomes, representing a helpful tool with the aim to delay the start of ADT.
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