PSMA-PET Guided Treatment in Prostate Cancer Patients with Oligorecurrent Progression after Previous Salvage Treatment

Abstract

Background: Prostate Specific Membrane Antigen-Positron Emission Tomography (PSMA-PET) is used to select recurrent prostate cancer (PCa) patients for metastases-directed therapy (MDT). We aimed to evaluate the oncologic outcomes of second-line PSMA-guided MDT in oligo-recurrent PCa patients. Methods: we performed a retrospective analysis of 113 recurrent PCa after previous radical prostatectomy and salvage therapies with oligorecurrent disease at PSMA-PET (≤3 lesions in N1/M1a-b) in three high-volume European centres. Patients underwent second-line salvage treatments: MDT targeted to PSMA (including surgery and/or radiotherapy), and the conventional approach (observation or Androgen Deprivation Therapy [ADT]). Patients were stratified according to treatments (MDT vs. conventional approach). Patients who underwent MDT were stratified according to stage in PSMA-PET (N1 vs. M1a-b). The primary outcome of the study was Progression-free survival (PFS). Secondary outcomes were Metastases-free survival (MFS) and Castration Resistant PCa free survival (CRPC-FS). Kaplan-Meier analyses assessed PFS, MFS and CRPC-FS. Multivariable Cox regression models identified predictors of progression and metastatic disease. Results: Overall, 91 (80%) and 22 (20%) patients were treated with MDT and the conventional approach, respectively. The median follow-up after PSMA-PET was 31 months. Patients who underwent MDT had a similar PFS compared to the conventional approach (p = 0.3). Individuals referred to MDT had significantly higher MFS and CRPC-FS compared to those who were treated with the conventional approach (73.5% and 94.7% vs. 30.5% and 79.5%; all p ≤ 0.001). In patients undergoing MDT, no significant differences were found for PFS and MFS according to N1 vs. M1a-b disease, while CRPC-FS estimates were significantly higher in patients with N1 vs. M1a-b (100% vs. 86.1%; p = 0.02). At multivariable analyses, age (HR = 0.96) and ADT during second line salvage treatment (HR = 0.5) were independent predictors of PFS; MDT (HR 0.27) was the only independent predictor of MFS (all p ≤ 0.04) Conclusion: Patients who underwent second-line PSMA-guided MDT experienced higher MFS and CRPC-FS compared to men who received conventional management.

True-Positive18F-Flotufolastat Lesions in Patients with Prostate Cancer Recurrence with Baseline-Negative Conventional Imaging: Results from the Prospective, Phase 3, Multicenter SPOTLIGHT Study

“…The VDR of 64% observed across all patients with negative imaging at baseline indicates that 18 F-flotufolastat PET/CT enabled visualization of at least 1 true-positive lesion in nearly two thirds of patients that had been missed by conventional imaging. Accurate localization of these recurrent lesions can help inform patient management ( 23 , 24 ), which may result in improved outcomes ( 25 , 26 ).…”

68Ga-PSMA-11 PET/CT versus 68Ga-PSMA-11 PET/MRI for the detection of biochemically recurrent prostate cancer: a systematic review and meta-analysis

“…The diagnosis of PSMA-PET has a significant impact on the management of recurrent patients, allowing clinicians to select better treatment options to treat them, such as the treatment of recurrent M1a prostate cancer, the MDT approach of targeting PSMA-positive lesions according to the pattern of recurrence (sLND, SBRT, combination of sLND and SBRT). Based on the PSMA-PET method, these treatments were chosen ( 50 – 53 ).…”

Metastasis-directed therapy in oligometastatic prostate cancer

“…Their comparison of MDT plus standard of care (SOC) with SOC treatment indicated significantly improved metastasis-free survival (MFS) and CRPC-free survival in patients receiving MDT. However, interpreting these findings requires caution due to the lack of propensity score matching and potential confounding inherent in nonrandomized treatment allocation [21].…”