Non-systemic treatment of low-volume metastatic disease.

Transcription

1 Non-systemic treatment of low-volume metastatic disease. Gert De Meerleer, M.D., Ph.D. Gent University Hospital om behalf of POMP study group

2 Background Patients with metastatic prostate cancer are considered palliative 1 st line treatment is androgen deprivation therapy (ADT) Aim ADT: Defer progression (asymptomatic patients) Palliate symptoms (symptomatic patients) Mottet et al., Eur Urol, 2011

3 Treatment of asymptomatic M+ disease Effect on survival Overall Survival PCa Specific Survival OR 95% CI OR 95% CI 1 year 1,18 0,90 1,49 1,18 0,67 2,08 2 years 1,08 0,89 1,33 1,21 0,93 1,57 5 years 1,19 0,95 1,50 1,54 1,04 2,28 10 years 1,50 1,04 2,16 1,45 1,13 1,87 Wilt T, Nair B, MacDonald R, Rutks I. Early versus deferred androgen suppression in the treatment of advanced prostatic cancer. The Cochrane Database of Systematic Reviews 2001, Issue 4. Art.

4 At what cost? Impaired physical activity

5 Sarcopenic obesity

6 ADT S Impotence Loss of libido

7 Metabolic Syndrome

8 Osteoporosis Anxiety / depression

9 DO METASTASES METASTAZISE? PT N YES? NO? M1 M2

10 Cross talk between PT, CTC, DTC, LR and DM PRIMARY TUMOR DTC CTC

11 Localized Oligometastases Polymetastases Hellman, J Clin Oncol, 1995

12 Localized Oligometastases Polymetastases Hellman, J Clin Oncol, 1995

13 Which tracers? FDG C11 of F18-Choline

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16 N=72 Mean PSA: 3.7 ng/ml 38% Gleason score 8-10

17 BRFS

18 CRFS

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24 ADT: median 12 months plnd: elective RT + boost Others: 5-6 times 5-6 Gy

25 Median follow-up 31 months

26 Hypothesis: A new idea?! Early detection and eradication of oligometastases defers initiation of ADT Primary endpoint: Androgen deprivation free survival Initiation of ADT upon one of the following conditions: Diagnosis of polymetastases: (> 3 metastases) PSA: > 50 ng/ml PSA doubling time: < 4 months Symptomatic disease

27 Clinical Genitourinary Cancer, In Press

28 10 times 5 Gy, 3 times a week.

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30 AD-FS: 82% at 1 year 57% at 2 years Median ADT deferment: 34 months N=32 Median Follow-up: 24 months (range: 1-81)

31 AD-FS: 87% at 1 year 65% at 2 years Median ADT deferment: 58 months N=52 30 LNN 20 bone 2 visceral Median Follow-up: 26 months (range: 1-81)

32 Acute Urinary GI Skin Late Urinary GI Grade 0 Grade 1 Grade 2 Skin 0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100%

33 Repeated salvage SBRT for oligometastatic prostate cancer Feasible Well tolerated Median deferment of ADT: 58 months Basis for current RCT: RT vs. Active Surveillance

34 Some brand new (unpublished) data Especially for you

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39 Repeated salvage SBRT for oligometastatic prostate cancer

40 Repeated salvage SBRT for oligometastatic prostate cancer Radiology Radiation Oncology Urology Nuclear Medicine POMP trial Pathology Medical Genetics Experimental Cancerology Infinity lab

41 Repeated salvage SBRT for oligometastatic prostate cancer

42 Take home message - Low volume metastatic prostate cancer could be a separate entity from polymetastatic disease - Local aggressive treatment seems to at least postpone ADT (early results, to be confirmed in RCT).

43 Future - extrapolate to postpone e.g. docetaxel? - extrapolate philosophy to RCC. Thank you!

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