Dalhousie University, Halifax, Canada; Jewish General Hospital, Montreal, Canada.
Department of Medical Oncology, Dana-Farber Cancer Institute, Boston, United States.
Radiother Oncol. 2020 Nov;152:80-88. doi: 10.1016/j.radonc.2020.08.011. Epub 2020 Aug 25.
The initial management of potentially oligometastatic hormone sensitive prostate cancer has been complicated by rapid advances in the field. Clinically, subgroup analyses of two randomized control trials have suggested that a specific synchronous oligometastatic prostate cancer state may be predictive for benefit from radiation to the primary. Further exploration of metastasis-directed therapy has been supported for various prostate cancer populations among three phase II clinical trials. There are numerous caveats in applying this evidence, a dilemma being addressed by present and upcoming clinical trials. Despite existing clinical equipoise and an avenue to address this uncertainty, the temptation to combine this evidence off-trial exists. Matters have become more complex as our ability to evaluate metastatic disease and tumour biology have also matured. This paper synthesizes our understanding of prostate cancer's natural history into a model which rationalizes both the theoretical benefits and limitations of metastasis directed therapy. We postulate that a metastatic prostate cancer's total disease activity is primarily driven by the combination of its burden of disease and underlying biology, namely genomic instability, then highlight the numerous remaining questions that challenge this hypothesis. This review focuses on harmonizing the language used to describe the disease, the current efforts exploring this hypothesis, and the need for clinical trial participation to appropriately advance patient care.
潜在寡转移激素敏感前列腺癌的初始管理因该领域的快速发展而变得复杂。临床上，两项随机对照试验的亚组分析表明，特定的同步寡转移前列腺癌状态可能对原发性放射治疗有益。三项 II 期临床试验进一步支持了针对各种前列腺癌人群的转移导向治疗的探索。在应用这些证据时存在许多注意事项，目前和即将进行的临床试验正在解决这一两难问题。尽管存在临床平衡和解决这一不确定性的途径，但在试验之外结合这一证据的诱惑仍然存在。随着我们评估转移性疾病和肿瘤生物学能力的提高，情况变得更加复杂。本文将我们对前列腺癌自然史的理解综合成一个模型，该模型使转移导向治疗的理论优势和局限性合理化。我们假设，转移性前列腺癌的总疾病活性主要由其疾病负担和潜在生物学（即基因组不稳定性）的组合驱动，然后强调了许多挑战这一假设的剩余问题。本综述重点是协调用于描述该疾病的语言、当前探索这一假设的努力，以及参与临床试验以适当推进患者护理的必要性。
