# The Optimal Management of Patients with Prostate Cancer with Oligometastatic Disease and Low Metastatic Burden in the PSMA-PET Era

## TL;DR

This paper reviews how adding targeted radiation or surgery to systemic therapy can improve outcomes for prostate cancer patients with limited metastases, using PSMA-PET imaging for better treatment planning.

## Contribution

The paper emphasizes the role of PSMA-PET in defining low metastatic burden disease and guiding local therapy integration for improved survival.

## Key findings

- PSMA-PET improves staging accuracy and patient selection for metastatic prostate cancer.
- Combining local therapy with systemic treatment shows promising outcomes in patients with limited metastases.
- Early intervention with local therapy targeting primary and metastatic sites is supported by emerging evidence.

## Abstract

Historically, metastatic prostate cancer has been treated primarily with medication that circulates throughout the body (systemic therapy), and radiation or surgery were mostly used for symptom relief. However, recent research suggests that adding targeted treatment with radiation or surgery to the prostate itself and to the metastatic sites might improve survival for patients whose cancer has metastasized to only a limited number of areas. Integration of functional imaging modalities is now essential in this field. Research continues to progress in this direction to optimize treatment.

Historically, systemic therapy has been the primary treatment for metastatic prostate cancer (MPC), with radiotherapy and surgery reserved for palliation. The recent literature suggests that adding local therapy (i.e., radiotherapy or surgery) to systemic therapy may improve survival for MPC patients with low metastatic burden (LMB). While some evidence supports the use of early intervention with local therapy targeting both the primary tumor and limited metastatic sites, the definition of LMB disease requires further clarification. Prostate-specific membrane antigen (PSMA) positron emission tomography (PET) scans play a vital role in staging MPC because they offer superior sensitivity and specificity compared to conventional imaging. PSMA PET thus improves patient selection and helps direct treatment planning. Local therapy in MPC can be separated into the treatment of primary and metastatic tumors. Furthermore, treatment of both the primary tumor and metastases can be managed using either radiotherapy or surgical intervention. Studies exploring the use of local therapy for both the primary tumor and oligometastatic sites have demonstrated promising clinical outcomes in patients with LMB or oligometastatic disease. This review provides a detailed description of the current optimal management of patients with metastatic prostate cancer with limited disease.