Early second salvage.

Top Line: How do you manage second biochemical recurrence following post-prostatectomy radiation?

The Study: This study argues that there’s still a chance for cure. The single-arm phase 2 trial from the University of Toronto assessed biochemical response rates for metastasis-directed therapy (SBRT or surgery) in 72 men with a rising PSA after postoperative radiation (3 rises and PSA 0.4-3.0). The key here is PSMA PET imaging, because we all know there’s a very low likelihood of finding a source of disease with conventional imaging. Seventy two men in the study underwent PSMA PET CT or MRI with an overall metastasis detection rate of 78%. Just over half of these were found to have oligo-metastatic disease (no strict definition), and they went on to receive MDT--without ADT. The rest had no visible disease, poly-metastatic disease, or prostate bed recurrence and were managed separately. Biochemical response was defined as a ≥50% decline in PSA. Among those treated with MDT, the biochemical response rate was 60% (31% of all enrolled) and 22% had a biochemical complete response. The median time to PSA progression was 17 months.

TBL: Among men with PSMA PET-defined oligometastatic prostate cancer after maximal local therapy, metastasis-directed therapy alone (no ADT) can render >20% biochemically free of disease. | Glicksman, Eur Urol 2021