[攝護腺癌] 轉移性攝護腺癌的放射治療

在臨床工作裡, 新診斷轉移性攝護腺癌病人非常多, NCCN guideline裡面整理的非常好, 以下搭配相關論文來說明這個主題 (不過這裡討論要做的部位不是轉移的地方, 而是prostate)
在所謂的 "castration-naive" 的攝護腺癌裡面, 可以再依照轉移的情形分成所謂的 low volume metastatic disease 和 high volume metastatic disease

p.s.  castration-naive: 並非指的是沒用ADT, 而是代表著目前沒有使用, 而且testicular function 在正常範圍

low volume metastatic disease: 非high volume metastatic disease

=> 治療: newly diagnosed metastastic prostate cancer, ADT + apalutamide or abiraterone or docetaxel or enzalutamide + RT to prostate 

=> 主要是根據 STAMPEDE trial:

把病人分成兩組:  ADT(+Doxetaxol)+ RT to prostate versus ADT(+Doxetaxol), 結果發現 ADT + RT 對failure free survival 有幫助, 對overall survival 沒有幫助; 不過在 low volume metastatic disease 的subset, ADT + RT 對failure free survival 以及 overall survival 都有幫助!

STAMPEDE 的 RT 作法是只針對prostate(後緣加8mm, 其他地方加10mm),  55Gy/20Fr/daily or 36Gy/6Fr/weekly

high volume metastatic disease: 有visceral metastasis 或/且 四顆以上的骨轉移(其中至少要有一顆在pelvic and vertebral column之外) => 不建議做RT to prostate, 根據兩個trial, 上面提到的STAMPEDE 以及 HORRAD trial 

HORRAD trial: primary bone metastatic prostate cancer, 分成 ADT+RT to prostate versus ADT, 發現overall survival 沒差! (收案病人6成多有五顆以上轉移, 不過這樣就要拿來支持high volume disease的治療感覺怪怪的, 因為high volume disease不是只看顆數還要看位子)


reference:

1. NCCN guideline

2. Parker, Christopher C., et al. "Radiotherapy to the primary tumour for newly diagnosed, metastatic prostate cancer (STAMPEDE): a randomised controlled phase 3 trial." The Lancet 392.10162 (2018): 2353-2366.

3. Boevé, Liselotte MS, et al. "Effect on survival of androgen deprivation therapy alone compared to androgen deprivation therapy combined with concurrent radiation therapy to the prostate in patients with primary bone metastatic prostate cancer in a prospective randomised clinical trial: data from the HORRAD trial." European urology 75.3 (2019): 410-418.