Optimal management of oligometastatic prostate cancer: current state and future directions.

Abstract

Purpose: Oligometastatic prostate cancer (oligoPCa) represents a clinical state of limited metastatic spread in which metastasis-directed therapy (MDT) may offer meaningful disease control either alone or with systemic therapy. As imaging, systemic therapy, and biologic characterization evolve, management strategies for both synchronous and metachronous presentations continue to undergo significant refinement.

Recent findings: Randomized trials such as STOMP and ORIOLE have demonstrated improved progression-free and androgen deprivation therapy (ADT)-free survival with MDT in metachronous oligometastatic disease. More recent studies, including EXTEND and RADIOSA, suggest that combining MDT with short-course systemic therapy may further enhance disease control, while ongoing trials continue to evaluate MDT in synchronous disease. In parallel, the systemic therapy landscape has expanded with early adoption of second-generation androgen receptor pathway inhibitors (ARPIs), PARP inhibitors for selected biomarker-defined populations, and radioligand therapies such as lutetium-177. Emerging evidence also suggests that molecular imaging with PSMA PET, genomic classifiers (e.g., Decipher), multimodal digital pathology tools (e.g., ArteraAI), and machine learning-based predictive models may help identify patients most likely to benefit from MDT. Additionally, novel immuno-oncology and bispecific antibody-based strategies are under active investigation.

Summary: The integration of MDT with modern systemic and biologically informed strategies holds promise for personalized management of oligoPCa. Future efforts should prioritize biomarker- driven patient selection and rational treatment sequencing to optimize long-term outcomes.