EURURO Vol. 72 No. 3

E66 476

Letter to the Editor
Re: Declan G. Murphy, Christopher J. Sweeney,
Bertrand Tombal. ‘‘Gotta Catch [4_TD$DIFF]’em All’’ or
Do We? Pokemet Approach to Metastatic
Prostate Cancer. Eur Urol [5_TD$DIFF]2017;72:1–3.
We read with interest the article by Murphy et al . Meta-
static disease in prostate cancer, analogous to the spectrum
forPoke´mon , comprises awide variety of clinical and genomic
scenarios. The recent evolution of stereotactic body radio-
therapy (SBRT) has provided the ability to ablate metastases
with very few side effects, so the question arises of whether
there is clinical benefit in doing so.
Simultaneously, academic centres around the world
have tested whether SBRT can improve outcomes for
patients. Local control of metastasis is consistently >90%
. Ost et al published outcomes for a large series of
prostate oligometastases and documented a median distant
progression-free survival (PFS) of 21 mo, with 31% free of
distant progression at 3 yr. Interestingly, Murphy’s own
institutional prospective study reported 2-yr PFS of 32%
Overall, current data indicate that after a single or few
outpatient SBRT sessions, delivered with minimal side
effects, a third of patients will be free from disease in the
medium term. SBRT can also defer the need for androgen
deprivation therapy (ADT) by 25 mo , improving quality
of life for men with prostate cancer. Randomised trials are
awaited with anticipation (STOMP, NCT01558427; SABR-
COMET, NCT01446744; CORE, NCT02759783; and SARON,
NCT02417662).
Clonal heterogeneity studies have shown that tumour
clones are seeded from metastases to new metastatic sites
Just like Poke´mon, metastases with the right stimuli will
evolve into more powerful and aggressive entities. For
example, systemic treatment might pressure individual
metastatic clones, giving rise to more heterogeneous,
resistant, and aggressive metastases. Hence, early ablation
of metastastic disease may prevent further metastatic
seeding, delay the time to castration resistance, and result
in long-term freedom from disease. Why then is there an
urgency to commit patients early to life-long systemic
agents associated with well-documented toxicities and
detriment to quality of life?
By contrast, Murphy et al argue that to ‘‘Catch [4_TD$DIFF]’em all’’ is
impossible, and that oligometastatic disease should be
treated with early systemic therapy and/or deferred ADT. In
the words of Arthur C. Clarke ‘‘The limits of possible can
only be defined by going beyond them into the impossible’’.
An example is a 59-yr-old patient at the Royal Marsden who
presented in 2011 with rapidly rising prostate-specific
antigen after low-dose rat brachytherapy. Choline positron
emission tomography showed a solitary node in the pelvis.
He received 30 Gy in three fractions without ADT in
2011. Some 6 yr later his PSA is 0.06 ng/ml without any
further intervention.
There are purportedly 802 types of Poke´mon with varying
prevalence and attributes. Common Poke´mon such as Pidgey
arouse little excitement (analogous to the case presented by
Murphy et al ). Rarer Poke´mon such as Snorlax, analogous
to the true oligometastatic state (such as the patient
described above), are prized and hence chased with fervour.
In advance of forthcoming level one evidence, we would
contend that one should search for, and ablate, oligometa-
static disease in patients with prostate cancer with the same
zeal as our children chase Poke´mon.
Conflicts of interest: The authors have nothing to disclose.
Acknowledgments: Alison C. Tree gratefully acknowledges the support
of the Royal Marsden/Institute of Cancer Research NIHR Biomedical
Research Centre.
References
[1] [8_TD$DIFF] [9_TD$DIFF]
[10_TD$DIFF]
[2]
.
[3]
[4]
.
available at
journal homepage:
DOI of original article: .
0302-2838/# 2017 European Association of Urology. Published by Elsevier B.V. All rights reserved.