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EAU 2026

EAU 2026: Debate: Optimal Management of Oligorecurrent Disease: Irradiate Them!

(UroToday.com) The 2026 European Association of Urology (EAU) annual meeting featured a plenary prostate cancer session and a presentation by Dr. Giulia Marvaso discussing the optimal management of oligorecurrent disease, and that we should irradiate all oligorecurrent lesions. Dr. Marvaso’s discussion was based on a prior case presentation of a 61 year old fit man with oligo-recurrent prostate cancer after radical prostatectomy, with a PSA of 1.5 ng/mL (PSA doubling time: 3 months) and 3 PSMA positive pelvic lymph node metastases. She notes that five years ago, this patient would already be receiving lifelong systemic therapy, highlighting that CT and PSMA PET have not created oligometastatic disease, but just revealed it. Today, PSMA PET gives us a second chance, but the key question is not whether to irradiate the nodes, but whether the disease is still regional or already systemic.

There are several metastases directed therapy trials in the evolution of prostate cancer, including STOMP1 (stereotactic body radiotherapy alone to postpone ADT), EXTEND2 (ADT versus stereotactic body radiotherapy + intermittent ADT), RADIOSA3 (stereotactic body radiotherapy versus stereotactic body radiotherapy + short term ADT), and LUNAR4 (systemic therapy + stereotactic body radiotherapy versus stereotactic body radiotherapy). As the following figure demonstrates, the hazard ratios favor metastasis directed therapy based strategies + systemic therapies:

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For the current patient, Dr. Marvaso states that she would recommend stereotactic body radiotherapy (30 Gy/3 Fr, BED > 100 Gy) on all metastatic lesions + concomitant short therapy ADT (6 months) with an LHRH agonist or antagonist.

Finally, Dr. Marvaso discussed the WOLVERINE meta analysis,5 which amalgamated individual patient data across trials to evaluate the effectiveness of metastasis directed therapy for oligometastatic prostate cancer. Overall, 7 phase 2 trials (n = 574) were included in the analysis. There were 6 trials randomly assigning 472 patients to metastasis directed therapy + standard of care (n = 248) versus standard of care (n = 224), used to evaluate metastasis directed therapy and had a median follow-up time of 40.7 months (IQR 25.6-53.7). Metastasis directed therapy was associated with improved progression free survival (trial level HR 0.44, 95% CI 0.35-0.56, p < 0.0001; patient level HR 0.45, 95% CI 0.35-0.57, p < 0.0001), radiographic progression free survival (trial level HR 0.60, 95% CI 0.42-0.85, p = 0.0039; patient level HR 0.59, 95% CI 0.46-0.76, p < 0.0001), and castration resistance free survival (trial level HR 0.58, 95% CI 0.37-0.92, p = 0.019; patient level HR 0.58, 95% CI 0.37-0.91, p = 0.017). The association between metastasis directed therapy and overall survival showed an HR of 0.63 (95% CI 0.39-1.00, p = 0.051) in trial level analyses and 0.64 (95% CI 0.40-1.01, p = 0.057) in patient level analyses:

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Dr. Marvaso concluded her presentation discussing the optimal management of oligorecurrent disease and that we should irradiate all oligorecurrent lesions with the following take-home points:

  • There is good news for our patients:
    • Metastasis directed therapy has local control of 90-100%
    • There is almost no toxicity
    • De-escalation and intermittent therapy approaches are the future (quality of life matters)
    • Patients may enter into a chronic/curable state of prostate cancer
  • But, there are still unsolved questions:
    • How do we handle ADT + androgen receptor pathway inhibitors? (EMBARK6 overall survival benefit)
    • Phase III radiotherapy trials are lacking
    • The decision for metastasis directed therapy is based on counting metastases and trying to assess disease biology

Presented by: Giulia Marvaso, MD IEO European Institute of Oncology IRCCS, Milan, Italy

Written by: Zachary Klaassen, MD, MSc – Urologic Oncologist, Associate Professor of Urology, Georgia Cancer Center, Wellstar MCG Health, @zklaassen_md on Twitter during the 2026 European Association of Urology (EAU) Annual Meeting, London, United Kingdom, Fri, Mar 13 – Mon, Mar 16, 2026. 

References:

  1. Ost P, Reynders D, Decaestecker K, et al. Surveillance of metastasis-directed therapy for oligometastatic cancer recurrence: A prospective, randomized, multicenter phase II trial. J Clin Oncol. 2018 Feb 10;36(5):446-453.
  2. Tang C, Sherry AD, Haymaker C, et al. Addition of metastasis-directed therapy to intermittent hormone therapy for oligometastatic prostate cancer: The EXTEND phase 2 randomized clinical trial. JAMA Oncol. 2023 Jun 1;9(6):825-834.
  3. Marvaso G, Corrao G, Zaffaroni M, et al. ADT with SBRT versus SBRT alone for hormone-sensitive oligorecurrent prostate cancer (RADIOSA): A randomized, open-label, phase 2 clinical trial. Lancet Oncol. 2025 Mar;26(3):300-311.
  4. Kishan AU, Valle LF, Wilhalme H, et al. 177Lu-Prostate-Specific Membrane Antigen Neoadjuvant to Stereotactic Ablative Radiotherapy for Oligorecurrent Prostate Cancer (LUNAR): An open-label, randomized, controlled, phase II study. J Clin Oncol. 2025 Dec 20;43(36):3812-3821.
  5. Tang C, Sherry AD, Hwang H, et al. Metastasis-directed therapy and standard of care versus standard of care for oligometastatic prostate cancer (WOLVERINE): A systematic review and individual patient data meta-analysis from the X-MET collaboration. Lancet Oncol. 2026 Feb;27(2):181-190.
  6. Freedland SJ, de Almeida Luz M, De Giorgi U, et al. Improved Outcomes with Enzalutamide in Biochemically Recurrent Prostate Cancer. N Engl J Med 2023 Oct 19;389(16):1453-1465.