In PCa, the distinction between HVD and LVD is clinically significant. LVD has been named oligo-metastasis in a number of studies. Many clinical trials have found that the number of metastatic lesions is associated with cancer prognosis. Patients with metastases, including less than five lesions, have a significantly better cancer-specific survival than those with more metastatic lesions. Therefore, local therapy for patients with primary cancer and limited number of metastatic lesions, in combination with ADT, has been largely recommended. Heidenreich et al have reported that radical prostatectomy provides a better clinical progression-free survival (38.6 vs. 26.5 months, P = 0.032) and cancer-specific survival rates (95.6% vs. 84.2%, P = 0.043) in PCa patients with no more than three bone metastases. The CHAARTED trial has shown that docetaxel-based chemotherapy had survival benefits for HVD patients. On the other hand, radiotherapy improved the survival of LVD patients in the Systemic Therapy in Advanced or Metastatic Prostate Cancer: Evaluation of Drug Efficacy: a multi-stage multi-arm randomised control trial (STAMPEDE) trial.
Still, there is not a current widely-accepted definition for HVD and LVD. According to former clinical trials, the cut-off of 3 to 5 lesions has been used to distinguish these categories.[17–20] However, these differences do not affect clinical applications. In this regard, the definitions of CHAARTED and LATITUDE trials are consistent, and both trials have added significant prognostic value for predicting overall survival. In this study, we adopted the definition of CHAARTED trial.
Nevertheless, a few limitations should be considered in this study. First, our work corresponds to a single-center retrospective study, so some statistically selective bias may be assumed. Second, despite our strict enrollment criteria, we were unable to completely exclude other conditions that might affect plasma fibrinogen levels, such as varicose vein of lower limb, atherosclerosis, and others. Third, although SPECT-CT is regarded as the “gold standard” for the detection of skeletal metastases in PCa patients, this platform could still lead an incorrect diagnosis. Fourth, since our focus was mainly to determine the number and location of bone metastatic lesions displayed by SPECT-CT, we did not calculate the size or the dimension of affected areas. Bone scan index as a means of estimating the percentage of tumors along the whole skeleton could be considered to better distinguish PCa-related metastatic conditions. Lastly, visceral metastasis was not assessed, and this condition may have been missed in some HVD patients. Multi-center prospective studies, including larger sample sizes, will be further required to confirm the results of this study.
The authors thank Yi-Zhen Jia (McGill University, Canada) for the critical reading of this manuscript.
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