{"status":"ok","message-type":"work","message-version":"1.0.0","message":{"indexed":{"date-parts":[[2026,6,29]],"date-time":"2026-06-29T03:45:55Z","timestamp":1782704755141,"version":"3.54.5"},"reference-count":26,"publisher":"MDPI AG","issue":"7","license":[{"start":{"date-parts":[[2026,6,28]],"date-time":"2026-06-28T00:00:00Z","timestamp":1782604800000},"content-version":"vor","delay-in-days":0,"URL":"https:\/\/creativecommons.org\/licenses\/by\/4.0\/"}],"content-domain":{"domain":[],"crossmark-restriction":false},"short-container-title":["Diseases"],"abstract":"<jats:p>Background\/Objectives: Metastatic prostate cancer is increasing in the Gulf Cooperation Council countries. This study presents a multimodal treatment protocol incorporating radiotherapy to primary and metastatic sites, guided by PSMA PET\/CT, combined with systemic therapy for non-metastatic pelvic node-positive and de novo low-volume metastatic prostate cancer. Methods: We conducted a retrospective cohort study of patients treated with radical radiotherapy doses (68 Gy\/25 Fr or 78 Gy\/39 Fr) to the prostate gland and gross pelvic disease, and SBRT (35\u201340 Gy\/5 Fr) to distant bone metastases. All patients received LHRH agonists \u00b1 abiraterone\/prednisone or enzalutamide. Results: Twenty-four consecutive patients were analyzed. The median age was 70.1 years (IQR, 65.7\u201377.7), the median baseline PSA was 27.9 ng\/mL (IQR = 19.7\u201353.8), and median follow up was 24 months (IQR = 20.4\u201331.2). Clinical staging was cT3b in (46%), cT2 in (25%), cT4 in (17%), cT3a in (13%) of patients. Pelvic nodal involvement (cN1) was present in 91.7% of patients, while 54.1% had metastatic disease. Treatment was well tolerated. Acute toxicity was predominantly grade 1 genitourinary (GU) toxicity, occurring in 87.5% of patients, with grade 2 GU toxicity observed in 8.2% and no acute gastrointestinal (GI) toxicity. Late toxicity remained minimal, with grade 1 and grade 2 GU toxicity reported in 45.8% and 4.2% of patients, respectively, and no late GI toxicity. Mild systemic treatment-related toxicities were reported in 25% of patients, including sexual dysfunction, hypokalemia, muscle weakness, osteoporosis and depression\/anxiety. At the six-month follow-up PSMA PET\/CT assessment, 85.7% achieved a complete metabolic response, and 14.2% achieved a partial response. Biochemically, 75% of patients achieved undetectable PSA levels (&lt;0.01 ng\/mL), with all patients achieving a PSA nadir &lt; 0.2 ng\/mL. Conclusions: This first, hypothesis-generating real-world experience from the GCC, suggests that an integrated approach combining systemic therapy with metastasis-directed therapy is feasible. Prospective randomized studies are required to validate these results.<\/jats:p>","DOI":"10.3390\/diseases14070232","type":"journal-article","created":{"date-parts":[[2026,6,29]],"date-time":"2026-06-29T02:16:44Z","timestamp":1782699404000},"page":"232","update-policy":"https:\/\/doi.org\/10.3390\/mdpi_crossmark_policy","source":"Crossref","is-referenced-by-count":0,"title":["PSMA PET\/CT-Guided Multimodal Therapy for Pelvic Lymph Node Positive and De Novo Low-Volume Metastatic Prostate Cancer: A Gulf Region Single-Institution Experience"],"prefix":"10.3390","volume":"14","author":[{"ORCID":"https:\/\/orcid.org\/0000-0003-3821-4357","authenticated-orcid":false,"given":"Nadeem","family":"Pervez","sequence":"first","affiliation":[{"name":"Department of Internal Medicine, College of Medicine and Health Sciences, United Arab Emirates University, Abu Dhabi P.O. Box 15551, United Arab Emirates"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Benazir Mir","family":"Khan","sequence":"additional","affiliation":[{"name":"Radiation Oncology, Saskatoon Cancer Center, Saskatoon, SK 5882, Canada"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Sharjeel","family":"Usmani","sequence":"additional","affiliation":[{"name":"Radiology & Nuclear Medicine, Sultan Qaboos Comprehensive Cancer Care and Research Centre (SQCCCRC), Muscat 112, Oman"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Hasan","family":"Al-Sayegh","sequence":"additional","affiliation":[{"name":"Research Laboratories Department, Sultan Qaboos Comprehensive Cancer Care and Research Centre (SQCCCRC), Muscat 112, Oman"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Iqbal","family":"Al Amri","sequence":"additional","affiliation":[{"name":"Medical Physics, Sultan Qaboos Comprehensive Cancer Care and Research Centre (SQCCCRC), Muscat 112, Oman"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0002-8156-6916","authenticated-orcid":false,"given":"Mahmoud","family":"Alfishawy","sequence":"additional","affiliation":[{"name":"Medical Physics, Sultan Qaboos Comprehensive Cancer Care and Research Centre (SQCCCRC), Muscat 112, Oman"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0002-3669-2155","authenticated-orcid":false,"given":"Sercan","family":"Yilmaz","sequence":"additional","affiliation":[{"name":"Radiation Oncology, Sultan Qaboos Comprehensive Cancer Care and Research Centre (SQCCCRC), Muscat 112, Oman"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Sulaiman","family":"Al Saadi","sequence":"additional","affiliation":[{"name":"Medical Oncology, Sultan Qaboos Comprehensive Cancer Care and Research Centre (SQCCCRC), Muscat 112, Oman"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Munjid","family":"Al Harthy","sequence":"additional","affiliation":[{"name":"Medical Oncology, Sultan Qaboos Comprehensive Cancer Care and Research Centre (SQCCCRC), Muscat 112, Oman"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Javeria","family":"Ahmed","sequence":"additional","affiliation":[{"name":"Medical School, Medical University of Lublin, 20-059 Lublin, Poland"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Zahid","family":"Almandhari","sequence":"additional","affiliation":[{"name":"Radiation Oncology, Sultan Qaboos Comprehensive Cancer Care and Research Centre (SQCCCRC), Muscat 112, Oman"}],"role":[{"vocabulary":"crossref","role":"author"}]}],"member":"1968","published-online":{"date-parts":[[2026,6,28]]},"reference":[{"key":"ref_1","doi-asserted-by":"crossref","first-page":"302","DOI":"10.1016\/j.eururo.2024.11.013","article-title":"Recent Patterns and Trends in Global Prostate Cancer Incidence and Mortality: An update","volume":"87","author":"Schafer","year":"2025","journal-title":"Eur. Urol."},{"key":"ref_2","doi-asserted-by":"crossref","first-page":"118","DOI":"10.1016\/j.prnil.2016.07.001","article-title":"Incidence and mortality of prostate cancer and their relationship with the Human Development Index worldwide","volume":"4","author":"Ghoncheh","year":"2016","journal-title":"Prostate Int."},{"key":"ref_3","doi-asserted-by":"crossref","first-page":"e2300439","DOI":"10.1200\/GO.23.00439","article-title":"Cancer Care Disparities: Overcoming Barriers to Cancer Control in Low- and Middle-Income Countries","volume":"10","author":"Bamodu","year":"2024","journal-title":"JCO Glob. Oncol."},{"key":"ref_4","doi-asserted-by":"crossref","first-page":"e70141","DOI":"10.1002\/cam4.70141","article-title":"The current and future cancer burden in the Gulf Cooperation Council (GCC) countries","volume":"13","author":"Alessy","year":"2024","journal-title":"Cancer Med."},{"key":"ref_5","doi-asserted-by":"crossref","first-page":"56","DOI":"10.1097\/MS9.0000000000001448","article-title":"Prostate cancer among Saudis: A registry review","volume":"86","author":"Alasker","year":"2024","journal-title":"Ann. Med. Surg."},{"key":"ref_6","doi-asserted-by":"crossref","first-page":"oyaf386","DOI":"10.1093\/oncolo\/oyaf386","article-title":"Best therapeutic approach in metastatic hormone-sensitive prostate cancer based on disease volume: A systematic review and network meta-analysis","volume":"31","author":"Mercinelli","year":"2026","journal-title":"Oncologist"},{"key":"ref_7","doi-asserted-by":"crossref","first-page":"178","DOI":"10.1097\/MOU.0000000000001169","article-title":"Metastasis-direced therapy in oligometastatic prostate cancer","volume":"34","author":"Miszczyk","year":"2024","journal-title":"Curr. Opin. Urol."},{"key":"ref_8","doi-asserted-by":"crossref","first-page":"1758835920978134","DOI":"10.1177\/1758835920978134","article-title":"Next-generation androgen receptor inhibitors in non-metastatic castration-resistant prostate cancer","volume":"12","author":"Lavaud","year":"2020","journal-title":"Ther. Adv. Med. Oncol."},{"key":"ref_9","doi-asserted-by":"crossref","unstructured":"Combes, A.D., Palma, C.A., Calopedos, R., Wetn, L., Woo, H., Fulham, M., and Leslie, S. (2022). PSMA PET-CT in the Diagnosis and Staging of Prostate Cancer. Diagnostics, 12.","DOI":"10.3390\/diagnostics12112594"},{"key":"ref_10","doi-asserted-by":"crossref","first-page":"384","DOI":"10.1016\/j.prro.2021.02.011","article-title":"Clinical Outcomes of the CHIRP Trial: A Phase II Prospective Randomized Trial of Conventionally Fractionated Versus Moderately Hypofractionated Prostate and Pelvic Nodal Radiation Therapy in Patients With High-Risk Prostate Cancer","volume":"11","author":"Wang","year":"2021","journal-title":"Pract. Radiat. Oncol."},{"key":"ref_11","doi-asserted-by":"crossref","first-page":"e222148","DOI":"10.1148\/radiol.222148","article-title":"Response Evaluation Criteria in PSMA PET\/CT (RECIP 1.0) in Metastatic Castration-resistant Prostate Cancer","volume":"308","author":"Gafita","year":"2023","journal-title":"Radiology"},{"key":"ref_12","doi-asserted-by":"crossref","unstructured":"Cooksey, R.W. (2020). Descriptive Statistics for Summarising Data. Illustrating Statistical Procedures: Finding Meaning in Quantitative Data, Springer.","DOI":"10.1007\/978-981-15-2537-7"},{"key":"ref_13","unstructured":"The R Foundation (2025, March 17). R Project for Statistical Computing. Available online: https:\/\/www.r-project.org\/."},{"key":"ref_14","doi-asserted-by":"crossref","unstructured":"Peng, Y., Song, Y., and Wang, H. (2022). Systematic Elucidation of the Aneuploidy Landscape and Identification of Aneuploidy Driver Genes in Prostate Cancer. Front. Cell Dev. Biol., 9.","DOI":"10.3389\/fcell.2021.723466"},{"key":"#cr-split#-ref_15.1","unstructured":"Froehner, M., Koch, R., and Graefen, M. (2021). Re: Nicolas Mottet, Roderick C.N. van den Bergh, Erik Briers"},{"key":"#cr-split#-ref_15.2","doi-asserted-by":"crossref","unstructured":"et al. EAU-EANM-ESTRO-ESUR-SIOG Guidelines on Prostate Cancer-2020 Update. Part 1: Screening, Diagnosis, and Local Treatment with Curative Intent. Eur Urol 2021;79:243-62: Comorbidity Measurement in Patients with Prostate Cancer. Eur. Urol., 79.","DOI":"10.1016\/j.eururo.2021.02.005"},{"key":"ref_16","doi-asserted-by":"crossref","first-page":"2353","DOI":"10.1016\/S0140-6736(18)32486-3","article-title":"Radiotherapy to the Primary Tumour for Newly Diagnosed, Metastatic Prostate Cancer (STAMPEDE): A Randomised Controlled Phase 3 Trial","volume":"392","author":"Parker","year":"2018","journal-title":"Lancet"},{"key":"ref_17","doi-asserted-by":"crossref","unstructured":"Parker, C.C., James, N.D., Brawley, C.D., Clarke, N.W., Ali, A., Amos, C.L., Attard, G., Chowdhury, S., Cook, A., and Cross, W. (2022). Radiotherapy to the Prostate for Men With Metastatic Prostate Cancer in the UK and Switzerland: Long-Term Results From the STAMPEDE Randomised Controlled Trial. PLoS Med., 19.","DOI":"10.1371\/journal.pmed.1003998"},{"key":"ref_18","doi-asserted-by":"crossref","first-page":"115","DOI":"10.1016\/j.eururo.2019.02.003","article-title":"Prostate Radiotherapy for Metastatic Hormone-sensitive Prostate Cancer: A STOPCAP Systematic Review and Meta-analysis","volume":"76","author":"Burdett","year":"2019","journal-title":"Eur. Urol."},{"key":"ref_19","doi-asserted-by":"crossref","first-page":"323","DOI":"10.1016\/S1470-2045(23)00063-3","article-title":"Testosterone suppression plus enzalutamide versus testosterone suppression plus standard antiandrogen therapy for metastatic hormone-sensitive prostate cancer (ENZAMET): An international, open-label, randomised, phase 3 trial","volume":"24","author":"Sweeney","year":"2023","journal-title":"Lancet Oncol."},{"key":"ref_20","doi-asserted-by":"crossref","first-page":"1695","DOI":"10.1016\/S0140-6736(22)00367-1","article-title":"Abiraterone plus prednisone added to androgen deprivation therapy and docetaxel in de novo metastatic castration-sensitive prostate cancer (PEACE-1): A multicentre, open-label, randomised, phase 3 study with a 2 \u00d7 2 factorial design","volume":"399","author":"Fizazi","year":"2022","journal-title":"Lancet"},{"key":"ref_21","doi-asserted-by":"crossref","first-page":"2065","DOI":"10.1016\/S0140-6736(24)01865-8","article-title":"PEACE-1 investigators. Efficacy and safety of prostate radiotherapy in de novo metastatic castration-sensitive prostate cancer (PEACE-1): A multicentre, open-label, randomised, phase 3 study with a 2 \u00d7 2 factorial design","volume":"404","author":"Bossi","year":"2024","journal-title":"Lancet"},{"key":"ref_22","doi-asserted-by":"crossref","first-page":"3377","DOI":"10.1200\/JCO.22.00644","article-title":"Long-Term Outcomes and Genetic Predictors of Response to Metastasis-Directed Therapy Versus Observation in Oligometastatic Prostate Cancer: Analysis of STOMP and ORIOLE Trials","volume":"40","author":"Deek","year":"2022","journal-title":"J. Clin. Oncol."},{"key":"ref_23","doi-asserted-by":"crossref","first-page":"496","DOI":"10.1016\/j.eururo.2025.07.006","article-title":"Continuous Androgen Deprivation Therapy with or Without Metastasis-directed Therapy for Oligometastatic Prostate Cancer: The Multicenter Phase 2 Randomized EXTEND Trial","volume":"88","author":"Sherry","year":"2025","journal-title":"Eur. Urol."},{"key":"ref_24","doi-asserted-by":"crossref","first-page":"2830","DOI":"10.1200\/JCO.20.00818","article-title":"Stereotactic Ablative Radiotherapy for the Comprehensive Treatment of Oligometastatic Cancers: Long-Term Results of the SABR-COMET Phase II Randomized Trial","volume":"38","author":"Palma","year":"2020","journal-title":"J. Clin. Oncol."},{"key":"ref_25","doi-asserted-by":"crossref","first-page":"120","DOI":"10.1002\/pro6.70014","article-title":"Deep learning (DL)-based advancements in prostate cancer imaging: Artificial intelligence (AI)-based segmentation of 68Ga-PSMSA PET for tumor volume assessment","volume":"9","author":"Usmani","year":"2025","journal-title":"Prec Radiat. Oncol."}],"container-title":["Diseases"],"original-title":[],"language":"en","link":[{"URL":"https:\/\/www.mdpi.com\/2079-9721\/14\/7\/232\/pdf","content-type":"unspecified","content-version":"vor","intended-application":"similarity-checking"}],"deposited":{"date-parts":[[2026,6,29]],"date-time":"2026-06-29T03:15:08Z","timestamp":1782702908000},"score":1,"resource":{"primary":{"URL":"https:\/\/www.mdpi.com\/2079-9721\/14\/7\/232"}},"subtitle":[],"short-title":[],"issued":{"date-parts":[[2026,6,28]]},"references-count":26,"journal-issue":{"issue":"7","published-online":{"date-parts":[[2026,7]]}},"alternative-id":["diseases14070232"],"URL":"https:\/\/doi.org\/10.3390\/diseases14070232","relation":{},"ISSN":["2079-9721"],"issn-type":[{"value":"2079-9721","type":"electronic"}],"subject":[],"published":{"date-parts":[[2026,6,28]]}}}