Utilising alternative cystoscopic schedules to minimise cost and patient burden after trimodality therapy for muscle-invasive bladder cancer

BACKGROUND

To assess urinary symptoms and urine cytology as screening tools for cystoscopic detection of local recurrence after bladder-preserving trimodality treatment (TMT).

METHODS

Patients with muscle-invasive bladder cancer receiving definitive TMT follow-up three monthly for 2 years, six monthly for the next 3 years and then yearly, with a clinical review, urine cytology and cystoscopy at each visit (triple assessment, TA). Grade 2+ cystitis/haematuria absent/present was scored 0/1, and urine cytology reported negative/suspicious or positive was scored 0/1, respectively. The performance of these two parameters for predicting local recurrence in cystoscopic biopsy was tested. Other hypothetical surveillance schedules included cystoscopy on alternate visits (COAV), or suspected recurrence (COSR), six-monthly COSR and six-monthly TA.

RESULTS

A total of 630 follow-up visits in 112 patients with 19 recurrences (7 muscle invasive, 12 non-muscle invasive) at a median follow-up of 19 months were analysed. The sensitivity and specificity of clinical symptoms were 47.4% and 92%, and for urine cytology 58% and 85%, respectively. The combination of clinical symptoms and cytology (COSR) was 95% sensitive and 78% specific for local recurrence but 100% sensitive for muscle-invasive recurrence. Both COAV and COSV schedules showed a high area under the curve (AUC) for detecting local recurrence (COAV = 0.84, COSR = 0.83), muscle-invasive recurrence (AUC = 0.848 each) and non-muscle-invasive recurrence (COAV = 0.82, COSR = 0.81); reducing the need for TAs by 64% and 67% respectively, and overall cost by 18% and 33%, respectively.

CONCLUSION

Cystoscopy at suspected recurrence during follow-up is safe and the most cost-effective for detecting muscle-invasive local recurrences, while cystoscopy at alternate visits may be more optimal for detecting any local recurrence.

Management of patients with advanced prostate cancer-metastatic and/or castration-resistant prostate cancer: Report of the Advanced Prostate Cancer Consensus Conference (APCCC) 2022

BACKGROUND

Innovations in imaging and molecular characterisation together with novel treatment options have improved outcomes in advanced prostate cancer. However, we still lack high-level evidence in many areas relevant to making management decisions in daily clinical practise. The 2022 Advanced Prostate Cancer Consensus Conference (APCCC 2022) addressed some questions in these areas to supplement guidelines that mostly are based on level 1 evidence.

OBJECTIVE

To present the voting results of the APCCC 2022.

DESIGN, SETTING, AND PARTICIPANTS

The experts voted on controversial questions where high-level evidence is mostly lacking: locally advanced prostate cancer; biochemical recurrence after local treatment; metastatic hormone-sensitive, non-metastatic, and metastatic castration-resistant prostate cancer; oligometastatic prostate cancer; and managing side effects of hormonal therapy. A panel of 105 international prostate cancer experts voted on the consensus questions.

OUTCOME MEASUREMENTS AND STATISTICAL ANALYSIS

The panel voted on 198 pre-defined questions, which were developed by 117 voting and non-voting panel members prior to the conference following a modified Delphi process. A total of 116 questions on metastatic and/or castration-resistant prostate cancer are discussed in this manuscript. In 2022, the voting was done by a web-based survey because of COVID-19 restrictions.

RESULTS AND LIMITATIONS

The voting reflects the expert opinion of these panellists and did not incorporate a standard literature review or formal meta-analysis. The answer options for the consensus questions received varying degrees of support from panellists, as reflected in this article and the detailed voting results are reported in the supplementary material. We report here on topics in metastatic, hormone-sensitive prostate cancer (mHSPC), non-metastatic, castration-resistant prostate cancer (nmCRPC), metastatic castration-resistant prostate cancer (mCRPC), and oligometastatic and oligoprogressive prostate cancer.

CONCLUSIONS

These voting results in four specific areas from a panel of experts in advanced prostate cancer can help clinicians and patients navigate controversial areas of management for which high-level evidence is scant or conflicting and can help research funders and policy makers identify information gaps and consider what areas to explore further. However, diagnostic and treatment decisions always have to be individualised based on patient characteristics, including the extent and location of disease, prior treatment(s), co-morbidities, patient preferences, and treatment recommendations and should also incorporate current and emerging clinical evidence and logistic and economic factors. Enrolment in clinical trials is strongly encouraged. Importantly, APCCC 2022 once again identified important gaps where there is non-consensus and that merit evaluation in specifically designed trials.

PATIENT SUMMARY

The Advanced Prostate Cancer Consensus Conference (APCCC) provides a forum to discuss and debate current diagnostic and treatment options for patients with advanced prostate cancer. The conference aims to share the knowledge of international experts in prostate cancer with healthcare providers worldwide. At each APCCC, an expert panel votes on pre-defined questions that target the most clinically relevant areas of advanced prostate cancer treatment for which there are gaps in knowledge. The results of the voting provide a practical guide to help clinicians discuss therapeutic options with patients and their relatives as part of shared and multidisciplinary decision-making. This report focuses on the advanced setting, covering metastatic hormone-sensitive prostate cancer and both non-metastatic and metastatic castration-resistant prostate cancer.

TWITTER SUMMARY

Report of the results of APCCC 2022 for the following topics: mHSPC, nmCRPC, mCRPC, and oligometastatic prostate cancer.

TAKE-HOME MESSAGE

At APCCC 2022, clinically important questions in the management of advanced prostate cancer management were identified and discussed, and experts voted on pre-defined consensus questions. The report of the results for metastatic and/or castration-resistant prostate cancer is summarised here.

Management of testicular tumours in patients with undescended testes – a challenging but rewarding task: experience from a tertiary care cancer centre in India

Objective

Primary objective: To study patients' clinical profile and outcomes with germ cell tumours developing in undescended testes.

Materials and methods

Case records of patients enlisted in the prospectively maintained 'testicular cancer database' at our tertiary cancer care hospital from 2014 to 2019 were retrospectively reviewed. Any patient who presented with testicular germ cell tumour with a documented history/diagnosis of undescended testes, whether surgically corrected or not, was considered for this study. The patients were managed along the standard lines of treatment for testicular cancer. We evaluated clinical features, difficulties and delays in diagnosis and complexities in management. We evaluated event-free survival (EFS) and overall survival (OS) using the Kaplan-Meier Method.

Results

Fifty-four patients were identified from our database. The mean age was 32.4 years (median age 32, range: 15-56 years). Seventeen (31.4%) had developed cancer in orchidopexy testes, and 37 (68.6%) presented with testicular cancer in uncorrected cryptorchid testes. The median age at orchidopexy was 13.5 years (range: 2-32 years). The median time from symptom onset to diagnosis was 2 months (1-36 months). There was a delay in the initiation of treatment of more than 1 month in 13 patients, with the longest delay being 4 months. Two patients were initially misdiagnosed as gastrointestinal tumours. Thirty-two (59.25%) patients had seminoma, and 22 (40.7%) patients had non-seminomatous germ cell tumours (NSGCT). Nineteen patients had metastatic disease at presentation. Thirty (55.5%) patients underwent orchidectomy upfront while in 22 (40.7%) patients, orchidectomy was done after chemotherapy. The surgical approach included high inguinal orchidectomy, exploratory laparotomy or laparoscopic surgery per the clinical situation. Post-operative chemotherapy was offered as clinically indicated. At a median follow-up of 66 months (95% CI: 51-76), there were four relapses (all NSGCT) and one death. The 5-year EFS was 90.7% (95% CI: 82.9-98.7). The 5-year OS was 96.3% (95% CI: 91.2-100).

Conclusions

The tumours in undescended testes, particularly those without prior orchiopexy, often presented late and with bulky masses, requiring complex multidisciplinary management. Despite the complexity and challenges, our patient's OS and EFS matched that of patients with tumours in normally descended testes. Orchiopexy may help in earlier detection. In the first such series from India, we show that testicular tumours in the cryptorchid are also as curable as the germ cell tumours developing in the descended testis.A multidisciplinary disease management group with expertise in managing complex cases is crucial for a favourable outcome in these groups of patients. We also found that orchiopexy done even later in life confers an advantage in terms of early detection in a subsequently developing testicular tumour.

Prophylactic versus reactive feeding approach in patients undergoing adjuvant radiation therapy for oral cavity squamous cell carcinoma: A propensity score matched-pair analysis

BACKGROUND

To assess the efficacy of prophylactic versus reactive feeding strategy in oral cavity squamous cell carcinoma (OCSCC) patients receiving adjuvant radiation therapy (RT).

METHODS

This was a post hoc analysis of patients of OCSCC enrolled in a randomized trial comparing three adjuvant strategies. In this trial, till 2010, a prophylactic feeding approach was followed for all patients. Since January 2011, a reactive feeding approach was followed.

RESULTS

Two hundred and sixty-eight in each cohort (total n = 526) were eligible for analysis after propensity score matching. At 6 weeks post-RT completion, the median weight loss in the prophylactic versus reactive cohort was 5 versus 3 kg, p = 0.002. At all other time points until 1 year, the median weight loss was lesser in reactive than in the prophylactic cohort.

CONCLUSIONS

A reactive feeding tube approach should be preferred for OCSCC receiving adjuvant RT.

Oral cavity adjuvant therapy (OCAT) -a phase III, randomized controlled trial of surgery followed by conventional RT (5 fr/wk) versus concurrent CT-RT versus accelerated RT (6fr/wk) in locally advanced, resectable, squamous cell carcinoma of oral cavity

BACKGROUND

Limited data exists regarding the impact of intensification of adjuvant therapy in resected Oral Cavity Squamous Cell Carcinomas (OCSCC) with adverse prognostic features on histopathology.

PATIENTS AND METHODS

This was a three-arm phase III, randomised trial including patients with resected advanced OCSCC. Randomisation was done in a 1:1:1 ratio: Arm-A- standard adjuvant radiation therapy (RT) 60Gy/30 fractions over 6 weeks versus Arm-B-concurrent chemoradiation versus Arm-C-accelerated radiation therapy (6 d a week). The trial was powered to detect an absolute difference of 10% in 5-year Locoregional Control (LRC).

RESULTS

The trial was conducted between June 2005 and March 2013. Majority of the patients were males, had T3-T4 disease, had N2-N3 nodal status and had Extra-Capsular Extension (ECE) in nodes. The median follow-up was 95.9 months. There was no difference between the three arms (A versus B versus C) for 10-year locoregional control (LRC): 60.2% versus 61.4% versus 65.7%, p = 0.57; disease free survival (DFS): 37.4% versus 43.9% versus 39.6%, p = 0.40; or Overall Survival (OS): 39.7% versus 46.6% versus 40.4%, p = 0.40. There was no benefit of intensification with either modality in patients with any single adverse pathological factor. A benefit of intensification could be seen in patients with a combination of high-risk features: T3-T4 primary tumours with N2-N3 nodes along with ECE for DFS (Arm B versus Arm A HR) = 0.53, Arm C versus Arm A HR = 0.63) and OS (Arm B versus Arm A HR = 0.58, Arm C versus Arm A HR = 0.60).

CONCLUSIONS

All optimally resected OCSCC with adverse features did not benefit from intensification of adjuvant therapy. Only a cohort of patients with a combination of high-risk features are likely candidates for intensification.

CLINICAL TRIAL REGISTRATION

NCT00193843.

Updates in staging of penile cancer: the evolution, nuances, and issues

Staging based on the tumor (T), node (N), and metastasis (M) schema of the American Joint Committee on Cancer (AJCC) is usually the most important prognostic factor for any tumor type. Although a rare tumor, in penile cancers, this staging has evolved rapidly in the last two editions of the AJCC Cancer Staging manuals. These changes and updates are largely based on the advancement in our knowledge of the complex anatomy of the penis, the role of histopathological variables in disease biology, and the results of multicentric studies comprising large data sets. In this review, we present the evolution of the AJCC staging model from its inception to the present day. The evidence and data that entailed these changes are also discussed. We highlight a few issues with the current staging model and also briefly discuss the future perspectives and the road map which, with the help of global efforts, can further refine the staging models.

Management of Patients with Advanced Prostate Cancer. Part I: Intermediate-/High-risk and Locally Advanced Disease, Biochemical Relapse, and Side Effects of Hormonal Treatment: Report of the Advanced Prostate Cancer Consensus Conference 2022

BACKGROUND

Innovations in imaging and molecular characterisation and the evolution of new therapies have improved outcomes in advanced prostate cancer. Nonetheless, we continue to lack high-level evidence on a variety of clinical topics that greatly impact daily practice. To supplement evidence-based guidelines, the 2022 Advanced Prostate Cancer Consensus Conference (APCCC 2022) surveyed experts about key dilemmas in clinical management.

OBJECTIVE

To present consensus voting results for select questions from APCCC 2022.

DESIGN, SETTING, AND PARTICIPANTS

Before the conference, a panel of 117 international prostate cancer experts used a modified Delphi process to develop 198 multiple-choice consensus questions on (1) intermediate- and high-risk and locally advanced prostate cancer, (2) biochemical recurrence after local treatment, (3) side effects from hormonal therapies, (4) metastatic hormone-sensitive prostate cancer, (5) nonmetastatic castration-resistant prostate cancer, (6) metastatic castration-resistant prostate cancer, and (7) oligometastatic and oligoprogressive prostate cancer. Before the conference, these questions were administered via a web-based survey to the 105 physician panel members ("panellists") who directly engage in prostate cancer treatment decision-making. Herein, we present results for the 82 questions on topics 1-3.

OUTCOME MEASUREMENTS AND STATISTICAL ANALYSIS

Consensus was defined as ≥75% agreement, with strong consensus defined as ≥90% agreement.

RESULTS AND LIMITATIONS

The voting results reveal varying degrees of consensus, as is discussed in this article and shown in the detailed results in the Supplementary material. The findings reflect the opinions of an international panel of experts and did not incorporate a formal literature review and meta-analysis.

CONCLUSIONS

These voting results by a panel of international experts in advanced prostate cancer can help physicians and patients navigate controversial areas of clinical management for which high-level evidence is scant or conflicting. The findings can also help funders and policymakers prioritise areas for future research. Diagnostic and treatment decisions should always be individualised based on patient and cancer characteristics (disease extent and location, treatment history, comorbidities, and patient preferences) and should incorporate current and emerging clinical evidence, therapeutic guidelines, and logistic and economic factors. Enrolment in clinical trials is always strongly encouraged. Importantly, APCCC 2022 once again identified important gaps (areas of nonconsensus) that merit evaluation in specifically designed trials.

PATIENT SUMMARY

The Advanced Prostate Cancer Consensus Conference (APCCC) provides a forum to discuss and debate current diagnostic and treatment options for patients with advanced prostate cancer. The conference aims to share the knowledge of international experts in prostate cancer with health care providers and patients worldwide. At each APCCC, a panel of physician experts vote in response to multiple-choice questions about their clinical opinions and approaches to managing advanced prostate cancer. This report presents voting results for the subset of questions pertaining to intermediate- and high-risk and locally advanced prostate cancer, biochemical relapse after definitive treatment, advanced (next-generation) imaging, and management of side effects caused by hormonal therapies. The results provide a practical guide to help clinicians and patients discuss treatment options as part of shared multidisciplinary decision-making. The findings may be especially useful when there is little or no high-level evidence to guide treatment decisions.

Function Preservation With Brachytherapy: Reviving the Art. Improving Quality of Life With Brachytherapy for Urological Malignancies

Brachytherapy for localised prostate, muscle-invasive bladder and penile cancer is well established, providing high tumour dose delivery and minimising normal tissue doses compared with external beam techniques. In prostate cancer, the main impact on quality of life relates to diminished sexual function and irritative or obstructive urinary symptoms, which are seen up to 15 years after treatment. Significant changes in bowel function are rare. Compared with radical prostatectomy or external beam radiotherapy, irritative or obstructive urinary symptoms are more prominent, whereas incontinence is less than after radical prostatectomy and bowel changes are less than after external beam radiotherapy. For muscle-invasive bladder cancer, when compared with radical cystectomy, although no difference is seen for urinary symptoms or fatigue, role and social functioning scores are higher and there is better post-treatment sexual function in both men and women. Compared with surgical treatment for penile cancer, brachytherapy results in better erectile function scores than after glansectomy and partial penectomy and high quality of life scores, with good satisfaction ratings for cosmetic appearance.

Salivary IgA as a Surrogate Biomarker for Microbial Infections in Postoperative Patients Receiving Chemo-Radio-Therapy for Head and Neck Cancer

Objective Radiotherapy (RT) and chemotherapy (CT) are important treatment options in patients with head and neck cancers. A common complication of this is microbial colonization or infection of mucosal surfaces. These infections may commonly be due to bacteria or yeasts. Salivary proteins with their buffering activity and immunoglobulin, especially immunoglobulin A (IgA), protect oral tissue, mucosal surfaces, and teeth from various microorganisms. This study characterizes the common microorganisms encountered and evaluates the role of salivary IgA in predicting microbial infections in this group of patients with mucositis.

Methods A total of 150 adult head and neck cancer patients on CTRT were evaluated at baseline and at the end of 3 and 6 weeks, respectively. Oral swabs collected from buccal mucosa were processed in the microbiology laboratory for the presence of microorganisms. Saliva was processed for IgA level estimation on Siemens Dimension Automated biochemistry analyzer.

Results Pseudomonas aeruginosa and Klebsiella pneumoniae were the most common organisms found in our patients, followed by Escherichia coli and group A beta-hemolytic Streptococci. A significant increase (p = 0.0203) in the incidence of bacterial infection was observed in post-CTRT patients (61%) compared to pre-CTRT patients (49.33%). There was significant increase in levels of salivary IgA (p = 0.003) in patients with bacterial and fungal infection (n = 135/267) when compared to those in samples showing no growth (n = 66/183).

Conclusion A significant increase in the incidence of bacterial infection in post-CTRT patients was observed in this study. This study also indicated that postoperative head and neck cancer patients with oral mucositis that developed an infection were associated with high salivary IgA levels, and it may serve as a surrogate biomarker of infection in these patients.

Plasmacytoid urothelial carcinoma - A clinicopathological case series of an aggressive variant of urothelial cancer

Background

Many new morphological variants of urothelial carcinoma of urinary bladder have been described in the literature, plasmacytoid/signet ring cell/diffuse variant being one of the rare amongst these. Till date, no case series has been reported from India, describing this variant.

Materials and Methods

We retrospectively analyzed the clinicopathological data of 14 patients diagnosed at our center with plasmacytoid urothelial carcinoma.

Results

Seven cases (50%) were pure forms while the remaining 50% of cases had a concurrent conventional urothelial carcinoma component. Immunohistochemistry was performed to rule out other mimickers of this variant. Treatment-related data were available for seven patients, while follow-up was available for nine cases.

Conclusion

Overall, plasmacytoid variant of urothelial carcinoma is considered to be an aggressive tumor with poor prognosis.

Genomic Classifiers in Personalized Prostate Cancer Radiation Therapy Approaches: A Systematic Review and Future Perspectives Based on International Consensus

Current risk-stratification systems for prostate cancer (PCa) do not sufficiently reflect the disease heterogeneity. Genomic classifiers (GC) enable improved risk stratification after surgery, but less data exist for patients treated with definitive radiation therapy (RT) or RT in oligo-/metastatic disease stages. To guide future perspectives of GCs for RT, we conducted (1) a systematic review on the evidence of GCs for patients treated with RT and (2) a survey of experts using the Delphi method, addressing the role of GCs in personalized treatments to identify relevant fields of future clinical and translational research. We performed a systematic review and screened ongoing clinical trials on ClinicalTrials.gov. Based on these results, a multidisciplinary international team of experts received an adapted Delphi method survey. Thirty-one and 30 experts answered round 1 and round 2, respectively. Questions with ≥75% agreement were considered relevant and included in the qualitative synthesis. Evidence for GCs as predictive biomarkers is mainly available to the postoperative RT setting. Validation of GCs as prognostic markers in the definitive RT setting is emerging. Experts used GCs in patients with PCa with extensive metastases (30%), in postoperative settings (27%), and in newly diagnosed PCa (23%). Forty-seven percent of experts do not currently use GCs in clinical practice. Expert consensus demonstrates that GCs are promising tools to improve risk-stratification in primary and oligo-/metastatic patients in addition to existing classifications. Experts were convinced that GCs might guide treatment decisions in terms of RT-field definition and intensification/deintensification in various disease stages. This work confirms the value of GCs and the promising evidence of GC utility in the setting of RT. Additional studies of GCs as prognostic biomarkers are anticipated and form the basis for future studies addressing predictive capabilities of GCs to optimize RT and systemic therapy. The expert consensus points out future directions for GC research in the management of PCa.

Bone metastases in prostate cancer - Gallium-68-labeled prostate-specific membrane antigen or Fluorine 18 sodium fluoride PET/computed tomography - the better tracer?

OBJECTIVE

The objective was to assess the roles of 68Ga-PSMA PET/CT and 18F-NaF PET/CT in evaluation of skeletal metastatic lesions in prostate cancer.

METHODS

Two hundred consecutive prostate cancer patients who had undergone 68Ga-PSMA PET/CT and 18F-NaF PET/CT at baseline evaluation (n = 80) and following suspected recurrence or disease progression (restaging) (n = 120) were analyzed retrospectively.

RESULTS

PSMA and NAF scans were positive for skeletal metastatic lesions in 67% (134 patients) and negative in 33% (66 patients). The scans were concordant in 80% (160 patients: 66 negative and 94 positive) and discordant in 20% (40 patients). Among 40 discordant results, 14 were baseline and 26 were restaging studies. PSMA detected more number of lesions in 11 (nine baseline and two restaging). These were true positive marrow or lytic metastatic lesions. NaF revealed more number of lesions in 29 (5 initial and 24 restaging). These were false positive on follow-up imaging. No statistical difference (P value = 0.7 by McNemar test) between the two scans for identifying absence or presence of at least one skeletal lesion was noted at baseline staging.

CONCLUSION

Though, both 18F-NaF and 68Ga-PSMA are excellent tracers for evaluation of skeletal metastases in prostate cancer, there is a distinct advantage of 68Ga-PSMA PET/CT due to detection of additional skeletal lesions and absence of false positive lesions. In addition, absence of PSMA avidity in healed metastases in the restaging setting opens up new avenue for assessment of response of skeletal metastases.

Exploring Texture Analysis to Optimize Bladder Preservation in Muscle Invasive Bladder Cancer

PURPOSE

To explore if texture analysis of Muscle Invasive Bladder Cancer (MIBC) can aid in better patient selection for bladder preservation.

METHODS

Pretreatment noncontrast CT images of 41 patients of MIBC treated with bladder preservation were included. The visible tumor was contoured on all slices by a single observer. The primary endpoint was to identify texture parameters associated with disease recurrence posttreatment. The secondary endpoints included intra and interobserver variability, single and multislice analysis, and differentiating the texture features of normal bladder and tumor. For interobserver variability of bladder tumor texture features, 3 observers contoured the visible tumor on all slices independently. Observer 1 contoured again at an interval of 1 month for intraobserver variability.

RESULTS

The median follow-up was 30 months with 12 patients having a recurrence. In the primary endpoint analysis, the mean of the pixels at Spatial Scaling Filter (SSF) 2 for the no recurrence group and recurrence group was 6.44 v 13.73 respectively (P = .031) and the same at SSF-3 was 11.95 and 22.32 respectively (P = .034). The texture features that could significantly differentiate tumor and normal bladder were mean, standard deviation and kurtosis of the pixels at SSF-2 and entropy and kurtosis of the pixels at SSF-3. Overall, there was an excellent intra and interobserver concordance in texture features. Only multislice analysis and not single-slice could differentiate recurrence and no recurrence posttreatment.

CONCLUSIONS

Texture analysis can be explored as a modality for patient selection for bladder preservation along with the established clinical parameters to improve outcomes.

Optimizing Target Volume for Adjuvant Radiotherapy in Penile Cancer

PURPOSE

Recent studies have reported improved outcomes with adjuvant radiation therapy in penile cancer. However, the appropriate target volumes to be irradiated in this group of patients for optimal outcomes are still unclear. This study aims to report the patterns of failure and define target volumes to be irradiated in patients with pN3 penile cancer.

METHODS AND MATERIALS

Patients with pT1-T4, pN3, cM0, and squamous cell carcinoma of the penis who received adjuvant radiation therapy (involved field or extended field), with or without concurrent chemotherapy were included in the study. Complete information on disease characteristics, radiation therapy target details, and patterns of failure were available for 75 patients. Disease-free (DFS) and overall survival (OS) were estimated using the Kaplan-Meier method, and log-rank test was used to compare survival outcomes between the involved field and extended field radiation therapy groups. Multivariate analysis was performed using the Cox proportional hazards model to analyze factors correlating with survival outcomes.

RESULTS

At a median follow-up of 39 months, 38.6% (29/75) of patients had relapsed either locally, regionally, or at distant sites. Of the 24 patients who received extended field radiation therapy (EFRT), only 1 (4%) patient experienced relapse. Twenty-eight (55%) patients experienced relapse after involved-field radiation therapy (IFRT), of which 28.5% were regional-only relapses and 64% relapses were associated with a regional component. The 2-year DFS and OS of the entire cohort were 62.2% and 70.8%, respectively. The 2-year DFS was 67.9% in patients who received IFRT and 94.1% in those who received EFRT (P = .002), and the 2-year OS was 62.4% with IFRT and 91.1% with EFRT (P = .014). Extended field radiation therapy was associated with an improved DFS (hazard ratio, 12.2; 95% confidence interval, 1.5-97.4; P = .02) and OS (hazard ratio, 4.6; 95% confidence interval, 1-21.5; P = .05) on multivariate analysis.

CONCLUSIONS

Extended field radiation therapy significantly improves clinical outcomes compared with involved-field radiation in patients with pN3 penile cancer.

Second malignancy probabilities in patients with prostate cancer treated with whole pelvis radiation therapy versus prostate only radiation therapy

BACKGROUND

Whole pelvic radiation therapy (WPRT) may improve outcomes compared with prostate only radiation therapy (PORT) in some subsets of men with prostate cancer, as in the POP-RT trial. However, there is concern about increased risk of adverse effects with WPRT, including the development of radiation-induced second malignancies (SM). Given the rarity of SM, little is known about relative rates of SM between WPRT and PORT.

METHODS

A retrospective cohort analysis was performed of men with nonmetastatic, node-negative prostate cancer with at least 60 months of follow-up using a national database. SM probabilities were compared in men receiving either WPRT or PORT using multivariable logistic models adjusting for clinical and sociodemographic factors. Temporal sensitivity analyses stratified by year of diagnosis and length of follow-up were also conducted.

RESULTS

Of 50,237 patients in the study, 39,338 (78.4%) received PORT, and 10,899 (21.7%) received WPRT. Median follow-up was 106.2 months (interquartile range 82.32-132.25). Crude probabilities of SM were 9.16% for WPRT and 8.88% for PORT. The adjusted odds ratio (AOR) for development of SM with PORT versus WPRT was 1.046 (95% confidence interval 0.968-1.130). Temporal sensitivity analyses by stratifying by year of diagnosis and follow-up length also did not demonstrate any significant difference in rates of SM between WPRT and PORT using AORs with WPRT as the referent.

CONCLUSIONS

Retrospective analysis of over 50,000 patients did not demonstrate an association between WPRT and an increased probability of SM compared to PORT. Given the findings of POP-RT, the use of WPRT may become widespread for certain subsets of men. Thus, our findings could help guide how we counsel patients deciding between WPRT and PORT and suggest the need for prospective assessment of SM risk with WPRT and PORT.

Common iliac node positive prostate cancer treated with curative radiotherapy: N1 or M1a?

PURPOSE

Common iliac (CI) nodes are staged as (oligo)metastatic M1a for prostate cancer. It is unclear if outcomes of pelvic node-positive (cN1) differ from CI node-positive (CI-M1a) prostate cancer after curative treatment. Present study compares outcomes in these patients treated with radical whole pelvic radiotherapy and long-term ADT.

MATERIALS AND METHODS

Patients with node positive adenocarcinoma prostate were identified, either CI-M1a or cN1, from a prospectively maintained database. Over 75% of these patients were staged with Ga68PSMA-PETCT at diagnosis. All patients received long-term ADT and moderately or extremely hypofractionated radiotherapy to the prostate and pelvis including the CI region. At biochemical failure (BCF), restaging was done with Ga68PSMA-PETCT to establish the patterns of failure. CI-M1a cohort was classified as proximal or distal CI nodal location and studied for outcomes.

RESULTS

Of the 130 patients analyzed, 87 had cN1 and 43 had CI-M1a stage. Median duration of ADT before RT was 7 months and total duration was atleast 24 months. Majority (65%) had Gleason grade group IV-V while 75% had ≥T3 disease. After a median FU of 61 months, BCF in the 2 groups were similar, cN1, 21/87 (24.1%); CI-M1a, 11/43 (25.6%), p=0.86. At BCF, restaging Ga68-PSMA-PET-CT located distant metastases in 20 (63%) of the 32 patients (57% in cN1, and 73% in CI-M1a, p=0.47). Five-year biochemical failure-free survival (cN1; 77.4% and CI-M1a; 70.4%, p=0.43), distant metastasis-free survival (cN1; 86.9% and CI-M1a; 79.4%, p=0.23) and overall survival (cN1 92.6% and CI-M1a 90.1%, p=0.80) were similar in the two groups. Outcomes within CI-M1a were similar for proximal versus distal CI nodal location, 5-year BFFS 73.6% vs 58.6% (p=0.81).

CONCLUSION

Oligometastatic CI-M1a and cN1 prostate cancer patients showed similar outcomes when treated with curative whole pelvic radiotherapy and long-term ADT. The treatment for these 'oligometastatic' patients should be prospectively evaluated and optimized accordingly.