Abstract PD9-03: Genomic analysis of the CALGB 40603 (Alliance) neoadjuvant trial in TNBC identifies immune features associated with pathological complete response and event-free survival

Purpose: CALGB (now part of the Alliance for Clinical Trials in Oncology) 40603 was a randomized Phase II study investigating pathological complete response rates (pCR) in triple-negative breast cancer (TNBC) patients receiving neoadjuvant weekly paclitaxel followed by doxorubicin and cyclophosphamide +/- bevacizumab and/or carboplatin for which 5-year event-free survival (EFS) results are now available. This is a valuable resource to characterize clinical and genomic features associated with response and survival. Methods: Clinical parameters and pre-treatment tumor biopsy RNA-sequencing (RNAseq) from 295 TNBC patients were analyzed to identify features associated with pCR and/or EFS. A panel of 689 previously published gene expression signatures were evaluated to provide insights regarding potential associations between clinical endpoints and genomically determined cell types and signaling pathway activities. Additionally, B cell receptor (BCR) and T cell receptor (TCR) sequences were examined, and repertoire abundance, richness, and diversity measures were calculated to investigate correlations with pCR and EFS status. Univariate Mann-Whitney U-Tests were used for continuous variables, and Fisher’s test was used for categorical features, with unadjusted p-values < 0.05 designated as significant. Results: While the addition of bevacizumab and carboplatin each significantly improved pCR rates, neither improved EFS. We examined outcomes according to race and no differences were seen for either pCR rate or EFS. 131 features, including high proliferation and multiple interferon signatures were significantly associated with pCR, but not with EFS. Alternatively, 69 features, including clinical factors for T stage and node status, were prognostic for EFS, but not significantly associated with pCR. Nevertheless, pCR itself was the strongest predictor of EFS, and was the only feature significantly associated with EFS after adjusting for multiple comparisons (Benjamini-Hochberg False Discovery Rate = 6.7e-3). In total, 52 genomic features were significantly correlated with both pCR and EFS, 44 of which were features of the immune microenvironment. Immune associated features included signatures of T cells, B cells and NK cells, immune checkpoint pathways (PD-1, PD-L1, CTLA4), and antigen presentation (dendritic cells, MHC-I, MHC-II). In particular, low BCR evenness, which is a measure of uniformity of unique BCR sequence abundance, was strongly associated with both pCR and EFS, suggesting that an antigen-specific adaptive immune response with clonally selected B cells is occurring in patients that have improved response and survival. Furthermore, a multivariate Cox Proportional Hazards model assessing BCR evenness along with age, T stage, N stage, grade and pCR found BCR evenness to be an independent prognostic feature for EFS in TNBC. Conclusions: Evidence of distinct predictors of pCR and EFS in TNBC patients treated with neoadjuvant chemotherapy suggests that, while pCR is still the strongest prognostic feature, high expression of many immune related gene expression signatures in pretreatment tumor samples are promising biomarkers of improved EFS. In addition to the important role of T cells in an anti-tumor response, these data show high IgG expression and evidence of B cell clonal selection associates with improved response and survival, supporting an important role for B cells in the adaptive response that portends a long-term benefit of chemotherapy in TNBC. Support: U10CA180821, U10CA180882, U24CA196171, P50-CA58223, Genentech, and The Breast Cancer Research Foundation. https://acknowledgments.alliancefound.org; ClinicalTrials.gov Identifier: NCT00861705

Citation Format: Jonathan H Shepherd, Terry Hyslop, Cheng Fan, Aranzazu Fernandez Martinez, Joel Parker, Katherine Hoadley, Zhiyuan Hu, Yun Li, Matthew Soloway, Patricia Spears, Ann Partridge, William Sikov, Lisa A Carey, Charles M Perou. Genomic analysis of the CALGB 40603 (Alliance) neoadjuvant trial in TNBC identifies immune features associated with pathological complete response and event-free survival [abstract]. In: Proceedings of the 2020 San Antonio Breast Cancer Virtual Symposium; 2020 Dec 8-11; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2021;81(4 Suppl):Abstract nr PD9-03.

BlackOPs: increasing confidence in variant detection through mappability filtering

Identifying variants using high-throughput sequencing data is currently a challenge because true biological variants can be indistinguishable from technical artifacts. One source of technical artifact results from incorrectly aligning experimentally observed sequences to their true genomic origin ('mismapping') and inferring differences in mismapped sequences to be true variants. We developed BlackOPs, an open-source tool that simulates experimental RNA-seq and DNA whole exome sequences derived from the reference genome, aligns these sequences by custom parameters, detects variants and outputs a blacklist of positions and alleles caused by mismapping. Blacklists contain thousands of artifact variants that are indistinguishable from true variants and, for a given sample, are expected to be almost completely false positives. We show that these blacklist positions are specific to the alignment algorithm and read length used, and BlackOPs allows users to generate a blacklist specific to their experimental setup. We queried the dbSNP and COSMIC variant databases and found numerous variants indistinguishable from mapping errors. We demonstrate how filtering against blacklist positions reduces the number of potential false variants using an RNA-seq glioblastoma cell line data set. In summary, accounting for mapping-caused variants tuned to experimental setups reduces false positives and, therefore, improves genome characterization by high-throughput sequencing.

Abstract 3939: Integrated genomic analysis of head and neck tumors reveals focal high-level copy number gains in chr11q13 are associated with increased expression of known regional oncogenes

Background: Head and neck squamous cell carcinoma (HNSCC) is a complex and heterogeneous disease for which the underlying genomic aberrations are unknown. Previous studies have suggested that chr11q13 is a region of interest in HNSCC. Independent studies suggest that genes from this region may be important – for example, CTTN, CCND1, MYEOV, and ANO1 – but to our knowledge no studies have focused on the integration of copy number data and potential targets, or investigated the prevalence of copy number aberrations (CNAs) and clinical covariates. Human papillomavirus-associated HNSCC (HPV-HNSCC) is of particular interest, and it is known that HPV-HNSCC is most commonly found in the oropharynx. However, to our knowledge no studies have examined the association between CNAs of chr11q13 and patient outcome for patients with oropharynx tumors.

Techniques: After receiving informed consent, we obtained tumor samples from an incident surgical series of HNSCC patients at the University of North Carolina Hospital. Copy number (CN) and gene expression (GE) assays were performed using Affymetrix Genome-Wide SNP6.0 and Agilent 44K Gene Expression platfoms, respectively. CN values were subsequently analyzed for amplifications in region of chr11q13 using an amplification threshold equivalent to at least a 50% increase in copy number.

Results: Samples from 162 patients were obtained, making this the largest genomic HNSCC series ever reported to our knowledge. After passing quality control on both platforms, CN, GE, and clinical data was available for 86 patients in the integrated analysis. Data from the remaining 76 samples was also reviewed, and for these samples either CN, GE, or clinical information is available. We estimate that amplifications of chr11q13 are found in approximately 30% of all HNSCC patients. The consensus region covers seven genes, and four of these genes – CTTN, CCND1, MYEOV, and ANO1 – have expression values that are statistically significantly correlated with copy number, supporting existing literature both for the region and these genes. If attention is restricted to patients with oropharynx tumors, we find that patients with chr11q13 amplifications have an increased risk of recurrence or death when compared to patients without chr11q13 amplifications. These amplifications are highly overlapping with smoking status in oropharynx patients, suggesting a potential mechanism for the worse outcome seen in HPV positive smokers relative to nonsmokers (N Eng J Med 2007;356:1944-1956).

Conclusion: Integrated genomic analysis unmasks frequent copy number gains in chr11q13. Copy number values in chr11q13 are associated with expression of known regional oncogenes. We suggest a potential explanation for the worse clinical outcomes seen in HPV positive smokers.

Citation Format: {Authors}. {Abstract title} [abstract]. In: Proceedings of the 102nd Annual Meeting of the American Association for Cancer Research; 2011 Apr 2-6; Orlando, FL. Philadelphia (PA): AACR; Cancer Res 2011;71(8 Suppl):Abstract nr 3939. doi:10.1158/1538-7445.AM2011-3939

Aberrant promoter methylation in serum of prostate cancer patients and controls

e16046

Background: The current screening method for prostate cancer (PC), which is based on prostate specific antigen (PSA) level lacks specificity and sensitivity. Previous studies have reported that increased levels of free circulating DNA (fcDNA) and hypermethylation of genes are associated with several cancers. In this study we evaluated the use of fcDNA level and aberrant promoter methylation of 4 genes in serum as biomarkers for PC. Methods: 89 PC patients, 59 with prostatitis (PT) and 104 with benign prostatic hyperplasia (BPH) were enrolled. Serum DNA was analyzed for methylation of GSTPi, RARB, RASSF1A and ECAD by methylation-specific PCR. FcDNA level was analyzed by quantitative PCR. We examined the effect of methylation and fcDNA on PC risk by fitting two logistic regression models, one comparing PC vs BPH and PT vs BPH and the other comparing PC vs PT+BPH. Models were adjusted for age, race, and log2PSA, and tested for variation in effect of methylation by race. Similar analyses assessed the effect of fcDNA as continuous variable, after log2 transformation, and as dichotomous variable with cutpoint near the upper quartile for BPH controls. Results: When adjusted for age and log2PSA, positive GSTPi methylation was associated with increased risk of PC in whites (OR = 6.11, p < 0.001, PC vs BPH; OR = 3.93, p = 0.001, PC vs BPH + PT). Methylation of RARB was associated with PT independent of race (OR = 2.85, p = 0.032, PT vs BPH). Patients with fcDNA ≥180ng/ml were at twice the risk of PC compared to those with levels <180ng/ml, and this result did not vary by race. Models including both GSTPi and fcDNA confirmed the independent effect of these two factors in whites (high fcDNA OR = 3.77, p = 0.002, positive GSTPi methylation OR = 5.41, p < 0.001, PC v. BPH + PT). Although high fcDNA also increased risk of PC in blacks, the effect was not statistically significant (OR = 1.91, p = 0.189, PC vs BPH + PT). Conclusions: Our results suggest that aberrant promoter methylation of GSTPi in serum is a potential biomarker for prostate cancer in whites. Level of fcDNA in serum also appears to be an independent diagnostic marker in whites.

No significant financial relationships to disclose.

Renal cell carcinoma invading the hepatic veins

BACKGROUND

Hepatic vein invasion by renal cell carcinoma with inferior vena cava tumor thrombus is relatively uncommon. The Budd-Chiari syndrome that results from obstruction of the suprahepatic venous drainage by the tumor could evolve toward liver fibrosis and death. Early diagnosis and surgical treatment of this condition is of prime importance. Complete mobilization of the liver and rotation of the inferior vena cava enhances exposure of the ostium of the hepatic veins. This maneuver allows for the complete removal of tumor from the hepatic veins and decompression of the liver.

METHODS

Between May 1997 and April 2000, four patients with renal cell carcinoma and inferior vena cava thrombus with hepatic vein invasion underwent surgery at the study institution. Three of the patients had Budd-Chiari syndrome. Surgical techniques were developed to handle these difficult tumors safely.

RESULTS

Three patients presented with the Budd-Chiari syndrome, one of whom was found to have severe liver failure before surgery. The fourth patient presented with a hepatic vein tumor thrombus. A caval atrial thrombus and hepatic vein thrombus in one patient were removed successfully without opening the chest. Three patients required cardiopulmonary bypass. Hypothermic arrest was required in one patient. At the time of last follow-up, 2 patients were alive at 14 months and 30 months after surgery, respectively, without recurrence. One patient died 6 months after surgery due to metastatic renal carcinoma and 1 patient who had prior severe liver failure died of multiple organ failure 2 weeks after undergoing surgery. None of the four patients required reoperation.

CONCLUSIONS

Prompt surgical treatment should be performed to avoid hepatic failure and disease progression. The surgical technique described in the current study allowed for removal of the tumor from the hepatic veins and the authors believe it can be used with cardiopulmonary bypass to enhance visibility of the hepatic veins.

Intraoperative T staging in radical retropubic prostatectomy: is it reliable?

OBJECTIVES

During radical prostatectomy, wide local excision of the lateral prostatic fascia and neurovascular bundle on the ipsilateral side of the tumor is advocated if nerve sparing is likely to result in a positive surgical margin. Our intent was to validate whether intraoperative T staging can predict the presence of positive surgical margins and aid in the decision of whether to perform nerve-sparing prostatectomy.

METHODS

One surgeon performed 100 consecutive radical prostatectomies, and one pathologist interpreted the pathologic findings. Topographic distribution of tumor within the specimen was assessed intraoperatively by palpation. The margin status was similarly assessed. This tactile clinical impression was compared with the final pathologic findings.

RESULTS

The surgical margins were positive in 39 (39%) of 100 cases. The intraoperative assessment of the margin status had a high false-negative rate and a sensitivity of only 7%. However, the specificity was 96%, because few margins were falsely positive. The overall accuracy was 62%, with a negative predictive value of 62%. The sensitivity of the intraoperative assessment of tumor location was 73%, and the positive predictive value was 65%.

CONCLUSIONS

The results of our study indicate that the intraoperative assessment of the margin status is not accurate and thus cannot help determine which patients require excision of the neurovascular bundle. We believe the decision to preserve the neurovascular bundle should be based on the preoperative prognostic factors and the presence of an intact capsule covering the region of the gland adjacent to this structure.

Casodex 10-200 mg daily, used as monotherapy for the treatment of patients with advanced prostate cancer. An overview of the efficacy, tolerability and pharmacokinetics from three phase II dose-ranging studies. Casodex Study Group

OBJECTIVES

To evaluate the efficacy, tolerability, endocrinological effects and the pharmacokinetics of Casodex, when given as monotherapy during daily dosing of 10-200 mg to patients with advanced prostate cancer.

METHODS

A total of 390 patients with advanced prostate cancer were treated for a minimum of 12 weeks with a daily monotherapy dose of Casodex. The doses ranged from 10 to 200 mg. Objective assessments of efficacy included: review of measurable metastases, prostate dimension, prostatic acid phosphatase and prostate-specific antigen (PSA) levels. Subjective assessments of efficacy included review of urological symptoms, performance status, bone scan and analgesic requirement. Pharmacokinetic samples were taken at various time points up to 3 months, and assayed using an achiral HPLC method.

RESULTS

Clear objective responses were observed, particularly at doses of 50 mg and above. Specifically, the median percentage decrease in PSA at 50 mg was 90.0%, and at 100 and 200 mg it was 93.4 and 94.8%, respectively. Up to 53% of symptomatic patients demonstrated a subjective response at 3 months. Casodex was well tolerated at all doses with no effect on haematological or cardiovascular parameters and no effect on renal function. The expected pharmacological effects of potent antiandrogen therapy, such as breast tenderness (58%), gynaecomastia (48%), and hot flushes (17%), were reported, but these incidences reflected the direct eliciting of these events. The intrinsic efficacy of Casodex was demonstrated despite increases of 60% in testosterone levels. However, this increase reached a plateau after 4-12 weeks of therapy, but the majority of values remained within the normal range. Casodex has a half-life of approximately 1 week, enabling once-daily dosing with no effect of age or renal impairment on its pharmacokinetics.

CONCLUSION

Casodex has a favourable side effect profile compared with the known safety profiles of other antiandrogens and has demonstrated intrinsic efficacy. Casodex warrants further investigation as a monotherapy for the management of advanced prostate cancer.

The use of liver transplant techniques to aid in the surgical management of urological tumors

PURPOSE

Inferior vena cava tumor thrombus complicates radical nephrectomy. Various approaches have been used to deal with this problem, including venovenous and cardiopulmonary bypass. Applying organ transplant techniques enhances the exposure of urological tumors and may avoid bypass.

MATERIALS AND METHODS

A total of 26 patients underwent surgery by techniques developed to facilitate orthotopic liver transplantation. Of the patients 15 with renal cell carcinoma and an intracaval tumor thrombus underwent piggyback style mobilization of the liver off of the retrohepatic inferior vena cava to allow enhanced access and vascular control, while 11 underwent conventional mobilization of the liver and retrohepatic inferior vena cava en bloc to allow enhanced access to various renal, adrenal and retroperitoneal tumors.

RESULTS

In the 11 patients surgery was successful with a median blood loss of 200 ml. Postoperative ileus in 1 case was the only complication. We resected 5 infrahepatic thrombi without complications and with a median blood loss of 500 ml. In 7 patients with a retrohepatic inferior vena caval thrombus median blood loss was 1,500 ml., including 1 who died postoperatively, presumably due to a massive pulmonary embolus. Caval atrial tumor thrombus in 3 cases was successfully removed via a completely abdominal approach and sternotomy in 2. Cardiopulmonary bypass with hypothermic circulatory arrest was required in 1 of these cases.

CONCLUSIONS

Liver mobilization was helpful for managing difficult urological tumors. Patients with a retrohepatic or even suprahepatic inferior vena caval thrombus may be treated without sternotomy or thoracotomy and cardiopulmonary bypass.

Assessment of endpoints for clinical trials for localized prostate cancer

OBJECTIVES

The AUA Practice Guidelines Panel convened to address the issue of appropriate endpoints for assessment of treatment modalities for localized carcinoma of the prostate.

METHODS

A review of the literature and the design of existing clinical trials produced a consensus, which was presented to and critiqued by the members of the general conference.

RESULTS

The pitfalls associated with identification of local failure endpoints were discussed, and the more accurate endpoints of freedom from metastatic progression and overall survival were recognized. The strict definition that must be fulfilled for intermediate endpoints to become surrogates for metastasis free and/or survival endpoints was stressed. For more efficient and rapid conduct of future clinical trials, the urgent need to validate such surrogate endpoints by evaluation in randomized control trials is obvious. PSA, while an indicator of disease activity and a critical marker for estimating disease progression or regression in response to therapy, is not a surrogate for metastasis free or overall survival.

CONCLUSION

Until surrogate endpoints are validated, the committee has evaluated the endpoints in current use, reviewed their limitations, and stressed the importance of quality-of-life assessment together with the traditional endpoint assessment.

PSA levels and the rate of positive surgical margins in radical prostatectomy specimens preceded by androgen blockade in clinical B2 (T2bNxMo) prostate cancer. The Lupron Depot Neoadjuvant Study Group

OBJECTIVES

Neoadjuvant hormonal therapy reduces positive margins in patients undergoing radical prostatectomy. All patients experience a decrease in serum prostate specific antigen (PSA), but not always to a level that is nondetectable. The results of several prospective, randomized trials indicate that the incidence of positive margins decreases with the use of androgen deprivation prior to radical prostatectomy. It has been suggested that a greater decline in PSA levels would result in fewer positive margins. In a recent US trial of patients with T2bNxMO prostate cancer, we reported that 18% of patients randomized to receive 3 months of leuprolide acetate and flutamide had positive margins, compared to 48% of those who had radical prostatectomy alone (P < 0.001). We correlated the PSA levels prior to and following androgen deprivation and the presence of a positive margin following radical prostatectomy (RP).

METHODS

One hundred and thirty-seven of 149 patients randomized to receive presurgery androgen deprivation (AD) underwent radical prostatectomy. Of these, 135 had a PSA level obtained both prior to androgen deprivation and prior to surgery. We analyzed the percent positive margins in patients whose PSA values became undetectable and in those whose values remained above 0.1 ng/mL despite androgen deprivation.

RESULTS

Eight of 43 patients (19%) with a nadir PSA < or = 0.1 ng/mL had a positive surgical margin and 16/92 (17%) with a nadir PSA > 0.1 ng/mL had tumor at the margin. There were no statistical differences in these two groups (P = 1.0 by Fisher's Exact Test [two-tailed], and the Pearson correlation was -0.015).

CONCLUSIONS

There was no correlation between an undetectable PSA and a PSA > 0.1 ng/mL and the presence of tumor at the margin when 3 months of AD was given prior to RP. It is possible that longer periods of AD prior to RP will reduce PSA to an undetectable level in a higher percent of patients. However, these data suggest that an undetectable level will not result in less positive margins.

Maximal androgen blockade for patients with metastatic prostate cancer: outcome of a controlled trial of bicalutamide versus flutamide, each in combination with luteinizing hormone-releasing hormone analogue therapy. Casodex Combination Study Group

OBJECTIVES

To review the outcome of therapy with maximal androgen blockade and compare the efficacy and safety of bicalutamide and flutamide, each used in combination with luteinizing hormone-releasing hormone analogue (LHRH-A) therapy, in patients with untreated metastatic (Stage D2) prostate cancer.

METHODS

Randomized, double-blind (for antiandrogen therapy), multicenter study with a 2 x 2 factorial design. A total of 813 patients were allocated 1:1 to bicalutamide (50 mg once daily) or flutamide (250 mg three times daily), plus 2:1 to goserelin acetate (3.6 mg every 28 days) or leuprolide acetate (7.5 mg every 28 days).

RESULTS

At the time of analysis (median follow-up, 49 weeks), bicalutamide plus LHRH-A was associated with a statistically significant improvement in time-to-treatment failure, the primary endpoint, when compared with flutamide plus LHRH-A. The results with longer follow-up (median, 95 weeks) support previous findings of an improved time-to-treatment failure with bicalutamide plus LHRH-A; however, the difference between groups was not statistically significant. A treatment failure endpoint was reached by 68% of patients in the bicalutamide plus LHRH-A group, compared with 72% of patients in the flutamide plus LHRH-A group. The hazard ratio of bicalutamide plus LHRH-A to flutamide plus LHRH-A was 0.87 (95% confidence interval [CI], 0.74-1.03; P = 0.10). The upper one-sided 95% confidence limit for survival was 1.00, meeting the definition for equivalence (< 1.25). With longer follow-up, overall mortality was 34%, with equivalent survival between groups: 32% of patients in the bicalutamide plus LHRH-A group died, compared with 35% in the flutamide plus LHRH-A group. The hazard ratio of bicalutamide plus LHRH-A to flutamide plus LHRH-A was 0.88 (95% CI, 0.69-1.11; P = 0.29). The upper one-sided 95% confidence limit for survival was 1.07, meeting the definition for equivalence (< 1.25). Diarrhea occurred in 24% of patients in the flutamide plus LHRH-A group compared with 10% of patients in the bicalutamide plus LHRH-A group (P < 0.001).

CONCLUSIONS

In patients with metastatic prostate cancer, bicalutamide plus LHRH-A is effective and well tolerated. Because of its efficacy and tolerability profile, together with its convenient once-daily dosing formulation, bicalutamide represents a prime candidate for antiandrogen of first choice in combination with LHRH-A therapy in the treatment of men with metastatic prostate cancer.

Incidental prostatic adenocarcinoma in patients undergoing radical cystoprostatectomy for bladder cancer

To determine if patients with bladder cancer have a higher incidence of unsuspected prostate cancer, 40 cases were studied. All except one case had no evidence of prostate cancer on preoperative clinical assessment. Detailed pathological evaluation of cystoprostatectomy specimens with sections at 2- to 3-mm intervals was done. Adenocarcinoma of the prostate was identified in 18 of 40 patients (45%). Multifocal prostatic intraepithelial neoplasia (PIN) was present in 19 cases (47.5%); 4 (10%) without an associated prostate cancer and 15 (37.5%) in conjunction with adenocarcinoma of the prostate. Twelve cases of unsuspected prostate cancer were stage pT1a, 4 were pT1b, and 2 were pT3. No patients exhibited nodal or distance metastases by the prostate cancer. At a mean follow-up of 15.2 months (range 3-34 months), 37 of the 40 patients are alive. Among prostate cancer patients, no clinical or biochemical evidence of disease recurrence or prostate cancer related mortality has been observed. Our findings support the previously reported high incidence rate of prostate cancer in patients undergoing cystoprostatectomy for bladder cancer. This, though, may not be higher than the observed incidence in an age-matched general population. We recommend DRE and PSA as part of the bladder cancer workup in males, and complete removal of the prostate at cystoprostatectomy to prevent the dilemma of residual prostate cancer.

A controlled trial of bicalutamide versus flutamide, each in combination with luteinizing hormone-releasing hormone analogue therapy, in patients with advanced prostate cancer. Casodex Combination Study Group

OBJECTIVES

To compare the efficacy and safety of bicalutamide and flutamide, each used in combination with luteinizing hormone-releasing analogue (LHRH-A) therapy, in patients with untreated metastatic (Stage D2) prostate cancer.

METHODS

Randomized, double-blind (for antiandrogen therapy), multicenter study with a 2 x 2 factorial design. Eight hundred thirteen patients were allocated 1:1 to bicalutamide (50 mg once daily) and flutamide (250 mg three times daily) and 2:1 to goserelin acetate (3.6 mg every 28 days) and leuprolide acetate (7.5 mg every 28 days).

RESULTS

With a median duration of follow-up of 49 weeks, time to treatment failure, the primary endpoint, was significantly (P = 0.005) better for the bicalutamide plus LHRH-A group than for the flutamide plus LHRH-A group. Patients in the flutamide plus LHRH-A group were 34% more likely to fail treatment over the given time period, as indicated by the hazard ratio of 0.749 (95% confidence interval, 0.61 to 0.92) for bicalutamide plus LHRH-A to flutamide plus LHRH-A. Results for secondary endpoints (survival, quality of life, and subjective response) were similar between groups. Diarrhea occurred in 24% of patients in the flutamide plus LHRH-A group, compared with 10% of patients in the bicalutamide plus LHRH-A group (P < 0.001).

CONCLUSIONS

In patients with metastatic prostate cancer, bicalutamide plus LHRH-A is well tolerated and provides superior efficacy to flutamide plus LHRH-A with respect to time to treatment failure. Assessment of the effects of these regimens on longer term survival requires additional time for follow-up.

Treatment with finasteride following radical prostatectomy for prostate cancer

OBJECTIVES

The objective of this study was to evaluate the effect of finasteride (10 mg/d) or placebo on serum prostate-specific antigen (PSA) and recurrence rates in men with detectable PSA levels after radical prostatectomy.

METHODS

A total of 120 men, 48 to 89 years old, previously treated with radical prostatectomy for prostate cancer within the past 10 years, with serum PSA levels between 0.6 and 10.0 ng/mL, with no evidence of skeletal metastasis on bone scan, and with no previous androgen deprivation therapy, were treated with 10 mg finasteride or placebo in a double-blind fashion for 12 months. After the first year, all patients were treated with finasteride for an additional 12 months. Primary endpoints were serum PSA levels and recurrence rates defined as positive bone scan or positive biopsy.

RESULTS

Patients treated with finasteride had a delayed increase in serum PSA compared with placebo of approximately 9 months in the first year and 14 months by the end of the second year. Patients with baseline PSA levels less then 1.0 ng/mL had no significant increase in serum PSA during the 2 years of treatment. Fewer recurrences were observed in the finasteride group, but these differences were not statistically significant. Finasteride was well tolerated, and side effects were balanced between treatment groups.

CONCLUSIONS

The results of this study indicate that treatment with finasteride delays but does not prevent the rise in serum PSA observed in untreated patients with detectable PSA levels after radical prostatectomy. The reduction in local and distant recurrences in the finasteride group suggests that the effect on PSA reflects a direct effect on tumor growth without affecting the initial response to subsequent hormonal therapy. These data require confirmation by studies that are longer and larger, focused on demonstrating significant differences in progression rates and survival before the use of finasteride can be considered as an option for men with detectable PSA levels after radical prostatectomy.

A randomized, placebo-controlled multicenter study of the efficacy and safety of terazosin in the treatment of benign prostatic hyperplasia

The clinical manifestations of benign prostatic hyperplasia (BPH) are related primarily to bladder outlet obstruction resulting from enlargement of the prostate gland. Transurethral prostatectomy is the most common treatment currently offered for BPH in the United States. The primary objective of the present randomized placebo controlled multicenter study was to determine the efficacy and safety of terazosin, a selective long-acting alpha 1-blocker, for the treatment of symptomatic BPH. A total of 285 men with symptomatic BPH was randomly assigned in equal proportions to receive placebo, or 2, 5 or 10 mg. terazosin administered once daily. Of the patients 237 completed the 4-week single-blind placebo lead-in and 12-week double-blind treatment periods. The primary outcome parameters were changes in peak and mean urinary flow rates, and changes in the Boyarsky symptom scores. All terazosin treatment groups exhibited significantly greater decreases in total Boyarsky symptom score than the placebo group. The 10 mg. terazosin group exhibited significantly greater increases in peak and mean urinary flow rates than the placebo group. The improvements in symptom scores and urinary flow rates did not reach a plateau within the dose range evaluated, suggesting that further efficacy may be achieved with doses of terazosin exceeding 10 mg. This study unequivocally demonstrates the safety and efficacy of terazosin for the treatment of BPH. Selective alpha 1-blockade is likely to gain widespread acceptance for the treatment of BPH due to its safety and efficacy.

The prognostic value of the pathological response to combination chemotherapy before cystectomy in patients with invasive bladder cancer. European Organization for Research on Treatment of Cancer--Genitourinary Group

The prognostic value of the pathological response to combination chemotherapy of deeply invasive transitional cell cancer of the bladder was retrospectively assessed in 147 patients. Data were collected from 8 different centers. Patients were eligible if they had received intravenous combination chemotherapy followed by partial, total or radical cystectomy, and if they had a minimum followup of 2 years after the start of chemotherapy. Of the patients 90% received methotrexate, vinblastine, doxorubicin and cisplatin (M-VAC) or cisplatin plus methotrexate for a median of 3 courses (range 1 to 6). Of the 83 patients who were alive at analysis actuarial median followup was 30.5 months (range 13.2 to 85.6 months). A major pathological response (stage P0, Pis, Pa or P1) was achieved in 41.5% of the patients. Patients with a major pathological response (p stage less than 2) had a 5-year survival of 75% in contrast to 20% for the remaining nonresponding patients (p stage 2 or more). The survival of patients with a major pathological response was independent of whether the response was induced by 2 or more courses of chemotherapy, or whether it was induced by M-VAC in comparison with cisplatin plus methotrexate. Preoperative clinical assessments can identify nonresponding patients correctly and in these cases alternative treatment programs are required, since 80% will die of the disease. Moreover, if neoadjuvant chemotherapy is proved to increase survival, the data emphasize the importance of the response rate of the primary tumor and the need to investigate the optimal number of courses to induce the best response, preferably in the individual patient.

Independent prognostic factors in patients with metastatic (stage D2) prostate cancer. The Zoladex Study Group

The independent prognostic factors affecting survival were assessed in 240 men undergoing treatment for metastatic prostate cancer as part of a randomized clinical trial comparing the gonadotropin releasing hormone analogue Zoladex (goserelin acetate implant) with castration. In a multivariate analysis, the most highly significant predictors were the presence or absence of bone pain, serum testosterone levels, serum alkaline phosphatase levels, and performance status. Patients with all four factors favorable for survival had a 2-year survival rate of 84% as compared with only 8% for patients with none of the four factors favorable for survival. No other factors were significant. A separate analysis of serum testosterone levels revealed that the higher the pretreatment serum testosterone level, the greater the survival rate. Compared with patients with serum testosterone levels less than 6.9 nmol/L, significant differences in survival were observed for patients with serum testosterone levels of 10.4 to 13.9, 13.9 to 17.3, and over 17.3 nmol/L. These results have important implications for the design and analysis of future clinical trials of hormone therapy and for counseling patients regarding the short-term prognosis of their disease.

'Acute on chronic' effect of depot leuprolide in patients with stage D2 cancer of prostate

During a phase III open study of depot leuprolide for stage D2 cancer of the prostate, we studied the effect of depot leuprolide on chronic leuprolide users. To determine whether there was a transient elevation of testosterone or luteinizing hormone (LH) 4-24 h and 3-5 days following the monthly injections, we monitored the changes of testosterone and LH before injection and 24 h post-injection in 10 patients who have been under depot leuprolide Rx for 24-36 weeks, and in 35 patients before injection and 3-5 days post-injection who have received depot leuprolide for 8-24 weeks prior to monitoring. Comparison of the data between pre-injection within 24 h and 3-5 days post-injection showed no significant changes of testosterone and LH values between these levels for either testosterone (P = 0.31) or LH (P = 0.45). We therefore conclude that there was no 'acute on chronic' effect of depot formulation in chronic users of depot leuprolide.

Clinical study of leuprolide depot formulation in the treatment of advanced prostate cancer. The Leuprolide Study Group

In a phase III, open, multicenter study we evaluated the safety and efficacy of the depot formulation of leuprolide (7.5 mg. injected intramuscularly every 4 weeks) in patients with stage D2 prostate cancer who had not previously received systemic treatment. Serum testosterone, luteinizing hormone and plasma leuprolide levels were monitored during the 24-week study period. Median interval to onset of castrate testosterone levels was 21 days and mean testosterone levels decreased to within the castrate range by week 3 of treatment. After onset of castrate levels there were no escapes (defined as 2 consecutive values of greater than 50 ng./dl.) of testosterone levels during the 24 weeks. Suppression of testosterone did not differ significantly from that observed in patients receiving the daily subcutaneous injection of leuprolide acetate in the first 24 weeks of another study. Objective response (no progression) to treatment occurred in 81% of 53 evaluable patients and adverse (related and unrelated) events were reported in 45 of the 56 patients. The response rate and incidence of adverse events in this study did not differ significantly from those occurring with the daily formulation. We conclude that the depot formulation of leuprolide is safe and effective in the treatment of advanced prostatic cancer, and that the safety and efficacy of this formulation do not differ significantly from those of the daily subcutaneous formulation.

Treatment of early prostate cancer

For the treatment of locally advanced prostate cancer, agents that induce androgen deprivation might be given several months prior to radical prostatectomy with the hope of reducing the size and extent of tumour prior to surgery.

Intravesical thiotepa versus mitomycin C in patients with Ta, T1 and TIS transitional cell carcinoma of the bladder: a phase III prospective randomized study

A prospective randomized clinical trial was conducted by the National Bladder Cancer Group to compare thiotepa and mitomycin C in ablating residual Ta, T1 and TIS transitional cell carcinoma of the bladder. Eight weekly instillations were given followed by cystoscopy 4 weeks after the treatment was stopped. The over-all complete response rate based on cystoscopy and either biopsy or cytology was 26 per cent for thiotepa versus 39 per cent for mitomycin C (p equals 0.08). The greatest efficacy was seen in the Ta group with mitomycin C demonstrating superiority over thiotepa. Patients with negative cystoscopy and biopsy but who had positive cytology were considered to be partial responders. When partial and complete responders were combined the over-all response rate was 53 per cent for thiotepa and 63 per cent for mitomycin C (p equals 0.23). Patients with TIS appeared to respond equally to thiotepa and mitomycin C. Toxicity included urinary frequency in 22 of the 73 patients in the thiotepa arm and 31 of the 76 patients receiving mitomycin C. A rash was observed in 2 of the thiotepa group versus 14 of the mitomycin C group. Bone marrow depression occurred in 15 patients receiving thiotepa and in 12 receiving mitomycin C.

Radical cystectomy in presence of fused "cake" kidney

Radical cystectomy is the optimal treatment for patients with invasive bladder cancer. The presence of a fused pelvic kidney is an uncommon congenital abnormality and when found in a patient with bladder cancer may alter the operative procedure. Herein we report on a patient presenting with invasive bladder cancer and a pelvic "cake" kidney.

Enhancement of high intensity Iodine-125 brachytherapy by cis-platinum in a murine bladder tumor model

The interaction of cis-platinum chemotherapy and high-intensity Iodine-125 brachytherapy was studied in C3H/He mice with MBT-2 tumors growing in the thigh. Brachytherapy was delivered by 3 Iodine-125 seeds of 10 mCi each implanted into the tumor. Ninety-six animals were randomly divided into 8 groups of 12 animals each. Each group was given either no treatment (control), cis-platinum alone or brachytherapy of 20, 40 or 50 Gy either alone or combined with cis-platinum. Cis-platinum 3 mg. per kg. was given every 5 days for 3 doses. The addition of cis-platinum enhanced the effects of Iodine-125 brachytherapy as shown by the end-points of tumor regrowth delay, local tumor control and median survival times. The sensitization enhancement ratio ranged from 1.2 to 1.9. Further experiments are to be conducted to study the normal tissue effect, therapeutic gain factor, effects of altering the time of administration of cis-platinum and the clinical use of high-intensity Iodine-125 for removable brachytherapy.

Fournier's syndrome: synergistic gangrene of the scrotum

Progressive spread of necrosis in the skin and subcutaneous tissues of the scrotum is the key feature of idiopathic scrotal gangrene. The disease may present initially as an acute abdomen, but laparotomy should be avoided. Usually an anaerobic Streptococcus is found, acting in synergism with aerobic, frequently gram-negative, bacilli. As in other synergistic gangrenes, wide dibridement with drainage of all sinus tracts is required. Although the testicles are frequently bared, they are usually not necrotic and should not be amputated. Once the infection has resolved, a surprising amount of skin coverage, including coverage of the testicles, can often be obtained from the scrotal remnants.