Multi-Institutional Clinical Outcomes of Biopsy Gleason Grade Group 5 Prostate Cancers Treated With Contemporary High-Dose Radiation and Long-Term Androgen Deprivation Therapy

AIMS

This multicentric retrospective study reports long-term clinical outcomes of non-metastatic grade group 5 prostate cancers treated with external beam radiotherapy (EBRT) alone with long-term androgen deprivation therapy (ADT).

MATERIALS AND METHODS

Patients treated across 19 institutions were studied. The key endpoints that were evaluated were 5-year biochemical recurrence-free survival (bRFS), metastases-free survival (MFS), overall survival, together with EBRT-related acute and late toxicities. The impact of various prognostic factors on the studied endpoints was analysed using univariate and multivariate analyses.

RESULTS

Among the 462 patients, 88% (405) had Gleason 9 disease and 31% (142) had primary Gleason pattern 5. A prostate-specific membrane antigen positron emission tomography-computed tomography scan was used for staging in 33% (153), 80% (371) were staged as T3/T4 and 30% (142) with pelvic nodal disease. The median ADT duration was 24 months; 66% received hypofractionated EBRT and 71.4% (330) received pelvic nodal irradiation. With a median follow-up of 56 months, the 5-year bRFS, MFS and overall survival were 73.1%, 77.4% and 90.5%, respectively. Primary Gleason pattern 5 was associated with worse bRFS, MFS and overall survival with hazard ratios of 0.51 (95% confidence interval 0.35 to 0.73, P < 0.001), 0.64 (95% confidence interval 0.43 to 0.96, P = 0.031) and 0.52 (95% confidence interval 0.28 to 0.97, P = 0.040), respectively, whereas pelvic nodal disease was associated with worse bRFS (hazard ratio 0.67, 95% confidence interval 0.46 to 0.98, P = 0.039) and MFS (hazard ratio 0.56, 95% confidence interval 0.37 to 0.85, P = 0.006). The acute and late radiation-related toxicities were low overall and pelvic nodal irradiation was associated with higher toxicities.

CONCLUSION

Contemporary EBRT and long-term ADT led to excellent 5-year clinical outcomes and low rates of toxicity in this cohort of non-metastatic grade group 5 prostate cancers. Primary Gleason pattern 5 and pelvic node disease portends inferior clinical 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.

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.

Acute and late toxicity of prostate-only or pelvic SBRT in prostate cancer: A Comparative Study

OBJECTIVE

To compare the urinary and gastrointestinal toxicity with or without the inclusion of pelvic nodal regions in patients treated with extreme hypofractionated stereotactic radiotherapy (SBRT) for prostate cancer.

METHODS

Patients treated with definitive SBRT for non-metastatic adenocarcinoma prostate were identified from prospectively maintained institutional database, and details of radiotherapy volume, dose, acute and late adverse effects were analyzed. Symptoms of acute (within 90 days of completing SBRT) and late gastrointestinal and urinary toxicities were graded using CTCAE version 5.0. Each symptom was scored according to the worst reported grading during treatment and follow-up period. Cumulative toxicity rates between prostate-only SBRT (PO-SBRT) and whole pelvic SBRT (WP-SBRT) were compared using chi-square test.

RESULTS

Total 220 patients were analyzed (PO-SBRT=118, WP-SBRT=102), with a median follow-up of 28 months (IQR 14-40). Most patients had locally advanced disease (PO-SBRT 60% high risk and 40% intermediate risk, WP-SBRT 79% node positive and 21% high risk). Median SBRT dose was 36.25Gy (IQR 35-36.25) to the prostate (EQD2=90.6Gy, a/b=1.5Gy) and simultaneous integrated 25Gy to the pelvis (EQD2=46.3Gy) in five fractions on alternate days. No grade 3-4 acute toxicities were observed except one grade 3 urinary obstruction (PO-SBRT). WP-SBRT was associated with significantly higher acute grade 2 gastrointestinal toxicity (29.4% vs 14.7%, p=0.008) and late grade 2 urinary toxicity (45.6% vs 25.0%, p=0.003). Both the groups had low incidence of late grade 3 toxicities (urinary 2.5%, gastrointestinal 1%).

CONCLUSION

WP-SBRT was associated with significantly higher acute gastrointestinal and late urinary toxicity as compared to PO-SBRT, though overall incidence of severe toxicity was low.

Locoregional recurrence after cystectomy in muscle invasive bladder cancer: Implications for adjuvant radiotherapy

PURPOSE

We report the patterns of locoregional recurrence (LRR) in muscle invasive bladder cancer (MIBC), and propose a risk stratification to predict LRR for optimizing the indication for adjuvant radiotherapy.

MATERIALS AND METHODS

The study included patients of urothelial MIBC who underwent radical cystectomy with standard perioperative chemotherapy between 2013 and 2019. Recurrences were classified into local and/or cystectomy bed, regional, systemic, or mixed. For risk stratification modelling, T stage (T2, T3, T4), N stage (N0, N1/2, N3) and lymphovascular invasion (LVI positive or negative) were given differential weightage for each patient. The cohort was divided into low risk (LR), intermediate risk (IR) and high risk (HR) groups based on the cumulative score.

RESULTS

Of the 317 patients screened, 188 were eligible for the study. Seventy patients (37.2%) received neoadjuvant chemotherapy (NACT) while 128 patients (68.1%) had T3/4 disease and 66 patients (35.1%) had N+ disease. Of the 55 patients (29%) who had a recurrence, 31 (16%) patients had a component of LRR (4% cystectomy bed, 11.5% regional 0.5% locoregional). The median time to LRR was 8.2 (IQR 3.3-18.8) months. The LR, IR and HR groups for LRR based on T, N and LVI had a cumulative incidence of 7.1%, 21.6%, and 35% LRR, respectively. The HR group was defined as T3, N3, LVI positive; T4 N1/2, LVI positive; and T4, N3, any LVI. The odds ratio for LRR was 3.37 (95% CI 1.16-9.73, P = 0.02) and 5.27 (95% CI 1.87-14.84, P = 0.002) for IR and HR respectively, with LR as reference.

CONCLUSION

LRR is a significant problem post radical cystectomy with a cumulative incidence of 35% in the HR group. The proposed risk stratification model in our study can guide in tailoring adjuvant radiotherapy in MIBC.

Prostate-Only Versus Whole-Pelvic Radiation Therapy in High-Risk and Very High-Risk Prostate Cancer (POP-RT): Outcomes From Phase III Randomized Controlled Trial

PURPOSE

We report the clinical outcomes of a randomized trial comparing prophylactic whole-pelvic nodal radiotherapy to prostate-only radiotherapy (PORT) in high-risk prostate cancer.

METHODS

This phase III, single center, randomized controlled trial enrolled eligible patients undergoing radical radiotherapy for node-negative prostate adenocarcinoma, with estimated nodal risk ≥ 20%. Randomization was 1:1 to PORT (68 Gy/25# to prostate) or whole-pelvic radiotherapy (WPRT, 68 Gy/25# to prostate, 50 Gy/25# to pelvic nodes, including common iliac) using computerized stratified block randomization, stratified by Gleason score, type of androgen deprivation, prostate-specific antigen at diagnosis, and prior transurethral resection of the prostate. All patients received image-guided, intensity-modulated radiotherapy and minimum 2 years of androgen deprivation therapy. The primary end point was 5-year biochemical failure-free survival (BFFS), and secondary end points were disease-free survival (DFS) and overall survival (OS).

RESULTS

From November 2011 to August 2017, a total of 224 patients were randomly assigned (PORT = 114, WPRT = 110). At a median follow-up of 68 months, 36 biochemical failures (PORT = 25, WPRT = 7) and 24 deaths (PORT = 13, WPRT = 11) were recorded. Five-year BFFS was 95.0% (95% CI, 88.4 to 97.9) with WPRT versus 81.2% (95% CI, 71.6 to 87.8) with PORT, with an unadjusted hazard ratio (HR) of 0.23 (95% CI, 0.10 to 0.52; P < .0001). WPRT also showed higher 5-year DFS (89.5% v 77.2%; HR, 0.40; 95% CI, 0.22 to 0.73; P = .002), but 5-year OS did not appear to differ (92.5% v 90.8%; HR, 0.92; 95% CI, 0.41 to 2.05; P = .83). Distant metastasis-free survival was also higher with WPRT (95.9% v 89.2%; HR, 0.35; 95% CI, 0.15 to 0.82; P = .01). Benefit in BFFS and DFS was maintained across prognostic subgroups.

CONCLUSION

Prophylactic pelvic irradiation for high-risk, locally advanced prostate cancer improved BFFS and DFS as compared with PORT, but OS did not appear to differ.

Fish and broiler optimal harvesting models in imprecise environment

In this paper, a two-species harvesting model has been considered and developed a solution procedure which is able to calculate the equilibrium points of the model where some biological parameters of the model are interval numbers. A parametric mathematical program is formulated to find the biological equilibrium of the model for different values of parameters. This interval-valued problem is converted into an equivalent crisp model using interval mathematics. The main advantage of the proposed procedure is that different characteristics of the model can be presented in a single framework. Analytically, the existence of steady state and stabilities are looked into. Using mathematical software, the model is illustrated and the results are obtained and presented in tabular and graphical forms.

Quantitation of pulmonary emboli with pulmonary cineangiography: preliminary report

Pulmonary angiography is considered the definite method of diagnosing pulmonary emboli. It is hypothesized that pulmonary cineangiography is superior to conventional pulmonary angiography for quantitation of pulmonary emboli. The present study was undertaken to test the hypothesis. Six patients with an age range from 27 to 70 years with documented pulmonary emboli by pulmonary angiogram, had pulmonary cineangiograms. Pulmonary angiogram defined pulmonary emboli in nine major vessels in the six patients; while, pulmonary cineangiogram revealed another 10 major vessels with pulmonary emboli, which were either not detected or considered equivocal by the conventional pulmonary angiography. The pulmonary embolic score as an index of the extent of pulmonary emboli was 24 (mean 4 +/- 2.52 1SD) by the conventional pulmonary angiography, while the score was 60 (mean 10 +/- 3.22 1SD) by the pulmonary cineangiography, P less than 0.2. Thus, in cases with pulmonary emboli, pulmonary cineangiogram is superior to conventional pulmonary angiogram for the quantitation of pulmonary emboli.

Effect of physical training on exercise hemodynamics in patients with stable coronary artery disease. The use of impedance cardiography

Seventeen consecutive patients with stable coronary artery disease with a previous history of myocardial infarction were studied for evaluation of the effect of physical training on exercise hemodynamics. The patients were divided into two groups: Group A (n = 10), the control group and Group B (n = 7), the rehabilitated group. Patients in Group B had physical training for five months. The mean exercise time in Group B (trained group) was significantly greater than in Group A (17.0 +/- 3.3 vs 11.6 +/- 3.2, p less than 0.01). Cardiac output was measured by impedance cardiography. The resting hemodynamic parameters were not statistically different between the two groups. At sub-maximal levels of exercise, the blood pressure X heart rate product was the same in both groups. At maximal workload, the heart rate X blood pressure product was the same in both groups, while the cardiac output was significantly greater in Group B compared to Group A (16.0 +/- 5.7 vs 12.1 +/- 3.2 1/min, p less than 0.001). These results suggest that physical training may improve cardiac function during exercise.