Systemic and tumor-directed therapy for oligometastatic prostate cancer: study protocol for a phase II trial for veterans with de novo oligometastatic disease

BACKGROUND

The treatment paradigm for metastatic hormone-sensitive prostate cancer (mHSPC) patients is evolving. PET/CT now offers improved sensitivity and accuracy in staging. Recent randomized trial data supports escalated hormone therapy, local primary tumor therapy, and metastasis-directed therapy. The impact of combining such therapies into a multimodal approach is unknown. This Phase II single-arm clinical trial sponsored and funded by Veterans Affairs combines local, metastasis-directed, and systemic therapies to durably render patients free of detectable disease off active therapy.

METHODS

Patients with newly-diagnosed M1a/b prostate cancer (PSMA PET/CT staging is permitted) and 1-5 radiographically visible metastases (excluding pelvic lymph nodes) are undergoing local treatment with radical prostatectomy, limited duration systemic therapy for a total of six months (leuprolide, abiraterone acetate with prednisone, and apalutamide), metastasis-directed stereotactic body radiotherapy (SBRT), and post-operative fractionated radiotherapy if pT ≥ 3a, N1, or positive margins are present. The primary endpoint is the percent of patients achieving a serum PSA of < 0.05 ng/mL six months after recovery of serum testosterone ≥150 ng/dL. Secondary endpoints include time to biochemical progression, time to radiographic progression, time to initiation of alternative antineoplastic therapy, prostate cancer specific survival, health related quality-of-life, safety and tolerability.

DISCUSSION

To our knowledge, this is the first trial that tests a comprehensive systemic and tumor directed therapeutic strategy for patients with newly diagnosed oligometastatic prostate cancer. This trial, and others like it, represent the critical first step towards curative intent therapy for a patient population where palliation has been the norm.

TRIAL REGISTRATION

Clinicaltrials.gov identifier: NCT03298087 (registration date: September 29, 2017).

Syringotropic cutaneous T-cell lymphoma: an immunophenotypic and genotypic study of five cases

There is uncertainty about the exact nosological relationship between mycosis fungoides, follicular mucinosis, syringolymphoid hyperplasia with alopecia (SLHA) and syringotropic cutaneous T-cell lymphoma (CTCL). We report the clinical, histological, immunophenotypic and genotypic characteristics of a series of five patients (three men and two women) with syringotropic CTCL. We also review the 15 cases of SLHA previously reported in the literature. We conclude that syringotropic CTCL is a distinct clinicopathological variant of mycosis fungoides which may present on its own with characteristic punctate erythema or more commonly in association with folliculotropic lesions. Syringotropic CTCL is characterized histologically by infiltration of sweat glands by atypical lymphocytes in association with syringolymphoid hyperplasia. Cases of SLHA represent a syringotropic form of CTCL in association with follicular involvement, and such cases need to be investigated using T-cell receptor gene analysis of both skin and blood. Only limited conclusions on prognosis can be derived from our preliminary data. However, a review of the literature suggests that the prognosis does not differ significantly from other types of mycosis fungoides of equivalent stage.

beta-Catenin expression in thyroid follicular lesions: potential role in nuclear envelope changes in papillary carcinomas

The morphologic distinction of benign and malignant thyroid follicular lesions can sometimes be challenging, therefore an immunohistochemical marker to aid in this distinction would be useful. beta-Catenin is one such potential marker. It is part of a membrane-bound cell growth-signaling complex that plays a role in cell adhesion, as well as in promotion of growth through activation of the Wnt signaling pathway. Oncogenic signaling occurs when beta-catenin is released, accumulates in the cytoplasm, translocates into the nucleus, and promotes transcription of genes including bcl-1 (cyclin D1) and c-myc that induce cell proliferation. Paraffin blocks from 133 thyroidectomy specimens were stained with monoclonal antibodies reactive with beta-catenin and cyclin D1. These included 53 cases of papillary thyroid carcinoma (PTC), 46 cases of follicular variant of papillary carcinoma (FVPC), 10 cases of follicular carcinoma (FC), and 24 cases of follicular adenoma (FA). Tissue from six normal thyroid specimens served as a control. The malignant lesions (PTC, FC, and FVPC) expressed strong cytoplasmic/nuclear staining and minimal residual membranous staining in 87%, 80%, and 71% of cases, respectively. In contrast, all normal thyroid tissue and 79% of FAs showed strong membranous reactivity with very minimal cytoplasmic staining. Interestingly, in 83% of PTC cases and 20% FVPCs, the intranuclear inclusions were distinctly beta-catenin positive. Cyclin D1 over expression correlated with cytoplasmic relocalization of beta-catenin in almost all cases, and no evidence of cyclin D1 gene amplification was observed. beta-Catenin can be of a diagnostic utility for thyroid lesions, because it highlights intranuclear inclusions in PTC, and shifts from a membranous localization to a cytoplasmic localization in malignant lesions. We speculate that the localization of beta-catenin in intranuclear inclusions may reflect a cytoskeletal remodeling activity of beta-catenin that is functionally significant for the PTC pathway.

Biological purging of breast cancer cells using an attenuated replication-competent herpes simplex virus in human hematopoietic stem cell transplantation

Autologous hematopoietic stem cell transplantation after myelosuppressive chemotherapy is used for the treatment of high-risk breast cancer and other solid tumors. However, contamination of the autologous graft with tumor cells may adversely affect outcomes. Human hematopoietic bone marrow cells are resistant to herpes simplex virus type 1 (HSV-1) replication, whereas human breast cancer cells are sensitive to HSV-1 cytotoxicity. Therefore, we examined the utility of G207, a safe replication-competent multimutated HSV-1 vector, as a biological purging agent for breast cancer in the setting of stem cell transplantation. G207 infection of human bone marrow cells had no effect on the proportion or clonogenic capacity of CD34+ cells but did enhance the proliferation of bone marrow cells in culture and the proportion of CD14+ and CD38+ cells. On the other hand, G207 at a multiplicity of infection of 0.1 was able to purge bone marrow of contaminating human breast cancer cells. Because G207 also stimulates the proliferation of human hematopoietic cells, it overcomes a limitation of other purging methods that result in delayed reconstitution of hematopoiesis. The efficient infection of human bone marrow cells in the absence of detected toxicity suggests that HSV vectors may also prove useful for gene therapy to hematopoietic progenitor cells.

Validation of an automated enzyme immunoassay for Interleukin-6 for routine clinical use

Serum levels of Interleukin-6 (IL-6), a proinflammatory cytokine, are increased in early stages of inflammatory diseases such as infection and sepsis. Assay systems which permit its measurement within a few hours and as a single measurement have not been reported so far. We therefore evaluated a now commercially available automated method for IL-6 measurement on the Cobas Core immunological analyzer (Roche Diagnostic Systems) which enables single IL-6 measurement within about 1 hour. The automated assay correlates well with an established, manual microtiter plate assay (Biosource GmbH) which uses the same antibodies and reagents (r=0.98). Accuracy of the automated method was established by adding known amounts of IL-6 international reference preparation. Recovery of the international standard was in the range of 92104%. The automated assay had a precision of singletons below 6% and was linear up to 2800 pg/ml. This automated assay provides a suitable, convenient and time saving method for measurement of IL-6 serum levels in the routine clinical laboratory.

Immunological markers of childhood fevers in an area of intense and perennial malaria transmission

In order to describe presumed paediatric malaria on a cell-immunological basis, the soluble receptors of IL-2 (sIL-2R) and tumour necrosis factor (sTNF-R55 and sTNF-R75) were quantified in highly exposed young Tanzanian children. Sera were obtained from 66 acute and 72 reported febrile patients during health post consultations and follow-ups and from 68 community controls. Levels of sIL-2R, sTNF-R55 and sTNF-R75 were significantly elevated during fever attacks, especially in very young children. Soluble TNF-R75 levels were most stable and those of sTNF-R55 least. Levels of sTNF-R55 were related to the magnitude of fever and thus appeared to reflect attack severity. Levels of sTNF-R75 were highly significantly associated with parasite density, indicating that this response is malaria-specific. The present study indicates that sTNF-R75 levels could become a useful immunological tool in malaria intervention studies, as they reflect changes in malaria-specific immune responses. Future studies should validate this potential in different endemic settings.

An intercomparison study of 237Np determination in artificial urine samples

An intercomparison study of low-level 237Np determination in artificial urine samples has been carried out. The purpose of this study was to find the "optimal" method presently available for use in a routine in-vitro radiobioassay program for occupationally exposed workers. Four synthetic urine samples with differing 237Np concentrations were prepared: (1) 3 mBq kg-1 of 237Np; (2) 3 mBq kg-1 of 237Np with natural uranium, 239Pu and 241Am as interferences; (3) 50 mBq kg-1 of 237Np; and (4) a matrix blank. The solutions were submitted to 10 alpha-particle and 10 inductively coupled plasma-mass spectrometry (ICP-MS) laboratories of which six and four laboratories, respectively, returned results. Two laboratories performed assays using both techniques. The radiochemical method of choice used 239Np as the tracer, which utilized a combination of coprecipitation and anion-exchange separation. The best results obtained by ICP-MS were comparable with but not better than the most accurate results obtained by alpha-particle spectrometry. Alpha-particle spectrometry measurements overall gave consistently better agreement with known values.

Bisulfite interacts with binding sites of the auxin-transport inhibitor N-1-naphthylphthalamic acid

The affinity of the auxin-transport inhibitor N-1-naphthylphthalamic acid (NPA) for membrane particles as well as for solubilized binding sites from Cucurbita pepo L. hypocotyls was reduced by low concentrations of bisulfite (half-maximal inhibition at 2·10(-3)-3·10(-3) M). Two membrane fractions obtained by sedimentation aided with polyethylene glycol showed differential sensitivity to bisulfite. Other oxidizing or reducing substances tested at 1 mM had no effect, except for N-ethylmaleimide (80% inhibition) and iodine (complete inhibition), both of which reduced the number of binding sites but not their affinity. Addition of bisulfite to either the isoalloxane ring of flavoproteins or to pyridoxal phosphate or quinones is proposed as a possible mechanism of action. Sulfur dioxide, at concentrations measured in polluted air, can lead to bisulfite concentrations in plant tissue sufficient to interfere with NPA-binding sites and hence with auxin transport.

A study of glucose handling by Buddhist monks

Fourteen Buddhist monks and comparable male subjects were studied in relation to their handling of glucose after a meal (consisting of 1190 kcal, 29 g protein, 21 g fat and 221 g carbohydrate) and afterwards subjected to an oral glucose tolerance test (oGTT). The time course of blood glucose levels after the meal indicated that the monks had enhanced absorption and utilization of glucose. The monks were also found to have increased tolerance to glucose on oGTT. In addition the mean total serum cholesterol level in the monks (157.2 +/- 5.53 mg/dl) was found to be significantly higher than that of the control subjects (117.4 +/- 2.85 mg/dl).

Aerobic capacity of some Burmese workers

The physiological responses to exercise of 18 sawmill workers and 17 trishaw pedallers were measured and compared. The oxygen intake and heart rates of the two groups were tested at different levels of exercise and samples of expired air were taken for analysis. Oxygen intake for a given work load was similar in both groups, but cardiac frequency was elevated in the sawmill group.

Comparison of human growth hormone levels in children with satisfactory and unsatisfactory growth

Sixty-six children with satisfactory growth and 73 with unsatisfactory growth (both sexes) from three different age groups (1 year, 5 years and 10 years) were included in this study. It was observed that the serum concentrations of human growth hormone (hGH) in children with satisfactory growth ranged from 1.00 to 4.00 ng/ml and never exceeded 4.00 ng/ml. In a comparative study there was a significant increase in serum hGH levels in subjects of all age groups who were not growing satisfactorily. Twelve children between 12 and 13 months of age with unsatisfactory growth were nutritionally rehabilitated for 4 months and the changes in weight and serum hGH levels were assessed monthly. The results indicated a definite fall of hGH level after rehabilitation and reached the normal level 3 months after rehabilitation. Moreover, an inverse relationship between body weight and serum hGH level was observed.

Effect of the preceding day's energy intake on the energy costs of rest, arm and leg exercise

Relatively little is known about the response of the human body to perturbations in the energy intake. In particular, results of the effect of a perturbation of the preceding day's energy intake on the energy expenditure on the following day are conflicting, ranging from no effect at all to an increase in the resting metabolic rate of 12 per cent following an increase in the preceding day's energy intake of 5 MJ. In the present study, the fasting energy expenditure of rest, light arm work and light leg work was determined on days following an intake of 4, 10 and 16 MJ in seven healthy men. In each subject, the difference in energy expenditure between days following intakes on the preceding day of 10-10 (control), 10-4 and 10-16 MJ was calculated for each of the three tasks. The mean percentage differences between the days following an intake of 10-10, 10-4 and 10-16 MJ were (s.d. in parenthesis) 0.0 (4.0), +1.3 (4.0) and +0.6 (3.2) for the resting metabolic rate, -1.7 (4.0), -2.2 (3.2) and -1.7 (3.7) for arm work and +0.3 (2.0), -1.2 (2.9) and -0.3 (3.2) for leg work. When the differences for the three tasks were averaged, the results were -0.5 (1.4), -0.7 (2.4) and -0.5 (1.3) for the three combinations respectively. None of these differences were found to be statistically different from zero. Changes in plasma adrenaline and noradrenaline concentrations were also measured but found not to be related to the changes in energy expenditure or to the energy intakes.(ABSTRACT TRUNCATED AT 250 WORDS)

Insecticide susceptibility of some vector fleas and mosquitoes in Burma

Rat fleas and mosquitoes are insect vectors of public health importance in Burma. Plague is endemic in Central Burma and DDT has been the principal insecticide used for its control to date. Dengue haemorrhagic fever, recently introduced and transmitted by Aedes aegypti, has been spreading to major towns since 1971. The rodents, Rattus rattus, R. exulans, Bandicota bengalensis, Mus musculus, as well as shrews were commonly caught during routine trapping in the country. Rattus norvegicus, prevalent in Rangoon City, is not found in Central Burma. The rat fleas, Xenopsylla cheopis and X. astia, were found to be infesting these rodents, the former being the principal vector of plague. Insecticide susceptibility tests have been carried out periodically in plague endemic areas and Rangoon since 1966 and it is now observed that rat fleas in most of these endemic towns and Rangoon Port are no longer susceptible to DDT. Subsequent rechecks in towns where fleas became resistance to DDT show that fleas are persistently resistant to the insecticide. Aedes aegypti is found to be highly prevalent both in rural and urban areas of almost every major town and townships below 900 meters. Insecticide susceptible tests on this mosquito in limited areas show that the mosquito is generally resistant to DDT but susceptible to other insecticides. With the development of DDT resistance in fleas, it is now necessary to change to an effective insecticide in the control of plague in Burma.