Three linked nomograms for predicting biochemical failure in prostate cancer treated with radiotherapy plus androgen deprivation therapy

Background

Nomograms were established to predict biochemical recurrence (BCR) after radiotherapy (RT) with a low weight of the characteristic variables of RT and androgen deprivation therapy (ADT). Our aim is to provide a new stratified tool for predicting BCR at 4 and 7 years in patients treated using RT with radical intent.

Materials and methods

A retrospective, nonrandomized analysis was performed on 5044 prostate cancer (PCa) patients with median age 70 years, who received RT—with or without ADT—between November 1992 and May 2007. Median follow-up was 5.5 years. BCR was defined as a rise in serum prostate-specific antigen (PSA) of 2 ng/ml over the post-treatment PSA nadir. Univariate association between predictor variables and BCR was assessed by the log-rank test, and three linked nomograms were created for multivariate prognosis of BCR-free survival. Each nomogram corresponds to a category of the Gleason score—either 6,7, or 8–10—and all of them were created from a single proportional hazards regression model stratified also by months of ADT (0, 1–6, 7–12, 13–24, 25–36, 36–60). The performance of this model was analyzed by calibration, discrimination, and clinical utility.

Results

Initial PSA, clinical stage, and RT dose were significant variables (p?<?0.01). The model showed a good calibration. The concordance probability was 0.779, improving those obtained with other nomograms (0.587, 0.571, 0.554) in the database. Survival curves showed best clinical utility in a comparison with National Comprehensive Cancer Network (NCCN) risk groups.

Conclusion

For each Gleason score category, the nomogram provides information on the benefit of adding ADT to a specific RT dose.

     

Pre-radiotherapy PSA progression is a negative prognostic factor in prostate cancer patients using 5‑alpha-reductase inhibitors

Objective

To investigate the impact of 5?alpha-reductase inhibitor (5-ARI) use on radiotherapy outcomes for localized prostate cancer.

Patients and methods

We included 203 patients on a 5-ARI from our institutional database comprising over 2500 patients who had been treated with either external beam radiotherapy (EBRT) or brachytherapy for localized prostate cancer. Patients received a 5-ARI for urinary symptoms or active surveillance. Cancer progressions at the time of definitive treatment were analyzed according to the following criteria: (a) progression of Gleason score or increase in cancer volume on biopsy, (b) first biopsy positive for cancer after being treated for urinary symptoms with a 5-ARI, and (c) prostate-specific antigen (PSA) progression with or without a previous cancer diagnosis. Biochemical failure (BF) was defined by the Phoenix definition. Log-rank test was used for survival analysis.

Results

At a median follow-up of 38.2 months (standard deviation 22.2 months), 10 (4.9%) patients experienced BF. Concerning prostate cancer progression criteria, 52% of men demonstrated none, 37% showed only one criterion, and 11% showed two. Using univariate analysis, PSA progression (p = 0.004) and appearance of a positive biopsy (p < 0.001) were significant predictive factors for BF, while Gleason progression (p = 0.3) was not. In multivariate analysis adjusted for cancer aggressiveness, rising PSA (hazard ratio, HR, 5.7; 95% confidence interval, CI, 1.1–28.8; p = 0.04) and the number of cancer progression factors (HR 2.9, 95% CI 1.2–7.0, p = 0.02) remained adverse risk factors.

Conclusion

PSA progression experienced during 5?ARI treatment before radiotherapy is predictive of worse biochemical outcome. Such details should be considered when counseling men prior to radiation therapy.

     

Analysis of histological findings obtained combining US/mp-MRI fusion-guided biopsies with systematic US biopsies: mp-MRI role in prostate cancer detection and false negative

Aims and objectives

To evaluate the diagnostic accuracy of mp-MRI correlating US/mp-MRI fusion-guided biopsy with systematic random US-guided biopsy in prostate cancer diagnosis.

Materials and methods

137 suspected prostatic abnormalities were identified on mp-MRI (1.5T) in 96 patients and classified according to PI-RADS score v2. All target lesions underwent US/mp-MRI fusion biopsy and prostatic sampling was completed by US-guided systematic random 12-core biopsies. Histological analysis and Gleason score were established for all the samples, both target lesions defined by mp-MRI, and random biopsies. PI-RADS score was correlated with the histological results, divided in three groups (benign tissue, atypia and carcinoma) and with Gleason groups, divided in four categories considering the new Grading system of the ISUP 2014, using t test. Multivariate analysis was used to correlate PI-RADS and Gleason categories to PSA level and abnormalities axial diameter. When the random core biopsies showed carcinoma (mp-MRI false-negatives), PSA value and lesions Gleason median value were compared with those of carcinomas identified by mp-MRI (true-positives), using t test.

Results

There was statistically significant difference between PI-RADS score in carcinoma, atypia and benign lesions groups (4.41, 3.61 and 3.24, respectively) and between PI-RADS score in Gleason < 7 group and Gleason > 7 group (4.14 and 4.79, respectively). mp-MRI performance was more accurate for lesions > 15 mm and in patients with PSA > 6 ng/ml. In systematic sampling, 130 (11.25%) mp-MRI false-negative were identified. There was no statistic difference in Gleason median value (7.0 vs 7.06) between this group and the mp-MRI true-positives, but a significant lower PSA median value was demonstrated (7.08 vs 7.53 ng/ml).

Conclusion

mp-MRI remains the imaging modality of choice to identify PCa lesions. Integrating US-guided random sampling with US/mp-MRI fusion target lesions sampling, 3.49% of false-negative were identified.

     

Relationships between serum PSA levels,Gleason scores and results of 68Ga-PSMAPET/CT in patients with recurrent prostate cancer

Aim

To investigate the relationship between serum PSA level, Gleason score of PCa and the outcomes of Ga⁶⁸-PSMA PET/CT in patients with recurrent PCa.

Methods

A total of 109 consecutive patients (median age 71 years; range 48–89 years) who had PSA recurrence after RP and/or hormonotherapy and/or radiotherapy were included in this study. Local recurrences, lymph node metastasis (pelvic, abdominal and/or supradiaphragmatic), bone metastases (oligometastatic/multimetastatic) and other metastatic sites (lung, liver, brain, etc) were documented.

Results

In 91(83.4%) patients at least one lesion characteristic for PCa was detected by⁶⁸Ga-PSMA PET/CT. The median serum total PSA (tPSA) was 6.5 (0.2–640) ng/ml.There was a significant difference between ⁶⁸Ga-PSMA PET/CT positive and negative patients in terms of serum total PSA value. No statistical significance was found between positive and negative ⁶⁸Ga-PSMA PET/CT findings in terms of Gleason score. Local recurrence was detected in 56 patients. whereas lymph node metastases were demonstrated in 46 patients. Pelvic nodal disease was the most frequent presentation followed by abdominal and supradiaphragmaticnodal involvement. Bone metastases [oligometastasis, (n?=?20); multimetastasis, (n?=?35)? were also detected in 55 patients. In the ROC analysis for the study cohort, the optimal cut-off value of total serum PSA was determined as 0.67 ng/ml for distinguishing between positive and negative ⁶⁸Ga-PSMA PET/CT images, with an area under curve of 0.952 (95% CI 0.911–0.993).

Conclusions

⁶⁸Ga-PSMA PET/CT was found to be an effective tool for the detection of recurrent PCa. Even though no relationship was detected between the GS and ⁶⁸Ga-PSMA PET/CT findings, serum total PSA values may be used for estimating the likelihood of positive ⁶⁸Ga-PSMA PET/CT results.

     

Use of androgen deprivation and salvage radiation therapy for patients with prostate cancer and biochemical recurrence after prostatectomy

Aim

Overview on the use of androgen deprivation therapy (ADT) added to salvage radiation therapy (SRT) for prostate cancer patients with biochemical recurrence after prostatectomy.

Methods

The German Society of Radiation Oncology (DEGRO) expert panel summarized available evidence published between January 2009 and May 2017, and assessed the validity of the information on outcome parameters including overall survival (OS) and treatment-related toxicity.

Results

Two randomized controlled trials and nine relevant retrospective analyses were identified. The RTOG 9601 trial showed an OS improvement for the combination of 2 years of bicalutamide and SRT compared to SRT alone after a median follow-up of 13 years. This improvement appeared to be restricted to those patients with a prostate specific antigen (PSA) level before SRT of ≥0.7?ng/mL. The GETUG AFU-16 trial showed that after a median follow-up of 5 years, the addition of 6 months of goserelin to SRT improved progression-free survival (PFS; based on biochemical recurrence) as compared to SRT alone. ADT in both trials was not associated with increased major late toxicities. Results of retrospective series were inconsistent with a suggestion that the addition of ADT improved biochemical PFS especially in patients with high-risk factors such as Gleason Score ≥8 and in the group with initially negative surgical margins.

Conclusions

ADT combined with SRT appears to improve OS in patients with a PSA level before SRT of ≥0.7?ng/mL. In patients without persistent PSA after prostatectomy and PSA levels of <0.7?ng/mL, ADT should not routinely be used, but may be considered in patients with additional risk factors such as Gleason Score ≥8 and negative surgical margins.

     

Prognostic impact of nodal relapse in definitive prostate-only irradiation

Background

Whole pelvic irradiation in prostate cancer patients might prevent metastatic spread of cancer cells through lymphatic drainages in patients eligible for definitive radiotherapy, but its use has declined in the last decades in favor of prostate-only irradiation (POI). The aim of our study is to assess the incidence of pelvic lymph nodal relapse and outcome in prostate cancer patients receiving POI.

Materials and methods

Data from 207 consecutive patients were collected. Clinical and treatment variables were collected. Biochemical relapse-free survival (BRFS), pelvic nodal relapse-free survival (PNRFS), distant metastasis-free survival (DMFS), disease-specific survival (DSS) and overall survival (OS) were calculated; analysis of prognostic variables was performed.

Results

Five-year BRFS, PNRFS, DMFS, DSS and OS were, respectively, 90, 98, 96, 97 and 91%. On multivariate analysis, independent negative predictors of BRFS were Gleason score ≥?7 (HR: 3.25) and PSA nadir ≥?0.08 (HR: 4.86). Pelvic nodal relapse was not correlated to impaired outcome.

Conclusions

Lymph nodal pelvic relapse occurs in 2% of patients at 5 years and does not correlate with impaired outcome, suggesting the lack of theoretical benefit of a prophylactic nodal irradiation. Tumor biology and response to treatment are the main determinants of outcome.

     

Salvage radiotherapy in prostate cancer patients with biochemical relapse after radical prostatectomy

Background

In patients with prostate cancer (PCa) and biochemical progression (BP) after radical prostatectomy (RP), salvage radiotherapy (sRT) improves prostate cancer-specific survival (PCSS), but this evidence is based only on retrospective data.

Patients and methods

In addition to our previous study of 151 patients with PCa and BP after RP, we performed univariate analyses of prostate-specific antigen (PSA) kinetics during sRT. In 11 patients with BP or initiation of hormonal treatment (HT) within 180 days after sRT, risk factors were assessed using Mann–Whitney U tests. PSA doubling times (PSADT) before and after sRT in 82 patients with BP after sRT were compared by a Wilcoxon test.

Results

After a median follow-up of 82 months, analysis of PSA kinetics during sRT did not show a statistically significant impact on a subsequent BP, PCSS, or overall survival at an administered dose of 30 or 45?Gy. The subgroup analysis of patients with early BP or early HT revealed higher Gleason scores (p = 0.008) and preoperative PSA values (p = 0.005), shorter PSADT prior to sRT (p < 0.0005), and longer time intervals from RP until the start of sRT (p = 0.005) compared to all other patients. In patients with subsequent BP, PSADTs were significantly prolonged after sRT (median PSADT 4.5 months before and 9.9 months after sRT, p < 0.0005).

Conclusion

PSA monitoring during sRT did not predict the therapeutic success. Subgroup analysis suggests a lower probability of benefit for patients with the abovenamed risk factors . However, the prolonged PSADT after sRT reflects a benefit of sRT for the vast majority of patients.

     

Role of postoperative radiotherapy in the management of malignant pleural mesothelioma

Introduction

This study assessed the prognostic impact of postoperative radiotherapy in patients with surgically resected malignant pleural mesothelioma (MPM).

Methods

MPM patients diagnosed between 2000 and 2013 were identified from the SEER (Surveillance, Epidemiology, and End Results) database. A propensity-matched analysis was performed considering baseline characteristics (age, gender, race, histology, TNM stage, and type of surgery).

Results

A total of 2166 patients were identified. The median age was 60 years (range 25–85 years), and 469 patients received postoperative radiotherapy. Both before and after propensity score matching, overall survival (P < 0.0001 and P = 0.012, respectively) was better in the postoperative radiotherapy group. When the overall survival was stratified by histology, postoperative radiotherapy did not improve the survival in sarcomatoid histology patients both before and after matching (P = 0.424 and P = 0.281, respectively). In multivariate analysis of the matched population, not receiving postoperative radiotherapy did not correlate with worse survival (hazard ratio: 1.175; P = 0.12). Factors associated with worse survival include sarcomatoid histology, nodal positivity, and age ≥70.

Conclusion

Evidence from this analysis is insufficient on its own to routinely recommend postoperative radiotherapy for surgically resected MPM. However, large-scale prospective clinical trials are warranted to further evaluate this intervention in nonsarcomatoid histology.

     

Extent of disease in recurrent prostate cancer determined by [<Superscript>68</Superscript>Ga]PSMA-HBED-CC PET/CT in relation to PSA levels,PSA doubling time and Gleason score

Purpose

To examine the relationship between the extent of disease determined by [⁶⁸Ga]PSMA-HBED-CC-PET/CT and the important clinical measures prostate-specific antigen (PSA), PSA doubling time (PSAdt) and Gleason score.

Methods

We retrospectively studied the first 155 patients with recurrent prostate cancer (PCA) referred to our university hospital for [⁶⁸Ga]PSMA-HBED-CC PET/CT.

Results

PET/CT was positive in 44 %, 79 % and 89 % of patients with PSA levels of ≤1, 1 – 2 and ≥2 ng/ml, respectively. Patients with high PSA levels showed higher rates of local prostate tumours (p?<?0.001), and extrapelvic lymph node (p?=?0.037) and bone metastases (p?=?0.013). A shorter PSAdt was significantly associated with pelvic lymph node (p?=?0.026), extrapelvic lymph node (p?=?0.001), bone (p?<?0.001) and visceral (p?=?0.041) metastases. A high Gleason score was associated with more frequent pelvic lymph node metastases (p?=?0.039). In multivariate analysis, both PSA and PSAdt were independent determinants of scan positivity and of extrapelvic lymph node metastases. PSAdt was the only independent marker of bone metastases (p?=?0.001). Of 20 patients with a PSAdt <6 months and a PSA ≥2 ng/ml, 19 (95 %) had a positive scan and 12 (60 %) had M1a disease. Of 14 patients with PSA <1 ng/ml and PSAdt >6 months, only 5 (36 %) had a positive scan and 1 (7 %) had M1a disease.

Conclusion

[⁶⁸Ga]PSMA-HBED-CC PET/CT will identify PCA lesions even in patients with very low PSA levels. Higher PSA levels and shorter PSAdt are independently associated with scan positivity and extrapelvic metastases, and can be used for patient selection for [⁶⁸Ga]PSMA-HBED-CC PET/CT.

     

Targeted MRI-guided prostate biopsy: are two biopsy cores per MRI-lesion required?

Purpose

This study evaluates the feasibility of performing less than two core biopsies per MRI-lesion when performing targeted MR-guided in-bore prostate biopsy.

Methods

Retrospectively evaluated were 1545 biopsy cores of 774 intraprostatic lesions (two cores per lesion) in 290 patients (66?±?7.8 years; median PSA 8.2 ng/ml) regarding prostate cancer (PCa) detection, Gleason score, and tumor infiltration of the first (FBC) compared to the second biopsy core (SBC). Biopsies were acquired under in-bore MR-guidance.

Results

For the biopsy cores, 491 were PCa positive, 239 of 774 (31 %) were FBC and 252 of 771 (33 %) were SBC (p?=?0.4). Patient PCa detection rate based on the FBC vs. SBC were 46 % vs. 48 % (p?=?0.6). For clinically significant PCa (Gleason score ≥4?+?3?=?7) the detection rate was 18 % for both, FBC and SBC (p?=?0.9). Six hundred and eighty-seven SBC (89 %) showed no histologic difference. On the lesion level, 40 SBC detected PCa with negative FBC (7.5 %). Twenty SBC showed a Gleason upgrade from 3?+?3?=?6 to ≥3?+?4?=?7 (2.6 %) and 4 to ≥4?+?3?=?7 (0.5 %).

Conclusion

The benefit of a second targeted biopsy core per suspicious MRI-lesion is likely minor, especially regarding PCa detection rate and significant Gleason upgrading. Therefore, a further reduction of biopsy cores is reasonable when performing a targeted MR-guided in-bore prostate biopsy.

Key Points

? Higher PI-RADS overall score (IV-V) correlated well with PCa detection rate ? In more than 80 % SBC was concordant regarding overall PCa detection ? In almost 90 % there was no Gleason upgrading by the SBC ? Only 2/54 (3.7 %) csPCa was missed when the SBC was omitted ? For IB-GB a further reduction of biopsy cores is reasonable

     

Late toxicity,evolving radiotherapy techniques,and quality of life in nasopharyngeal carcinoma

Purpose

To analyze quality of life (QoL) and functional state (FS) by patient-reported outcome (PRO) questionnaires (FACT-G, FACT-NP, PSS-HN, XeQOLS, and EQ-5D-3L) in long-term survivors nasopharyngeal carcinoma (NPC) treated with conventional radiotherapy (RT) and intensity modulated radiotherapy (IMRT).

Methods

25 patients answered to five questionnaires about QoL and FS. All patients were assessed also for late toxicity.

Results

Functional Assessment of Cancer Therapy-General (FACT-G) and Performance Status Scale Head and Neck (PSS-HN) scores were significantly elevated (better QoL) in age <50 years (p = 0.03). PSS-HN score was higher in IMRT group. The observed xerostomia was lower in the IMRT group and in patients who received conventional RT had worse QoL according to XeQOLS (University of Michigan Xerostomia-Related Quality of Life Scale) score questionnaire. Lower PSS-HN score and higher XeQOLS score were significantly related with the late xerostomia (p = 0.009 and 0.002, respectively).

Conclusions

Our preliminary data suggest that age, older techniques, xerostomia, and hearing loss are negative predictors of QoL.

     

Delayed response after repeated <Superscript>177</Superscript>Lu-PSMA-617 radioligand therapy in patients with metastatic castration resistant prostate cancer

Purpose

Radioligand therapy (RLT) using Lutetium-177 labeled PSMA-617 (Lu-PSMA) ligand is a new therapeutic option for salvage therapy in heavily pretreated patients with metastatic castration resistant prostate cancer. The aim of this retrospective study was to analyze response in patients receiving 3 cycles of Lu-PSMA.

Methods

Seventy-one patients (median age: 72 years; range 44–87) received 3 cycles of RLT with Lu-PSMA (mean administered activity: 6.016 ± 0.543 GBq) every 8 weeks. Response was evaluated using serum PSA levels and a PSA decline ≥50% was considered as biochemical response. Additionally, any PSA decline after the first cycle was evaluated for further therapy effects after the second and third cycle.

Results

A total of 213 cycles were performed in 71 patients. Data for response and adverse events were available for all patients. A PSA decline ≥50% and some PSA decline occurred in 56% and 66% of the patients. Of 30 patients with a PSA response after the first cycle, 28 remained responders and 12/41 of non-responders responded to further therapy cycles.

Conclusion

RLT with Lu-177-PSMA-617 shows respectable response rates. In this retrospective analysis, a relevant number of patients showed a delayed response, even if they did not respond to the first cycle of the therapy.

     

Factors predicting intolerance to definitive conventional radiotherapy in geriatric patients

Purpose

Although radiotherapy can be administered with a relatively low therapeutic burden, many elderly patients do not complete radiotherapy. In order to predict intolerance during radiotherapy, this study retrospectively analyzed the frequency of and risk factors for radiotherapy interruption among geriatric patients.

Methods

From September 2009 to December 2016, 353 patients aged ≥70 years received definitive radiotherapy with a conventionally fractionated schedule. “Total interruption” included completion of ≤90% of a planned radiotherapy, temporary discontinuation, and treatment-related mortality within 2 months. “Early-phase incompletion” and “mid-phase incompletion” represented completion of ≤50 and ≤80% of a planned radiotherapy, respectively.

Results

The median age of patients was 74 years. Early- and mid-phase incompletions and total interruption occurred in 4.2, 9.3, and 19.3% of patients, respectively. Total interruption occurred frequently in cancers involving the thorax (27.4%), head and neck (23.1%), abdomen (20.0%), pelvis (17.4%), and breast/extremity (8.1%). The Eastern Cooperative Oncology Group (ECOG) performance score (P?=?0.004 and 0.002), serum albumin level (P?=?0.016 and 0.002), and the expected 5?year survival (P?=?0.033 and 0.034) were significant factors for mid-phase incompletion and total interruption. Age?≥?75 years (P?=?0.008), concurrent chemotherapy (P?=?0.017), and the extent of radiation field (P?=?0.027) were factors associated with total interruption.

Conclusion

Overall, 19.3% of the elderly patients showed treatment intolerance during conventional radiotherapy. Serum albumin level and ECOG performance score should be considered as surrogate markers for radiotherapy interruption prior to the decision regarding definite conventional radiotherapy.

     

Incremental value of high <Emphasis Type="Italic">b</Emphasis> value diffusion-weighted magnetic resonance imaging at 3-T for prediction of extracapsular extension in patients with prostate cancer: preliminary experience

Purpose

To investigate whether high b value diffusion-weighted imaging (DWI) contributes to the improvement of diagnostic ability of extracapsular extension (ECE) in prostate cancer (PC).

Materials and methods

Forty-three patients with PC underwent multiparametric MRI including DWI (b values: 0, 2000 s/mm²) at 3-T. Two radiologists assessed the presence of ECE and the diagnostic certainty degree using conventional diagnostic method by consensus. Tumor apparent diffusion coefficient (ADC, ×10^?3 mm²/s) was also measured. Independent predictors of ECE were identified among PSA, tumor ADC, Gleason score, and conventional MRI. ECE in patients with low diagnostic certainty by conventional MRI was further reevaluated using ADC cutoff value, and the results were combined with those of patients with high diagnostic certainty by conventional MRI (MRI + ADC method).

Results

Tumor ADC was an independent predictor of ECE, and the ADC cutoff value was 0.72. The sensitivity, specificity, and accuracy of conventional MRI and MRI + ADC method in the diagnosis of ECE were 44, 92, and 72%, and 78, 96, and 88%, respectively. Among MRI findings leading to the judgement of low diagnostic certainty, broad tumor contact was most common (72% of the patients).

Conclusions

The addition of ADC obtained with high b value DWI at 3-T to conventional MRI improved the diagnostic ability of ECE.

     

<Superscript>68</Superscript>Ga-PSMA PET/CT in patients with recurrent prostate cancer after radical treatment: prospective results in 314 patients

Purpose

We studied the usefulness of ⁶⁸Ga-prostate-specific membrane antigen (PSMA) PET/CT for detecting relapse in a prospective series of patients with biochemical recurrence (BCR) of prostate cancer (PCa) after radical treatment.

Methods

Patients with BCR of PCa after radical surgery and/or radiotherapy with or without androgen-deprivation therapy were included in the study. ⁶⁸Ga-PSMA PET/CT scans performed from the top of the head to the mid-thigh 60 min after intravenous injection of 150?±?50 MBq of ⁶⁸Ga-PSMA were interpreted by two nuclear medicine physicians. The results were correlated with prostate-specific antigen (PSA) levels at the time of the scan (PSApet), PSA doubling time, Gleason score, tumour stage, postsurgery tumour residue, time from primary therapy to BCR, and patient age. When available, ⁶⁸Ga-PSMA PET/CT scans were compared with negative ¹⁸F-choline PET/CT scans routinely performed up to 1 month previously.

Results

From November 2015 to October 2017, 314 PCa patients with BCR were evaluated. Their median age was 70 years (range 44–92 years) and their median PSApet was 0.83 ng/ml (range 0.003–80.0 ng/ml). ⁶⁸Ga-PSMA PET/CT was positive (one or more suspected PCa lesions detected) in 197 patients (62.7%). Lesions limited to the pelvis, i.e. the prostate/prostate bed and/or pelvic lymph nodes (LNs), were detected in 117 patients (59.4%). At least one distant lesion (LNs, bone, other organs, separately or combined with local lesions) was detected in 80 patients (40.6%). PSApet was higher in PET-positive than in PET-negative patients (P?<?0.0001). Of 88 patients negative on choline PET/CT scans, 59 (67%) were positive on ⁶⁸Ga-PSMA PET/CT.

Conclusion

We confirmed the value of ⁶⁸Ga-PSMA PET/CT in restaging PCa patients with BCR, highlighting its superior performance and safety compared with choline PET/CT. Higher PSApet was associated with a higher relapse detection rate.

     

Impact of a rectal and bladder preparation protocol on prostate cancer outcome in patients treated with external beam radiotherapy

Purpose and objective

To test the hypothesis that a rectal and bladder preparation protocol is associated with an increase in prostate cancer specific survival (PCSS), clinical disease free survival (CDFS) and biochemical disease free survival (BDFS).

Patients and methods

From 1999 to 2012, 1080 prostate cancer (PCa) patients were treated with three-dimensional conformal radiotherapy (3DCRT). Of these patients, 761 were treated with an empty rectum and comfortably full bladder (RBP) preparation protocol, while for 319 patients no rectal/bladder preparation (NRBP) protocol was adopted.

Results

Compared with NRBP patients, patients with RBP had significantly higher BDFS (64% vs 48% at 10 years, respectively), CDFS (81% vs 70.5% at 10 years, respectively) and PCSS (95% vs 88% at 10 years, respectively) (log-rank test p < 0.001). Multivariate analysis (MVA) indicated for all treated patients and intermediate high-risk patients that the Gleason score (GS) and the rectal and bladder preparation were the most important prognostic factors for PCSS, CDFS and BDFS. With regard to high- and very high-risk patients, GS, RBP, prostate cancer staging and RT dose were predictors of PCSS, CDFS and BDFS in univariate analysis (UVA).

Conclusion

We found strong evidence that rectal and bladder preparation significantly decreases biochemical and clinical failures and the probability of death from PCa in patients treated without daily image-guided prostate localization, presumably since patients with RBP are able to maintain a reproducibly empty rectum and comfortably full bladder across the whole treatment compared with NRPB patients.

     

Are iatrogenic renal artery pseudoaneurysms more challenging to embolize when associated with an arteriovenous fistula?

Background

Iatrogenic injuries of the renal artery include pseudoaneurysms (PSA) and pseudoaneurysms with arteriovenous fistula (PSA?+?AVF). They can cause hematuria, anemization and flank pain. Endovascular treatment is recommended due to its effectiveness.

Objective

To assess the potential difference between the embolization of iatrogenic renal PSA and iatrogenic renal PSA?+?AVF, in terms of technical and clinical success rate, procedure complexity and impact on the renal function.

Methods

We retrospectively reviewed 30 embolization procedures of iatrogenic renal PSA and renal PSA?+?AVF in 27 patients in two centers between December 2006 and February 2017, comparing technical and clinical success rate, total procedural time, creatinine before and after the procedure and parenchymal ischemic area after the procedure. All patients underwent CT before embolization procedure and different embolization materials were used.

Results

We identified 15 iatrogenic renal PSA and 15 iatrogenic renal PSA?+?AVF (causes: 23 nephron-sparing surgery, 2 nephrostomies, 1 lithotripsy, 1 ureteroscopic pyelolithotomy, 1 renal biopsy). Microcoils were used in 21 cases, microcoils and Spongostan in 3 cases, microcoils and controlled-release microcoils in 4 cases and controlled-release microcoils in 1 case. No significant statistical differences were found in the comparison of technical and clinical success rate, total procedural time, creatinine and parenchymal ischemic area after the procedure.

Conclusions

Transarterial embolization can be considered as the first-line treatment for renal artery iatrogenic lesions, considering its effectiveness. No statistical significant differences were found in the comparison of the embolization procedures of iatrogenic renal PSA and PSA?+?AVF.

     

Multiple Renal Artery Pseudoaneurysms in Patients Undergoing Renal Artery Embolization Following Partial Nephrectomy: Correlation with RENAL Nephrometry Scores

Purpose

To describe the incidence of multiple renal artery pseudoaneurysms (PSA) in patients referred for renal artery embolization following partial nephrectomy and to study its relationship to RENAL nephrometry scores.

Materials and Methods

The medical records of 25 patients referred for renal artery embolization after partial nephrectomy were retrospectively reviewed for the following parameters: size and number of tumors, RENAL nephrometry scores, angiographic abnormalities, technical and clinical outcomes, and estimated glomerular filtration rates (eGFRs) after embolization.

Results

Twenty-four patients had primary renal tumors, while 1 patient had a pancreatic tumor invading the kidney. Multiple tumors were resected in 4 patients. Most patients (92 %) were symptomatic, presenting with gross hematuria, flank pain, or both. Angiography revealed PSA with (n = 5) or without (n = 20) AV fistulae. Sixteen patients (64 %) had multiple PSA involving multiple renal vessels. Higher RENAL nephrometry scores were associated with an increasing likelihood of multiple PSA. Multiple vessels were embolized in 14 patients (56 %). Clinical success was achieved after one (n = 22) or two (n = 3) embolization sessions in all patients. Post-embolization eGFR values at different time points after embolization were not significantly different from the post-operative eGFR.

Conclusion

A majority of patients requiring renal artery embolization following partial nephrectomy have multiple pseudoaneurysms, often requiring selective embolization of multiple vessels. Higher RENAL nephrometry score is associated with an increasing likelihood of multiple pseudoaneurysms. We found transarterial embolization to be a safe and effective treatment option with no long-term adverse effect on renal function in all but one patient with a solitary kidney.

     

Individualization of post-mastectomy radiotherapy and regional nodal irradiation based on treatment response after neoadjuvant chemotherapy for breast cancer

Purpose

To review the evidence regarding post-mastectomy radiotherapy (PMRT) and regional nodal irradiation (RNI) after neoadjuvant chemotherapy (NACT) for breast cancer, with a special focus on individualization of adjuvant radiotherapy based on treatment response.

Methods

A systematic literature search using the PubMed/Medline database was performed. We included prospective and retrospective reports with a minimum of 10 patients that had been published since 1^st January 2000, and provided clinical outcome data analyzed by treatment response and radiotherapy.

Results

Out of 763 articles identified via PubMed/Medline and hand search, 68 full text-articles were assessed for eligibility after screening of title and abstract. 13 studies were included in the systematic review, 9 for PMRT and 5 for RNI. All included studies were retrospective reports.

Conclusions

There is a considerable lack of evidence regarding the role of adjuvant radiotherapy and its individualization based on treatment response after NACT. Results of prospective randomized trials such as NSABP B?51/RTOG 1304 and Alliance A11202 are eagerly awaited.

     

Computer-assisted navigation decreases the change in the tibial posterior slope angle after closed-wedge high tibial osteotomy

Purpose

The purpose of the present study was to compare the change in tibial posterior slope angle (PSA) between patients treated via computer-assisted and conventional closed-wedge high tibial osteotomy (CWHTO). It was hypothesized that a decrease in the PSA would be less in the computer-assisted group than in the conventional group.

Methods

Data on a total of 75 computer-assisted CWHTOs (60 patients) and 75 conventional CWHTOs (49 patients) were retrospectively compared using matched pair analysis. The pre- and postoperative mechanical axis (MA) and the PSA were radiographically evaluated. The parallel angle was defined as the angle between the joint line and the osteotomy surface. The data were compared between the two groups.

Results

The postoperative radiographic MA averaged 1.3° ± 2.6° valgus in the computer-assisted group and 0.3° ± 3.1° varus in the conventional group. The change in PSA averaged ?0.8° ± 0.9° in the computer-assisted group and ?4.0° ± 2.2° in the conventional group. The parallel angle averaged 0.2° ± 3.0° in the computer-assisted group and 6.2° ± 5.3° in the conventional group.

Conclusion

Computer-assisted CWHTO using four guide pins could avoid inadvertent change in the PSA. The navigation can be used in anticipation of decreasing the risk of change in the PSA in CWHTO, especially in patients whose preoperative PSA is small. The special attention should be paid to locate the hinge axis acutely and to make the parallel proximal and distal osteotomy surfaces during CWHTO.

Level of evidence

III.