The value of external beam radiation in node positive prostate cancer: a multivariate analysis

Purpose: The goal of this study was to evaluate the effect of local/regional treatment, particularly external beam radiation alone vs. radical prostatectomy plus radiation therapy in patients with pathologic node positive prostate cancer on survival. Methods: Medical records of all 116 patients who received their initial treatment at the Massachusetts General Hospital between 1980 and 1996 for adenocarcinoma of the prostate with pathologic confirmed nodal metastases and no distant metastases were reviewed. The mean follow up was 5.5 years. Overall survival, time to PSA failure on endocrine therapy, and time to first intervention were evaluated. The effect of the different treatment options were compared using multivariate Cox proportional hazard models to adjust for tumor characteristics that might influence survival. These included clinical T stage, clinical N stage, Gleason grade, number and location of positive lymph nodes and pretreatment PSA. Results: The combined patient population had a 5-year survival rate of 74% and a 10-year survival rate of 48%. Patients receiving local/regional treatment had adjusted 5 year survival rates of 80% compared to 27% for patients receiving no local/regional treatment (p = .001) with corresponding cumulative intervention rates (CIR) of 11% vs. 73% (p = .01) Patients receiving external beam radiation (XRT) alone did not differ significantly from those receiving prostatectomy plus radiation therapy in terms of survival (75 vs. 82%, P = .23) or cumulative intervention rates (14% vs. 14%, P = .94) Conclusion: Although it appears that all patients with node positive prostate cancer will eventually develop failure, this paper suggests local/regional therapy offers a medium term survival advantage over no local/regional treatment. The addition of prostatectomy did not confer a demonstrable advantage over radiation alone.     

Reverse total shoulder arthroplasty in wheelchair-dependent patients: a matched cohort study

BackgroundShoulder function in wheelchair-dependent patients is critical for preserving independence and quality of life due to lower extremity impairment. The purpose of this study was to report the revision rate, as well as clinical and radiological outcome in wheelchair-dependent patients treated with reverse total shoulder arthroplasty (RTSA) and to compare them to an ambulating population.MethodsProspectively obtained data of 21 primary RTSAs in 17 wheelchair-dependent patients (5 male, 12 female) with a median age of 72.4 years (range: 49-80) and a minimum follow-up of 2 years were analyzed retrospectively. Revision rate, clinical (Subjective Shoulder Value = SSV, relative Constant-Murley Score = rCS, wheelchair user’s shoulder pain index = WUSPI) and radiological (glenoid loosening, scapular notching, glenoid inclination) outcome, as well as implant-related parameters (baseplate peg length, glenosphere size, bony augmentation), were compared with a 2:1 matching cohort of 42 ambulating patients (10 male, 32 female) with a median age of 72.5 years (range: 56-78).ResultsThe revision rate was 9.5% in both cohorts. In the wheelchair cohort, two shoulders had to be revised due to a complete baseplate dislocation. In the matching cohort, four shoulders had to be revised due to one prosthetic dislocation, one traumatic and one atraumatic scapular spine fracture with glenoid baseplate dislocation, and one fracture of the greater tuberosity. Median preoperative SSV and rCS did not differ significantly between cohorts. Postoperative SSV was also comparable (wheelchair: median 70 (range: 10-99) vs. matching: median 70 (30-100), p = n.s.). Relative CS was significantly lower in the wheelchair cohort (65% vs. 81.4%, P = .004). Median postoperative WUSPI was 35 points (range: 13-40) for difficulty and 0 points for pain (range: 0-29). The highest difficulty and pain were found for ‘hygiene behind the back’ and ‘propulsion of wheelchair up a ramp or on uneven surface’. Glenoid loosening, scapular notching, and postoperative baseplate inclination did not differ significantly between cohorts. In the wheelchair cohort, glenoid autograft augmentation (38.1% vs. 7.1%, P = .002) and implantation of baseplates with longer pegs were performed more often (≥ 25mm: 38.1% vs. 7.1%, P = .004).ConclusionRTSA is a valuable therapeutic option for the treatment of advanced OA or irreparable rotator cuff tears in wheelchair-bound patients with high patient satisfaction. Postoperatively, poorer function and a higher rate of baseplate dislocations might be anticipated compared to ambulating patients.