Timing of Radiotherapy (RT) After Radical Prostatectomy (RP): Long-term outcomes in the RADICALS-RT trial [NCT00541047]

BACKGROUND

The optimal timing of radiotherapy (RT) after radical prostatectomy for prostate cancer has been uncertain. RADICALS-RT compared efficacy and safety of adjuvant RT versus an observation policy with salvage RT for PSA failure.

METHODS

RADICALS-RT was a randomised controlled trial enrolling patients with ≥1 risk factor (pT3/4, Gleason 7-10, positive margins, pre-op PSA≥10ng/ml) for recurrence after radical prostatectomy. Patients were randomised 1:1 to adjuvant RT ("Adjuvant-RT") or an observation policy with salvage RT for PSA failure ("Salvage-RT") defined as PSA≥0.1ng/ml or 3 consecutive rises. Stratification factors were Gleason score, margin status, planned RT schedule (52.5Gy/20 fractions or 66Gy/33 fractions) and treatment centre. The primary outcome measure was freedom-from-distant metastasis, designed with 80% power to detect an improvement from 90% with Salvage-RT (control) to 95% at 10yr with Adjuvant-RT. Secondary outcome measures were bPFS, freedom-from-non-protocol hormone therapy, safety and patient-reported outcomes. Standard survival analysis methods were used; HR<1 favours Adjuvant-RT.

FINDINGS

Between Oct-2007 and Dec-2016, 1396 participants from UK, Denmark, Canada and Ireland were randomised: 699 Salvage-RT, 697 Adjuvant-RT. Allocated groups were balanced with median age 65yr. 93% (649/697) Adjuvant-RT reported RT within 6m after randomisation; 39% (270/699) Salvage-RT reported RT during follow-up. Median follow-up was 7.8 years. With 80 distant metastasis events, 10yr FFDM was 93% for Adjuvant-RT and 90% for Salvage-RT: HR=0.68 (95%CI 0·43-1·07, p=0·095). Of 109 deaths, 17 were due to prostate cancer. Overall survival was not improved (HR=0.980, 95%CI 0.667-1.440, p=0.917). Adjuvant-RT reported worse urinary and faecal incontinence one year after randomisation (p=0.001); faecal incontinence remained significant after ten years (p=0.017).

INTERPRETATION

Long-term results from RADICALS-RT confirm adjuvant RT after radical prostatectomy increases the risk of urinary and bowel morbidity, but does not meaningfully improve disease control. An observation policy with salvage RT for PSA failure should be the current standard after radical prostatectomy.

Survey: acceptability of opportunistic bilateral salpingectomy in Flanders

Background

The VVOG (Flemish Society of Obstetrics and Gynaecology) published a consensus statement promoting opportunistic bilateral salpingectomy (OBS).

Objectives

The aim of the study was to obtain insight into the current opinion and general practice of Flemish gynaecologists to counsel and perform OBS.

Materials and Methods

A questionnaire was distributed to Flemish gynaecologists three months after publication of the consensus statement.

Main outcome measures

The drawbacks and incentives to counsel and perform OBS were questioned.

Results

Complete response rate was obtained from 99 gynaecologists (17%) and 37 trainees (19%). The majority of respondents (77%) always counselled for OBS in patients scheduled for hysterectomy without oophorectomy. Eighteen per cent counselled only above a certain age cut off and/or if patient was already menopausal. The most important incentive to counsel in cases of hysterectomy by the abdominal approach and vaginal hysterectomy (VH) was the opportunity to prevent ovarian cancer. The yet-undetermined risk of premature ovarian failure was mentioned as the most important barrier in counselling women for OBS in those undergoing hysterectomy by the abdominal approach. For VH, the respondents saw the risk of complications and increased surgical time as the most important barriers. Sixty-one percent of gynaecologists preferred to perform bilateral salpingectomy as sterilisation method.

Conclusions

Our study suggests that the concept of OBS is already well known in Flanders. There is a positive attitude towards the routine implementation of OBS, although some barriers and doubts about an age cut-off still exist in practice.

Incorporating PARP-inhibitors into clinical routine: A tailored treatment strategy to tackle ovarian cancer

DNA repair mechanisms play a key role in oncogenesis and cancer progression in women with BRCA mutation-positive (BRCAm) ovarian cancer (OC). The BRCA1/2 and poly(ADP-ribose) polymerase (PARP) proteins are considered the foremost mediators among the various components of double-strand and single-strand repair, respectively. A series of new therapeutic drugs that target PARP have been developed for BRCAm OC. This class of agents provokes tumour-specific cytotoxicity with minimal side effects by inducing synthetic lethality, of which they are the first clinical example. The European Medicines Agency granted accelerated licensing approval for the first-in-class-drug that inhibits PARP, olaparib (Lynparza™, AstraZeneca). Olaparib can be used as a monotherapeutic maintenance treatment in patients with platinum-sensitive relapsed (germline and/or somatic) BRCAm high-grade serous epithelial ovarian, fallopian tube or primary peritoneal cancer responsive to platinum-based chemotherapy. Seen in light of these recent events, this review article will focus on (a) how PARP-inhibitors exploit cancer-specific defects in the homologous recombination repair apparatus and (b) how BRCA testing is implemented in routine clinical care.

Leiomyomatosis peritonealis disseminata associated with ascites and endometriosis: a case report and review of the literature

We present a case of leiomyomatosis peritonealis disseminata (LPD) and review the literature. LPD is a rare, benign disorder that is characterized by multiple subperitoneal or peritoneal nodules of varying sizes on the omentum and peritoneal surfaces, grossly resembling disseminated carcinoma. It should be differentiated from other peritoneal tumors. It is mostly asymptomatic and diagnosis is often incidental during surgery. One should be aware of the iatrogenic component of this entity. LPD is being documented with increasing frequency. We report the case of a 39-year-old woman with chronic abdominal pain and heavy dysmenorrhea due to endometriosis associated with LPD. She underwent an abdominal hysterectomy with bilateral salpingo-oophorectomy and omentectomy. LPD and endometriosis is a known association. LPD with ascites and endometriosis however has not yet been reported.

Intensity-modulated arc therapy with cisplatin as neo-adjuvant treatment for primary irresectable cervical cancer. Toxicity, tumour response and outcome

PURPOSE

The goal of this work was to evaluate the feasibility and outcome of intensity-modulated arc therapy ± cisplatin (IMAT ± C) followed by hysterectomy for locally advanced cervical cancer.

PATIENTS AND METHODS

A total of 30 patients were included in the study. The primary tumour and PET-positive lymph node(s) received a simultaneous integrated boost. Four weeks after IMAT ± C treatment, response was evaluated. Resection consisted of hysterectomy with or without lymphadenectomy. Tumour response, acute and late radiation toxicity, postoperative morbidity and outcome were evaluated.

RESULTS

All hysterectomy specimens were macroscopically tumour-free with negative resection margins; pathological complete response was 40%. In 2 patients, one resected lymph node was positive. There was no excess in postoperative morbidity. Apart from two grade 3 hematologic toxicities, no grade 3 or 4 acute radiation toxicity was observed. No grade 3, 1 grade 4 (4%) intestinal, and 4 grade 3 (14%) urinary late toxicities were observed. The 2-year local and regional control rates were 96% and 100%, respectively. The 2-year distant control rate was 92%. Actuarial 2-year progression free survival rate was 89%. Actuarial 1- and 2-year overall survival rates were 96% and 91%, while 3-year overall survival was 84%.

CONCLUSION

Surgery after IMAT ± C is feasible with low postoperative morbidity and radiation toxicity. Local, regional, distant control and survival rates are promising.

Detection of estrogen DNA-adducts in human breast tumor tissue and healthy tissue by combined nano LC-nano ES tandem mass spectrometry

For the first time estrogen DNA-adducts were identified in DNA human breast tumor tissue using nano-LC coupled to nano-Electrospray Tandem Mass Spectrometry. Normal breast tissue was analyzed analogously. The data obtained in the five breast tumor and five adjacent normal tissue samples were compared qualitatively, but no straightforward difference was observed. Prior to LC-MS analysis the DNA was enzymatically hydrolyzed to a nucleoside pool. The DNA-hydrolysates were directly injected onto a column switching system developed for on-line sample clean-up and subsequent analysis of the DNA-adducts. In four patients using Premarin, DNA-adducts of 4-hydroxy-equilenin (4OHEN) were detected. All except three samples contained DNA-adducts from 4-hydroxy-estradiol or 4-hydroxy-estrone. Also DNA isolated from eight alcohol fixed and paraffin embedded breast tumor tissue showed the presence of different estrogen DNA-adducts. Worthwhile mentioning is the presence of adducts responding to m/z 570 > m/z 454 transition. This is a well-known SRM-transition indicative for the presence of the 2'-deoxyguanosine (dGuo) adduct of Benzo[a]pyrene.

[Surgery and sentinel node examination in early vulvar cancer]

BACKGROUND

Less than radical vulvectomy for primary vulvar cancer has been controversial. Less mutilating surgery without sacrificing benefits in prognosis is warranted.

MATERIAL AND METHODS

Based on relevant literature and our own experience, we give a review of surgery and sentinel node examination in early vulvar cancer.

RESULTS

Regional lymph node metastasis rarely occurs when tumour thickness is less than 1 mm. Smaller lesions (< 2 cm in diameter) should therefore be treated by wide excision only and without lymph node dissection. Other T1 lesions with deeper invasion should be radically excised with at least 2 cm margins and extend deep to the inferior fascia of the urogenital diaphragm. Complete inguinal-femoral lymphadenectomy should be performed in patients without groin metastases to avoid a small, but definite risk of recurrence, although the incidence of lymph node metastases for all clinical stage I patients is less than 10%. Lymphatic mapping with 99mTechnetium and patent blue technique is a potentially valuable intraoperative tool for assuring removal of the sentinel node most likely to have metastasis, defining the extent of the superficial inguinal lymphadenectomy and identifying uncommon anatomic variations.

INTERPRETATION

Until reliable data on the benefits of selective lymphadenectomy using intraoperative lymphoscintigraphy are available, the procedure should only be performed in an approved research setting.

Surgery for borderline tumor of the ovary

The five-year survival for women with Stage I borderline tumors is about 95% to 97%, but because of late recurrence the 10-year survival is only 70% to 95%. The five-year survival for Stage II-III patients is 65% to 87%. A more correct staging procedure, classification of true serous implants, and agreement on how the presence of gelatinous ascites in mucinous tumors contributes to cancer stage might change the distribution of stage and survival data by stage for women with borderline tumors in the future. Independent prognostic factors for patients with borderline tumors without residual tumor after primary surgery are: DNA ploidy, morphometry, International Federation of Gynecology and Obstetrics (FIGO) stage, histologic type, and age. Different types of surgery and chemotherapy were not independent prognostic factors. Questions which should be addressed include the following: 1) Have patients with borderline tumors been over treated in general, and how should these patients be treated? 2) In which group of patients is fertility-sparing surgery advisable? 3) Do patients with borderline tumors benefit from adjuvant treatment? And 4) How is the high-risk patient defined?

Surgery for borderline tumor of the ovary

The five-year survival for women with Stage I borderline tumors is about 95% to 97%, but because of late recurrence the 10-year survival is only 70% to 95%. The five-year survival for Stage II-III patients is 65% to 87%. A more correct staging procedure, classification of true serous implants, and agreement on how the presence of gelatinous ascites in mucinous tumors contributes to cancer stage might change the distribution of stage and survival data by stage for women with borderline tumors in the future. Independent prognostic factors for patients with borderline tumors without residual tumor after primary surgery are: DNA ploidy, morphometry, International Federation of Gynecology and Obstetrics (FIGO) stage, histologic type, and age. Different types of surgery and chemotherapy were not independent prognostic factors. Questions which should be addressed include the following: 1) Have patients with borderline tumors been over treated in general, and how should these patients be treated? 2) In which group of patients is fertility-sparing surgery advisable? 3) Do patients with borderline tumors benefit from adjuvant treatment? And 4) How is the high-risk patient defined?

[Controversies in surgical treatment of advanced ovarian cancer]

Cytoreductive surgery has traditionally been regarded as a cornerstone in the primary treatment of advanced ovarian cancer. Both five year survival and median survival are better for patients with small residual masses. Despite many similar reports showing the prognostic significance of postoperative residual tumour, the survival benefits of cytoreductive surgery still remain scientifically unproven and controversial. There have been no prospective controlled clinical trials. The question remains as to whether the observed survival benefits for patients subjected to primary cytoreductive surgery are an effect of surgery skills or tumour biology. The proponents of tumour biology claim that cytoreductive surgery is a selective procedure and that patients with better prognosis are selected. Therefore a randomized study between primary cytoreduction and neoadjuvant chemotherapy in patients that cannot be optimally cytoreduced seems warranted, though one problem with such a study is how to select eligible patients. During chemotherapy and after relapse several types of operations are used in ovarian cancer: secondary cytoreductive surgery, interval cytoreductive surgery, second-look surgery and palliative secondary surgery. So far interval cytoreductive surgery during chemotherapy is the only type of operation which in a prospective randomized study showed significant improvement in long-term survival. This paper discusses indirect evidence in the literature in support of or in contradiction to the primary debulking hypotheses and also indications and impact of surgical procedures during chemotherapy.

Transnasal butorphanol: a new method for pain relief in post-cesarean section pain

This study was undertaken to evaluate the efficacy and the safety of transnasal butorphanol (TNB) compared to intravenous butorphanol (IVB) in 186 patients experiencing moderate to severe post-cesarean section pain. Patients were randomly assigned to five groups in a double-blind fashion: Group I (n = 37) received 2 mg IVB, Group II (n = 38) 2 mg TNB, Group III (n = 36) 1 mg TNB followed by a repeat dose of 1 mg TNB at 60 min, Group IV (n = 38) 0.5 mg TNB followed by a repeat dose of 0.5 mg at 60 min, and Group V (n = 37) received placebo. All administrations were double dummy. Pain intensity and relief were noted and the incidence of side effects was recorded. Remedication with the same study drug was allowed up to 72 h. Onset of analgesia was more rapid in the 2 mg IV group compared to the three TN groups: 5 min vs 15 min, respectively. However, the 2 mg and the 1-1 mg TN groups had a longer duration of analgesia, approximately 4.5 h, compared to 3.0 h for the 2 mg IV group (P less than 0.05). Somnolence was dose related and was the most frequent side effect, and was less frequent when the TN dose was divided into 2 doses administered 1 h apart. Multiple doses of TNB and IVB were safe and clinically acceptable up to 3 days at all doses studied. There were no incidences of nasal mucosa irritation, or cardiovascular or respiratory depression. It is concluded that transnasal butorphanol represents a safe and effective alternative to injectable butorphanol for post-cesarean section pain and offers a better and longer duration of analgesia compared to IV butorphanol. The optimum dose seems to be 2 mg TN butorphanol and it is tolerated better when divided into 1 mg increments, given 1 h apart.

Mini-dose intrathecal morphine for the relief of post-cesarean section pain: safety, efficacy, and ventilatory responses to carbon dioxide

To determine the safety, efficacy, and the ventilatory responses to carbon dioxide (CO2) of mini-dose intrathecal morphine, 33 healthy women who underwent cesarean section with spinal anesthesia using 0.75% bupivacaine in 8.25% dextrose were studied. Patients were randomly assigned to receive, in a double-blind fashion, either morphine 0.25 mg (group I, n = 11), morphine 0.1 mg (group II, n = 10), or saline (group III, placebo group, n = 12) in 0.5 ml volume mixed with the bupivacaine. In both groups I and II excellent postoperative analgesia with long duration was obtained (27.7 +/- 4.0 and 18.6 +/- 0.9 hours, respectively, X +/- SEM). All patients in group III required an analgesic (8 mg subcutaneous morphine) within 3 hours of spinal anesthesia. Seven patients in group I and four patients in group II developed mild pruritus that did not require treatment. Ventilatory responses to CO2 showed no evidence of depression attributable to either the 0.25 or 0.1 mg of morphine, but significant depression of the CO2 responses was observed in group III patients after administration of subcutaneous morphine. It is concluded that a dose as low as 0.1 mg of intrathecal morphine gives excellent analgesia with minimal to no side effects and that subcutaneous morphine is associated with marked depression of the ventilatory variables.

Role of histamine in the aetiology of byssinosis. II. Lung histamine concentrations in guinea pigs chronically exposed to cotton and flax dusts

Data presented in this study support the finding that cotton and flax dusts contain agents which potentiate the formation or accumulation of histamine or both in the lungs of guinea pigs exposed to dust, and that such agents are present at much higher levels in cotton dust than in flax dust. The potentiating effect may be through the recruitment of mast cells into the lung. Both cotton and flax dusts contain methylating enzyme inhibitory agents, whereas cotton dust also contains agents that inhibit histaminase activity; flax dust contains agents potentiating histamine activity. These agents working together result in the accumulation or depletion of histamine observed in the different groups of animals exposed to either cotton or flax dust in this study.