Abiraterone acetate plus prednisolone with or without enzalutamide for patients with metastatic prostate cancer starting androgen deprivation therapy: final results from two randomised phase 3 trials of the STAMPEDE platform protocol

BACKGROUND

Abiraterone acetate plus prednisolone (herein referred to as abiraterone) or enzalutamide added at the start of androgen deprivation therapy improves outcomes for patients with metastatic prostate cancer. Here, we aimed to evaluate long-term outcomes and test whether combining enzalutamide with abiraterone and androgen deprivation therapy improves survival.

METHODS

We analysed two open-label, randomised, controlled, phase 3 trials of the STAMPEDE platform protocol, with no overlapping controls, conducted at 117 sites in the UK and Switzerland. Eligible patients (no age restriction) had metastatic, histologically-confirmed prostate adenocarcinoma; a WHO performance status of 0-2; and adequate haematological, renal, and liver function. Patients were randomly assigned (1:1) using a computerised algorithm and a minimisation technique to either standard of care (androgen deprivation therapy; docetaxel 75 mg/m² intravenously for six cycles with prednisolone 10 mg orally once per day allowed from Dec 17, 2015) or standard of care plus abiraterone acetate 1000 mg and prednisolone 5 mg (in the abiraterone trial) orally or abiraterone acetate and prednisolone plus enzalutamide 160 mg orally once a day (in the abiraterone and enzalutamide trial). Patients were stratified by centre, age, WHO performance status, type of androgen deprivation therapy, use of aspirin or non-steroidal anti-inflammatory drugs, pelvic nodal status, planned radiotherapy, and planned docetaxel use. The primary outcome was overall survival assessed in the intention-to-treat population. Safety was assessed in all patients who started treatment. A fixed-effects meta-analysis of individual patient data was used to compare differences in survival between the two trials. STAMPEDE is registered with ClinicalTrials.gov (NCT00268476) and ISRCTN (ISRCTN78818544).

FINDINGS

Between Nov 15, 2011, and Jan 17, 2014, 1003 patients were randomly assigned to standard of care (n=502) or standard of care plus abiraterone (n=501) in the abiraterone trial. Between July 29, 2014, and March 31, 2016, 916 patients were randomly assigned to standard of care (n=454) or standard of care plus abiraterone and enzalutamide (n=462) in the abiraterone and enzalutamide trial. Median follow-up was 96 months (IQR 86-107) in the abiraterone trial and 72 months (61-74) in the abiraterone and enzalutamide trial. In the abiraterone trial, median overall survival was 76·6 months (95% CI 67·8-86·9) in the abiraterone group versus 45·7 months (41·6-52·0) in the standard of care group (hazard ratio [HR] 0·62 [95% CI 0·53-0·73]; p<0·0001). In the abiraterone and enzalutamide trial, median overall survival was 73·1 months (61·9-81·3) in the abiraterone and enzalutamide group versus 51·8 months (45·3-59·0) in the standard of care group (HR 0·65 [0·55-0·77]; p<0·0001). We found no difference in the treatment effect between these two trials (interaction HR 1·05 [0·83-1·32]; p_interaction=0·71) or between-trial heterogeneity (I² p=0·70). In the first 5 years of treatment, grade 3-5 toxic effects were higher when abiraterone was added to standard of care (271 [54%] of 498 vs 192 [38%] of 502 with standard of care) and the highest toxic effects were seen when abiraterone and enzalutamide were added to standard of care (302 [68%] of 445 vs 204 [45%] of 454 with standard of care). Cardiac causes were the most common cause of death due to adverse events (five [1%] with standard of care plus abiraterone and enzalutamide [two attributed to treatment] and one (<1%) with standard of care in the abiraterone trial).

INTERPRETATION

Enzalutamide and abiraterone should not be combined for patients with prostate cancer starting long-term androgen deprivation therapy. Clinically important improvements in survival from addition of abiraterone to androgen deprivation therapy are maintained for longer than 7 years.

FUNDING

Cancer Research UK, UK Medical Research Council, Swiss Group for Clinical Cancer Research, Janssen, and Astellas.

Clinical testing of transcriptome-wide expression profiles in high-risk localized and metastatic prostate cancer starting androgen deprivation therapy: an ancillary study of the STAMPEDE abiraterone Phase 3 trial

Metastatic and high-risk localized prostate cancer respond to hormone therapy but outcomes vary. Following a pre-specified statistical plan, we used Cox models adjusted for clinical variables to test associations with survival of multi-gene expression-based classifiers from 781 patients randomized to androgen deprivation with or without abiraterone in the STAMPEDE trial. Decipher score was strongly prognostic (p<2×10-5) and identified clinically-relevant differences in absolute benefit, especially for localized cancers. In metastatic disease, classifiers of proliferation, PTEN or TP53 loss and treatment-persistent cells were prognostic. In localized disease, androgen receptor activity was protective whilst interferon signaling (that strongly associated with tumor lymphocyte infiltration) was detrimental. Post-Operative Radiation-Therapy Outcomes Score was prognostic in localized but not metastatic disease (interaction p=0.0001) suggesting the impact of tumor biology on clinical outcome is context-dependent on metastatic state. Transcriptome-wide testing has clinical utility for advanced prostate cancer and identified worse outcomes for localized cancers with tumor-promoting inflammation.

Accumulation of copy number alterations and clinical progression across advanced prostate cancer

BACKGROUND

Genomic copy number alterations commonly occur in prostate cancer and are one measure of genomic instability. The clinical implication of copy number change in advanced prostate cancer, which defines a wide spectrum of disease from high-risk localised to metastatic, is unknown.

METHODS

We performed copy number profiling on 688 tumour regions from 300 patients, who presented with advanced prostate cancer prior to the start of long-term androgen deprivation therapy (ADT), in the control arm of the prospective randomised STAMPEDE trial. Patients were categorised into metastatic states as follows; high-risk non-metastatic with or without local lymph node involvement, or metastatic low/high volume. We followed up patients for a median of 7 years. Univariable and multivariable Cox survival models were fitted to estimate the association between the burden of copy number alteration as a continuous variable and the hazard of death or disease progression.

RESULTS

The burden of copy number alterations positively associated with radiologically evident distant metastases at diagnosis (P=0.00006) and showed a non-linear relationship with clinical outcome on univariable and multivariable analysis, characterised by a sharp increase in the relative risk of progression (P=0.003) and death (P=0.045) for each unit increase, stabilising into more modest increases with higher copy number burdens. This association between copy number burden and outcome was similar in each metastatic state. Copy number loss occurred significantly more frequently than gain at the lowest copy number burden quartile (q=4.1 × 10-6). Loss of segments in chromosome 5q21-22 and gains at 8q21-24, respectively including CHD1 and cMYC occurred more frequently in cases with higher copy number alteration (for either region: Kolmogorov-Smirnov distance, 0.5; adjusted P<0.0001). Copy number alterations showed variability across tumour regions in the same prostate. This variance associated with increased risk of distant metastases (Kruskal-Wallis test P=0.037).

CONCLUSIONS

Copy number alteration in advanced prostate cancer associates with increased risk of metastases at diagnosis. Accumulation of a limited number of copy number alterations associates with most of the increased risk of disease progression and death. The increased likelihood of involvement of specific segments in high copy number alteration burden cancers may suggest an order underlying the accumulation of copy number changes.

TRIAL REGISTRATION

ClinicalTrials.gov NCT00268476 , registered on December 22, 2005. EudraCT  2004-000193-31 , registered on October 4, 2004.

1254 Virtual Fracture Clinic Management of Little (5th) Metacarpal Neck Fractures; a Safe and Feasible Option?

Aim

To determine the safety and efficacy of a Virtual Fracture Clinic (VFC) in managing little metacarpal neck fractures.

Method

Retrospective review of consecutive little MC neck fractures presenting to the ED June-December 2020 and subsequently referred on to VFC. Patient demographics and clinic outcomes were reviewed using electronic patient records and radiographs.

Results

Fifty patients were identified (Male:Female 37:13; mean age 26 years, range 3-89 years). Of these, 41/50 were discharged directly following VFC advice, with no adverse event. The remaining 9/50 had a face-to-face Fracture Clinic review due to safeguarding concerns (2), concurrent neck of fourth MC fracture (2), concerns regarding fracture pattern (4), and an unclear indication (1). These 9/50 were discharged after single review, with no adverse events to date.

Conclusions

Our data suggest that VFC review of patients with little MC neck fractures is a safe and feasible means of patient care which has the potential to reduce the requirement of face-to-face patient contact during the Covid-19 pandemic and reduce fracture clinic attendance. We suggest the routine incorporation of a Virtual Fracture Clinic for these hand injuries. Further work is needed to formally investigate associated patient satisfaction and the application of this approach to other trauma presentations.

Proliferation index and survival in men with prostate cancer starting long-term androgen deprivation therapy in the STAMPEDE clinical trial

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Background: Treatment intensification with docetaxel or abiraterone improved survival for advanced prostate cancer starting androgen deprivation therapy (ADT) in the Systemic Therapy in Advancing or Metastatic Prostate Cancer: Evaluation of Drug Efficacy (STAMPEDE, NCT00268476) trial. However, survival and time-to-progression is highly variable on ADT, introducing the risk of unnecessary toxicity from additional treatments for some patients. Here we test the prognostic association of proliferation index using Ki67 scores in the control arm of the STAMPEDE population of high-risk localised (M0) and metastatic (M1) prostate cancer. Methods: Pre-ADT diagnostic needle biopsies were obtained from 517 men randomized in STAMPEDE arm A between 2006 and 2015. These were assessed for proliferation using an analytically optimised Ki67 immunohistochemistry assay. Ki67 was tested for associations with baseline clinico-pathological variables (Grade group, pre-ADT serum PSA and imaging metastatic burden) in univariable linear-regression models, and for associations with survival outcomes in multivariable Cox-regression models adjusted for these and additional confounding variables. Primary outcome measure was overall survival, secondary outcomes were prostate cancer-specific, failure-free, progression-free and metastatic progression-free survival. Results: Ki67 was available for 475 patients who received ADT only for at least 2 years ± radiotherapy. Of 202 M0, 74 were node positive. Of 273 M1, 116, 127 and 30 were respectively low, high and unknown radiological M1 volume. Ki67 score associated with higher Gleason (p=7.15x10-11) and presence of extra-pelvic metastases (p=1.41x10-8). Increasing Ki67 scores showed a strong linear association with poorer overall survival, with an estimated 2% increase in the hazard of death per percentage increase in the score (adjusted HR=1.02, 95% CI 1.01-1.02; p=1.04x10-5). There was also strong evidence that Ki67 associated positively with all secondary outcomes, including prostate cancer-specific survival (adjusted p=5.50x10-6) and metastatic progression-free survival (adjusted p=3.50x10-9). Conclusions: Ki67 immuno-score is strongly prognostic in clinically advanced prostate cancer independent of Gleason score and the other clinicopathological variables tested in this study. Ki67 is a clinically scalable assay that could improve selection for treatment intensification and provide a tool for screening patients most likely to benefit from further molecular investigation.

Copy number profiles of primary tumors for risk stratification of advanced prostate cancer: A biomarker study embedded in the multicenter STAMPEDE trial

5021

Background: Men with advanced hormone-sensitive prostate cancer (HSPC) starting long term androgen deprivation therapy (ADT) follow a highly variable clinical course. Treatment intensification with docetaxel or AR targeted therapies improves outcomes but there is a risk of overtreatment, especially in non-metastatic (M0) or metastatic (M1) low volume disease. We established a framework for biomarker evaluation in the STAMPEDE trial. We aimed to evaluate the feasibility and clinical utility of assessing the burden of copy number (CN) aberrations in newly diagnosed advanced HSPC. We hypothesised that increased percentage genome altered (PGA) would associate with higher disease burden and worse prognosis. Methods: We implemented a scalable strategy using low coverage whole genome sequencing (lpWGS) of formalin fixed paraffin embedded (FFPE) diagnostic core biopsies from STAMPEDE participants randomised to the standard of care ADT arm, between 2005 and 2016. Tissue was retrieved from 136 trial sites. 315 cases were randomly selected, aiming for a biomarker population of 300, anticipating an assay failure rate ̃5%. We defined 40% as the minimum histopathologically determined tumor cellularity (TC) for inclusion. We performed a survival analysis investigating PGA at diagnosis as a continuous measure with fractional polynomial specification in Cox models adjusting for disease burden, Gleason grade, pre-ADT PSA (log-transformed), age at randomisation and TC. We pre-specified that all hypothesis tests required evidence at the 5% significance level to consider rejecting the null hypothesis. Results: We successfully CN profiled 300/315 cases. There were no significantly different baseline clinico-pathological features between the full trial comparison n = 3106 and final biomarker population n = 300, 290/300 cases were de novo presentations. PGA in the core with highest Gleason grade and TC was median 18% (range 0%-75%; n = 300). PGA was significantly higher in M1 (n = 169) compared to M0 (n = 131) cases (median: 21% vs 14%; p = 0.00006). 284/300 were subclassified by disease burden into M0 node negative and node positive, and M1 low and high volume. PGA was significantly associated with increased disease burden (p = 0.00002). Increased PGA was significantly and non-linearly associated with an increased hazard of failure-free survival (p = 0.004), progression-free survival (p = 0.002), metastatic progression-free survival (p = 0.003), overall survival (p = 0.045) and prostate cancer-specific survival (p = 0.011). Conclusions: Evaluation of the burden of CN aberrations in archival, poor quality FFPE diagnostic tissue from men randomised in the STAMPEDE trial is feasible using lpWGS and has potential clinical utility to identify better prognosis advanced HSPC patients, who may not require treatment intensification.

649 COVID BOAST In Practice: Our Experience Implementing BOA Recommendations During the UK Coronavirus Pandemic Peak

Background

In anticipation of the UK coronavirus pandemic peak, BOA published new pandemic-specific guidance (“COVID BOAST”) in April 2020. We describe our experience implementing this restructured T&O service in a busy DGH setting during the pandemic peak.

Method

A rapid retrospective audit was conducted of all patients presenting to our T&O service in April 2020, with particular emphasis compliance with COVID BOAST.

Results

Our service conducted 511 outpatient reviews, and 95 operative procedures. 94% of outpatients were treated non-operatively. We provided telephone appointments to 12.8% of follow-up patients, and 39% of new patients. 82% of patients were treated with removable casts/splints/boots. 23% of patients were discharged direct from VFC or after one face-to-face fracture clinic review. Residual deformity was consciously accepted in 13% of patients. Theatre throughput fell significantly due to pandemic precautions however, femoral neck fracture volumes remained constant.

Conclusions

We demonstrate broad compliance with COVID BOAST guidance. The majority of patients were treated non-operatively, including conscious acceptance of residual deformity. Our pre-existing VFC allowed us to provide a significant number of telephone consultations, although despite the practice shift towards removable splintage, face-to-face consultations were required for clinical and/or radiological assessment. The impact of increased conservative management on patients’ long-term outcomes needs further evaluation.

Association of Bone Metastatic Burden With Survival Benefit From Prostate Radiotherapy in Patients With Newly Diagnosed Metastatic Prostate Cancer: A Secondary Analysis of a Randomized Clinical Trial

IMPORTANCE

Prostate radiotherapy (RT) improves survival in men with low-burden metastatic prostate cancer. However, owing to the dichotomized nature of metastatic burden criteria, it is not clear how this benefit varies with bone metastasis counts and metastatic site.

OBJECTIVE

To evaluate the association of bone metastasis count and location with survival benefit from prostate RT.

DESIGN, SETTING, AND PARTICIPANTS

This exploratory analysis of treatment outcomes based on metastatic site and extent as determined by conventional imaging (computed tomography/magnetic resonance imaging and bone scan) evaluated patients with newly diagnosed metastatic prostate cancer randomized within the STAMPEDE trial's metastasis M1 RT comparison. The association of baseline bone metastasis counts with overall survival (OS) and failure-free survival (FFS) was assessed using a multivariable fractional polynomial interaction procedure. Further analysis was conducted in subgroups.

INTERVENTIONS

Patients were randomized to receive either standard of care (androgen deprivation therapy with or without docetaxel) or standard of care and prostate RT.

MAIN OUTCOMES AND MEASURES

The primary outcomes were OS and FFS.

RESULTS

A total of 1939 of 2061 men were included (median [interquartile range] age, 68 [63-73] years); 1732 (89%) had bone metastases. Bone metastasis counts were associated with OS and FFS benefit from prostate RT. Survival benefit decreased continuously as the number of bone metastases increased, with benefit most pronounced up to 3 bone metastases. A plot of estimated treatment effect indicated that the upper 95% CI crossed the line of equivalence (hazard ratio [HR], 1) above 3 bone metastases without a detectable change point. Further analysis based on subgroups showed that the magnitude of benefit from the addition of prostate RT was greater in patients with low metastatic burden with only nonregional lymph nodes (M1a) or 3 or fewer bone metastases without visceral metastasis (HR for OS, 0.62; 95% CI, 0.46-0.83; HR for FFS, 0.57; 95% CI, 0.47-0.70) than among patients with 4 or more bone metastases or any visceral/other metastasis (HR for OS, 1.08; 95% CI, 0.91-1.28; interaction P = .003; HR for FFS, 0.87; 95% CI, 0.76-0.99; interaction P = .002).

CONCLUSIONS AND RELEVANCE

In this exploratory analysis of a randomized clinical trial, bone metastasis count and metastasis location based on conventional imaging were associated with OS and FFS benefit from prostate RT in M1 disease.

TRIAL REGISTRATION

ClinicalTrials.gov Identifier: NCT00268476; ISRCTN.com Identifier: ISRCTN78818544.

Genomic Profiles of De Novo High- and Low-Volume Metastatic Prostate Cancer: Results From a 2-Stage Feasibility and Prevalence Study in the STAMPEDE Trial

PURPOSE

The STAMPEDE trial recruits men with newly diagnosed, high-risk, hormone-sensitive prostate cancer. To ascertain the feasibility of targeted next-generation sequencing (tNGS) and the prevalence of baseline genomic aberrations, we sequenced tumor and germline DNA from patients with metastatic prostate cancer (mPCa) starting long-term androgen-deprivation therapy (ADT).

METHODS

In a 2-stage approach, archival, formalin-fixed, paraffin-embedded (FFPE) prostate tumor core biopsy samples were retrospectively subjected to 2 tNGS assays. Prospective enrollment enabled validation using tNGS in tumor and germline DNA.

RESULTS

In stage 1, tNGS data were obtained from 185 tumors from 287 patients (65%); 98% had de novo mPCa. We observed PI3K pathway aberrations in 43%, due to PTEN copy-number loss (34%) and/or activating mutations in PIK3 genes or AKT (18%) and TP53 mutation or loss in 33%. No androgen receptor (AR) aberrations were detected; RB1 loss was observed in < 1%. In stage 2, 93 (92%) of 101 FFPE tumors (biopsy obtained within 8 months) were successfully sequenced prospectively. The prevalence of DNA damage repair (DDR) deficiency was 14% (somatic) and 5% (germline). BRCA2 mutations and mismatch repair gene mutations were exclusive to high-volume disease. Aberrant DDR (22% v 15%), Wnt pathway (16% v 4%), and chromatin remodeling (16% v 8%) were all more common in high-volume compared with low-volume disease, but the small numbers limited statistical comparisons.

CONCLUSION

Prospective genomic characterization is feasible using residual diagnostic tumor samples and reveals that the genomic landscapes of de novo high-volume mPCa and advanced metastatic prostate cancer have notable similarities (PI3K pathway, DDR, Wnt, chromatin remodeling) and differences (AR, RB1). These results will inform the design and conduct of biomarker-directed trials in men with metastatic hormone-sensitive prostate cancer.

Addition of docetaxel to hormonal therapy in low- and high-burden metastatic hormone sensitive prostate cancer: long-term survival results from the STAMPEDE trial

BACKGROUND

STAMPEDE has previously reported that the use of upfront docetaxel improved overall survival (OS) for metastatic hormone naïve prostate cancer patients starting long-term androgen deprivation therapy. We report on long-term outcomes stratified by metastatic burden for M1 patients.

METHODS

We randomly allocated patients in 2 : 1 ratio to standard-of-care (SOC; control group) or SOC + docetaxel. Metastatic disease burden was categorised using retrospectively-collected baseline staging scans where available. Analysis used Cox regression models, adjusted for stratification factors, with emphasis on restricted mean survival time where hazards were non-proportional.

RESULTS

Between 05 October 2005 and 31 March 2013, 1086 M1 patients were randomised to receive SOC (n = 724) or SOC + docetaxel (n = 362). Metastatic burden was assessable for 830/1086 (76%) patients; 362 (44%) had low and 468 (56%) high metastatic burden. Median follow-up was 78.2 months. There were 494 deaths on SOC (41% more than the previous report). There was good evidence of benefit of docetaxel over SOC on OS (HR = 0.81, 95% CI 0.69-0.95, P = 0.009) with no evidence of heterogeneity of docetaxel effect between metastatic burden sub-groups (interaction P = 0.827). Analysis of other outcomes found evidence of benefit for docetaxel over SOC in failure-free survival (HR = 0.66, 95% CI 0.57-0.76, P < 0.001) and progression-free survival (HR = 0.69, 95% CI 0.59-0.81, P < 0.001) with no evidence of heterogeneity of docetaxel effect between metastatic burden sub-groups (interaction P > 0.5 in each case). There was no evidence that docetaxel resulted in late toxicity compared with SOC: after 1 year, G3-5 toxicity was reported for 28% SOC and 27% docetaxel (in patients still on follow-up at 1 year without prior progression).

CONCLUSIONS

The clinically significant benefit in survival for upfront docetaxel persists at longer follow-up, with no evidence that benefit differed by metastatic burden. We advocate that upfront docetaxel is considered for metastatic hormone naïve prostate cancer patients regardless of metastatic burden.

Importance of non-regional lymph nodes in assigning risk in primary metastatic prostate cancer

OBJECTIVE

To determine the prognostic relevance of non-regional lymph node (NRLN) metastases presenting synchronously with bone metastases in metastatic prostate cancer (mPCa) for guiding treatment decisions based on oligometastatic definitions.

PATIENTS AND METHODS

Patients diagnosed with mPCa between 2004 and 2013 were identified from the Surveillance, Epidemiology and End Results database and were grouped by metastatic sites into only NRLN, only bone, bone + NRLN and other sites ± bone/NRLN metastases. Multivariate Cox and competing risk regression analyses were performed to compare the risks of all-cause mortality (ACM) and prostate cancer-specific mortality (PCSM) associated with bone + NRLN metastases before and after propensity-score matching to patients with only bone metastases. This was complemented with landmark and supplementary analyses.

RESULTS

Of 17 167 patients with mPCa identified, 63.1% presented with only bone metastases, while bone and NRLN metastases co-occurred in 8.9% of the cohort. On multivariate analyses, after adjusting for potential confounders (clinical and sociodemographic), patients with bone + NRLN metastases had a significantly higher risk of ACM (hazard ratio [HR] 1.161, 95% confidence interval [CI] 1.084-1.243; P < 0.001) and PCSM (subdistribution HR 1.149, 95% CI 1.067-1.237; P < 0.001) compared with patients with only bone metastases. Landmark analyses limited to survivors of ≥6 and ≥12 months again showed a significantly increased risk of ACM for patients presenting with bone + NRLN metastases compared with patients with only bone metastases. In a subsequent 1:1 propensity-score-matched cohort of patients with bone + NRLN metastases and only bone metastases, the bone + NRLN group had higher multivariate-adjusted hazard rates for ACM (HR 1.202, 95% CI 1.102-1.311; P < 0.001) and PCSM (subdistribution HR 1.146, 95% CI 1.044-1.259; P = 0.004).

CONCLUSIONS

Patients with concomitant NRLN and bone metastases have a higher risk of death, NRLN and bone metastases therefore representing a high-risk feature, when compared with patients with bone metastases alone. The current therapeutic stratification of 'low-' vs 'high-volume' disease does not account for this phenomenon, and patients requiring aggressive combination therapy may not receive maximum therapeutic benefit as a consequence.

The importance of non-regional lymph nodes in assigning risk in primary metastatic prostate cancer

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Background: Patients diagnosed with non-regional lymph nodes (NRLN) in isolation exhibit a more prolonged clinical course than those with bone or visceral metastases in trial data, but evaluation of survival data in general populations is sparse and their presence doesn’t feature in risk estimations based on tumour volume. Methods: The evaluation and prognostic relevance of NRLN metastasis presenting synchronously with osseous or non-ossesous metastasis in hormone-naive prostate cancer was evaluated using the Surveillance, Epidemiology and End-results (SEER) database. Patients with stage M1a-c PCa diagnosed between 2004 and 2009 were identified and included within the analysis. Kaplan Meier was used to estimate overall (OS) and cancer specific survival (CSS) rates in relation to metastatic distribution. Multivariate cox-regression models were used to identify predictors of OS and CSS. Results: Of 4869 metastatic PCa patients identified, osseous metastasis was the most common finding (65.1%); followed by non-osseous (17.5%), osseous + NRLN (7.8%), NRLN (4.9%), non-osseous + osseous (±NRLN) (2.9%) and non-osseous + NRLN (1.8%). Median follow-up was 93 mo. Median OS and CSS were 28 and 34 mo respectively. Patients with osseous + NRLN metastasis had a significantly worse median OS (30 mo vs 25 mo, p = 0.001) and CSS (37 mo vs 29 mo, p < 0.001) compared to osseous only metastasis. On multivariate cox regression, osseous + NRLN metastasis was an independent predictor of OS and CSS when compared to osseous only metastasis (both p-values < 0.01). Conclusions: NRLN metastasis in the presence of osseous metastasis represents a poor prognostic feature when compared to osseous metastasis alone. The current therapeutic stratification of “low vs high volume” disease does not account for this phenomenon and patients requiring aggressive therapy may not receive maximal therapeutic benefit as a consequence.

Surgical Management of Stuttering Ischemic Priapism: A Case Report and Concise Clinical Review

Stuttering priapism is an extremely rare and poorly understood entity. We present a rare case of a 47-year-old Afro-Caribbean gentleman who required proximal shunt procedure to treat his ischemic stuttering priapism after he had failed medical management. We provided a concise review of the literature on the surgical management of ischemic priapism. This case highlighted the importance of prompt surgical intervention in prolonged stuttering priapism to avoid serious psychological and functional complications.

Methanol-based fixation is superior to buffered formalin for next-generation sequencing of DNA from clinical cancer samples

BACKGROUND

Next-generation sequencing (NGS) of tumour samples is a critical component of personalised cancer treatment, but it requires high-quality DNA samples. Routine neutral-buffered formalin (NBF) fixation has detrimental effects on nucleic acids, causing low yields, as well as fragmentation and DNA base changes, leading to significant artefacts.

PATIENTS AND METHODS

We have carried out a detailed comparison of DNA quality from matched samples isolated from high-grade serous ovarian cancers from 16 patients fixed in methanol and NBF. These experiments use tumour fragments and mock biopsies to simulate routine practice, ensuring that results are applicable to standard clinical biopsies.

RESULTS

Using matched snap-frozen tissue as gold standard comparator, we show that methanol-based fixation has significant benefits over NBF, with greater DNA yield, longer fragment size and more accurate copy-number calling using shallow whole-genome sequencing (WGS). These data also provide a new approach to understand and quantify artefactual effects of fixation using non-negative matrix factorisation to analyse mutational spectra from targeted and WGS data.

CONCLUSION

We strongly recommend the adoption of methanol fixation for sample collection strategies in new clinical trials. This approach is immediately available, is logistically simple and can offer cheaper and more reliable mutation calling than traditional NBF fixation.

Acute paraspinal compartment syndrome as a rare cause of loin pain

A significant proportion of emergency urological admissions are comprised of ureteric colic presenting as loin pain. A variety of alternative pathologies present in this manner and should be considered during systematic assessment. We report the case of a patient admitted with severe unilateral back and flank pain after strenuous deadlift exercise. Clinical examination and subsequent investigation following a significant delay demonstrated acute paraspinal compartment syndrome (PCS) after an initial misdiagnosis of ureteric colic. The patient was managed conservatively. We review the current literature surrounding the rare diagnosis of PCS and discuss the management options.

Delirium affects length of hospital stay after lung transplantation

BACKGROUND

Delirium is relatively common after lung transplantation, although its prevalence and prognostic significance have not been systematically studied. The purpose of the present study was to examine pretransplant predictors of delirium and the short-term impact of delirium on clinical outcomes among lung transplant recipients.

METHODS

Participants underwent pretransplant cognitive testing using the Repeatable Battery for the Assessment of Neuropsychological Status and the Trail Making Test. After transplant, delirium was assessed using the Confusion Assessment Method until discharge.

RESULTS

Sixty-three patients were transplanted between March and November 2013, of which 23 (37%) developed delirium. Among transplanted patients, 48 patients completed pretransplant cognitive testing. Better pretransplant cognitive function was associated with lower risk of delirium (odds ratio, 0.69 [95% confidence interval 0.48, 0.99], P = .043); and demographic and clinical features including native disease (P = .236), the Charlson comorbidity index (P = .581), and the lung allocation score (P = .871) were unrelated to risk of delirium, although there was a trend for women to experience delirium less frequently (P = .071). The presence (P = .006) and duration (P = .027) of delirium were both associated with longer hospital stays.

CONCLUSION

Delirium occurs in more than one-third of patients after lung transplantation. Delirium was associated with poorer pretransplant cognitive functioning and longer hospital stays, after accounting for other medical and demographic factors.

Orthotopic liver transplantation for alcoholic liver disease: a retrospective analysis of survival, recidivism, and risk factors predisposing to recidivism

The aim of this study performed at the Liver Unit at the Queen Elizabeth Hospital, Birmingham, UK, is to assess posttransplantation alcohol consumption and identify risk factors associated with recidivism. This retrospective case-control study used a self-report questionnaire to assess pretransplantation and posttransplantation drinking, and a retrospective cohort study used patient notes to analyze risk factors for recidivism. Of 64 patients who underwent transplantation for alcoholic liver disease (ALD) between May 1996 and November 1999, a total of 49 surviving patients (40 men, 9 women) were available for study. The comparison group consisted of 49 patients matched for age, sex, and date of transplantation who underwent transplantation for non-alcohol-induced chronic liver disease. Two-year patient survival rates were 82% in both study groups. The questionnaire response rate was 69.3% and 75.5% in patients with and without ALD, respectively. Data on recidivism (defined as any alcohol consumption after transplantation) were available in 46 of the 49 patients with ALD. Of these, 45.6% were drinking; 21.7% reported only occasionally drinking; 17.3%, moderate drinking; and 6.5%, heavy drinking. Information on alcohol consumption was available from 41 of the 49 controls. Of these, 52.5% consumed alcohol; 22.0% reported drinking only on special occasions; 24.4%, moderate drinking; and 4.9%, a return to heavy drinking. However, these differences were not statistically significant, and log-rank analysis found no significant difference in time to resumption of drinking. In the ALD cohort, no significant risk factors were identified to predict recidivism. No pretransplantation risk factors (including period of abstinence before transplantation) correlated with recidivism. Survival after transplantation for ALD is similar to that in other forms of chronic liver disease. Recidivism rates for patients with ALD are high, but patients with ALD do not drink more than their control counterparts posttransplantation. In most instances, alcohol consumption posttransplantation is minimal to moderate (<20 units/wk) and seems to be controlled.

RNA polymerase inhibitors with activity against rifampin-resistant mutants of Staphylococcus aureus

A collection of rifampin-resistant mutants of Staphylococcus aureus with characterized RNA polymerase beta-subunit (rpoB) gene mutations was cross-screened against a number of other RNA polymerase inhibitors to correlate susceptibility with specific rpoB genotypes. The rpoB mutants were cross-resistant to streptolydigin and sorangicin A. In contrast, thiolutin, holomycin, corallopyronin A, and ripostatin A retained activity against the rpoB mutants. The second group of inhibitors may be of interest as drug development candidates.

The development of removable appliances in the United Kingdom

The evolution since 1900 of the removable orthodontic appliance is described. The effects upon this evolution of political and economic events, the introduction of new materials and the British approach to orthodontic treatment are discussed. Present opinion favours the increased use of fixed appliances but it seems likely that removable appliances will still be suitable in about half those cases requiring active treatment.