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Hartrampf PE, Hüttmann T, Seitz AK, Kübler H, Serfling SE, Higuchi T, Schlötelburg W, Michalski K, Gafita A, Rowe SP, Pomper MG, Buck AK, Werner RA. Prognostic Performance of RECIP 1.0 Based on [ 18F]PSMA-1007 PET in Prostate Cancer Patients Treated with [ 177Lu]Lu-PSMA I&T. J Nucl Med 2024; 65:560-565. [PMID: 38453363 DOI: 10.2967/jnumed.123.266702] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/19/2023] [Revised: 01/05/2024] [Indexed: 03/09/2024] Open
Abstract
In metastatic castration-resistant prostate cancer (mCRPC) patients treated with prostate-specific membrane antigen (PSMA)-targeted radioligand therapy (RLT), the recently proposed criteria for evaluating response to PSMA PET (RECIP 1.0) based on 68Ga- and 18F-labeled PET agents provided prognostic information in addition to changes in prostate-specific antigen (PSA) levels. Our aim was to evaluate the prognostic performance of this framework for overall survival (OS) in patients undergoing RLT and imaged with [18F]PSMA-1007 PET/CT and compare the prognostic performance with the PSA-based response assessment. Methods: In total, 73 patients with mCRPC who were scanned with [18F]PSMA-1007 PET/CT before and after 2 cycles of RLT were retrospectively analyzed. We calculated the changes in serum PSA levels (ΔPSA) and quantitative PET parameters for the whole-body tumor burden (SUVmean, SUVmax, PSMA tumor volume, and total lesion PSMA). Men were also classified following the Prostate Cancer Working Group 3 (PCWG3) criteria for ΔPSA and RECIP 1.0 for PET imaging response. We performed univariable Cox regression analysis, followed by multivariable and Kaplan-Meier analyses. Results: Median OS was 15 mo with a median follow-up time of 14 mo. Univariable Cox regression analysis provided significant associations with OS for ΔPSA (per percentage, hazard ratio [HR], 1.004; 95% CI, 1.002-1.007; P < 0.001) and PSMA tumor volume (per unit, HR, 1.003; 95% CI, 1.000-1.005; P = 0.03). Multivariable Cox regression analysis confirmed ΔPSA (per percentage, HR, 1.004; 95% CI, 1.001-1.006; P = 0.006) as an independent prognosticator for OS. Kaplan-Meier analyses provided significant segregation between individuals with versus those without any PSA response (19 mo vs. 14 mo; HR, 2.00; 95% CI, 0.95-4.18; P = 0.04). Differentiation between patients with or without progressive disease (PD) was also feasible when applying PSA-based PCWG3 (19 mo vs. 9 mo for non-PD and PD, respectively; HR, 2.29; 95% CI, 1.03-5.09; P = 0.01) but slightly failed when applying RECIP 1.0 (P = 0.08). A combination of both response systems (PCWG3 and RECIP 1.0), however, yielded the best discrimination between individuals without versus those with PD (19 mo vs. 8 mo; HR, 2.78; 95% CI, 1.32-5.86; P = 0.002). Conclusion: In patients with mCRPC treated with RLT and imaged with [18F]PSMA-1007, frameworks integrating both the biochemical (PCWG3) and PET-based response (RECIP 1.0) may best assist in identifying subjects prone to disease progression.
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Affiliation(s)
- Philipp E Hartrampf
- Department of Nuclear Medicine, University Hospital Würzburg, Würzburg, Germany;
| | - Thomas Hüttmann
- Department of Nuclear Medicine, University Hospital Würzburg, Würzburg, Germany
| | - Anna Katharina Seitz
- Department of Urology and Pediatric Urology, University Hospital Würzburg, Würzburg, Germany
| | - Hubert Kübler
- Department of Urology and Pediatric Urology, University Hospital Würzburg, Würzburg, Germany
| | | | - Takahiro Higuchi
- Department of Nuclear Medicine, University Hospital Würzburg, Würzburg, Germany
| | - Wiebke Schlötelburg
- Department of Nuclear Medicine, University Hospital Würzburg, Würzburg, Germany
| | - Kerstin Michalski
- Department of Nuclear Medicine, University Hospital Würzburg, Würzburg, Germany
| | - Andrei Gafita
- Russell H. Morgan Department of Radiology and Radiological Science, Johns Hopkins School of Medicine, Baltimore, Maryland
| | - Steven P Rowe
- Division of Molecular Imaging and Therapeutics, Department of Radiology, University of North Carolina, Chapel Hill, North Carolina; and
| | - Martin G Pomper
- Russell H. Morgan Department of Radiology and Radiological Science, Johns Hopkins School of Medicine, Baltimore, Maryland
| | - Andreas K Buck
- Department of Nuclear Medicine, University Hospital Würzburg, Würzburg, Germany
| | - Rudolf A Werner
- Department of Nuclear Medicine, University Hospital Würzburg, Würzburg, Germany
- Russell H. Morgan Department of Radiology and Radiological Science, Johns Hopkins School of Medicine, Baltimore, Maryland
- Division of Nuclear Medicine, Department of Diagnostic and Interventional Radiology and Nuclear Medicine, University Hospital, Goethe University Frankfurt, Frankfurt, Germany
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Kowalski C, Sibert NT, Hammerer P, Wesselmann S, Feick G, Carl EG, Klotz T, Apel H, Dieng S, Nyarangi-Dix J, Knoll T, Reike MJ, Duwe G, Bartolf E, Steiner T, Borowitz R, Lümmen G, Seitz AK, Pfitzenmaier J, Aziz A, Brock M, Berger FP, Kaftan BT, Grube C, Häfner T, Hamza A, Schmelz H, Haas J, Lenart S, Lafita A, Sippel C, Winter A, Kedia G, Hadaschik B, Varga Z, Buse S, Richter M, Distler F, Simon J, Wiegel T, Baltes S, Janitzky A, Sommer JP, Hijazi S, Fülkell P, Harke NN, Bolenz C, Khalil C, Breidenbach C, Tennstedt P, Burchardt M. [Urinary incontinence after radical prostatectomy for prostate cancer-data from 17,149 patients from 125 certified centers]. Urologie 2024; 63:67-74. [PMID: 37747493 DOI: 10.1007/s00120-023-02197-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Accepted: 08/24/2023] [Indexed: 09/26/2023]
Abstract
BACKGROUND In addition to erectile dysfunction, urinary incontinence is the most common functional limitation after radical prostatectomy (RPE) for prostate cancer (PCa). The German S3 guideline recommends informing patients about possible effects of the therapy options, including incontinence. However, only little data on continence from routine care in German-speaking countries after RPE are currently available, which makes it difficult to inform patients. OBJECTIVE The aim of this work is to present data on the frequency and severity of urinary incontinence after RPE from routine care. MATERIALS AND METHODS Information from the PCO (Prostate Cancer Outcomes) study is used, which was collected between 2016 and 2022 in 125 German Cancer Society (DKG)-certified prostate cancer centers in 17,149 patients using the Expanded Prostate Cancer Index Composite Short Form (EPIC-26). Changes in the "incontinence" score before (T0) and 12 months after RPE (T1) and the proportion of patients who used pads, stratified by age and risk group, are reported. RESULTS The average score for urinary incontinence (value range: 0-worst possible to 100-best possible) was 93 points at T0 and 73 points 12 months later. At T0, 97% of the patients did not use a pad, compared to 56% at T1. 43% of the patients who did not use a pad before surgery used at least one pad a day 12 months later, while 13% use two or more. The proportion of patients using pads differs by age and risk classification. CONCLUSION The results provide a comprehensive insight into functional outcome 12 months after RPE and can be taken into account when informing patients.
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Affiliation(s)
- Christoph Kowalski
- Deutsche Krebsgesellschaft, Berlin, Kuno-Fischer-Str. 8, 14057, Berlin, Deutschland.
| | - Nora Tabea Sibert
- Deutsche Krebsgesellschaft, Berlin, Kuno-Fischer-Str. 8, 14057, Berlin, Deutschland
| | - Peter Hammerer
- Städtisches Klinikum Braunschweig, Braunschweig, Deutschland
| | - Simone Wesselmann
- Deutsche Krebsgesellschaft, Berlin, Kuno-Fischer-Str. 8, 14057, Berlin, Deutschland
| | - Günter Feick
- Bundesverband Prostatakrebs Selbsthilfe, Bonn, Deutschland
| | | | | | | | | | | | - Thomas Knoll
- Klinikum Sindelfingen-Böblingen, Sindelfingen, Deutschland
| | | | - Gregor Duwe
- Klinik und Poliklinik für Urologie und Kinderurologie, Universitätsmedizin der Johannes Gutenberg-Universität Mainz, Mainz, Deutschland
| | | | | | | | - Gerd Lümmen
- GFO Kliniken Troisdorf, Troisdorf, Deutschland
| | - Anna Katharina Seitz
- Klinik und Poliklinik für Urologie und Kinderurologie, Universitätsklinikum Würzburg, Würzburg, Deutschland
| | - Jesco Pfitzenmaier
- Ev. Klinikum Bethel, Universitätsklinikum OWL d, Universität Bielefeld, Bielefeld, Deutschland
| | | | - Marko Brock
- Stiftungsklinikum PROSELIS Recklinghausen, Recklinghausen, Deutschland
| | | | | | | | - Tim Häfner
- Universitätsklinikum Leipzig, Leipzig, Deutschland
| | - Amir Hamza
- Klinikum St. Georg Leipzig, Leipzig, Deutschland
| | - Hans Schmelz
- BundeswehrZentralkrankenhaus Koblenz, Koblenz, Deutschland
| | - Jürgen Haas
- Klinikum am Steinenberg, Reutlingen, Deutschland
| | | | | | | | - Alexander Winter
- Universitätsklinik für Urologie, Klinikum Oldenburg, Department für Humanmedizin, Fakultät für Medizin und Gesundheitswissenschaften, Carl von Ossietzky Universität Oldenburg, Oldenburg, Deutschland
| | - George Kedia
- DIAKOVERE Friederikenstift, Hannover, Deutschland
| | | | - Zoltan Varga
- SRH Kliniken Landkreis Sigmaringen, Sigmaringen, Deutschland
| | | | - Matthias Richter
- Kliniken Maria Hilf Mönchengladbach, Mönchengladbach, Deutschland
| | - Florian Distler
- Universitätsklinik der Paracelsus, Privatuniversität am Klinikum Nürnberg, Nürnberg, Deutschland
| | - Jörg Simon
- Ortenau-Klinikum Offenburg, Offenburg, Deutschland
| | | | | | | | | | | | | | - Nina N Harke
- Medizinische Hochschule Hannover, Hannover, Deutschland
| | | | | | | | - Pierre Tennstedt
- Martini Klinik am Universitätsklinikum Hamburg-Eppendorf, Hamburg-Eppendorf, Deutschland
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Knies K, Wagenhäuser I, Hofmann D, Rauschenberger V, Eisenmann M, Reusch J, Flemming S, Andres O, Petri N, Topp MS, Papsdorf M, McDonogh M, Verma-Führing R, Scherzad A, Zeller D, Böhm H, Gesierich A, Seitz AK, Kiderlen M, Gawlik M, Taurines R, Wurmb T, Ernestus RI, Forster J, Weismann D, Weißbrich B, Liese J, Vogel† U, Kurzai O, Dölken L, Gabel A, Krone M. The Sensitivity of Rapid Tests for SARS-CoV-2 Antigen. Dtsch Arztebl Int 2023; 120:763-764. [PMID: 38051563 PMCID: PMC10745559 DOI: 10.3238/arztebl.m2023.0185] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/04/2023] [Revised: 08/02/2023] [Accepted: 08/02/2023] [Indexed: 12/07/2023]
Affiliation(s)
- Kerstin Knies
- Institute for Virology and Immunobiology, University of Würzburg, Würzburg, Germany
- * The authors share first authorship
| | - Isabell Wagenhäuser
- University Hospital Würzburg, Würzburg, Germany,
- * The authors share first authorship
| | - Daniela Hofmann
- Institute for Virology and Immunobiology, University of Würzburg, Würzburg, Germany
| | - Vera Rauschenberger
- University Hospital Würzburg, Würzburg, Germany,
- Institute for Hygiene and Microbiology, University of Würzburg, Würzburg, Germany
| | | | - Julia Reusch
- University Hospital Würzburg, Würzburg, Germany,
| | | | | | - Nils Petri
- University Hospital Würzburg, Würzburg, Germany,
| | - Max S. Topp
- University Hospital Würzburg, Würzburg, Germany,
| | | | | | | | | | | | - Hartmut Böhm
- University Hospital Würzburg, Würzburg, Germany,
| | | | | | | | - Micha Gawlik
- University Hospital Würzburg, Würzburg, Germany,
| | | | - Thomas Wurmb
- University Hospital Würzburg, Würzburg, Germany,
| | | | - Johannes Forster
- Institute for Hygiene and Microbiology, University of Würzburg, Würzburg, Germany
| | | | - Benedikt Weißbrich
- Institute for Virology and Immunobiology, University of Würzburg, Würzburg, Germany
| | | | - Ulrich Vogel†
- University Hospital Würzburg, Würzburg, Germany,
- Institute for Hygiene and Microbiology, University of Würzburg, Würzburg, Germany
| | - Oliver Kurzai
- Institute for Hygiene and Microbiology, University of Würzburg, Würzburg, Germany
| | - Lars Dölken
- Institute for Virology and Immunobiology, University of Würzburg, Würzburg, Germany
| | - Alexander Gabel
- University Hospital Würzburg, Würzburg, Germany,
- *The authors share last authorship
| | - Manuel Krone
- University Hospital Würzburg, Würzburg, Germany,
- Institute for Hygiene and Microbiology, University of Würzburg, Würzburg, Germany
- *The authors share last authorship
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Hartrampf PE, Hüttmann T, Seitz AK, Kübler H, Serfling SE, Schlötelburg W, Michalski K, Rowe SP, Pomper MG, Buck AK, Eberlein U, Werner RA. SUV mean on baseline [ 18F]PSMA-1007 PET and clinical parameters are associated with survival in prostate cancer patients scheduled for [ 177Lu]Lu-PSMA I&T. Eur J Nucl Med Mol Imaging 2023; 50:3465-3474. [PMID: 37272956 PMCID: PMC10542708 DOI: 10.1007/s00259-023-06281-6] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/07/2023] [Accepted: 05/19/2023] [Indexed: 06/06/2023]
Abstract
BACKGROUND Quantification of [68 Ga]-labeled PSMA PET predicts response in patients with prostate cancer (PC) who undergo PSMA-targeted radioligand therapy (RLT). Given the increasing use [18F]-labeled radiotracers, we aimed to determine whether the uptake derived from [18F]PSMA-1007 PET can also identify responders and to assess its prognostic value relative to established clinical parameters. METHODS We retrospectively analyzed 103 patients with metastatic, castration-resistant PC who were treated with [177Lu]Lu-PSMA I&T. We calculated SUVmean, SUVmax, PSMA-avid tumor volume (TV), and total lesion PSMA (defined as PSMA-TV*SUVmean) on pre-therapeutic [18F]PSMA-1007 PET. Laboratory values for hemoglobin, C-reactive protein (CRP), lactate dehydrogenase (LDH), aspartate aminotransferase (AST), and alkaline phosphatase (AP) were also collected prior to RLT. We performed univariable Cox regression followed by multivariable and Kaplan-Meier analyses with overall survival (OS) serving as endpoint. Last, we also computed a risk factor (RF) model including all items reaching significance on multivariable analysis to determine whether an increasing number of RFs can improve risk stratification. RESULTS A total of 48 patients died and median OS was 16 months. On univariable Cox regression, SUVmean, CRP, LDH, hemoglobin, and the presence of liver metastases were significantly associated with OS. On multivariable Cox regression, the following significant prognostic factors for OS were identified: SUVmean (per unit, HR, 0.91; P = 0.04), the presence of liver metastases (HR, 2.37; P = 0.03), CRP (per mg/dl, HR, 1.13; P = 0.003), and hemoglobin (per g/dl, HR, 0.76; P < 0.01). Kaplan-Meier analysis showed significant separation between patients with a SUVmean below or above a median SUVmean of 9.4 (9 vs 19 months, HR 0.57; P = 0.03). Of note, patients with only one RF (median OS not reached) showed longest survival compared to patients with two (11 months; HR 2.43 95% CI 1.07-5.49, P = 0.02) or more than two RFs (7 months; HR 3.37 95% CI 1.62-7.03, P < 0.001). CONCLUSION A lower SUVmean derived from [18F]PSMA-1007, higher CRP, lower hemoglobin, and the presence of liver metastases are associated with reduced OS in patients undergoing RLT. An early RF model also demonstrated that an increasing number of those factors is linked to worse outcome, thereby emphasizing the importance of clinical and imaging parameters for adequate risk stratification.
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Affiliation(s)
- Philipp E Hartrampf
- Department of Nuclear Medicine, University Hospital Würzburg, Würzburg, Germany.
| | - Thomas Hüttmann
- Department of Nuclear Medicine, University Hospital Würzburg, Würzburg, Germany
| | - Anna Katharina Seitz
- Department of Urology and Paediatric Urology, University Hospital Würzburg, Würzburg, Germany
| | - Hubert Kübler
- Department of Urology and Paediatric Urology, University Hospital Würzburg, Würzburg, Germany
| | | | - Wiebke Schlötelburg
- Department of Nuclear Medicine, University Hospital Würzburg, Würzburg, Germany
| | - Kerstin Michalski
- Department of Nuclear Medicine, University Hospital Würzburg, Würzburg, Germany
| | - Steven P Rowe
- The Russell H Morgan Department of Radiology and Radiological Science, Johns Hopkins School of Medicine, Baltimore, MD, USA
| | - Martin G Pomper
- The Russell H Morgan Department of Radiology and Radiological Science, Johns Hopkins School of Medicine, Baltimore, MD, USA
| | - Andreas K Buck
- Department of Nuclear Medicine, University Hospital Würzburg, Würzburg, Germany
| | - Uta Eberlein
- Department of Nuclear Medicine, University Hospital Würzburg, Würzburg, Germany
| | - Rudolf A Werner
- Department of Nuclear Medicine, University Hospital Würzburg, Würzburg, Germany
- The Russell H Morgan Department of Radiology and Radiological Science, Johns Hopkins School of Medicine, Baltimore, MD, USA
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Hartrampf PE, Mihatsch PW, Seitz AK, Solnes LB, Rowe SP, Pomper MG, Kübler H, Bley TA, Buck AK, Werner RA. Elevated Body Mass Index Is Associated with Improved Overall Survival in Castration-Resistant Prostate Cancer Patients Undergoing Prostate-Specific Membrane Antigen-Directed Radioligand Therapy. J Nucl Med 2023:jnumed.122.265379. [PMID: 37290794 DOI: 10.2967/jnumed.122.265379] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/29/2022] [Revised: 03/21/2023] [Indexed: 06/10/2023] Open
Abstract
In patients with prostate cancer scheduled for systemic treatment, being overweight is linked to prolonged overall survival (OS), whereas sarcopenia is associated with shorter OS. We investigated fat-related and body composition parameters in patients undergoing prostate-specific membrane antigen (PSMA)-directed radioligand therapy (RLT) to assess their predictive value for OS. Methods: Body mass index (BMI, in kg/m2) and CT-derived body composition parameters (total, subcutaneous, visceral fat area, and psoas muscle area at the L3-L4 level) were determined for 171 patients scheduled for PSMA-directed RLT. After normalization for stature, the psoas muscle index was used to define sarcopenia. Outcome analysis was performed using Kaplan-Meier curves and Cox regression including fat-related and other clinical parameters (Gleason score, C-reactive protein [CRP], lactate dehydrogenase [LDH], hemoglobin, and prostate-specific antigen levels). The Harrell C-index was used for goodness-of-fit analysis. Results: Sixty-five patients (38%) had sarcopenia, and 98 patients (57.3%) had increased BMI. Relative to the 8-mo OS in normal-weight men (BMI < 25), overweight men (25 ≥ BMI > 30) and obese men (BMI ≥ 30) achieved a longer OS of 14 mo (hazard ratio [HR], 0.63; 95% CI, 0.40-0.99; P = 0.03) and 13 mo (HR, 0.47; 95% CI, 0.29-0.77; P = 0.004), respectively. Sarcopenia showed no impact on OS (11 vs. 12 mo; HR, 1.4; 95% CI, 0.91-2.1; P = 0.09). Most of the body composition parameters were tightly linked to OS on univariable analyses, with the highest C-index for BMI. In multivariable analysis, a higher BMI (HR, 0.91; 95% CI, 0.86-0.97; P = 0.006), lower CRP (HR, 1.09; 95% CI, 1.03-1.14; P < 0.001), lower LDH (HR, 1.08; 95% CI, 1.03-1.14; P < 0.001), and longer interval between initial diagnosis and RLT (HR, 0.95; 95% CI, 0.91-0.99; P = 0.02) were significant predictors of OS. Conclusion: Increased fat reserves assessed by BMI, CRP, LDH, and interval between initial diagnosis and RLT, but not CT-derived body composition parameters, were relevant predictors for OS. As BMI can be altered, future research should investigate whether a high-calorie diet before or during PSMA RLT may improve OS.
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Affiliation(s)
- Philipp E Hartrampf
- Department of Nuclear Medicine, University Hospital of Würzburg, Würzburg, Germany;
| | - Patrick W Mihatsch
- Department of Diagnostic and Interventional Radiology, University Hospital of Würzburg, Würzburg, Germany
| | - Anna Katharina Seitz
- Department of Urology and Paediatric Urology, University Hospital of Würzburg, Würzburg, Germany; and
| | - Lilja B Solnes
- Russell H. Morgan Department of Radiology and Radiological Science, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Steven P Rowe
- Russell H. Morgan Department of Radiology and Radiological Science, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Martin G Pomper
- Russell H. Morgan Department of Radiology and Radiological Science, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Hubert Kübler
- Department of Urology and Paediatric Urology, University Hospital of Würzburg, Würzburg, Germany; and
| | - Thorsten A Bley
- Department of Diagnostic and Interventional Radiology, University Hospital of Würzburg, Würzburg, Germany
| | - Andreas K Buck
- Department of Nuclear Medicine, University Hospital of Würzburg, Würzburg, Germany
| | - Rudolf A Werner
- Department of Nuclear Medicine, University Hospital of Würzburg, Würzburg, Germany
- Russell H. Morgan Department of Radiology and Radiological Science, Johns Hopkins University School of Medicine, Baltimore, Maryland
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Roch C, Kielkopf JA, Stefenelli U, Kübler H, van Oorschot B, Seitz AK. Preliminary results regarding automated identification of patients with a limited six-month survival prognosis using nursing assessment in uro-oncology patients. Urol Oncol 2023; 41:255.e1-255.e6. [PMID: 36739195 DOI: 10.1016/j.urolonc.2023.01.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/16/2022] [Revised: 09/14/2022] [Accepted: 01/09/2023] [Indexed: 02/05/2023]
Abstract
INTRODUCTION Contrary to current recommendations, palliative co-management of tumor patients often occurs late in daily clinical practice. Palliative care specialist (PCS) co-management should be considered at the latest after a 6-month prognosis has been presumed. Therefore, identifying patients with a limited prognosis is a reasonable measure. METHODS Patients were identified using a screening tool for limited prognosis, which combined their tumor stage and data from the nursing anamnesis. In this retrospective study, a monocentric cohort of patients with urological malignancies-UICC (Union for International Cancer Control) stages III and IV - were enrolled from March to December 2019, with a 6-month follow-up period ending in May 2020. RESULTS Most patients were male and suffered from prostate cancer. Patients with uro-oncological tumors dying within 6 months correlated significantly with the presence of repeated hospitalizations within three months, pain on admission, malnutrition, impaired breathing and reduced mobility (P < 0.001). The test was fair in quality (AUC 0.727) at a cut-point of five; a sensitivity of 97% and a specificity of 25% were obtained. The PPV was 0.64 and NPV was 0.82. DISCUSSION/CONCLUSION We specifically identified the predictors of limited prognosis in urological cancer patients across several entities using an automated scoring system based on tumor stage and data from the nursing anamnesis. Therefore, we recognized hospitalization as an important transition point and determined nurses to be valuable partners in identifying unmet palliative care needs without additional technical, personnel or financial effort.
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Affiliation(s)
- Carmen Roch
- Interdisciplinary Center for Palliative Medicine, University Hospital Würzburg, Würzburg, Germany.
| | | | - Ulrich Stefenelli
- Interdisciplinary Center for Palliative Medicine, University Hospital Würzburg, Würzburg, Germany
| | - Hubert Kübler
- Department of Urology and Pediatric Urology, University Hospital Würzburg, Würzburg, Germany
| | - Birgitt van Oorschot
- Interdisciplinary Center for Palliative Medicine, University Hospital Würzburg, Würzburg, Germany
| | - Anna Katharina Seitz
- Department of Urology and Pediatric Urology, University Hospital Würzburg, Würzburg, Germany
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Hartrampf PE, Weinzierl FX, Seitz AK, Kübler H, Essler M, Buck AK, Werner RA, Bundschuh RA. Any decline in prostate-specific antigen levels identifies survivors scheduled for prostate-specific membrane antigen-directed radioligand therapy. Prostate 2022; 82:1406-1412. [PMID: 35860909 DOI: 10.1002/pros.24414] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/14/2022] [Revised: 06/08/2022] [Accepted: 06/28/2022] [Indexed: 11/12/2022]
Abstract
BACKGROUND Prostate-specific membrane antigen (PSMA)-targeted radioligand therapy (RLT) is increasingly incorporated in the therapeutic algorithm of patients with metastatic castration-resistant prostate cancer (mCRPC). We aimed to elucidate the predictive performance of early biochemical response for overall survival (OS). MATERIALS AND METHODS In this bicentric analysis, we included 184 mCRPC patients treated with 177 Lu-PSMA RLT. Response to treatment was defined as decrease in prostate-specific antigen (PSA) levels 8 weeks after the first cycle of RLT (any decline or >50% according to Prostate Cancer Working Group 3). OS of responders and nonresponders was then compared using Kaplan-Meier curves and log-rank comparison. RESULTS A total of 114/184 patients (62.0%) showed any PSA decline (PSA response >50%, 55/184 [29.9%]). For individuals exhibiting a PSA decline >50%, OS of 19 months was significantly longer relative to nonresponders (13 months; hazard ratio of death [HR] = 0.64, 95% confidence interval [95% CI] = 0.44-0.93; p = 0.02). However, the difference was even more pronounced for any PSA decline, with an OS of 19 months in responders, but only 8 months in nonresponders (HR = 0.39, 95% CI = 0.25-0.60; p < 0.001). CONCLUSIONS In mCRPC patients scheduled for RLT, early biochemical response was tightly linked to prolonged survival, irrespective of the magnitude of PSA decline. As such, even in patients with PSA decrease of less than 50%, RLT should be continued.
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Affiliation(s)
- Philipp E Hartrampf
- Department of Nuclear Medicine, University Hospital Wuerzburg, Würzburg, Germany
| | | | - Anna Katharina Seitz
- Department of Urology and Paediatric Urology, University Hospital Wuerzburg, Würzburg, Germany
| | - Hubert Kübler
- Department of Urology and Paediatric Urology, University Hospital Wuerzburg, Würzburg, Germany
| | - Markus Essler
- Department of Nuclear Medicine, University Hospital Bonn, Bonn, Germany
| | - Andreas K Buck
- Department of Nuclear Medicine, University Hospital Wuerzburg, Würzburg, Germany
| | - Rudolf A Werner
- Department of Nuclear Medicine, University Hospital Wuerzburg, Würzburg, Germany
- Division of Nuclear Medicine and Molecular Imaging, The Russell H Morgan Department of Radiology and Radiological Science, Johns Hopkins School of Medicine, Baltimore, Maryland, USA
| | - Ralph A Bundschuh
- Department of Nuclear Medicine, University Hospital Bonn, Bonn, Germany
- Nuclear Medicine, Medical Faculty, University of Augsburg, Augsburg, Germany
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Hartrampf PE, Bundschuh RA, Weinzierl FX, Serfling SE, Kosmala A, Seitz AK, Kübler H, Buck AK, Essler M, Werner RA. mCRPC patients with PSA fluctuations under radioligand therapy have comparable survival benefits relative to patients with sustained PSA decrease. Eur J Nucl Med Mol Imaging 2022; 49:4727-4735. [PMID: 35852555 PMCID: PMC9606086 DOI: 10.1007/s00259-022-05910-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/10/2022] [Accepted: 07/10/2022] [Indexed: 11/14/2022]
Abstract
Introduction In men with metastatic castration-resistant prostate cancer (mCRPC) scheduled for prostate-specific membrane antigen (PSMA)-targeted radioligand therapy (RLT), biochemical response is assessed based on repeated measurements of prostate-specific antigen (PSA) levels. We aimed to determine overall survival (OS) in patients experiencing sustained PSA increase, decrease, or fluctuations during therapy. Materials and methods In this bicentric study, we included 176 mCRPC patients treated with PSMA-directed RLT. PSA levels were determined using blood samples prior to the first RLT and on the admission days for the following cycles. We calculated relative changes in PSA levels compared to baseline. Kaplan–Meier curves as well as log-rank test were used to compare OS of different subgroups, including patients with sustained PSA increase, decrease, or fluctuations (defined as change after initial decrease or increase after the first cycle). Results Sixty-one out of one hundred seventy-six (34.7%) patients showed a sustained increase and 86/176 (48.8%) a sustained decrease in PSA levels. PSA fluctuations were observed in the remaining 29/176 (16.5%). In this subgroup, 22/29 experienced initial PSA decrease followed by an increase (7/29, initial increase followed by a decrease). Median OS of patients with sustained decrease in PSA levels was significantly longer when compared to patients with sustained increase of PSA levels (19 vs. 8 months; HR 0.35, 95% CI 0.22–0.56; P < 0.001). Patients with PSA fluctuations showed a significantly longer median OS compared to patients with sustained increase of PSA levels (18 vs. 8 months; HR 0.49, 95% CI 0.30–0.80; P < 0.01), but no significant difference relative to men with sustained PSA decrease (18 vs. 19 months; HR 1.4, 95% CI 0.78–2.49; P = 0.20). In addition, in men experiencing PSA fluctuations, median OS did not differ significantly between patients with initial decrease or initial increase of tumor marker levels (16 vs. 18 months; HR 1.2, 95% CI 0.38–4.05; P = 0.68). Conclusion Initial increase or decrease of PSA levels is sustained in the majority of patients undergoing RLT. Sustained PSA decrease was linked to prolonged survival and men with PSA fluctuations under treatment experienced comparable survival benefits. As such, transient tumor marker oscillations under RLT should rather not lead to treatment discontinuation, especially in the absence of radiological progression. Supplementary Information The online version contains supplementary material available at 10.1007/s00259-022-05910-w.
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Hartrampf PE, Seitz AK, Weinzierl FX, Serfling SE, Schirbel A, Rowe SP, Kübler H, Buck AK, Werner RA. Baseline clinical characteristics predict overall survival in patients undergoing radioligand therapy with [ 177Lu]Lu-PSMA I&T during long-term follow-up. Eur J Nucl Med Mol Imaging 2022; 49:4262-4270. [PMID: 35650263 PMCID: PMC9525362 DOI: 10.1007/s00259-022-05853-2] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2022] [Accepted: 05/24/2022] [Indexed: 12/14/2022]
Abstract
Background Radioligand therapy (RLT) with 177Lu-labeled prostate-specific membrane antigen (PSMA) ligands is associated with prolonged overall survival (OS) in patients with advanced, metastatic castration-resistant prostate cancer (mCRPC). A substantial number of patients, however, are prone to treatment failure. We aimed to determine clinical baseline characteristics to predict OS in patients receiving [177Lu]Lu-PSMA I&T RLT in a long-term follow-up. Materials and methods Ninety-two mCRPC patients treated with [177Lu]Lu-PSMA I&T with a follow-up of at least 18 months were retrospectively identified. Multivariable Cox regression analyses were performed for various baseline characteristics, including laboratory values, Gleason score, age, prior therapies, and time interval between initial diagnosis and first treatment cycle (intervalDiagnosis-RLT, per 12 months). Cutoff values for significant predictors were determined using receiver operating characteristic (ROC) analysis. ROC-derived thresholds were then applied to Kaplan–Meier analyses. Results Baseline C-reactive protein (CRP; hazard ratio [HR], 1.10, 95% CI 1.02–1.18; P = 0.01), lactate dehydrogenase (LDH; HR, 1.07, 95% CI 1.01–1.11; P = 0.01), aspartate aminotransferase (AST; HR, 1.16, 95% CI 1.06–1.26; P = 0.001), and intervalDiagnosis-RLT (HR, 0.95, 95% CI 0.91–0.99; P = 0.02) were identified as independent prognostic factors for OS. The following respective ROC-based thresholds were determined: CRP, 0.98 mg/dl (area under the curve [AUC], 0.80); LDH, 276.5 U/l (AUC, 0.83); AST, 26.95 U/l (AUC, 0.73); and intervalDiagnosis-RLT, 43.5 months (AUC, 0.68; P < 0.01, respectively). Respective Kaplan–Meier analyses demonstrated a significantly longer median OS of patients with lower CRP, lower LDH, and lower AST, as well as prolonged intervalDiagnosis-RLT (P ≤ 0.01, respectively). Conclusion In mCRPC patients treated with [177Lu]Lu-PSMA I&T, baseline CRP, LDH, AST, and time interval until RLT initiation (thereby reflecting a possible indicator for tumor aggressiveness) are independently associated with survival. Our findings are in line with previous findings on [177Lu]Lu-PSMA-617, and we believe that these clinical baseline characteristics may support the nuclear medicine specialist to identify long-term survivors.
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Affiliation(s)
- Philipp E Hartrampf
- Department of Nuclear Medicine, University Hospital Würzburg, Oberdürrbacherstraße 6, 97080, Würzburg, Germany.
| | - Anna Katharina Seitz
- Department of Urology and Paediatric Urology, University Hospital Würzburg, Oberdürrbacherstraße 6, 97080, Würzburg, Germany
| | - Franz-Xaver Weinzierl
- Department of Nuclear Medicine, University Hospital Würzburg, Oberdürrbacherstraße 6, 97080, Würzburg, Germany
| | - Sebastian E Serfling
- Department of Nuclear Medicine, University Hospital Würzburg, Oberdürrbacherstraße 6, 97080, Würzburg, Germany
| | - Andreas Schirbel
- Department of Nuclear Medicine, University Hospital Würzburg, Oberdürrbacherstraße 6, 97080, Würzburg, Germany
| | - Steven P Rowe
- Department of Radiology and Radiological Science, The Russell H Morgan, Johns Hopkins University School of Medicine, 601 N Caroline Str, Baltimore, MD, USA
| | - Hubert Kübler
- Department of Urology and Paediatric Urology, University Hospital Würzburg, Oberdürrbacherstraße 6, 97080, Würzburg, Germany
| | - Andreas K Buck
- Department of Nuclear Medicine, University Hospital Würzburg, Oberdürrbacherstraße 6, 97080, Würzburg, Germany
| | - Rudolf A Werner
- Department of Nuclear Medicine, University Hospital Würzburg, Oberdürrbacherstraße 6, 97080, Würzburg, Germany.,Department of Radiology and Radiological Science, The Russell H Morgan, Johns Hopkins University School of Medicine, 601 N Caroline Str, Baltimore, MD, USA
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Hartrampf PE, Weinzierl FX, Buck AK, Rowe SP, Higuchi T, Seitz AK, Kübler H, Schirbel A, Essler M, Bundschuh RA, Werner RA. Matched-pair analysis of [ 177Lu]Lu-PSMA I&T and [ 177Lu]Lu-PSMA-617 in patients with metastatic castration-resistant prostate cancer. Eur J Nucl Med Mol Imaging 2022; 49:3269-3276. [PMID: 35243517 PMCID: PMC9250457 DOI: 10.1007/s00259-022-05744-6] [Citation(s) in RCA: 19] [Impact Index Per Article: 9.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/04/2022] [Accepted: 02/19/2022] [Indexed: 01/12/2023]
Abstract
Background Labelled with lutetium-177, the urea-based small molecules PSMA I&T and PSMA-617 are the two agents most frequently used for radioligand therapy (RLT) in patients with advanced metastatic castration-resistant and prostate-specific membrane antigen (PSMA) expressing prostate cancer (mCRPC). In this matched-pair analysis, we aimed to compare the toxicity and efficacy of both agents for PSMA-directed RLT. Materials and methods A total of 110 mCRPC patients from two centres were accrued, 55 individuals treated with [177Lu]Lu-PSMA I&T, and a matched cohort of 55 patients treated with [177Lu]Lu-PSMA-617. Matching criteria included age at the first cycle, Gleason score, prostate-specific antigen (PSA) values, and previous taxane-based chemotherapy. Using common terminology criteria for adverse events (CTCAE v. 5.0), toxicity profiles were investigated (including bone marrow and renal toxicity). Overall survival (OS) between both groups was compared. Results Toxicity assessment revealed grade III anaemia in a single patient (1.8%) for [177Lu]Lu-PSMA I&T and five (9.1%) for [177Lu]Lu-PSMA-617. In addition, one (1.9%) grade III thrombopenia for [177Lu]Lu-PSMA-617 was recorded. Apart from that, no other grade III/IV toxicities were present. A median OS of 12 months for patients treated with [177Lu]Lu-PSMA I&T did not differ significantly when compared to patients treated with [177Lu]Lu-PSMA-617 (median OS, 13 months; P = 0.89). Conclusion In this matched-pair analysis of patients receiving one of the two agents most frequently applied for PSMA RLT, the rate of clinically relevant toxicities was low for both compounds. In addition, no relevant differences for OS were observed.
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Affiliation(s)
- Philipp E Hartrampf
- Department of Nuclear Medicine, University Hospital Wuerzburg, Oberdürrbacherstraße 6, 97080, Würzburg, Germany.
| | - Franz-Xaver Weinzierl
- Department of Nuclear Medicine, University Hospital Wuerzburg, Oberdürrbacherstraße 6, 97080, Würzburg, Germany
| | - Andreas K Buck
- Department of Nuclear Medicine, University Hospital Wuerzburg, Oberdürrbacherstraße 6, 97080, Würzburg, Germany
| | - Steven P Rowe
- Department of Radiology and Radiological Science, The Russell H Morgan, Johns Hopkins University School of Medicine, 601 N Caroline Str, Baltimore, MD, USA
| | - Takahiro Higuchi
- Department of Nuclear Medicine, University Hospital Wuerzburg, Oberdürrbacherstraße 6, 97080, Würzburg, Germany
| | - Anna Katharina Seitz
- Department of Urology and Paediatric Urology, University Hospital Wuerzburg, Oberdürrbacherstraße 6, 97080, Würzburg, Germany
| | - Hubert Kübler
- Department of Urology and Paediatric Urology, University Hospital Wuerzburg, Oberdürrbacherstraße 6, 97080, Würzburg, Germany
| | - Andreas Schirbel
- Department of Nuclear Medicine, University Hospital Wuerzburg, Oberdürrbacherstraße 6, 97080, Würzburg, Germany
| | - Markus Essler
- Department of Nuclear Medicine, University Hospital Bonn, Venusberg-Campus 1, 53127, Bonn, Germany
| | - Ralph A Bundschuh
- Department of Nuclear Medicine, University Hospital Bonn, Venusberg-Campus 1, 53127, Bonn, Germany
| | - Rudolf A Werner
- Department of Nuclear Medicine, University Hospital Wuerzburg, Oberdürrbacherstraße 6, 97080, Würzburg, Germany
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11
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Hartrampf PE, Weinzierl FX, Serfling SE, Pomper MG, Rowe SP, Higuchi T, Seitz AK, Kübler H, Buck AK, Werner RA. Hematotoxicity and Nephrotoxicity in Prostate Cancer Patients Undergoing Radioligand Therapy with [ 177Lu]Lu-PSMA I&T. Cancers (Basel) 2022; 14:cancers14030647. [PMID: 35158913 PMCID: PMC8833540 DOI: 10.3390/cancers14030647] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/04/2021] [Revised: 12/01/2021] [Accepted: 01/25/2022] [Indexed: 02/04/2023] Open
Abstract
Simple Summary Radioligand therapy (RLT) with prostate-specific membrane antigen (PSMA)-directed agents has shown remarkable results in patients with advanced prostate cancer. Our objective was to provide data on the side effect profile of PSMA-directed RLT using the therapeutic radiotracer [177Lu]Lu-PSMA I&T. We evaluated patients with castration-resistant metastatic prostate cancer treated with at least three cycles of [177Lu]Lu-PSMA I&T. A substantial fraction of the patients already had impaired renal function and/or reduced white blood cell counts at baseline, but the degree of nephrotoxicity or hematotoxicity under RLT was low. No severe toxicities occurred under RLT. Abstract (1) Background: Prostate-specific membrane antigen (PSMA)-directed radioligand therapy (RLT) has shown remarkable results in patients with advanced prostate cancer. We aimed to evaluate the toxicity profile of the PSMA ligand [177Lu]Lu-PSMA I&T. (2) Methods: 49 patients with metastatic, castration-resistant prostate cancer treated with at least three cycles of [177Lu]Lu-PSMA I&T were evaluated. Prior to and after RLT, we compared leukocytes, hemoglobin, platelet counts, and renal functional parameters (creatinine, eGFR, n = 49; [99mTc]-MAG3-derived tubular extraction rate (TER), n = 42). Adverse events were classified according to the Common Terminology Criteria for Adverse Events (CTCAE) v5.0 and KDIGO Society. To identify predictive factors, we used Spearman’s rank correlation coefficient. (3) Results: A substantial fraction of the patients already showed impaired renal function and reduced leukocyte counts at baseline. Under RLT, 11/49 (22%) patients presented with nephrotoxicity CTCAE I or II according to creatinine, but 33/49 (67%) according to eGFR. Only 5/42 (13%) showed reduced TER, defined as <70% of the age-adjusted mean normal values. Of all renal functional parameters, absolute changes of only 2% were recorded. CTCAE-based re-categorization was infrequent, with creatinine worsening from I to II in 2/49 (4.1%; GFR, 1/49 (2%)). Similar results were recorded for KDIGO (G2 to G3a, 1/49 (2%); G3a to G3b, 2/49 (4.1%)). After three cycles, follow-up eGFR correlated negatively with age (r = −0.40, p = 0.005) and the eGFR change with Gleason score (r = −0.35, p < 0.05) at baseline. Leukocytopenia CTCAE II occurred only in 1/49 (2%) (CTCAE I, 20/49 (41%)) and CTCAE I thrombocytopenia in 7/49 (14%), with an absolute decrease of 15.2% and 16.6% for leukocyte and platelet counts. Anemia CTCAE II occurred in 10/49 (20%) (CTCAE I, 36/49 (73%)) with a decrease in hemoglobin of 4.7%. (4) Conclusions: After PSMA-targeted therapy using [177Lu]Lu-PSMA I&T, no severe (CTCAE III/IV) toxicities occurred, thereby demonstrating that serious adverse renal or hematological events are unlikely to be a frequent phenomenon with this agent.
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Affiliation(s)
- Philipp E. Hartrampf
- Department of Nuclear Medicine, University Hospital Wuerzburg, Oberdürrbacherstraße 6, 97080 Wurzburg, Germany; (F.-X.W.); (S.E.S.); (T.H.); (A.K.B.); (R.A.W.)
- Correspondence: ; Tel.: +49-931-201-35001
| | - Franz-Xaver Weinzierl
- Department of Nuclear Medicine, University Hospital Wuerzburg, Oberdürrbacherstraße 6, 97080 Wurzburg, Germany; (F.-X.W.); (S.E.S.); (T.H.); (A.K.B.); (R.A.W.)
| | - Sebastian E. Serfling
- Department of Nuclear Medicine, University Hospital Wuerzburg, Oberdürrbacherstraße 6, 97080 Wurzburg, Germany; (F.-X.W.); (S.E.S.); (T.H.); (A.K.B.); (R.A.W.)
| | - Martin G. Pomper
- The Russell H Morgan Department of Radiology and Radiological Science, Johns Hopkins University School of Medicine, 601 N Caroline Str., Baltimore, MD 21205, USA; (M.G.P.); (S.P.R.)
| | - Steven P. Rowe
- The Russell H Morgan Department of Radiology and Radiological Science, Johns Hopkins University School of Medicine, 601 N Caroline Str., Baltimore, MD 21205, USA; (M.G.P.); (S.P.R.)
| | - Takahiro Higuchi
- Department of Nuclear Medicine, University Hospital Wuerzburg, Oberdürrbacherstraße 6, 97080 Wurzburg, Germany; (F.-X.W.); (S.E.S.); (T.H.); (A.K.B.); (R.A.W.)
- Graduate School of Medicine, Dentistry and Pharmaceutical Sciences, Okayama University, Okayama 700-8530, Japan
| | - Anna Katharina Seitz
- Department of Urology and Paediatric Urology, University Hospital Wuerzburg, Oberdürrbacherstraße 6, 97080 Wurzburg, Germany; (A.K.S.); (H.K.)
| | - Hubert Kübler
- Department of Urology and Paediatric Urology, University Hospital Wuerzburg, Oberdürrbacherstraße 6, 97080 Wurzburg, Germany; (A.K.S.); (H.K.)
| | - Andreas K. Buck
- Department of Nuclear Medicine, University Hospital Wuerzburg, Oberdürrbacherstraße 6, 97080 Wurzburg, Germany; (F.-X.W.); (S.E.S.); (T.H.); (A.K.B.); (R.A.W.)
| | - Rudolf A. Werner
- Department of Nuclear Medicine, University Hospital Wuerzburg, Oberdürrbacherstraße 6, 97080 Wurzburg, Germany; (F.-X.W.); (S.E.S.); (T.H.); (A.K.B.); (R.A.W.)
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12
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Kalogirou C, Linxweiler J, Schmucker P, Snaebjornsson MT, Schmitz W, Wach S, Krebs M, Hartmann E, Puhr M, Müller A, Spahn M, Seitz AK, Frank T, Marouf H, Büchel G, Eckstein M, Kübler H, Eilers M, Saar M, Junker K, Röhrig F, Kneitz B, Rosenfeldt MT, Schulze A. MiR-205-driven downregulation of cholesterol biosynthesis through SQLE-inhibition identifies therapeutic vulnerability in aggressive prostate cancer. Nat Commun 2021; 12:5066. [PMID: 34417456 PMCID: PMC8379214 DOI: 10.1038/s41467-021-25325-9] [Citation(s) in RCA: 25] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/22/2020] [Accepted: 07/29/2021] [Indexed: 12/19/2022] Open
Abstract
Prostate cancer (PCa) shows strong dependence on the androgen receptor (AR) pathway. Here, we show that squalene epoxidase (SQLE), an enzyme of the cholesterol biosynthesis pathway, is overexpressed in advanced PCa and its expression correlates with poor survival. SQLE expression is controlled by micro-RNA 205 (miR-205), which is significantly downregulated in advanced PCa. Restoration of miR-205 expression or competitive inhibition of SQLE led to inhibition of de novo cholesterol biosynthesis. Furthermore, SQLE was essential for proliferation of AR-positive PCa cell lines, including abiraterone or enzalutamide resistant derivatives, and blocked transactivation of the AR pathway. Inhibition of SQLE with the FDA approved antifungal drug terbinafine also efficiently blocked orthotopic tumour growth in mice. Finally, terbinafine reduced levels of prostate specific antigen (PSA) in three out of four late-stage PCa patients. These results highlight SQLE as a therapeutic target for the treatment of advanced PCa.
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Affiliation(s)
- C Kalogirou
- Department of Biochemistry and Molecular Biology, Theodor-Boveri-Institute, Biocenter, Würzburg, Germany
- Department of Urology and Paediatric Urology, University Hospital Würzburg, Würzburg, Germany
| | - J Linxweiler
- Department of Urology, Saarland University, Homburg/Saar, Germany
| | - P Schmucker
- Department of Urology and Paediatric Urology, University Hospital Würzburg, Würzburg, Germany
| | - M T Snaebjornsson
- German Cancer Research Center, Division of Tumor Metabolism and Microenvironment, Heidelberg, Germany
| | - W Schmitz
- Department of Biochemistry and Molecular Biology, Theodor-Boveri-Institute, Biocenter, Würzburg, Germany
| | - S Wach
- Department of Urology, University Hospital Erlangen, Friedrich-Alexander University of Erlangen-Nuremberg, Erlangen, Germany
| | - M Krebs
- Department of Urology and Paediatric Urology, University Hospital Würzburg, Würzburg, Germany
| | - E Hartmann
- Institute of Pathology, Julius Maximilians University and Comprehensive Cancer Center (CCC) Mainfranken, Würzburg, Germany
| | - M Puhr
- Department of Urology, Medical University of Innsbruck, Innsbruck, Austria
| | - A Müller
- Clinic for Diagnostic and Interventional Radiology, Saarland University, Homburg/Saar, Germany
| | - M Spahn
- Center for Urology, Hirslanden Private Hospital Group, Zurich, Switzerland
| | - A K Seitz
- Department of Urology and Paediatric Urology, University Hospital Würzburg, Würzburg, Germany
| | - T Frank
- Department of Urology and Paediatric Urology, University Hospital Würzburg, Würzburg, Germany
| | - H Marouf
- Department of Biochemistry and Molecular Biology, Theodor-Boveri-Institute, Biocenter, Würzburg, Germany
| | - G Büchel
- Department of Biochemistry and Molecular Biology, Theodor-Boveri-Institute, Biocenter, Würzburg, Germany
- Mildred Scheel Early Career Center, University Hospital Würzburg, Würzburg, Germany
| | - M Eckstein
- Institute of Pathology, University Hospital Erlangen, Friedrich-Alexander University of Erlangen-Nuremberg, Erlangen, Germany
| | - H Kübler
- Department of Urology and Paediatric Urology, University Hospital Würzburg, Würzburg, Germany
| | - M Eilers
- Department of Biochemistry and Molecular Biology, Theodor-Boveri-Institute, Biocenter, Würzburg, Germany
| | - M Saar
- Department of Urology, Saarland University, Homburg/Saar, Germany
| | - K Junker
- Department of Urology, Saarland University, Homburg/Saar, Germany
| | - F Röhrig
- Department of Biochemistry and Molecular Biology, Theodor-Boveri-Institute, Biocenter, Würzburg, Germany
| | - B Kneitz
- Department of Urology and Paediatric Urology, University Hospital Würzburg, Würzburg, Germany
| | - M T Rosenfeldt
- Institute of Pathology, Julius Maximilians University and Comprehensive Cancer Center (CCC) Mainfranken, Würzburg, Germany
| | - A Schulze
- Department of Biochemistry and Molecular Biology, Theodor-Boveri-Institute, Biocenter, Würzburg, Germany.
- German Cancer Research Center, Division of Tumor Metabolism and Microenvironment, Heidelberg, Germany.
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Michalski K, Ruf J, Goetz C, Seitz AK, Buck AK, Lapa C, Hartrampf PE. Prognostic implications of dual tracer PET/CT: PSMA ligand and [ 18F]FDG PET/CT in patients undergoing [ 177Lu]PSMA radioligand therapy. Eur J Nucl Med Mol Imaging 2020; 48:2024-2030. [PMID: 33336265 PMCID: PMC8113196 DOI: 10.1007/s00259-020-05160-8] [Citation(s) in RCA: 52] [Impact Index Per Article: 13.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/28/2020] [Accepted: 12/08/2020] [Indexed: 01/29/2023]
Abstract
BACKGROUND Prostate-specific membrane antigen (PSMA)-targeted radioligand therapy (RLT) with 177Lu-labeled PSMA ligands has achieved remarkable results in advanced disease stages of metastatic castration-resistant prostate cancer (mCRPC). However, not all patients benefit from this therapy. Different treatment responses could be explained by tumor heterogeneity triggered by progression and the number of prior treatments. PSMA-negative lesions can be missed on PSMA ligand PET/CT, which subsequently results in an underestimation of tumor burden. Conversely, high FDG uptake may also be an indicator of tumor aggressiveness and thus a poor prognostic marker for response to RLT and overall survival (OS). The aim of this analysis was to investigate the prognostic value of combined PSMA ligand PET/CT and [18F]fluorodeoxyglucose (FDG) PET/CT for outcome prediction in patients undergoing RLT. MATERIALS AND METHODS This bicentric analysis included 54 patients with mCRPC who underwent both FDG and PSMA ligand PET/CT imaging before RLT. In all patients, the pattern of PSMA ligand and FDG uptake was visually assessed. Patients with at least one FDG-positive, but PSMA-negative (FDG+/PSMA-) lesions were compared to patients without any FDG+/PSMA- lesions. A log-rank analysis was used to assess the difference in OS between subgroups. RESULTS Median OS was 11 ± 1.8 months (95% CI 7.4-14.6). A significantly lower OS (p < 0.001) was found in patients with at least one FDG+/PSMA- lesion at baseline PET/CTs (n = 18) with a median OS of 6.0 ± 0.5 months (95% CI: 5.0-7.0 months). In comparison, patients without any FDG+/PSMA- lesions (n = 36) had a median OS of 16.0 ± 2.5 months (95% CI: 11.2-20.8 months). CONCLUSION FDG+/PSMA- lesions are a negative predictor of overall survival in patients with mCRPC undergoing RLT. However, it remains to be determined if patients with FDG+/PSMA- lesions should be excluded from PSMA RLT.
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Affiliation(s)
- Kerstin Michalski
- Department of Nuclear Medicine, Faculty of Medicine, Medical Center-University of Freiburg, Freiburg, Germany
| | - Juri Ruf
- Department of Nuclear Medicine, Faculty of Medicine, Medical Center-University of Freiburg, Freiburg, Germany
| | - Christian Goetz
- Department of Nuclear Medicine, Faculty of Medicine, Medical Center-University of Freiburg, Freiburg, Germany
| | - Anna Katharina Seitz
- Department of Urology and Paediatric Urology, University Hospital Würzburg, Würzburg, Germany
| | - Andreas K Buck
- Department of Nuclear Medicine, University Hospital Würzburg, Würzburg, Germany
| | - Constantin Lapa
- Nuclear Medicine, Medical Faculty, University of Augsburg, Augsburg, Germany
| | - Philipp E Hartrampf
- Department of Nuclear Medicine, University Hospital Würzburg, Würzburg, Germany.
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14
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Brumberg J, Beckl M, Dierks A, Schirbel A, Krebs M, Buck A, Kübler H, Lapa C, Seitz AK. Detection Rate of 68Ga-PSMA Ligand PET/CT in Patients with Recurrent Prostate Cancer and Androgen Deprivation Therapy. Biomedicines 2020; 8:biomedicines8110511. [PMID: 33217931 PMCID: PMC7698713 DOI: 10.3390/biomedicines8110511] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/24/2020] [Revised: 11/08/2020] [Accepted: 11/16/2020] [Indexed: 01/10/2023] Open
Abstract
Prostate-specific membrane antigen (PSMA) ligand PET/CT enables the localization of tumor lesions in patients with recurrent prostate cancer, but it is unclear whether androgen deprivation therapy (ADT) influences diagnostic accuracy. The aim of this study was to evaluate the effect of ADT on the detection rate of 68Ga-PSMA ligand PET/CT. Thus, 399 patients with initial radical prostatectomy and 68Ga-PSMA ligand PET/CT during PSA relapse were retrospectively evaluated. Propensity score matching was used to create two balanced groups of 62 subjects who either did or did not receive ADT within six months before imaging. All 68Ga-PSMA ligand PET/CT were evaluated visually and with semiquantitative measures. The detection rate of tumor recurrence was significantly higher in the group with ADT (88.7% vs. 72.6%, p = 0.02) and improved with increasing PSA-levels in both groups. In subjects with pathological PET/CT and ADT, whole-body total lesion PSMA (p < 0.01) and PSMA-derived tumor volume (p < 0.01) were significantly higher than in those without ADT. More PSMA-positive lesions and higher PSMA-derived volumetric parameters in patients with ADT suggest that a better detection rate is related to a (biologically) more advanced disease stage. Due to high detection rates in patients with PSA-levels < 2 ng/mL, the withdrawal of ADT before PSMA ligand PET/CT cannot be recommended.
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Affiliation(s)
- Joachim Brumberg
- Department of Nuclear Medicine, University Hospital Würzburg and Julius-Maximilian University Würzburg, 97080 Würzburg, Germany; (M.B.); (A.D.); (A.S.); (A.B.); (C.L.)
- Correspondence: ; Tel.: +49-931-201-35000
| | - Melanie Beckl
- Department of Nuclear Medicine, University Hospital Würzburg and Julius-Maximilian University Würzburg, 97080 Würzburg, Germany; (M.B.); (A.D.); (A.S.); (A.B.); (C.L.)
| | - Alexander Dierks
- Department of Nuclear Medicine, University Hospital Würzburg and Julius-Maximilian University Würzburg, 97080 Würzburg, Germany; (M.B.); (A.D.); (A.S.); (A.B.); (C.L.)
- Department of Nuclear Medicine, Medical Faculty, University of Augsburg, 86156 Augsburg, Germany
| | - Andreas Schirbel
- Department of Nuclear Medicine, University Hospital Würzburg and Julius-Maximilian University Würzburg, 97080 Würzburg, Germany; (M.B.); (A.D.); (A.S.); (A.B.); (C.L.)
| | - Markus Krebs
- Department of Urology, University Hospital Würzburg and Julius-Maximilian University Würzburg, 97080 Würzburg, Germany; (M.K.); (H.K.); (A.K.S.)
- Comprehensive Cancer Center Mainfranken, University Hospital Würzburg and Julius-Maximilian University Würzburg, 97080 Würzburg, Germany
| | - Andreas Buck
- Department of Nuclear Medicine, University Hospital Würzburg and Julius-Maximilian University Würzburg, 97080 Würzburg, Germany; (M.B.); (A.D.); (A.S.); (A.B.); (C.L.)
| | - Hubert Kübler
- Department of Urology, University Hospital Würzburg and Julius-Maximilian University Würzburg, 97080 Würzburg, Germany; (M.K.); (H.K.); (A.K.S.)
| | - Constantin Lapa
- Department of Nuclear Medicine, University Hospital Würzburg and Julius-Maximilian University Würzburg, 97080 Würzburg, Germany; (M.B.); (A.D.); (A.S.); (A.B.); (C.L.)
- Department of Nuclear Medicine, Medical Faculty, University of Augsburg, 86156 Augsburg, Germany
| | - Anna Katharina Seitz
- Department of Urology, University Hospital Würzburg and Julius-Maximilian University Würzburg, 97080 Würzburg, Germany; (M.K.); (H.K.); (A.K.S.)
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Schmid SC, Koll FJ, Beckert F, Seitz AK. [Immuno-oncological approaches in the perioperative therapy of muscle invasive bladder cancer]. Urologe A 2020; 59:790-796. [PMID: 32472221 DOI: 10.1007/s00120-020-01234-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
Perioperative chemotherapy has become a standard treatment for muscle invasive bladder cancer and is recommended by national and international guidelines. The treatment of metastatic urothelial cancer evolved by the use of immune-modulating therapies like checkpoint inhibitors. Many clinical trials have been initiated which try to evaluate the role of immune checkpoint inhibition in the neoadjuvant and adjuvant setting. These trials focus not only on monotherapy, but also on the combination of checkpoint inhibitors with classical chemotherapy or with local radiation therapy (radioimmunotherapy). In neoadjuvant radioimmunotherapy, the radiation is supposed to act as a sensitizer for the systemic effects of checkpoint inhibition, in addition to the local effects. This review presents and discusses current trials and published results for perioperative immunomodulating treatment-alone or in combination-in muscle invasive bladder cancer.
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Affiliation(s)
- S C Schmid
- Klinik und Poliklinik für Urologie, Klinikum rechts der Isar der Technischen Universität München, Ismaningerstr. 22, 81675, München, Deutschland.
| | - F J Koll
- Klinik und Poliklinik für Urologie, Klinikum rechts der Isar der Technischen Universität München, Ismaningerstr. 22, 81675, München, Deutschland
| | - F Beckert
- Klinik und Poliklinik für Urologie, Klinikum rechts der Isar der Technischen Universität München, Ismaningerstr. 22, 81675, München, Deutschland
| | - A K Seitz
- Klinik und Poliklinik für Urologie und Kinderurologie, Universitätsklinikum Würzburg, Würzburg, Deutschland
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16
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Hartrampf PE, Heinrich M, Seitz AK, Brumberg J, Sokolakis I, Kalogirou C, Schirbel A, Kübler H, Buck AK, Lapa C, Krebs M. Metabolic Tumour Volume from PSMA PET/CT Scans of Prostate Cancer Patients during Chemotherapy-Do Different Software Solutions Deliver Comparable Results? J Clin Med 2020; 9:jcm9051390. [PMID: 32397223 PMCID: PMC7290891 DOI: 10.3390/jcm9051390] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/12/2020] [Revised: 05/04/2020] [Accepted: 05/06/2020] [Indexed: 02/07/2023] Open
Abstract
(1) Background: Prostate-specific membrane antigen (PSMA)-derived tumour volume (PSMA-TV) and total lesion PSMA (TL-PSMA) from PSMA PET/CT scans are promising biomarkers for assessing treatment response in prostate cancer (PCa). Currently, it is unclear whether different software tools for assessing PSMA-TV and TL-PSMA produce comparable results. (2) Methods: 68Ga-PSMA PET/CT scans from n = 21 patients with castration-resistant PCa (CRPC) receiving chemotherapy were identified from our single-centre database. PSMA-TV and TL-PSMA were calculated with Syngo.via (Siemens) as well as the freely available Beth Israel plugin for FIJI (Fiji Is Just ImageJ) before and after chemotherapy. While statistical comparability was illustrated and quantified via Bland-Altman diagrams, the clinical agreement was estimated by matching PSMA-TV, TL-PSMA and relative changes of both variables during chemotherapy with changes in serum PSA (ΔPSA) and PERCIST (Positron Emission Response Criteria in Solid Tumors). (3) Results: Comparing absolute PSMA-TV and TL-PSMA as well as Bland-Altman plotting revealed a good statistical comparability of both software algorithms. For clinical agreement, classifying therapy response did not differ between PSMA-TV and TL-PSMA for both software solutions and showed highly positive correlations with BR. (4) Conclusions: due to the high levels of statistical and clinical agreement in our CRPC patient cohort undergoing taxane chemotherapy, comparing PSMA-TV and TL-PSMA determined by Syngo.via and FIJI appears feasible.
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Affiliation(s)
- Philipp E. Hartrampf
- Department of Nuclear Medicine, University Hospital Würzburg, 97080 Würzburg, Germany; (M.H.); (J.B.); (A.S.); (A.K.B.); (C.L.)
- Correspondence:
| | - Marieke Heinrich
- Department of Nuclear Medicine, University Hospital Würzburg, 97080 Würzburg, Germany; (M.H.); (J.B.); (A.S.); (A.K.B.); (C.L.)
| | - Anna Katharina Seitz
- Department of Urology and Paediatric Urology, University Hospital Würzburg, 97080 Würzburg, Germany; (A.K.S.); (C.K.); (H.K.); (M.K.)
| | - Joachim Brumberg
- Department of Nuclear Medicine, University Hospital Würzburg, 97080 Würzburg, Germany; (M.H.); (J.B.); (A.S.); (A.K.B.); (C.L.)
| | - Ioannis Sokolakis
- Department of Urology, Martha-Maria Hospital Nuremberg, 90491 Nuremberg, Germany;
| | - Charis Kalogirou
- Department of Urology and Paediatric Urology, University Hospital Würzburg, 97080 Würzburg, Germany; (A.K.S.); (C.K.); (H.K.); (M.K.)
| | - Andreas Schirbel
- Department of Nuclear Medicine, University Hospital Würzburg, 97080 Würzburg, Germany; (M.H.); (J.B.); (A.S.); (A.K.B.); (C.L.)
| | - Hubert Kübler
- Department of Urology and Paediatric Urology, University Hospital Würzburg, 97080 Würzburg, Germany; (A.K.S.); (C.K.); (H.K.); (M.K.)
| | - Andreas K. Buck
- Department of Nuclear Medicine, University Hospital Würzburg, 97080 Würzburg, Germany; (M.H.); (J.B.); (A.S.); (A.K.B.); (C.L.)
| | - Constantin Lapa
- Department of Nuclear Medicine, University Hospital Würzburg, 97080 Würzburg, Germany; (M.H.); (J.B.); (A.S.); (A.K.B.); (C.L.)
- Nuclear Medicine, Medical Faculty, University of Augsburg, Stenglinstrasse 2, 86156 Augsburg, Germany
| | - Markus Krebs
- Department of Urology and Paediatric Urology, University Hospital Würzburg, 97080 Würzburg, Germany; (A.K.S.); (C.K.); (H.K.); (M.K.)
- Comprehensive Cancer Center Mainfranken, University Hospital Würzburg, 97080 Würzburg, Germany
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17
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Cytawa W, Seitz AK, Kircher S, Fukushima K, Tran-Gia J, Schirbel A, Bandurski T, Lass P, Krebs M, Połom W, Matuszewski M, Wester HJ, Buck AK, Kübler H, Lapa C. 68Ga-PSMA I&T PET/CT for primary staging of prostate cancer. Eur J Nucl Med Mol Imaging 2019; 47:168-177. [PMID: 31529265 DOI: 10.1007/s00259-019-04524-z] [Citation(s) in RCA: 52] [Impact Index Per Article: 10.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/18/2019] [Accepted: 09/04/2019] [Indexed: 12/22/2022]
Abstract
PURPOSE The present study is based on a retrospective analysis of Gallium-68 (68Ga)-labelled prostate-specific membrane antigen (68Ga-PSMA I&T) PET/CT performed in newly diagnosed, treatment-naïve prostate cancer (PCa) patients prior to definitive treatment. METHODS A total of 82 men were included in the study and were imaged with 68Ga-PSMA I&T PET/CT to assess the distribution of PSMA-avid disease for staging purposes (11 with low-risk, 32 with intermediate-risk, and 39 with high-risk PCa). Forty patients (20 with intermediate- and 20 with high-risk disease) underwent subsequent radical prostatectomy with extended pelvic lymph node dissection which allowed for correlation of imaging findings with histopathologic data. RESULTS PSMA-positive disease was detected in 83% of patients with 66/82 (80.5%) primary tumours being visualized. PSMA-avid lymph nodes were recorded in 17/82 patients (20.7%, 3 with intermediate-risk and 14 with high-risk PCa); distant disease was found in 14/82 subjects (17.1%, 2 with intermediate-risk and 12 with high-risk PCa). No extraprostatic disease was found in low-risk PCa. SUVmax of primary tumours showed a weak but significant correlation with serum PSA values (r = 0.51, p < 0.001) and Gleason scores (GSC; r = 0.35, p = 0.001), respectively. In correlation with histopathology, calculated per-region sensitivity, specificity, positive predictive value, negative predictive value, and accuracy for detection of lymph node metastases were 35.0%, 98.4%, 63.6%, 95.0%, and 93.0%, respectively. CONCLUSIONS In patients with initial diagnosis of intermediate- and high-risk prostate cancer, 68Ga-PSMA I&T PET/CT emerges as a relevant staging procedure by identifying nodal and/or distant metastases. Due to the low prevalence of extraprostatic disease, its value seems to be limited in low-risk disease.
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Affiliation(s)
- Wojciech Cytawa
- Department of Nuclear Medicine, Medical University of Gdańsk, Smoluchowskiego Str. 17, 80-952, Gdańsk, Poland.,Department of Nuclear Medicine, University Hospital Würzburg, Oberdürrbacher Str. 6, 97080, Würzburg, Germany
| | | | - Stefan Kircher
- Institute of Pathology, Comprehensive Cancer Center Mainfranken (CCCMF), University of Würzburg, Würzburg, Germany
| | - Kazuhito Fukushima
- Department of Nuclear Medicine, University Hospital Würzburg, Oberdürrbacher Str. 6, 97080, Würzburg, Germany
| | - Johannes Tran-Gia
- Department of Nuclear Medicine, University Hospital Würzburg, Oberdürrbacher Str. 6, 97080, Würzburg, Germany
| | - Andreas Schirbel
- Department of Nuclear Medicine, University Hospital Würzburg, Oberdürrbacher Str. 6, 97080, Würzburg, Germany
| | - Tomasz Bandurski
- Department of Radiology Informatics and Statistics, Medical University of Gdańsk, Gdańsk, Poland
| | - Piotr Lass
- Department of Nuclear Medicine, Medical University of Gdańsk, Smoluchowskiego Str. 17, 80-952, Gdańsk, Poland
| | - Markus Krebs
- Department of Urology, University Hospital Würzburg, Würzburg, Germany
| | - Wojciech Połom
- Department of Urology, Medical University of Gdansk, Gdańsk, Poland
| | | | - Hans-Jürgen Wester
- Pharmaceutical Radiochemistry, Technische Universität München, Munich, Germany
| | - Andreas K Buck
- Department of Nuclear Medicine, University Hospital Würzburg, Oberdürrbacher Str. 6, 97080, Würzburg, Germany
| | - Hubert Kübler
- Department of Urology, University Hospital Würzburg, Würzburg, Germany
| | - Constantin Lapa
- Department of Nuclear Medicine, University Hospital Würzburg, Oberdürrbacher Str. 6, 97080, Würzburg, Germany.
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Abstract
In modern oncology, molecular tumor boards are the interface between the public healthcare system and clinical research institutions. An interdisciplinary team of medical and scientific experts assesses if extensive molecular testing for tumor profiling is appropriate and discusses therapeutic options for patients with newly diagnosed treatable alterations. In the field of metastatic prostate cancer, patients especially with a strong family history, young age of diagnosis and those who have exhausted standard treatments may benefit from molecular profiling. Expression of the androgen receptor splice variant 7 (AR-V7) predicts nonresponse to next-generation AR-directed therapy like abiraterone or enzalutamide. Different blood tests for AR-V7 detection are now commercially available. Mutations in the DNA repair pathway are another frequent event in metastatic prostate cancer. Homologous recombination defects sensitize cancer cells to poly(ADP-ribose) polymerase (PARP) inhibitors. In the TOPARP-A trial, the PARP inhibitor olaparib led to high response rates (88%) in patients with mutated DNA repair genes. Furthermore, patients with DNA mismatch repair deficiency and/or microsatellite instability seem to benefit from PD-1 inhibitors, particularly pembrolizumab. At this time neither PARP inhibitors nor PD-1 inhibitors are approved for metastatic prostate cancer treatment in Germany. Therefore, a recommendation of a molecular tumor board for biomarker-matched off-label use of approved drugs across entity barriers will support coverage by health insurance.
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Affiliation(s)
- A K Seitz
- Klinik und Poliklinik für Urologie und Kinderurologie, Zentrum Operative Medizin, Universitätsklinikum Würzburg, Oberdürrbacher Str. 6, 97080, Würzburg, Deutschland.
| | - M M Heck
- Klinik und Poliklinik für Urologie, Klinikum rechts der Isar, Technische Universität München, München, Deutschland
| | - M W Kamer
- Klinik für Urologie, Universitätsklinikum Schleswig-Holstein, Campus Lübeck, Lübeck, Deutschland
| | - C Grüllich
- Klinik für Medizinische Onkologie, Nationales Zentrum für Tumorerkrankungen, Universitätsklinikum Heidelberg, Heidelberg, Deutschland
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Seitz AK, Thoene S, Bietenbeck A, Nawroth R, Tauber R, Thalgott M, Schmid S, Secci R, Retz M, Gschwend JE, Ruland J, Winter C, Heck MM. AR-V7 in Peripheral Whole Blood of Patients with Castration-resistant Prostate Cancer: Association with Treatment-specific Outcome Under Abiraterone and Enzalutamide. Eur Urol 2017; 72:828-834. [PMID: 28818355 DOI: 10.1016/j.eururo.2017.07.024] [Citation(s) in RCA: 76] [Impact Index Per Article: 10.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/14/2017] [Accepted: 07/20/2017] [Indexed: 02/07/2023]
Abstract
BACKGROUND It has been demonstrated that androgen receptor splice variant 7 (AR-V7) expression in circulating tumor cells (CTCs) predicts poor treatment response in metastatic castration-resistant prostate cancer (mCRPC) patients treated with abiraterone or enzalutamide. OBJECTIVE To develop a practical and robust liquid profiling approach for direct quantification of AR-V7 in peripheral whole blood without the need for CTC capture and to determine its potential for predicting treatment response in mCRPC patients. DESIGN, SETTING, AND PARTICIPANTS Whole blood samples from a prospective biorepository of 85 mCRPC patients before treatment initiation with abiraterone (n=56) or enzalutamide (n=29) were analyzed via droplet digital polymerase chain reaction. OUTCOME MEASUREMENTS AND STATISTICAL ANALYSIS The association of AR-V7 status with prostate-specific antigen (PSA) response defined by PSA decline ≥50% and with PSA-progression-free survival (PSA-PFS), clinical PFS, and overall survival (OS) was assessed. RESULTS AND LIMITATIONS High AR-V7 expression levels in whole blood were detectable in 18% (15/85) of patients. No patient with high AR-V7 expression achieved a PSA response, and AR-V7 status was an independent predictor of PSA response in multivariable logistic regression analysis (p=0.03). High AR-V7 expression was associated with shorter PSA-PFS (median 2.4 vs 3.7 mo; p<0.001), shorter clinical PFS (median 2.7 vs 5.5 mo; p<0.001), and shorter OS (median 4.0 vs. 13.9 mo; p<0.001). On multivariable Cox regression analysis, high AR-V7 expression remained an independent predictor of shorter PSA-PFS (hazard ratio [HR] 7.0, 95% confidence interval [CI] 2.3-20.7; p<0.001), shorter clinical PFS (HR 2.3, 95% CI 1.1-4.9; p=0.02), and shorter OS (HR 3.0, 95% CI 1.4-6.3; p=0.005). CONCLUSIONS Testing of AR-V7 mRNA levels in whole blood is a simple and promising approach to predict poor treatment outcome in mCRPC patients receiving abiraterone or enzalutamide. PATIENT SUMMARY We established a method for determining AR-V7 status in whole blood. This test predicted treatment resistance in patients with metastatic castration-resistant prostate cancer undergoing treatment with abiraterone or enzalutamide. Prospective validation is needed before application to clinical practice.
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Affiliation(s)
- Anna Katharina Seitz
- Department of Urology, Klinikum rechts der Isar, Technical University of Munich, Germany
| | - Silvia Thoene
- Institute of Clinical Chemistry and Pathobiochemistry, Klinikum rechts der Isar, Technical University of Munich, Munich, Germany; German Cancer Consortium, partner site Munich, Germany; German Cancer Research Center, Heidelberg, Germany
| | - Andreas Bietenbeck
- Institute of Clinical Chemistry and Pathobiochemistry, Klinikum rechts der Isar, Technical University of Munich, Munich, Germany
| | - Roman Nawroth
- Department of Urology, Klinikum rechts der Isar, Technical University of Munich, Germany
| | - Robert Tauber
- Department of Urology, Klinikum rechts der Isar, Technical University of Munich, Germany
| | - Mark Thalgott
- Department of Urology, Klinikum rechts der Isar, Technical University of Munich, Germany
| | - Sebastian Schmid
- Department of Urology, Klinikum rechts der Isar, Technical University of Munich, Germany
| | - Ramona Secci
- Institute of Clinical Chemistry and Pathobiochemistry, Klinikum rechts der Isar, Technical University of Munich, Munich, Germany; German Cancer Consortium, partner site Munich, Germany; German Cancer Research Center, Heidelberg, Germany
| | - Margitta Retz
- Department of Urology, Klinikum rechts der Isar, Technical University of Munich, Germany
| | - Jürgen E Gschwend
- Department of Urology, Klinikum rechts der Isar, Technical University of Munich, Germany
| | - Jürgen Ruland
- Institute of Clinical Chemistry and Pathobiochemistry, Klinikum rechts der Isar, Technical University of Munich, Munich, Germany; German Cancer Consortium, partner site Munich, Germany; German Cancer Research Center, Heidelberg, Germany
| | - Christof Winter
- Institute of Clinical Chemistry and Pathobiochemistry, Klinikum rechts der Isar, Technical University of Munich, Munich, Germany; German Cancer Consortium, partner site Munich, Germany; German Cancer Research Center, Heidelberg, Germany.
| | - Matthias M Heck
- Department of Urology, Klinikum rechts der Isar, Technical University of Munich, Germany.
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20
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Erlmeier F, Seitz AK, Hatzichristodoulou G, Stecher L, Retz M, Gschwend JE, Weichert W, Kübler HR, Horn T. The Role of PD-L1 Expression and Intratumoral Lymphocytes in Response to Perioperative Chemotherapy for Urothelial Carcinoma. Bladder Cancer 2016; 2:425-432. [PMID: 28035323 PMCID: PMC5181663 DOI: 10.3233/blc-160067] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
Introduction: Immunological pathways are relevant for the effectiveness of conventional cytotoxic chemotherapy. Recently, checkpoint inhibition of the PD-1/PD-L1 axis has been shown to be therapeutically relevant in urothelial carcinoma. Objective: To monitor PD-L1 expression on tumor cells and intratumoral infiltration with CD8 positive lymphocytes during perioperative chemotherapy for urothelial cancer and to evaluate their use as potential predictive markers for chemotherapy. Patients and Methods: Sixty-four patients with muscle-invasive urothelial cancer were included in the analysis. Twenty-two patients received preoperative chemotherapy and 42 were treated in an adjuvant setting for locally advanced disease or lymph node metastases. PD-L1 status and the density of infiltration with CD8-positive cells were assessed by immunohistochemistry and analysed for their association with survival (adjuvant group) and response to chemotherapy (preoperative group). For PD-L1 positivity we used a cutoff of 10% positive tumor cells. Results: In the adjuvant group, 11 of 42 patients (26.2%) had PD-L1 positive tumor cells. Twenty-six of 42 (61.9%) patients were highly infiltrated with CD8 + lymphocytes. There was no significant evidence of an association with overall survival for PD-L1 status nor for CD8 infiltration density (p = 0.63 and 0.71). In the preoperative group, eight of the 22 (36.4%) patients were PD-L1 positive and 13 (59%) were highly infiltrated with CD8 + lymphocytes before chemotherapy. There was no evidence of associations with response or survival. Eight patients showed a pathological response to preoperative treatment. These had a significantly longer overall survival than non-responders (p = 0.01). In the preoperative group the pre-treatment expression of the immunologic markers could be compared to the post-treatment status. Only one patient showed a changed PD-L1 status and three patients a changed CD8 status. Conclusions: The tumoral expression of PD-L1 in urothelial carcinoma does not seem to be largely influenced by chemotherapy. Our data do not provide evidence that tumoral expression of PD-L1 and CD8 are useful as prognostic or predictive markers. Small sample size is the major limitation of our study.
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Affiliation(s)
- F Erlmeier
- Institute for Pathology and Pathological Anatomy, Technische Universität München , Munich, Germany
| | - A K Seitz
- Department of Urology, Klinikum rechts der Isar, Technische Universität München , Munich, Germany
| | - G Hatzichristodoulou
- Department of Urology, Klinikum rechts der Isar, Technische Universität München , Munich, Germany
| | - L Stecher
- Institute for Medical Statistics and Epidemiology, Technische Universität München , Munich, Germany
| | - M Retz
- Department of Urology, Klinikum rechts der Isar, Technische Universität München , Munich, Germany
| | - J E Gschwend
- Department of Urology, Klinikum rechts der Isar, Technische Universität München , Munich, Germany
| | - W Weichert
- Institute for Pathology and Pathological Anatomy, Technische Universität München, Munich, Germany; Member of the German Cancer Consortium (DKTK)
| | - H R Kübler
- Department of Urology, Klinikum rechts der Isar, Technische Universität München , Munich, Germany
| | - T Horn
- Department of Urology, Klinikum rechts der Isar, Technische Universität München , Munich, Germany
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21
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Hedegaard J, Lamy P, Nordentoft I, Algaba F, Høyer S, Ulhøi BP, Vang S, Reinert T, Hermann GG, Mogensen K, Thomsen MBH, Nielsen MM, Marquez M, Segersten U, Aine M, Höglund M, Birkenkamp-Demtröder K, Fristrup N, Borre M, Hartmann A, Stöhr R, Wach S, Keck B, Seitz AK, Nawroth R, Maurer T, Tulic C, Simic T, Junker K, Horstmann M, Harving N, Petersen AC, Calle ML, Steyerberg EW, Beukers W, van Kessel KEM, Jensen JB, Pedersen JS, Malmström PU, Malats N, Real FX, Zwarthoff EC, Ørntoft TF, Dyrskjøt L. Comprehensive Transcriptional Analysis of Early-Stage Urothelial Carcinoma. Cancer Cell 2016; 30:27-42. [PMID: 27321955 DOI: 10.1016/j.ccell.2016.05.004] [Citation(s) in RCA: 416] [Impact Index Per Article: 52.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/26/2015] [Revised: 02/18/2016] [Accepted: 05/13/2016] [Indexed: 01/01/2023]
Abstract
Non-muscle-invasive bladder cancer (NMIBC) is a heterogeneous disease with widely different outcomes. We performed a comprehensive transcriptional analysis of 460 early-stage urothelial carcinomas and showed that NMIBC can be subgrouped into three major classes with basal- and luminal-like characteristics and different clinical outcomes. Large differences in biological processes such as the cell cycle, epithelial-mesenchymal transition, and differentiation were observed. Analysis of transcript variants revealed frequent mutations in genes encoding proteins involved in chromatin organization and cytoskeletal functions. Furthermore, mutations in well-known cancer driver genes (e.g., TP53 and ERBB2) were primarily found in high-risk tumors, together with APOBEC-related mutational signatures. The identification of subclasses in NMIBC may offer better prognostication and treatment selection based on subclass assignment.
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Affiliation(s)
- Jakob Hedegaard
- Department of Molecular Medicine, Aarhus University Hospital, Aarhus 8200, Denmark
| | - Philippe Lamy
- Department of Molecular Medicine, Aarhus University Hospital, Aarhus 8200, Denmark
| | - Iver Nordentoft
- Department of Molecular Medicine, Aarhus University Hospital, Aarhus 8200, Denmark
| | - Ferran Algaba
- Section of Pathology, Fundació Puigvert, University Autonoma de Barcelona, Barcelona 08025, Spain
| | - Søren Høyer
- Department of Pathology, Aarhus University Hospital, Aarhus 8000, Denmark
| | | | - Søren Vang
- Department of Molecular Medicine, Aarhus University Hospital, Aarhus 8200, Denmark
| | - Thomas Reinert
- Department of Molecular Medicine, Aarhus University Hospital, Aarhus 8200, Denmark
| | - Gregers G Hermann
- Department of Urology, Frederiksberg Hospital, Frederiksberg 2000, Denmark
| | - Karin Mogensen
- Department of Urology, Frederiksberg Hospital, Frederiksberg 2000, Denmark
| | | | | | - Mirari Marquez
- Spanish National Cancer Research Centre (CNIO), Madrid 28029, Spain
| | - Ulrika Segersten
- Department of Surgical Sciences, Uppsala University, Uppsala 75185, Sweden
| | - Mattias Aine
- Division of Oncology and Pathology, Department of Clinical Sciences Lund, Lund University, Lund 22100, Sweden
| | - Mattias Höglund
- Division of Oncology and Pathology, Department of Clinical Sciences Lund, Lund University, Lund 22100, Sweden
| | | | - Niels Fristrup
- Department of Molecular Medicine, Aarhus University Hospital, Aarhus 8200, Denmark
| | - Michael Borre
- Department of Urology, Aarhus University Hospital, Aarhus 8200, Denmark
| | - Arndt Hartmann
- Institute of Pathology, University Hospital Erlangen, Friedrich Alexander-University Erlangen-Nürnberg, Erlangen 91054, Germany
| | - Robert Stöhr
- Institute of Pathology, University Hospital Erlangen, Friedrich Alexander-University Erlangen-Nürnberg, Erlangen 91054, Germany
| | - Sven Wach
- Department of Urology, University Hospital Erlangen, Friedrich Alexander-University Erlangen-Nürnberg, Erlangen 91054, Germany
| | - Bastian Keck
- Department of Urology, University Hospital Erlangen, Friedrich Alexander-University Erlangen-Nürnberg, Erlangen 91054, Germany
| | - Anna Katharina Seitz
- Department of Urology, Klinikum rechts der Isar der Technischen Universität München, Munich 81675, Germany
| | - Roman Nawroth
- Department of Urology, Klinikum rechts der Isar der Technischen Universität München, Munich 81675, Germany
| | - Tobias Maurer
- Department of Urology, Klinikum rechts der Isar der Technischen Universität München, Munich 81675, Germany
| | - Cane Tulic
- Faculty of Medicine, Clinic of Urology, Clinical Centre of Serbia, University of Belgrade, 11000 Belgrade, Serbia
| | - Tatjana Simic
- Faculty of Medicine, Institute of Medical and Clinical Biochemistry, University of Belgrade, 11000 Belgrade, Serbia
| | - Kerstin Junker
- Department of Urology, Saarland University, Homburg 66421, Germany
| | - Marcus Horstmann
- Department of Urology, Friedrich-Schiller-University Jena, Jena 07737, Germany
| | - Niels Harving
- Department of Urology, Aalborg University Hospital, Aalborg 9000, Denmark
| | | | - M Luz Calle
- Systems Biology Department, University of Vic, Vic, Barcelona 08500, Spain
| | - Ewout W Steyerberg
- Department of Public Health, Erasmus Medical Centre, 3015 CE Rotterdam, the Netherlands
| | - Willemien Beukers
- Department of Pathology, Erasmus Medical Centre, 3015 CE Rotterdam, the Netherlands
| | - Kim E M van Kessel
- Department of Pathology, Erasmus Medical Centre, 3015 CE Rotterdam, the Netherlands
| | | | - Jakob Skou Pedersen
- Department of Molecular Medicine, Aarhus University Hospital, Aarhus 8200, Denmark
| | - Per-Uno Malmström
- Department of Surgical Sciences, Uppsala University, Uppsala 75185, Sweden
| | - Núria Malats
- Spanish National Cancer Research Centre (CNIO), Madrid 28029, Spain
| | - Francisco X Real
- Spanish National Cancer Research Centre (CNIO), Madrid 28029, Spain; Departament de Ciències Experimentals i de la Salut, Universitat Pompeu Fabra, Barcelona 08003, Spain
| | - Ellen C Zwarthoff
- Department of Pathology, Erasmus Medical Centre, 3015 CE Rotterdam, the Netherlands
| | - Torben Falck Ørntoft
- Department of Molecular Medicine, Aarhus University Hospital, Aarhus 8200, Denmark
| | - Lars Dyrskjøt
- Department of Molecular Medicine, Aarhus University Hospital, Aarhus 8200, Denmark.
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22
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Horn T, Laus J, Seitz AK, Maurer T, Schmid SC, Wolf P, Haller B, Winkler M, Retz M, Nawroth R, Gschwend JE, Kübler HR, Slotta-Huspenina J. The prognostic effect of tumour-infiltrating lymphocytic subpopulations in bladder cancer. World J Urol 2015; 34:181-7. [PMID: 26055646 DOI: 10.1007/s00345-015-1615-3] [Citation(s) in RCA: 59] [Impact Index Per Article: 6.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/11/2015] [Accepted: 06/02/2015] [Indexed: 12/21/2022] Open
Abstract
BACKGROUND Intratumoural lymphocytic infiltration is strongly associated with the outcome of many human epithelial cancers. The current paper investigated whether subpopulations of tumour-infiltrating T lymphocytes are associated with certain clinicopathological parameters and the prognosis of patients with invasive bladder cancer (BCa). PATIENTS AND METHODS The infiltration densities of the adaptive immune markers CD3 (the whole T cell population), FOXP3 (regulatory T cells; Tregs), CD8 (T effector cells) and CD45R0 (T effector memory cells) were analysed by immunohistochemistry and image analysis with tissue microarrays of tumour tissues from 149 patients with invasive BCa treated with radical cystectomy. The findings were correlated with certain clinicopathological parameters. RESULTS Higher FOXP3/CD3 [OS: p = 0.016, HR 1.29, 95% confidence intervals (95% CIs 1.05-1.59)] and FOXP3/CD8 (OS: p = 0.013, HR 1.32, 95% CIs 1.06-1.65) ratios were significantly associated with briefer overall survival and time to cancer-specific death; the latter ratio represented an independent prognostic factor according to a multivariate analysis adjusted for pathological T and N stages (HR 1.32, 95% CIs 1.05-1.67, p = 0.018). The infiltration densities of individual markers (CD3, CD8, FOXP3 and CD45R0) were not significantly associated with clinicopathological parameters or survival; however, a trend towards a better outcome was observed for higher log-transformed CD8 (p = 0.070, HR 0.80, 95% CIs 0.63-1.02) and CD3 (p = 0.113, HR 0.84, 95% CIs 0.68-1.04) infiltration values. CONCLUSIONS A high fraction of Tregs amongst CD3- and CD8-positive lymphocytes indicated a poor prognosis, thereby emphasising the important role that Tregs play in the suppression of the anti-tumour immune response. No single lymphocytic marker was significantly correlated with clinical outcomes, but high CD3 and CD8 infiltration showed trends towards better prognosis.
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Affiliation(s)
- T Horn
- Department of Urology, Klinikum rechts der Isar, Technische Universität München, Munich, Germany. .,Urologische Klinik und Poliklinik der Technischen Universität München, Ismaningerstraße 22, 81675, Munich, Germany.
| | - J Laus
- Department of Urology, Klinikum rechts der Isar, Technische Universität München, Munich, Germany
| | - A K Seitz
- Department of Urology, Klinikum rechts der Isar, Technische Universität München, Munich, Germany
| | - T Maurer
- Department of Urology, Klinikum rechts der Isar, Technische Universität München, Munich, Germany
| | - S C Schmid
- Department of Urology, Klinikum rechts der Isar, Technische Universität München, Munich, Germany
| | - P Wolf
- Institute of Medical Statistics and Epidemiology, Technische Universität München, Munich, Germany
| | - B Haller
- Institute of Medical Statistics and Epidemiology, Technische Universität München, Munich, Germany
| | - M Winkler
- Institute for Pathology and Pathological Anatomy, Technische Universität München, Munich, Germany
| | - M Retz
- Department of Urology, Klinikum rechts der Isar, Technische Universität München, Munich, Germany
| | - R Nawroth
- Department of Urology, Klinikum rechts der Isar, Technische Universität München, Munich, Germany
| | - J E Gschwend
- Department of Urology, Klinikum rechts der Isar, Technische Universität München, Munich, Germany
| | - H R Kübler
- Department of Urology, Klinikum rechts der Isar, Technische Universität München, Munich, Germany
| | - J Slotta-Huspenina
- Institute for Pathology and Pathological Anatomy, Technische Universität München, Munich, Germany
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23
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Schmid SC, Geith A, Böker A, Tauber R, Seitz AK, Kuczyk M, von Klot C, Gschwend JE, Merseburger AS, Retz M. Enzalutamide after docetaxel and abiraterone therapy in metastatic castration-resistant prostate cancer. Adv Ther 2014; 31:234-41. [PMID: 24442834 DOI: 10.1007/s12325-014-0092-1] [Citation(s) in RCA: 52] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/11/2013] [Indexed: 11/26/2022]
Abstract
INTRODUCTION Enzalutamide is a novel antiandrogen which is approved for the treatment of metastatic, castration-resistant prostate cancer (mCRPC) after taxane-based chemotherapy. The efficacy of enzalutamide after the sequence docetaxel and abiraterone is not proven. METHODS Thirty-five mCRPC patients in the German compassionate use program, who received enzalutamide after progression with taxane-based chemotherapy and abiraterone were prospectively evaluated. The endpoints of the study were overall survival, radiologic progression-free survival and safety. RESULTS The median treatment duration on enzalutamide was 2.8 months. The median overall survival was 7.5 months [95% confidence interval (CI) 4.7-10.3] while median progression-free survival assessed by imaging was 3.1 months (95% CI 1.4-4.8). The most common toxicities of all grades were anemia and weight loss. CONCLUSION Although the results are limited by a small patient number, the consecutive use of enzalutamide and abiraterone after taxane-based chemotherapy shows a modest clinical activity. Thus, sequence therapy alternating between chemotherapy and antihormonal drugs might be a more promising approach in mCRPC treatment.
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Affiliation(s)
- Sebastian Christoph Schmid
- Department of Urology, Technische Universität München, Rechts der Isar Medical Center, Ismaninger Str. 22, 81675, Munich, Germany,
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24
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Horn T, Ladwein B, Maurer T, Redlin J, Seitz AK, Gschwend JE, Retz M, Kübler HR. The method of GFR determination impacts the estimation of cisplatin eligibility in patients with advanced urothelial cancer. World J Urol 2013; 32:359-63. [DOI: 10.1007/s00345-013-1104-5] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2012] [Accepted: 05/20/2013] [Indexed: 10/26/2022] Open
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