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

BACKGROUND

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

METHODS

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

FINDINGS

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

INTERPRETATION

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

Supine arm cycling during the post-flap recovery period for persons with spinal cord injuries: The multi-purpose arm cycle ergometer (M-PACE) safety and pilot testing

OBJECTIVE

To describe how using a supine arm cycle ergometer can safely reduce deconditioning experienced by patients with spinal cord injury or disorder (SCI/D) during their four to six weeks of complete bed rest after surgery to close a stage 4 pressure injury.

DESIGN

This pilot project used a newly designed arm cycle ergometer (known as the M-PACE) that extends over the bed, allowing a patient to lie completely supine while exercising.

SETTING

The M-PACE was designed and built at the Minneapolis Veterans Affairs Health Care System (MVAHCS) and pilot tested at the MVAHCS SCI/D Center.

PARTICIPANTS

Patients with SCI/D, recovering from flap surgery and deemed appropriate to use the arm cycle ergometer were enrolled in the pilot study (n = 47).

OUTCOME MEASURES

A pre-post six-minute arm test (6MAT), a proxy for conditioning, was conducted on a subset (n = 15) of participants before and after the supine cycling exercise training program. Participants' rating of perceived exertion (RPE) scores were collected at cessation of each 6MAT. Participants gave feedback on their perception of using the M-PACE.

RESULTS/CONCLUSIONS

The 6MAT RPE was significantly reduced after training with the M-PACE while on bed rest (P = 0.003). Also, significantly more rotations were performed after completing the training program (P = 0.02). Further, study participants who accessed the M-PACE found using it helped offset the tedium of laying supine during flap surgery recovery. The differences in the 6MAT pre- to post measures indicate the M-PACE should be further studied for offsetting the normal deconditioning that occurs with extended bedrest.

Visualization of user interactions with a pressure mapping mobile application for wheelchair users at risk for pressure injuries

Pressure injuries for individuals with spinal cord injuries (SCI) are correlated with mortality and are a leading cause for rehospitalizations. The Assisted Weight Shift (AW-Shift©) is a mobile pressure mapping application designed to provide users with a live map view and reminders to perform weight shifts. Novel visualization techniques were used to understand daily distributions of user interaction wit h AW-Shift©. The date and time of system interactions were recorded for six participants with SCI over 7 days (five males/one female, five manual users/one power user, 55.3 ± 17.3 years old, 10.6 ± 6.5 years since injury). Circular frequency plots were created to visualize the time and frequency participants brought the app to the foreground of their phone and received alerts and reminders to complete weight shifts. While some participants used the system regularly throughout the day, others primarily used it before 8am; highlighting the system's importance for regular spot checks and morning wheelchair setup. Participant adherence to weight shift reminders was low suggesting the live pressure map may be more useful. Circular frequency plots can be used by clinicians to more easily review large amounts of patient data. Future work will investigate raw pressure mat data and create a closed-loop weight shift detection algorithm.

Development of a comprehensive mobile assessment of pressure (CMAP) system for pressure injury prevention for veterans with spinal cord injury

Objective: This paper reports the iterative redesign, feasibility and usability of the Comprehensive Mobile Assessment of Pressure (CMAP) system's mobile app used by Veterans with SCI.Design: This three-year, multi-staged study used a mixed-methods approach.Setting: Minneapolis VA Health Care System, Minneapolis, Minnesota.Participants: Veterans with spinal cord injury (N = 18).Interventions: Veterans with spinal cord injury engaged in iterative focus groups and personal interviews, sharing their needs and desires for the CMAP app redesign. App developers used these data for the redesign. The redesigned CMAP app was tested for six-weeks in users' homes.Outcome Measures: Quantitative (surveys) and qualitative (interviews) methods measured feasibility for self-management of seating pressure. Qualitative data were audio recorded, transcribed, anonymized, and coded. Survey data were analyzed using summary statistics.Results: After the CMAP system's redesign, the in-home use interview found: (1) any tool that can assist in prevention and monitoring of skin ulcers is important; (2) the desired key features are present in the app; (3) the main barrier to CMAP use was inconsistent functionality; (4) when functioning as expected, the live pressure map was the central feature, with reminders to weight shift also of high importance. The survey found: power wheelchair users tended to score closer than manual wheelchair users to the positive response end ranges on two separate surveys.Conclusions: Overall both the power and manual wheelchair users reported that they wanted to use the system, felt confident using the system, and that the functions of the system were well integrated.

Reliability of pre-operative biopsies in the histological grading of colorectal adenocarcinomas

BACKGROUND

Management of colorectal cancer depends on many patient and tumour variables. Decisions are sometimes based on the histological grade of tumour as assessed by initial biopsy. This retrospective study looked at the reliability of grading colorectal cancer from pre-operative biopsies.

METHODS

118 patients with a diagnosis of colorectal cancer, who had adequate pre-operative biopsies, were included in the study. A single consultant histopathologist re-examined all the preoperative biopsy slides, but was blinded to the final grading of the resection specimen.

RESULTS

Of the 118 resection specimens, 41 were graded well-differentiated, 52 moderately differentiated and 25 poorly differentiated. When compared with postoperative grading, 37 (31%) initial biopsies were undergraded, 49 (43%) were correctly graded and 32 (26%) were overgraded.

CONCLUSIONS

These results suggest that the histological grading of pre-operative specimens is inaccurate and should be used with caution to determine treatment. The difficulty with grading pre-operative biopsies in colorectal cancer may be owing to a lack of specific criteria such as is used in, for example, breast cancer.

Alpha 1-adrenergic receptor structure

The structure of the alpha 1-adrenergic receptor was investigated by comparing polypeptides identified by sodium dodecyl sulfate (NaDodSO4)-polyacrylamide gel electrophoresis with the size of the intact receptor in cell membranes as determined by target size analysis. The alpha 1-adrenergic receptor from rat liver membranes affinity-labeled with [3H]phenoxybenzamine, a covalent affinity reagent, appeared as a single polypeptide with a molecular mass of 85,000 daltons (Da) on NaDodSO4-polyacrylamide gels. In the absence of protease inhibitors, smaller peptides of 58-62 kDa and 40-45 kDa, specifically labeled with [3H]phenoxybenzamine, were also apparent on NaDodSO4 gels. In order to determine whether the 85-kDa protein represented all or only a portion of the alpha 1-receptor, radiation inactivation (target size analysis) was undertaken. Radiation-induced receptor inactivation was measured by the loss of specific [3H]phenoxybenzamine and [3H]prazosin binding and by the loss of affinity-labeled alpha 1-adrenergic receptors on NaDodSO4 gels. Target size analysis of rat liver alpha 1-receptors indicated that the intact membrane-bound receptor has an average molecular mass of 160,000 Da. These data suggest that the intact alpha-receptor may exist in the membrane as a dimer of two 85,000-Da subunits. The structure of the alpha 1-receptor was further studied by limited proteolysis of the 85-kDa protein isolated from NaDodSO4 gels. Trypsin, chymotrypsin, and papain produce smaller peptides similar to those produced during membrane isolation in the absence of protease inhibition. Limited proteolysis of the membrane-bound receptor produces water-soluble peptides, the largest of which is 45,000 Da. This peptide contains the ligand-binding domain and protrudes from the membrane into the extracellular space.

Monoclonal antibodies detect the conservation of muscarinic cholinergic receptor structure from Drosophila to human brain and detect possible structural homology with alpha 1-adrenergic receptors

Muscarinic cholinergic receptors isolated from Drosophila heads, rat and human brain, dog heart, and monkey ciliary muscle were examined for structural similarities/differences by utilizing isoelectric focusing, sodium dodecyl sulfate/polyacrylamide gel electrophoresis, and monoclonal antibody crossreactivity. Muscarinic receptors were affinity labeled with [3H]propylbenzilylcholine mustard and subjected to isoelectric focusing. Muscarinic receptors from each species focused with an isoelectric point of 5.9. The same proteins all migrated with an apparent molecular mass of 80,000 daltons on sodium dodecyl sulfate gels. Six hybridomas secreting monoclonal antibodies specific for muscarinic receptors were developed by using purified rat brain muscarinic receptors as the antigen. The six different monoclonal antibodies immunoprecipitated muscarinic receptors from all tissues and species tested, including human and Drosophila brains, with equal efficacy. These data indicate that muscarinic receptors are highly conserved over a considerable evolutionary period. One of the six muscarinic receptor monoclonal antibodies also immunoprecipitated rat liver alpha 1-adrenergic receptors. Furthermore, two out of five monoclonal antibodies raised against alpha 1-receptors immunoprecipitated muscarinic receptors. These data suggest that some degree of structural homology exists between muscarinic cholinergic receptors and alpha 1-adrenergic receptors.

Autoantibodies and monoclonal antibodies in the purification and molecular characterization of neurotransmitter receptors

The combination of immunological advances with membrane receptor research has promoted rapid progress in the molecular characterization of neurotransmitter receptor molecules. We have to date produced monoclonal antibodies to beta 1-, beta 2-, and alpha 1-adrenergic, D2-dopaminergic, and muscarinic receptors. In addition we have discovered that some allergic respiratory disease patients possess circulating autoantibodies to beta 2-adrenergic receptors. These antireceptor antibodies in conjunction with specific receptor affinity reagents have allowed us to isolate, purify, and begin to characterize alpha- and beta-adrenergic, dopaminergic, and muscarinic receptors. For example, immunoprecipitation of turkey erythrocyte beta 1 receptors with monoclonal antibodies yields a single polypeptide Mr 65--70 K. In contrast, purification of beta 2-adrenergic receptors using either autoantibodies or monoclonal antibodies yields a receptor species with a subunit of Mr 55--59 K. Autoantibodies to beta 2 receptors demonstrate a 50--100% homology among beta 2 receptors from humans to rats, whereas monoclonal antibody FV-104 recognizes a determinant in the ligand binding site of all beta 1 and beta 2 receptors tested to date. These data suggest that beta 1- and beta 2-adrenergic receptors may have evolved from a common ancestor, perhaps by gene duplication.