Long-term outcomes of SBRT for PSMA PET detected oligometastatic prostate cancer

BACKGROUND

Oligometastatic disease in prostate cancer (PCa) is a challenging clinical scenario encountered more frequently with the widespread adoption of PSMA-PET. SBRT aims to defer androgen deprivation and may deliver sustained biochemical failure (BF) free survival in selected patients. Little long-term data is currently available regarding the effectiveness of this approach.

METHODS

A retrospective single institution study of PSMA-PET directed SBRT without initial ADT for oligo-metachronous PCa. Median dose/fractionation was 24 Gy in 2# to bones and 30 Gy in 3# to lymph nodes. The primary endpoint was time to BF (PSA + 0.2 ug/L above nadir). Secondary endpoints included time to ADT for relapse (i.e. palliative ADT), BF defined as PSA nadir + 2 ug/L, toxicity, patterns of failure and survival. Patients were excluded if they received ADT with their SBRT, had short disease-free interval, or > 3 metastases on PSMA-PET.

RESULTS

103 patients treated from November-2014 to December-2019 were analysed from our prospective database. Median follow-up was 5 years. 64 patients were treated for nodal only disease, 35 bone only and 4 mixed. 15% were free of any BF at 5 years with median time to BF of 1.1 years. 32% (33/103) of patients had further curative-intent radiation treatment following their first BF after SBRT, including subsequent SBRT. Eight patients underwent potentially curative treatment for their second or third relapse. Allowing for salvage treatment, 29/103 (28%) were biochemically disease free at last follow up. At 5 years, 39% of patients had never received any ADT and 55% had not started ADT for relapse with a median time to ADT for relapse of 5.5 years. There were 2 grade 3 toxicities (rib fracture and lymphoedema), and no local failures.

CONCLUSION

PSMA-PET guided SBRT for oligo-metachronous PCa recurrence in appropriately triaged patients results in excellent local control, low toxicity and over 50% ADT free at 5 years.

Resistance to local anaesthetics administered via epidural, intrathecal and pudendal injections

A primigravida presented to our institution in established labour. Her past medical history included joint hypermobility, postural orthostatic tachycardia syndrome, Raynaud's syndrome, fibromyalgia and gastroparesis. Two technically uneventful lumbar epidurals with bupivacaine and fentanyl provided no analgesia. The spinal element of a planned combined spinal and epidural was also ineffective, so alternative analgesia was offered. While this was being prepared, the obstetric team recommended an instrumental delivery. An attempted pudendal nerve block with lidocaine had no effect, and general anaesthesia was therefore provided for a lower segment caesarean delivery. We believe this is the first report of local anaesthetic resistance via three distinct routes of administration in a single patient. Resistance to local anaesthetics is unusual and is more common in patients with hypermobility spectrum disorders. This case demonstrates the unique experience of a patient with a hypermobility condition who had failed epidural, spinal and pudendal local anaesthetic. We suggest that patients with a hypermobility condition should be specifically assessed for local anaesthetic resistance as part of anaesthetic pre-assessment, to enable early planning.

FDG-PET response and outcome from anti-PD-1 therapy in metastatic melanoma

Background

Immune checkpoint inhibitor therapy has resulted in impressive and durable clinical activity for many cancers including melanoma; however, there remain few reliable predictors for long-term response. This study investigated whether [18F]2-fluoro-2-deoxy-D-glucose (FDG-PET) imaging may better predict long-term outcomes compared with standard computed tomography (CT) response criteria.

Patients and methods

Retrospective analysis of metastatic melanoma patients treated with anti-PD-1-based immunotherapy with baseline and 1-year FDG-PET and CT imaging at Melanoma Institute Australia. One-year response was determined using RECIST for CT and EORTC criteria for PET, coded as complete response (CR or CMR), partial response (PR or PMR), stable disease (SD or SMD) or progressive disease (PD or PMD). Progression-free survival (PFS) was determined from the 1-year landmark.

Results

Patients (n = 104) were evaluated with median follow-up 30.1 months and 98% remain alive. Most received anti-PD-1 as monotherapy (67%) or combined with ipilimumab (31%). At 1 year, 28% had CR, 66% had PR and 6% had SD on CT, while 75% had CMR, 16% PMR and 9% SMD/PMD on PET. CMR was observed in 68% of patients with PR on CT. RECIST PFS post 1-year landmark was similar in patients with CR versus PR/SD, but improved in patients with CMR versus non-CMR {median not reached [NR] versus 12.8 month; hazard ratio [HR] 0.06 [95% confidence interval (CI) 0.02-0.23]; P < 0.01}. In patients with PR on CT, PFS was improved in patients with PR + CMR versus PR + non-CMR (median NR versus 12.8 months; HR 0.07 [95% CI 0.02-0.27]; P < 0.01). In the 78 CMR patients, 78% had discontinued treatment and 96% had ongoing response.

Conclusions

Whilst only a small proportion of patients have a CR at 1 year, most patients with a PR have CMR on PET. Almost all patients with CMR at 1 year have ongoing response to therapy thereafter. PET may have utility in predicting long-term benefit and help guide discontinuation of therapy.

Melanoma patient imaging in the era of effective systemic therapies

Imaging plays a critical role in the current multi-disciplinary management of patients with melanoma. It is used for primary disease staging, surgical planning, and surveillance in high-risk patients, and for monitoring the effects of systemic or loco-regional therapies. Several different imaging modalities have been utilised in the past. Contemporary imaging practises vary geographically depending on clinical guidelines, physician preferences, availability and cost. Targeted therapies and immunotherapies have revolutionised the treatment of patients with metastatic melanoma over the last few years. With this have come new patterns of disease that were not observed after conventional therapies, and new criteria to assess therapeutic responses. In this article we review the role of imaging for patients with melanoma in the era of effective systemic therapies and discuss likely future developments.

Recent outbreaks of infectious syphilis, United Kingdom, January 2012 to April 2014

Six outbreaks of infectious syphilis in the United Kingdom, ongoing since 2012, have been investigated among men who have sex with men (MSM) and heterosexual men and women aged under 25 years. Interventions included case finding and raising awareness among healthcare professionals and the public. Targeting at-risk populations was complicated as many sexual encounters involved anonymous partners. Outbreaks among MSM were influenced by the use of geospatial real-time networking applications that allow users to locate other MSM within close proximity.

Investigation of a cluster of syphilis among heterosexuals in an English town

A cluster of five (3 primary and 2 early latent) cases of syphilis were identified in young heterosexuals in the east of England. Three were symptomatic at presentation. No further cases linked to this cluster have been diagnosed since June 2010. Effective partner notification is key to the identification and treatment of infected contacts.

Surveillance of community genital Chlamydia trachomatis testing in the East of England, 2008-2010

BACKGROUND

Widespread testing for chlamydia is expected to result in a reduction in prevalence. In 2008, coverage indicators introduced by the Department of Health (DH) required collection and submission of all tests performed outside of genitourinary medicine clinics. No mechanism existed to collect community-based tests conducted outside of the National Chlamydia Screening Programme. The Health Protection Agency Regional Epidemiology Unit in the East of England (EoE) set up a new system to routinely collect and submit these tests on behalf of the regional Primary Care Organizations (PCOs).

METHODS

Testing data were requested from all laboratories commissioned to undertake chlamydia testing by EoE PCOs. Data were imported into a bespoke Structured Query Language server database and automated data processing routines were run. Data fulfilling national criteria were submitted for inclusion in the DH indicators.

RESULTS

High-quality data were submitted to set deadlines with minimum impact on laboratories. Completeness of data variables varied by laboratory and by variable type. After complex data processing, 96% of laboratory reported tests in the 15-24 year age range were eligible for submission.

CONCLUSIONS

This centralized method of data collection provides high-quality data, allowing for further analysis, which can be used to inform improvements in health care. These methods could be transferred to any of the hundreds of organisms for which similar laboratory data exist.

Lung perfusion and chest wall configuration is altered by glossopharyngeal breathing

Glossopharyngeal insufflation is used by competitive breath-hold divers to increase lung gas content above baseline total lung capacity (TLC) in order improve performance. Whilst glossopharyngeal insufflation is known to induce hypotension and tachycardia, little is known about the effects on the pulmonary circulation and structural integrity of the thorax. Six male breath-hold divers were studied. Exhaled lung volumes were measured before and after glossopharyngeal insufflation. On two study days, subjects were studied in the supine position at baseline TLC and after maximal glossopharyngeal insufflation above TLC. Tc 99(m) labelled macro-aggregated albumin was injected and a computed tomography (CT) scan of the thorax was performed during breath-hold. Single photon emission CT images determined flow and regional deposition. Registered CT images determined change in the volume of the thorax. CT and perfusion comparisons were possible in four subjects. Lung perfusion was markedly diminished in areas of expanded lung. 69% of the increase in expired lung volume was via thoracic expansion with a caudal displacement of the diaphragm. One subject who was not proficient at glossopharyngeal insufflation had no change in CT appearance or lung perfusion. We have demonstrated areas of hyperexpanded, under perfused lung created by glossopharyngeal insufflation above TLC.

Platelet activation in acute pulmonary embolism

BACKGROUND

Platelet activation is implicated in thrombotic disorders, but has not been described in acute clinical pulmonary embolism (PE).

OBJECTIVES

To investigate the natural history of platelet activation in PE and associated markers of inflammation, thrombosis and cardiac dysfunction.

METHODS

Thirty-five consecutive patients (age 62 +/-17 years) with acute PE were prospectively enrolled and followed for 6 months. Platelet activation was assessed by flow cytometry [measuring expression of platelet P-selectin, conformational activation of glycoprotein IIb/IIIa complex (PAC-1) and formation of platelet-leukocyte complexes] and by plasma soluble P-selectin. Platelet activation, right ventricular (RV) function (assessed as RV ejection area by transthoracic echocardiography), D-dimer and high-sensitivity C-reactive protein (hs-CRP) were measured at presentation and repeated over 6 months follow-up.

RESULTS

Soluble P-selectin (56 +/-19 ng mL(-1), anovaP < 0.0001) and PAC-1 (1.5 +/- 1.8%, anovaP = 0.005) were mildly but significantly increased in patients with acute PE relative to healthy young men (soluble P-selectin 33 +/- 13 ng mL(-1), P < 0.001; PAC-1 binding 0.5 +/- 0.6%, P < 0.01) and age-matched controls (soluble P-selectin 31 +/- 9 ng mL(-1), P < 0.001; PAC-1 binding 0.4 +/-0.4%, P < 0.05). Platelet P-selectin expression and platelet-leukocyte complexes were not increased during acute PE. Echocardiographic RV ejection area correlated inversely with soluble P-selectin (r = -0.47, P = 0.007) and positively with platelet P-selectin (r = 0.49, P = 0.0007), suggesting P-selectin is shed from activated platelets in proportion to the severity of RV dysfunction. Elevated soluble P-selectin, D-dimer and hs-CRP demonstrated a time-dependent return to normal during 6 months follow-up.

CONCLUSION

Platelet activation is evident after acute PE. Platelet activation correlates with the severity of RV dysfunction, and can persist for several months after acute PE.

Modelling the effectiveness of chlamydia screening in England

BACKGROUND

Several developed countries have initiated chlamydia screening programmes. Screening for a sexually transmitted infection has both direct individual and indirect population-wide effects. Mathematical models can incorporate these non-linear effects and estimate the likely impact of different screening programmes and identify areas where more data are needed.

METHODS

A stochastic, individual based dynamic network model, parameterised from UK screening studies and data on sexual behaviour and chlamydia epidemiology, was used to investigate the likely impact of opportunistic screening on chlamydia prevalence. Three main strategies were considered for <25 year olds: (1) annual offer to women; (2) annual offer to women or if changed partner within last 6 months; (3) annual offer to men and women. Sensitivity analyses were performed for key screening parameters including uptake rate, targeted age range, percentage of partners notified, and screening interval.

RESULTS

Under strategy 1, continuous opportunistic screening of women <25 years of age is expected to reduce the population prevalence by over 50% after 5 years. Prevalence is also expected to decrease in unscreened older women and in men. For all three strategies screening those aged over 25 results in small additional reductions in prevalence. Including men led to a faster and greater reduction in overall prevalence, but involved approximately twice as many tests as strategy 1 and 10% more than strategy 2. The frequency of attendance at healthcare sites limits the number of opportunities to screen and the effect of changing the screening interval.

CONCLUSIONS

The model suggests that continuous opportunistic screening at high uptake rates could significantly reduced chlamydia prevalence within a few years. Opportunistic programmes depend on regular attendance at healthcare providers, but there is a lack of high quality data on patterns of attendance. Inequalities in coverage may result in a less efficient and less equitable outcome.

Re-training refugee and other overseas doctors: re-qualification through the United Examining Board examination

The Professional and Linguistic Assessments Board test is well suited to overseas doctors who have migrated for reasons of career development but less so for groups such as refugees who have not had time to prepare for migration and may not speak English. We describe a 12-month structured clinical course leading to re-qualification, for 70 refugee and other overseas doctors. Between 1996 and 2003, 69 of the 70 overseas doctors on the course (27 of whom were refugees) re-qualified through the examination of the United Examining Board. We report on early and later outcomes of these 69 doctors who, by achieving provisional registration, were entitled to pre-registration house officer posts. Of the 69, 33 are now principals in general practice or GPs in training; a further 32 are in NHS hospital posts. Opportunities for disadvantaged overseas doctors to re-train are severely lacking; yet in the UK there are significant numbers who warrant special help. A very modest investment of resources could help them re-qualify and contribute to the health and economy of the nation.

A community study of health promotion in rural West Africa: details of a household survey and population census

BACKGROUND

Hypertension is an important problem in sub-Saharan Africa. The low use of processed food in this area makes a population approach to reducing salt intake feasible.

AIM

To create an age-sex register for 12 villages in Ghana as the first stage of a community study of the effect of dietary salt reduction on blood pressure and urinary sodium excretion in West African villagers.

DESIGN

Household survey and population census.

METHODS

Over three months, village maps were sketched and a complete list of total number of households, adults (with age and gender) and children in each village was obtained.

RESULTS

The six semi-urban villages were larger than the six rural villages (10368 vs. 6597 inhabitants) and almost half the total population was under 16.

CONCLUSIONS

Accurate census data are important in the design, implementation and interpretation of community studies and intervention trials. We outline the methods by which census data can be collected in rural and semi-urban sub-Saharan African villages, and emphasize the importance of painstaking, thorough work in the collection of such data.

Acute and chronic rejection

The major histocompatibility complex molecules are the primary antigens responsible for causing graft rejection, and T-cell recognition of alloantigens is the cardinal event initiating cellular rejection. Current concepts suggest that direct allorecognition mediates acute rejection, whereas indirect allorecognition mediates chronic rejection. In biopsy tissue of rejecting human renal allografts, several cytotoxic T-lymphocyte molecules are upregulated. The net result of cytokine release and the acquisition of cell surface receptors is the emergence of antigen-specific and graft-destructive T cells. Acute rejection is more frequent in children than in adults. By the end of the first year posttransplantation, 45% of living donor recipients and 60% of cadaver donor recipients will have an episode of rejection. In recent years, with improved immunosuppressive therapy, the incidence of acute rejection is decreasing at a rate of about 8% each year, however, chronic rejection graft loss has increased to 41% of all graft losses in the last 2 years. The mechanisms leading to chronic rejection and attempts to reduce acute rejections should provide a better half-life to children postrenal transplantation.

The 12th Annual Report of the North American Pediatric Renal Transplant Cooperative Study: renal transplantation from 1987 through 1998

The North American Pediatric Renal Transplant Cooperative Study (NAPRTCS) presents an annual report for all transplants registered from January 1987 onwards. In this report we reviewed 6,534 renal transplants recorded for 5,958 patients who had entered the study by January 1999, and attempted to identify changes in practice patterns that had led to improved graft survival. There has been a steady decline in cadaver source transplants nationally and our accrual for 1996 and 1997 reflected this trend. There has also been a decrease in the number of infants and young children receiving a transplant in recent years. From a peak of 23.3% in the 1987-91 cohort, the current report shows that children under 6 yr of age now account for only 20.4% of all transplants. Changing disease patterns and rates of progression of disease have decreased the percentage of Caucasian children in the transplant registry, from 68.5% in the first 5 yr to 62.9% in the most recent cohort. Changing practice patterns have markedly reduced the use of cadaver donor (CD) kidneys (recovered from donors younger than 10 yr of age) from 35% in 1991 to 22% in the current report. Acute rejection patterns are identical for CD and living donor (LD) grafts for the first 2 weeks post-transplant. The comparative percentages on days 30 and 45 are 36% and 44% for CD, and 26% and 32% for LD recipients respectively. By the end of the first year post-transplant, 45% of LD and 60% CD recipients have had an acute rejection. There has been a marked improvement in our ability to reverse the initial episode of rejection; in 1987, 52% were completely reversed in LD recipients, and in 1997 61% were reversed. Rejection percentages continued to be lower in patients maintained on cyclosporin A (CsA) doses of > 6.4 mg/kg. One-, 3-, and 5-yr graft survival probabilities were 91%, 85%, and 80%, respectively, for LD recipients, and 83%, 73%, and 65% for CD recipients. Comparative 1- and 3-yr figures from 1987 to 1991 were 88% and 81% for LD and 74% and 63% for CD recipients. When short-term graft survival (1 yr) results were compared, a significant improvement was demonstrated from 71.7% in 1987/88 to 92.6% in 1998/1999 for CD transplants. Hence, changing practice patterns have gradually brought the short-term graft survival of CD transplants very close to that of LD transplants. The continuing decrease in the incidence of acute rejections in more recent years should translate into a further delay in the onset of chronic rejection, thus improving graft longevity.

SPET of a computerised model of diffuse lung disease

Emphysema is a common and debilitating disease that is the commonest cause of end-stage respiratory failure. Treatment is either by lung transplantation or by lung volume reduction surgery (LVRS) that improves the biomechanics of respiration. Patient selection for LVRS hinges on the demonstration of heterogeneous disease, predominantly involving the upper lobes, as a good surgical outcome is most likely in these patients. We used a virtual model of lung scintigraphy to compare planar with tomographic scintigraphy for the detection of diffuse lung disease. Lesions of the magnitude of the lung acinus, as well as larger and smaller lesions, were distributed throughout the lungs in volumes from 2% to 50%. Single-photon emission tomography does not add incremental value to planar images for the detection of diffuse lung disease.

Continuing improvement in cadaver donor graft survival in North American children: the 1998 annual report of the North American Pediatric Renal Transplant Cooperative Study (NAPRTCS)

This report of the North American Pediatric Renal Transplant Cooperative Study (NAPRTCS) covers the years 1987-1997, and analyses data on 3,133 cadaver donor (CD) transplants performed in 2,736 patients. There has been a steady decline in the number of CD transplants in children since 1996. Kidneys recovered from donors under 10 years of age accounted for 35% of all transplants in 1987, whereas by 1996 they comprised less than 20%. Caucasian children received 54% of CD transplants, whereas African-American children received 21%. Children under 6 years of age received 17% of CD transplants. Approximately half (46%) of the patients were induced with a T-cell antibody, and at 7 years post-transplant triple therapy is used in 70% of those with a functioning graft. Cyclosporin A is the primary immunosuppressant, with 92% of the patients being maintained on it at 5 years post-transplant. Among patients receiving a transplant in 1997, 11% were initiated with another calcineurin inhibitor, tacrolimus. At 15 days post-transplant 20% of the patients have had a rejection episode and by day 45, 46% have had an acute rejection. The probability of developing a rejection within the first year was reduced from 71% in 1987-1988 to 47% in 1995-1996.

A decade of living donor transplantation in North American children: the 1998 annual report of the North American Pediatric Renal Transplant Cooperative Study (NAPRTCS)

This report of the North American Pediatric Renal Transplant Cooperative Study (NAPRTCS) covers the years 1987-1997, and analyzes data on 2,904 living donor (LD) transplants performed in 2,779 patients. Since 1991, approximately 300 LD transplants have been performed each year at the participating centers of the NAPRTCS. Caucasian children account for 72% of all LD recipients while African-American children constitute only 11%. There has been a gradual decline in the number of transplants performed in children under the age of 6 years from a peak of 30% in 1987, to 21% in 1997. Preoperative calcineurin inhibitor therapy has dropped from 71% in 1987 to 38% in 1997. Through 1996, at six months post-transplant 97% of recipients were receiving prednisone, 88% were maintained on cyclosporin A, and 79% were receiving azathioprine. Of patients transplanted in 1997, 47% are maintained on mycophenolate and 10% are maintained on tacrolimus. By day 15, 20% of index transplant patients have had an acute rejection and by the end of the first year 47% have had a rejection episode. Among patients transplanted in 1995-1996, 40% had a rejection in the first year. Nine per cent of rejection episodes are irreversible in children under 2 years of age and 5% of the episodes are irreversible in 25-year-old children. Estimated graft survival probability at 1 year is 91%, at 3 years it is 84% and at 5 years it is 78.5%. Rejection accounts for 33% of graft loss and recurrence constitutes another 10%. Influential prognostic variables for graft survival are race (African-American vs. others, relative risk (RR) = 2.0, p < 0.001), > 5 random transfusions (RR = 1.6, p < 0.001, T cell induction therapy (RR = 0.78, p = 0.01), and later year of entry (1989-1990 vs. 1994-1995, RR = 0.95, p = 0.04). Patient survival at 1 and 3 years was 97% and 96.5%, respectively, however, the 3-year patient survival of children under 2 years was 89%. The mean height deficit baseline (n=2,677) was -1.86, at 1 year post-transplant (n=1,459) it was -1.80, and at 5 years post-transplant (n=592) it was -2,06. This report, devoted specifically to LD pediatric transplants, raises the issues regarding the use of immunosuppression such as preoperative calcineurin inhibitors and T-cell antibodies. Studies to address the high incidence of chronic rejection and recurrence of original disease are necessary. Additional areas of concern are the high infant mortality and continued growth retardation post-transplantation.

Pediatric renal transplantation--the NAPRTCS experience

The NAPRTCS has enrolled 4,329 children who have received an index renal transplant since 1987. Seventy-three percent of the transplant recipients were children above 6 years of age. In the age group below 6 years rejection episodes are not more frequent, however the first acute rejection episode is frequently irreversible leading to graft failure. Many of the renal disorders that lead to ESRD and transplantation in adults, such as diabetes and hypertension, are less often observed in the pediatric population. Developmental disorders, such as renal dysplasia and obstructive uropathy, are frequent diagnostic entities, and the most common glomerular disorder leading to transplantation in children is focal segmental glomerulosclerosis. In an attempt to overcome dialysis-associated growth retardation many pediatric renal centers resort to preemptive transplantation, thus 24% of the children receiving a transplant have never undergone dialysis. Graft survival in these children is similar to that observed in children receiving maintenance dialysis, however accelerated growth is not noted. Catch-up growth, defined as gain of 1 SDS, is observed in 47% of children below the age of 6 years and in only 22% of children over the age of 6 years. Infants (below 2 years) have a higher mortality rate following transplantation compared to older children. Long-term (5-year) graft survival for children receiving a cadaver donor graft is 60%, and for living donor kidney recipients the graft survival is 76%. Due to changes in practice patterns, such as a judicious use of cadaver donors, increased use of prophylactic T-cell antibody, and better maintenance immunosuppression, cadaver donor graft survival has improved each year since 1987. The cohorts of children with a cadaver donor transplant in the years 1991 and 1992 have a 2-year graft survival which is 10% better than that observed in the earlier years.

Steady improvement in short-term graft survival of pediatric renal transplants: the NAPRTCS experience

This report of pediatric renal transplantation covers the years 1987-1998. Since its inception in 1987, the NAPRTCS has collected data on 6,038 transplants performed in 5,516 patients provided by 73 renal centers across the country. FSGS, together with developmental lesions of dysplasia and obstructive uropathy, account for 40% of all transplants. There has been a steady increase in the use of LD donors among children with 54% of all transplants in 1996 and 1997 being live-related. About 72% of LD transplants are performed in Caucasian children, with African-American children unfortunately receiving a disproportionate percentage of CD kidneys. There has been a steady decline in the use of CD kidneys recovered from young individuals and a gradual decline in the number of transplants performed in young recipients (< 6 years old). Graft survival for LD recipients was 91%, 84% and 79% at one, 3 and 5 years, respectively, and the comparative figures for CD recipients were 81%, 72% and 64%, respectively. Acute and chronic rejections account for most of the graft losses, with chronic rejection accounting for more than 30%. There has been a steady improvement in one-year graft survival of CD recipients with the 1997-1998 cohort exhibiting an improvement of 16% over the 1987-1988 cohort. This improvement has been brought about by eliminating the use of infant donor kidneys, reducing the number of random transfusions and increasing the maintenance dose of cyclosporine. Posttransplant growth continues to be poor, with catch-up growth being exhibited only in children under age 6.