Extreme hypofractionated stereotactic radiotherapy for localized prostate Cancer: Efficacy and late urinary toxicity according to transurethral resection of the prostate history

Background and purpose

Extreme hypofractionated stereotactic body radiotherapy (SBRT) is a therapeutic alternative for localized low- or intermediate-risk prostate cancer. Despite the availability of several studies, the toxicity profile of SBRT has not been comprehensively described. This real-world evidence study assessed the efficacy and toxicities associated with this regimen, and potential prognosis factors for genitourinary toxicities.

Materials and methods

This retrospective study included 141 consecutive patients with localized prostatic adenocarcinoma treated with CyberKnife™ SBRT, as primary irradiation, at the Oscar Lambret Center between 2010 and 2020. The prescribed dose was 36.25 Gy in 5 fractions. Acute and late toxicities were graded according to the CTCAE (version 5.0). Biochemical recurrence-free survival (bRFS) and overall survival (OS) were estimated using the Kaplan-Meier method. The cumulative incidence of biochemical recurrence (cBR) was estimated using the Kalbfleisch-Prentice method.

Results

Among the included patients, 13.5 % had a history of transurethral resection of the prostate (TURP). The median follow-up was 48 months. At 5 years, bRFS, cBR, and OS were 72 % (95 %CI: 61-81), 7 % (95 %CI: 3-14), and 82 % (95 %CI: 73-89), respectively. Twenty-nine patients experienced at least one late toxicity of grade ≥ 2; genitourinary (N = 29), including 3 cases of chronic hematuria, and/or gastrointestinal (N = 1). The cumulative incidence of late urinary toxicity of grade ≥ 2 was 20.6 % at 5 years (95 %CI: 13.9-28.1). Multivariate analysis revealed that a history of TURP was significantly associated with late urinary toxicity of grade ≥ 2, after adjusting for clinical target volume (Odds Ratio = 3.06; 95%CI: 1.05-8.86; P = 0.04).

Conclusion

Extreme hypofractionated SBRT is effective for localized prostate cancer with a low risk of late toxicity. A history of TURP is associated with a higher risk of late urinary toxicity. These findings may contribute to the optimal management of patients treated with this regimen, particularly those with a history of TURP.

Interstitial needles versus intracavitary applicators only for locally advanced cervical cancer: results from real-life dosimetric comparisons

Background and purpose

Image-guided adapted brachytherapy (IGABT) is superior to other radiotherapy techniques in the treatment of locally advanced cervical cancer (LACC). We aimed to investigate the benefit of interstitial needles (IN) for a combined intracavitary/interstitial (IC/IS) approach using IGABT over the intracavitary approach (IC) alone in patients with LACC after concomitant external beam radiotherapy (EBRT) and chemotherapy.

Materials and methods

We included consecutive patients with LACC who were treated with IC/IS IGABT after radiochemotherapy (RCT) in our retrospective, observational study. Dosimetric gain and sparing of organs at risk (OAR) were investigated by comparing the IC/IS IGABT plan with a simulated plan without needle use (IC IGABT plan) and the impact of other clinical factors on the benefit of IC/IS IGABT.

Results

Ninety-nine patients were analyzed, with a mean EBRT dose of 45.5 ± 1.7 Gy; 97 patients received concurrent chemotherapy. A significant increase in median D90% High Risk Clinical target volume (HR-CTV) was found for IC/IS (82.8 Gy) vs IC (76.2 Gy) (p < 10-4). A significant decrease of the delivered dose for all OAR was found for IC/IS vs IC for median D2cc to the bladder (77.2 Gy), rectum (68 Gy), sigmoid (53.2 Gy), and small bowel (47 Gy) (all p < 10-4).

Conclusion

HR-CTV coverage was higher with IC/IS IGABT than with IC IGABT, with lower doses to the OAR in patients managed for LACC after RCT. Interstitial brachytherapy in the management of LACC after radiotherapy provides better coverage of the target volumes, this could contribute to better local control and improved survival of patients.

Complete DPYD genotyping combined with dihydropyrimidine dehydrogenase phenotyping to prevent fluoropyrimidine toxicity: A retrospective study

INTRODUCTION

In April 2019, French authorities mandated dihydropyrimidine dehydrogenase (DPD) screening, specifically testing uracilemia, to mitigate the risk of toxicity associated with fluoropyrimidine-based chemotherapy. However, this subject is still of debate as there is no consensus on a standardized DPD deficiency screening test. We conducted a real-life retrospective study with the aim of assessing the impact of DPD screening on the occurrence of severe toxicity and exploring the potential benefits of complete genotyping using next-generation sequencing.

METHODS

All adult patients consecutively treated with 5-fluorouracil (5-FU) or its oral prodrug at six cancer centers between March 2018 and February 2019 were considered for inclusion. Dihydropyrimidine dehydrogenase deficiency screening included gene encoding DPD (DPYD) genotyping using complete genome sequencing and DPD phenotyping (uracilemia or dihydrouracilemia/uracilemia ratio) or both tests. Associations between each DPD screening method and (i) severe (grade ≥3) early toxicity and (ii) fluoropyrimidine dose reduction in the second chemotherapy cycle were evaluated using multivariable logistic regression analysis. Furthermore, we assessed the concordance between DPD genotype and phenotype using Cohen's kappa.

RESULTS

A total of 551 patients were included. Most patients were tested for DPD deficiency (86%) including DPYD genotyping only (6%), DPD phenotyping only (8%), or both (72%). Complete DPD deficiency was not detected in the study population. Severe early toxicity events were observed in 73 patients (13%), with two patients (0.30%) presenting grade 5 toxicity. Despite the numerically higher toxicity rate in untested patients, the occurrence of severe toxicity was not significantly associated with the DPD screening method (p = 0.69). Concordance between the DPD genotype and phenotype was weak (Cohen's kappa of 0.14).

CONCLUSION

Due to insufficient numbers, our study was not able to demonstrate any added value of DPYD genotyping using complete genome sequencing to prevent 5-FU toxicity. The optimal strategy for DPD screening before fluoropyrimidine-based chemotherapy requires further clinical evaluation.

Stereotactic reirradiation in the treatment of head and neck cancers: A retrospective study on the long-term experience of the Oscar Lambret Center

BACKGROUND AND PURPOSE

Stereotactic radiotherapy potentially treats unresectable recurrences of previously irradiated head and neck (H&N) cancer. This study aimed to assess its efficacy and safety and evaluate prognostic factors.

MATERIALS AND METHODS

We conducted a large retrospective series that included 110 patients who had undergone 36-Gy, six-fraction stereotactic reirradiation (CyberKnife®) for recurrent/secondary H&N cancer between 2007 and 2020 at the Oscar Lambret Center. Patient characteristics and toxicities were assessed. Overall survival (OS) and progression-free survival (PFS) were estimated using the Kaplan-Meier method.

RESULTS

Median follow-up time was 106.3 months. The 2-year OS rate was 43.8 % (95 % confidence interval, 95 % CI, 34.3-52.9) and the median survival was 20.8 months (95 % CI, 16.5-26.3). The cumulative 2-year local-recurrence, regional-recurrence, and distant-metastasis rates were 52.2 % (95 % CI, 42.4-61.1 %), 12.8 % (95 % CI, 7.4-19.8 %), and 11 % (95 % CI, 6.0-17.6 %), respectively. 73 patients received concomitant cetuximab, and it was not significantly beneficial (HR = 1.34; 95 % CI, 0.80-2.26; p = 0.26). The cumulative incidences of grade ≥ 2 late toxicity was 42 % (CI95%: 33-51) at 24 months. Two grade 4 bleedings and no treatment-related deaths were reported.

CONCLUSION

In a large retrospective series of SBRT reirradiation for recurrent or second primary H&N cancers, we observed a median OS of 20.8 months, with a cumulative incidence of grade ≥ 2 late toxicity of 42 % at 24 months. Such a treatment is feasible. However, local recurrence rates remain non-negligible, warranting further research. Radiosensitizer use is currently under study. Therefore, establishing a balance between therapeutic modifications and toxicity is essential.

IMRT in the treatment of locally advanced or inoperable NSCLC in the pre-durvalumab era: clinical outcomes and pattern of relapses, experience from the Oscar Lambret Center

Background

Intensity-modulated conformal radiotherapy (IMRT) has become the technique of choice for the treatment of locally advanced or inoperable non-small cell lung cancer (NSCLC). Nevertheless, this technique presents dosimetric uncertainties, particularly in treating moving targets such as pulmonary neoplasms. Moreover, it theoretically increases the risk of isolated nodal failure (INF) due to reduced incidental irradiation.

Objective

The objective of this study was to evaluate the efficacy and safety of IMRT in patients with inoperable NSCLC and to describe the pattern of relapses.

Methods

Patients with locally advanced NSCLC treated with radiotherapy and chemotherapy between 2015 and 2018 at the Oscar Lambret Center were retrospectively included in the study. Overall and progression-free survival were estimated using the Kaplan-Meier method. The cumulative incidence of the different components of relapse was estimated using the Kalbfleisch and Prentice method. Prognostic factors for relapse/death were investigated using the Cox model. A comparison with literature data was performed using a one-sample log-rank test.

Results

Seventy patients were included, and 65 patients (93%) had stage III disease. All the patients received chemotherapy, most frequently with cisplatin and navelbine. The dose received was 66 Gy administered in 33 fractions. The median follow-up and survival were 49.1 and 39.1 months, respectively. A total of 35 deaths and 43 relapses, including 29 with metastatic components, were reported. The overall survival rates at 1 and 2 years were 80.2% (95% confidence interval 68.3%-88.0%) and 67.2% (95% confidence interval 54.2%-77.3%), respectively. Locoregional relapse was observed in 14 patients, including two INF, one of which was located in the lymph node area adjacent to the clinical target volume. Median relapse-free survival was 15.2 months. No variable was statistically associated with the risk of relapse/death in multivariate analysis. Seven patients (10%) experienced grade 3 or higher toxicity.

Conclusion

The use of IMRT for locally advanced or inoperable NSCLC led to favorable long-term clinical outcomes. The rate of locoregional relapse, particularly isolated lymph node failure, was low and comparable with that of the three-dimensional radiotherapy series, as was the rate of early and late toxicities.

A Multicenter Phase 2 Study of Ultrahypofractionated Stereotactic Boost After External Beam Radiotherapy in Intermediate-risk Prostate Carcinoma: A Very Long-term Analysis of the CKNO-PRO Trial

Background

Genitourinary (GU) or gastrointestinal (GI) complications and tumor relapse can occur in the long term after radiotherapy for prostate cancer.

Objective

To assess the late tolerance and relapse-free survival (RFS) in patients undergoing hypofractionated stereotactic boost therapy after external beam radiotherapy (EBRT) for intermediate-risk prostate cancer.

Design setting and participants

Seventy-six patients with intermediate-risk prostate carcinoma between August 2010 and April 2013 were included. The first course delivered a dose of 46 Gy by conventional fractionation; the second course was a boost of 18 Gy (3 × 6 Gy) within 10 d.

Outcome measurements and statistical analysis

GU and GI toxicities were evaluated as the primary outcomes. The secondary outcomes were overall survival and RFS. The cumulative incidence of toxicity was calculated using a competing-risk approach. Overall survival and RFS were estimated using the Kaplan-Meier method.

Results and limitations

The median follow-up period was 88 mo (range, 81-99 mo). Sixty (79%) patients were treated with the CyberKnife and 16 (21%) using a linear accelerator. The cumulative incidences of GU and GI grade ≥2 toxicities at 120 mo were 1.4% (95% confidence interval [CI]: 0.1-6.6%) and 11.0% (95% CI: 5.1-19.4%), respectively. The overall survival and RFS rates at 8 yr were 89.1% (95% CI: 77-95%) and 76.9% (95% CI: 63.1-86.1), respectively.

Conclusions

A very long follow-up showed low GU and GI toxicities after a hypofractionated stereotactic boost after EBRT for intermediate-risk prostate cancer. Dose escalation of the boost delivered by hypofractionated radiation therapy appears safe for use in future trials.

Patient summary

We found low toxicity and good survival rates after a short and high-precision boost after external beam radiotherapy for intermediate-risk prostate cancer, with a long-term follow-up of 88 mo. This long-term treatment is safe and should be considered in future trials.

Long-term follow-up of survivors of a first acute coronary syndrome: Results from the French MONICA registries from 2009 to 2017

AIM

The objectives of the study were to characterize the long-term risk of first recurrence of acute coronary syndrome (ACS) among survivors of an incident ACS, as a function of the STEMI/NSTEMI/UA diagnosis.

METHODS

Men and women (aged 35-74) hospitalized between 2009 and 2016 for an incident ACS in the French MONICA registries and still alive on discharge were followed-up until December 2017. Recurrent events were defined as the first (non-fatal or fatal) ACS occurring after hospital discharge from the incident event.

RESULTS

The study comprised 15,739 incident ACSs with 63,777 patient-years of follow-up. The cumulative probability [95% confidence interval] of recurrent ACS was 6.7% [6.3-7.1%] at 1 year and 18.4% [17.4-19.5%] at 9 years. The cumulative probability of fatal recurrent ACS was 1.4% [1.2-1.5%] at 1 year and 4.3% [3.6-4.9%] at 9 years. The risk of recurrence did not depend on the type of the incident ACS after adjustment for confounding factors. The most frequent forms of recurrence were NSTEMI and UA. The presence of a major complication (OR = 1.59) and an impaired left ventricular ejection fraction (LVEF) (OR > 1.26) increased the risk of recurrence. The annual 1-year recurrence rates decreased from 7.4% in 2009 to 4.0% in 2016 (p < 0.001).

CONCLUSION

The recurrence rate after an incident ACS remained high in France, and the risk of recurrence did not depend on the etiology of the first event. Our results emphasize the importance of targeting patients with a major complication and/or an impaired LVEF who are at a higher risk of recurrence.

Intracranial Solitary Fibrous Tumour Management: A French Multicentre Retrospective Study

BACKGROUND

Intracranial solitary fibrous tumour (iSFT) is an exceptional mesenchymal tumour with high recurrence rates. We aimed to analyse the clinical outcomes of newly diagnosed and recurrent iSFTs.

METHODS

We carried out a French retrospective multicentre (n = 16) study of histologically proven iSFT cases. Univariate and multivariate Cox models were used to estimate the prognosis value of the age, location, size, WHO grade, and surgical extent on overall survival (OS), progression-free survival (PFS), and local recurrence-free survival (LRFS).

RESULTS

Eighty-eight patients were included with a median age of 54.5 years. New iSFT cases were treated with gross tumour resection (GTR) (n = 75) or subtotal resection (STR) (n = 9) and postoperative radiotherapy (PORT) (n = 32, 57%). The median follow-up time was 7 years. The median OS, PFS, and LRFS were 13 years, 7 years, and 7 years, respectively. Forty-two patients experienced recurrence. Extracranial metastasis occurred in 16 patients. Median OS and PFS after the first recurrence were 6 years and 15.4 months, respectively. A higher histological grade was a prognosis factor for PFS (p = 0.04) and LRFS (p = 0.03). GTR influenced LRFS (p = 0.03).

CONCLUSION

GTR provided benefits as a first treatment for iSFTs. However, approximately 40% of patients experienced relapse, which remains a challenging state.

Long-term follow-up of incident acute coronary syndrome: results from the French MONICA registries over the 2009-2017 period

Funding Acknowledgements

Type of funding sources: Public hospital(s). Main funding source(s): Univ. Lille, Inserm, CHU Lille, Institut Pasteur de Lille, Santé Publique France, U1167 - RID-AGE - Facteurs de risque et déterminants moléculaires des maladies liées au vieillissement, Lille, France.

Background

The prognosis of an acute coronary syndrome (ACS) is strongly affected by the clinical, biological, and angiographic features of the event. However, few studies have characterized long-term recurrences of ACS after an incident (first) event.

Aim

The goals of this study were (i) to estimate the long-term (9 years) risk of ACS recurrence, including fatal ACS recurrence, among survivors of a first-ever ACS, according to its diagnosis subtype (STEMI / NSTEMI / Unstable angina (UA)) and (ii) to identify factors associated with these risks.

Methods

We assessed all men and women (aged 35-74) hospitalized between January 2009 and December 2016 for an incident (first-ever) ACS, in the 3 distinct geographical areas covered by the MONICA registries in the north, east and south-west of France, and still alive at discharge (Index event). ACSs were classified as STEMI, NSTEMI and UA. Patients were followed-up until December 2017. Recurrent events were defined as the first non-fatal or fatal ACS occurring after hospital discharge from the index event. Multivariate Cox regression models were used to assess the relationships between recurrent ACS and variables of interest.

Results

A total of 15,739 incident ACSs were included. The study comprised a total of 63,777 patients-years and a median duration of follow-up of 3.8 [1.6-6.0] years. There were 1,963 (12,4%) recurrent ACSs of which almost half (1,046; 53%) occurred during the first year. The 1-, 5- and 9- year cumulative probabilities of recurrent ACS were 6.7% [6.3-7.1%], 13.4% [12.8-14.0%] and 18.4% [17.4-19.5%], respectively, and those of fatal recurrent ACS were 1.4% [1.2-1.5%], 2.7% [2.3-3.0%] and 4.3% [3.6-4.9%], respectively. Annual 1-year recurrence rates decreased between 2009 and 2016, from 7.4% to 4.0% (p Cochran-Armitage test &lt;0.001). After an index STEMI and NSTEMI, the most frequent form of recurrent event was a NSTEMI, whereas UA was more likely event after an index UA. The age at the time of the event, the geographical region (North to South gradient), the presence of a major event (i.e. resuscitated cardiac arrest, acute pulmonary oedema or cardiogenic shock), and an impaired left ventricular ejection fraction (LVEF) were significantly associated with the risk of recurrence and fatal recurrence. ACS subtype was not associated with recurrent risk after adjustment for confounders.

Conclusions

In conclusion, after an incident ACS the recurrence rate remained elevated, with one in five patients experiencing a recurrent ACS during a 9-years follow-up. Half of recurrent events occurred within the first year after the index event and NSTEMI was the most frequent form of recurrent event. Age at the time of the event, region, major event and impaired LVEF are factors associated with a higher risk of recurrence, the most important one being an LVEF &lt;35%.

Natural History of Perianal Fistulising Lesions in Patients With Elderly-onset Crohn's Disease: A Population-based Study

INTRODUCTION

Most studies of elderly-onset Crohn's disease [CD; diagnosed in patients aged 60 or over] have described a mild course. However, data on the natural history of perianal fistulising CD [pfCD] in this population are scarce. In a population-based cohort study, we described the prevalence, natural history, and treatment of pfCD in patients with elderly-onset CD vs patients with paediatric-onset CD.

METHOD

All patients diagnosed with CD at or after the age of 60 between 1988 and 2006, were included [n = 372]. Logistic regression, Cox models, and a nested case-control method were used to identify factors associated with pfCD.

RESULTS

A total of 34 elderly patients [9% of the 372] had pfCD at diagnosis. After a median follow-up of 6 years (interquartile range [IQR]: 3; 10), 59 patients [16%] had pfCD; the same prevalence [16%] was observed in paediatric-onset patients. At last follow-up, anal incontinence was more frequent in elderly patients with pfCD than in elderly patients without pfCD [22% vs 4%, respectively; p < 10-4]. Rectal CD at diagnosis was associated with pfCD: hazard ratio (95% confidence interval [CI] = 2.8 [1.6-5.0]). Although 37% of the patients received immunosuppressants and 17% received anti-tumour necrosis factor agents, 24% [14 out of 59] had a definitive stoma at last follow-up.

CONCLUSION

During the first 6 years of disease, the prevalence of pfCD was similar in elderly and paediatric patients. Rectal involvement was associated with the appearance of pfCD in elderly-onset patients. Around a quarter of patients with elderly-onset CD will have a stoma. Our results suggest that treatment with biologics should be evaluated in these patients.

Revisions of total shoulder arthroplasty: Clinical results and complications of various modalities

INTRODUCTION

The number of primary total shoulder arthroplasties has increased exponentially in recent years, with a corresponding increase in the number of revision procedures.

OBJECTIVE

To assess clinical results and complications in a series of shoulder implant replacement, of whatever etiology.

MATERIALS AND METHODS

Thirty-seven patients, with a mean age of 68.3±11.8 years at time of implant replacement, were included in a retrospective study. Mean interval between primary arthroplasty and revision was 78.4±59.7 months (range, 1-200 months). The main assessment criterion was changed in Constant score between preoperative value and follow-up. Secondary criteria were: onset of intra- and postoperative complications, and reoperation related to a complication.

RESULTS

Mean follow-up was 41.5±32.0 months (range, 12-105 months). Absolute Constant score increased by a mean 17.5±15.1 points (P<0.001) and weighted Constant score by 26.3±23.6 points (P<0.001). Intraoperative complications occurred in 24.3% of patients (9/37) and postoperative complications in 29.7% (11/37). Among the patients, 21.6% (8/37) required reoperation for postoperative complications. Overall, 54% of patients (20/37) suffered from intra- or postoperative complications.

CONCLUSION

Shoulder implant replacement improved function in the present series, but with a high rate of complications and reoperations.

LEVEL OF EVIDENCE

IV, retrospective case-control study without control group.

Evaluation of the Utility of in utero Treatment of Twin Anemia-Polycythemia Sequence

OBJECTIVE

The aim of this study is to evaluate the interest in the in utero treatment of twin anemia-polycythemia sequence (TAPS).

METHODS

The obstetrical and neonatal data on all cases of TAPS followed up in our institution between 2006 and 2013 were reviewed. Statistical analyses were conducted using Bayesian methods.

RESULTS

Twenty cases of TAPS were included. Laser therapy or intrauterine transfusion (IUT) was performed on the donor twin in 9 cases. Eleven cases were included in the 'nontreated' group (managed expectantly or diagnosed at birth). The gestational age at diagnosis was lower in the group with treated TAPS [difference (diff) = -22.20 days (-57.13, 14.28), probability (Pr) (diff >0) = 10.6%]. The rate of preterm premature rupture of membranes was higher in the group with treated TAPS [diff = 22.5% (-14, 57), Pr (diff >0) = 89%], but overall mortality was similar. The interval between diagnosis and delivery was longer [diff = 44.37 days (9.41, 77.90), Pr (diff >0) = 99.2%], the TAPS resolution rate was higher [diff = 49.9% (12, 81), Pr (diff >0) = 99.4%], and the neonatal transfusion rate was lower [diff = -30.5% (-60, 0), Pr (diff >0) = 2.6%] in the treated group.

CONCLUSION

In utero treatment for TAPS is associated with a higher resolution rate of TAPS and a longer time between diagnosis and birth, but overall mortality is the same as with expectant management.