The prognostic power of inflammatory indices and clinical factors in metastatic castration-resistant prostate cancer patients treated with radium-223 (BIO-Ra study)

Purpose

To combine peripheral blood indices and clinical factors in a prognostic score for metastatic castration-resistant prostate cancer (mCRPC) patients treated with radium-223 dichloride ([²²³Ra]RaCl₂).

Patients and methods

Baseline neutrophil-to-lymphocyte ratio (NLR), derived NLR (donor), lymphocyte-to-monocyte ratio (LMR), platelet-to-lymphocyte ratio (PLR), systemic inflammation index (SII), Eastern Cooperative Oncology Group performance status (ECOG PS), Gleason score (GS) group, number of bone metastases, prostate-specific antigen (PSA), alkaline phosphatase (ALP), line of therapy, previous chemotherapy, and the presence of lymphadenopathies were collected from seven Italian centers between 2013 and 2020. Lab and clinical data were assessed in correlation with the overall survival (OS). Inflammatory indices were then included separately in the multivariable analyses with the prognostic clinical factors. The model with the highest discriminative ability (c-index) was chosen to develop the BIO-Ra score.

Results

Five hundred and nineteen mCRPC patients (median OS: 19.9 months) were enrolled. Higher NLR, dNLR, PLR, and SII and lower LMR predicted worse OS (all with a p < 0.001). The multivariable model including NLR, ECOG PS, number of bone metastases, ALP, and PSA (c-index: 0.724) was chosen to develop the BIO-Ra score. Using the Schneeweiss scoring system, the BIO-Ra score identified three prognostic groups (36%, 27.3%, and 36.6% patients, respectively) with distinct median OS (31, 26.6, and 9.6 months, respectively; hazard ratio: 1.62, p = 0.008 for group 2 vs. 1 and 5.77, p < 0.001 for group 3 vs. 1).

Conclusions

The BIO-Ra score represents an easy and widely applicable tool for the prognostic stratification of mCRPC patients treated with [²²³Ra]RaCl₂ with no additional costs.

Supplementary Information

The online version contains supplementary material available at 10.1007/s00259-021-05550-6.

Prognostic role of inflammatory biomarkers from peripheral blood and clinical factors in metastatic castration-resistant prostate cancer (mCRPC) patients (pts) treated with radium-223 (Ra-223) (BIO-Ra-223 study)

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Background: Ra-223 is a treatment option for mCRPC pts with bone metastases according to the survival benefit observed compared to placebo in the ALSYMPCA trial. In the last years, many studies showed this benefit in the real-life pts is lower than that reported in the trial, probably due to a suboptimal selection of pts with poor prognostic characteristics. Therefore, the identification of prognostic factors to select mCRPC pts most likely to benefit from Ra-223 is needed. The multicentre retrospective BIO-Ra-223 study has investigated the prognostic role of peripheral blood immune cells and clinical factors to develop a novel prognostic score for mCRPC pts treated with Ra-223. Methods: Complete blood count was assessed before Ra-223 treatment calculating neutrophil-to-lymphocyte ratio (NLR), derived NLR (dNLR), lymphocyte-to-monocyte ratio (LMR), platelet-to-lymphocyte ratio (PLR), systemic inflammation index (SII). Clinical factors included pre-treatment Eastern Cooperative Oncology Group performance status (ECOG PS), Gleason Score (GS) group, number of bone metastases, alkaline phosphatase (ALP), line of therapy, previous chemotherapy and the presence of lymphadenopathies. Statistical analyses included survival ROC curves for biomarkers’ cutoffs, univariable and multivariable Cox analyses, internal validation, c-index calculation and Schneeweiss scoring system. Results: From September 2013 to July 2020, 519 mCRPC pts received Ra-223 as 1st-2nd, 3rd-4th and further-line in 48%, 38% and 14% of pts. The median overall survival (mOS) of the entire cohort was 19.9 months. All biomarkers and clinical factors (except for GS group) significantly predicted OS at the univariable analyses. In the multivariable ones, all biomarkers, ECOG PS, number of bone metastases and ALP significantly correlated with OS. The multivariable model with NLR (< 3.1 vs ≥3.1), ECOG PS (0-1 vs 2-3), number of bone metastases (< 6, 6-20, > 20) and ALP (< 220 vs ≥220) showed the highest c-index (0.711), which was maintained after internal validation (bootstrap re-sampling) (c-index: 0.707). Using the Schneeweiss scoring system, ten categories were identified in 494 pts with complete data and merged in two prognostic groups with distinctive OSs: group 1 (score 0-4, 337 pts) with a mOS of 27.8 months and group 2 (score 5-10, 157 pts) with a mOS of 9.7 months (HR 4.03, p < 0.001). Conclusions: The obtained score, composed of NLR, ECOG PS, number of bone metastases, and ALP identifies two distinctive prognostic groups of mCRPC pts. Moreover, this score is easily and widely applicable for clinical practice and trials at no additional costs. Although external validation is needed, these preliminary results showed that this novel prognostic score is promising and could help the patients’ selection for Ra-223 treatment.

Sequencing Life-Prolonging Agents in Castration-Resistant Prostate Cancer Patients: Comparison of Sequences With and Without 223Ra

Background: The retrospective studies that have so far described the outcomes of the sequential use of life-prolonging agents (LPAs) did not include metastatic castration-resistant prostate cancer (mCRPC) patients who received radium-223 (²²³Ra) as part of their treatment. Consequently, it is not known whether including ²²³Ra in the therapeutic sequence has an impact on cumulative survival. The aim of this study was to evaluate this impact by comparing the cumulative overall survival (OS) in two series of mCRPC patients sequentially treated with two or three LPAs after first-line docetaxel (DOC), including ²²³Ra and not. Materials and Methods: The authors retrospectively reviewed the records of mCRPC patients with bone involvement alone who received two or three LPAs (including ²²³Ra) after first-line DOC. The control group was a contemporary series of mCRPC patients with bone involvement alone treated with sequences of two or three LPAs other than ²²³Ra after first-line DOC. Results: Median cumulative OS was 40.6 months in the ²²³Ra group of 78 patients and 36.2 months in the non-²²³Ra group of 186 patients (p = 0.08). OS outcomes were significantly influenced by the number of treatment lines, and baseline Eastern Cooperative Oncology Group performance status (PS) and prostate-specific antigen levels. Conclusions: To the best of the authors' knowledge, this is the first study designed to evaluate the impact of introducing ²²³Ra in the treatment sequences for mCRPC patients, and the results show that its use does not negatively affect cumulative OS.

Sequencing radium 223 and other life-prolonging agents in castration-resistant prostate cancer patients

Background: Radium 223 (RA223) is currently administered as part of a therapeutic sequence with the other life-prolonging agents (LPAs) for metastatic castration-resistant prostate cancer (mCRPC). Patients & methods: We retrospectively reviewed the clinical records of patients who had received at least three LPAs including RA223. Results: Median overall survival (OS) from the start of first-line treatment was 39.8 months, with the patients who completed all six planned courses of RA223 having a longer OS than those who did not (53.2 vs 29.5 months; p < 0.0001). Conclusions: Our study confirms the activity of RA223 regardless of the treatment line in which it is administered and suggests that patient selection plays a central role in maximizing this activity.

Therapeutic effect of RA223 in the management of breast cancer bone metastases

Radium 223 dichloride (Ra223) is the only targeted alpha therapy able to extend survival in patients with bone metastases from prostate cancer. Mechanism of action and data currently available focused mainly on osteoblastic metastases from prostate cancer. Phase 1 and 2 trials documented a clinical efficacy also in breast cancer patients with predominately bone disease, highlighting a reduction in alkaline phosphatase and other bone biomarkers. In our institution, a patient with breast cancer affected by osteolytic metastases was treated with off-label use of Ra223. Our patient had a good treatment compliance and up to now she has not been revealed the presence of SSE or hematological complications. Our preliminary experience shows that Ra223 may play a critical role to bone metastates in patients with breast cancer.

Can radium 223 be a conservative non-surgical management of medication-related osteonecrosis of the jaw?

Osteonecrosis of the jaw (ONJ) is a rare and severe necrotic bone disease reflecting a compromise in the body's osseous healing mechanisms and unique to the craniofacial region. Radium 223 dichloride (Ra223) is the only targeted alpha therapy able to extend survival in patients with bone metastases from prostate cancer. Mechanism of action and data currently available focused mainly on osteoblastic metastases from prostate cancer. In 2018, a Caucasian 54-year-old woman presented to our institution for a breast cancer with bone metastases. Since the patient refused any treatment and taking into account the bone disease, our multidisciplinary team evaluated a supplementary strategy with radium 223. A total of six treatments were planned with a dose of 50 KBq/kg every 4 weeks according to Phase 2 data. Four days after the second cycle administration, the patient presented for examination with a self-extracted necrotic bone fragment. Oroantral communication remained in the absence of algic symptomatology or suppuration. The multidisciplinary approach between oncologists, nuclear physicians, and dental health teams is crucial throughout the treatment process to avoid unnecessary suffering in patients at risk. More prospective studies are needed; however, considering the limitation of the present case, radio 223 may play an adjuvant role in the medical treatment of cancer patients with active ONJ.

Cause of radium 223 treatment discontinuation in elderly mCRPC patients

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Background: Prostate cancer is the most common cancer among adult men. Bones are the main metastatic site of prostate cancer. Radium-223 is indicated to treat metastatic castrate-resistant prostate cancer ( mCRPC) with symptomatic skeletal metastases. We evaluate the tolerability of Ra223 treatment in real life setting. Methods: We reported the cases of 38 consecutive non-selected patients with mCRPC symptomatic bone metastases treated in two Italian hospital cancer center from August 2016 to October 2017. The cause of Ra 223 treatment discontinuation in elderly prostate cancer patients were evaluated. Results: due bones metastases, 38 patients were treated with Radium-223; 20 were ≥75 years old (range 75-85 yrs). Patients characteristics and main toxicity are reported (Table). Regarding the elderly patients, hematologic toxicity were the most common adverse events reported. Anemia G2-G3 was observed in 10 pts (50%), thrombocytopoenia G3 in 2 patients (10%) and neutropenia G3 in 4 patients (20%); 12/20 patients interrupted the treatment, of which 10 were ECOG PS2. The number of patients who discontinued the drug because of hematologic adverse events was higher than ALSYMPCA clinical trial. Fatigue G1-G2 incidence was 32%. Unexpectedly we did not record any cases of gastrointestinal toxicity (diarrhea, nausea or constipation). Conclusions: In patients ≥75 years old, anemia G2-G3 was more frequent than data reported in literature, while diarrhea is not found. The data of this experience suggest that elderly vulnerable patients are more exposed to hematologic toxicity that may compromise the outcome of the treatment. For these patients surveillance for early supportive care is relevant. Characteristics of patients with ≥75y. [Table: see text]

The Clinical Efficacy of Radium-223 for Bone Metastasis in Patients with Castration-Resistant Prostate Cancer: An Italian Clinical Experience

BACKGROUND/AIM

Prostate cancer frequently causes bone metastases and skeletal events that impair quality of life (QoL) and survival. The alpha emitter radium-223 is a new drug that improves treatment in men with castration-resistant prostate cancer (CRPC) and bone metastases. Our aim was to evaluate the effectiveness of radium-223.

SUBJECTS AND METHODS

In this retrospective study we enrolled 48 subjects. Pain reduction, alkaline phosphatase (ALP), time to first symptomatic skeletal event, and QoL were the variables we evaluated.

RESULTS

Radium-223 was well tolerated, with a manageable toxicity profile and a modest objective response rate. A considerable difference in serum ALP levels before and after treatment was observed, with a significant correlation between pain relief and QoL, which showed a value of R2 to 0.44 with a slope of 1.50 (p = 0.0021).

CONCLUSIONS

Radium-223 showed a clinical benefit, with a reduction in pain symptoms in 58% of patients. Radium-223 was shown to be an effective and well-tolerated therapeutic option in patients with metastatic CRPC progressing after docetaxel plus prednisone treatment.

The intraoperative use of the mini-gamma camera (MGC) in the surgical treatment of primary hyperparathyroidism: Technical reports and immediate results from the initial experience

INTRODUCTION

The treatment of primary hyperparathyroidism consists almost exclusively in the parathyroidectomy. The preoperative imaging (ultrasonography, 99mTc sestamibi scan) can allow to localize the pathologic gland and perform minimally-invasive focused techniques, but in presence of ectopic or intrathyroidal glands, parathyroid hyperplasia or coexistent thyroid disease, the sensitivity of these imaging techniques worsens. The present study shows a new technique of preoperative scintigraphic imaging and describes the early applications of this technique investigating if it is useful in improving the localization of the pathologic parathyroid.

METHODS

Five female patients were enrolled in the study. In all cases, we performed a parathyroidectomy using a systematic recognition of the four parathyroid glands under intraoperative PTH monitoring, adding the use of the intraoperative gamma camera to usual surgical procedures. We evaluate the concordance of the results of the intraoperative gamma camera with the preoperative diagnosis, the intraoperative PTH monitoring and the intraoperative findings. Moreover, the results of the treatment one month after the surgical procedure were also considered.

RESULTS

The results of intraoperative scintigraphy were always concordant with intraoperative findings. The intraoperative PTH monitoring and the results of the follow-up confirmed the completeness of the excision, at least in a short period of observation.

CONCLUSIONS

The intraoperative gamma camera could help to improve the localization of a pathologic parathyroid gland. These results could be useful in improving the results of minimally invasive surgery as well as "difficult" situations.

EPILAB: a software package for studies on the prediction of epileptic seizures

A Matlab®-based software package, EPILAB, was developed for supporting researchers in performing studies on the prediction of epileptic seizures. It provides an intuitive and convenient graphical user interface. Fundamental concepts that are crucial for epileptic seizure prediction studies were implemented. This includes, for example, the development and statistical validation of prediction methodologies in long-term continuous recordings. Seizure prediction is usually based on electroencephalography (EEG) and electrocardiography (ECG) signals. EPILAB is able to process both EEG and ECG data stored in different formats. More than 35 time and frequency domain measures (features) can be extracted based on univariate and multivariate data analysis. These features can be post-processed and used for prediction purposes. The predictions may be conducted based on optimized thresholds or by applying classifications methods such as artificial neural networks, cellular neuronal networks, and support vector machines. EPILAB proved to be an efficient tool for seizure prediction, and aims to be a way to communicate, evaluate, and compare results and data among the seizure prediction community.

A computational environment for long-term multi-feature and multi-algorithm seizure prediction

The daily life of epilepsy patients is constrained by the possibility of occurrence of seizures. Until now, seizures cannot be predicted with sufficient sensitivity and specificity. Most of the seizure prediction studies have been focused on a small number of patients, and frequently assuming unrealistic hypothesis. This paper adopts the view that for an appropriate development of reliable predictors one should consider long-term recordings and several features and algorithms integrated in one software tool. A computational environment, based on Matlab (®), is presented, aiming to be an innovative tool for seizure prediction. It results from the need of a powerful and flexible tool for long-term EEG/ECG analysis by multiple features and algorithms. After being extracted, features can be subjected to several reduction and selection methods, and then used for prediction. The predictions can be conducted based on optimized thresholds or by applying computational intelligence methods. One important aspect is the integrated evaluation of the seizure prediction characteristic of the developed predictors.

Botulinum toxin in preparation of oral cavity for microsurgical reconstruction

CONCLUSIONS

Infiltration of botulinum toxin in the major salivary glands allows a temporary reduction of salivation that begins 8 days afterwards and returns to normal within 2 months. The inhibition of salivary secretion, carried out before the oral cavity reconstructive surgery, could allow a reduction of the incidence of oro-cutaneous fistulas and local complications.

OBJECTIVES

Saliva stagnation is a risk factor for patients who have to undergo reconstructive microsurgery of the oral cavity, because of fistula formation and local complications in the oral cavity. The authors suggest infiltration of botulinum toxin in the major salivary glands to reduce salivation temporarily during the healing stage.

PATIENTS AND METHODS

During the preoperative stage, 20 patients with oral cavity carcinoma who were candidates for microsurgical reconstruction underwent sialoscintigraphy and a quantitative measurement of the salivary secretion. Injection of botulinum toxin was carried out in the salivary glands 4 days before surgery. The saliva quantitative measurement was repeated 3 and 8 days after infiltration, sialoscintigraphy after 15 days.

RESULTS

In all cases, the saliva quantitative measurement revealed a reduction of 50% and 70% of the salivary secretion after 72 h and 8 days, respectively. A lower rate of local complications was observed.

T-cell repertoire analysis in acute and chronic human Chagas' disease: differential frequencies of Vbeta5 expressing T cells

Here, we analysed the use of Vbeta-TCR regions by CD4+ and CD8+ T cells from acute and chronic chagasic patients using flow cytometry. We determined the Vbeta expression in cells freshly isolated from patients, as well as after in vitro stimulation with antigens derived from epimastigote (EPI) or trypomastigote (TRYPO) forms of Trypanosoma cruzi. Analysis of Vbeta-TCR expression of T cells freshly isolated from patients showed a decrease in Vbeta5 expression in the CD4+ T-cell population from acutely infected individuals, whereas CD4+Vbeta5+ T cells were found to be increased in chronic patients with the cardiac, but not indeterminate, clinical form. After culturing peripheral blood mononuclear cells (PBMC) from chronic patients with EPI or TRYPO, we found that both antigenic preparations led to a preferential expansion of CD4+Vbeta5+ T cells. EPI stimulation also led to the expansion of CD8+Vbeta5+ T cells, whereas TRYPO led to the expansion of this cell population only if PBMC were from cardiac and not indeterminate patients. We observed that TRYPO stimulation led to an increase in the frequency of CD4+Vbeta17+ T cells in cultures of PBMC from indeterminate patients, whereas an increase in the frequency of CD8+Vbeta17+ T cells was found upon TRYPO stimulation of PBMC from cardiac patients. Despite this increase in the frequency of Vbeta17+ T-cell populations upon TRYPO stimulation, the same antigenic preparation led to a much higher expansion of Vbeta5+ T cells. These results show a differential expression of Vbeta5-TCR in cells freshly isolated from chagasic patients in different stages of the disease and that parasite-specific antigens stimulate a portion of the T-cell repertoire with preferential usage of Vbeta5-TCR.

[Treatment of hemangioma of the glans penis using Nd:Yag laser. Apropos of a case]

Hemangioma of urinary tract are unusual, being about 2% of all hemangiomas. We present a case of a glans penis hemangioma. There is controversy concerning their treatment and outcome. Our patient was treated with a Neodymium: Yag laser irradiation, with complete morphological recuperation.

Participation of the sternocleidomastoid muscle on deep inspiration in man. An electromyographic study

The sternocleidomastoid muscle (SCM), which is responsible for the mechanical action in the majority of the head movements, is also considered an accessory muscle for respiration. Its action in the inspiratory movements was studied electromyographically in 30 healthy young adults by considering the types of respiration, the different forms of deep inspiration, the breathing effort and the body position of these subjects. A prominent activity was found in those subjects whose respiration was of the costal type when they breathed rapidly and roughly and during the breathing effort. An outstanding difference of the action potentials of the SCM muscle was not observed during variation of the body positions.