Prostate cancer therapy using immune checkpoint molecules to target recombinant dendritic cells

PURPOSE

We developed immune checkpoint molecules to target recombinant dendritic cells (DCs) and verified their anti-tumor efficacy and immune response against prostate cancer.

MATERIALS AND METHODS

DCs were generated from mononuclear cells in the tibia and femur bone marrow of mice. We knocked down the programmed death ligand 1 (PD-L1) on monocyte-derived DCs through siRNA PD-L1. Cell surface antigens were immune fluorescently stained through flow cytometry to analyze cultured cell phenotypes. Furthermore, we evaluated the efficacy of monocyte-derived DCs and recombinant DCs in a prostate cancer mouse model with subcutaneous TRAMP-C1 cells. Lastly, DC-induced mixed lymphocyte and lymphocyte-only proliferations were compared to determine cultured DCs' function.

RESULTS

Compared to the control group, siRNA PD-L1 therapeutic DC-treated mice exhibited significantly inhibited tumor volume and increased tumor cell apoptosis. Remarkably, this treatment substantially augmented interferon-gamma and interleukin-2 production by stimulating T-cells in an allogeneic mixed lymphocyte reaction. Moreover, we demonstrated that PD-L1 gene silencing improved cell proliferation and cytokine production.

CONCLUSIONS

We developed monocyte-derived DCs transfected with PD-L1 siRNA from mouse bone marrow. Our study highlights that PD-L1 inhibition in DCs increases antigen-specific immune responses, corroborating previous immunotherapy methodology findings regarding castration-resistant prostate cancer.

Oncological Outcomes in Men with Metastatic Castration-Resistant Prostate Cancer Treated with Enzalutamide with versus without Confirmatory Bone Scan

PURPOSE

In men with metastatic castration-resistant prostate cancer (mCRPC), new bone lesions are sometimes not properly categorized through a confirmatory bone scan, and clinical significance of the test itself remains unclear. This study aimed to demonstrate the performance rate of confirmatory bone scans in a real-world setting and their prognostic impact in enzalutamide-treated mCRPC.

MATERIALS AND METHODS

Patients who received oral enzalutamide for mCRPC during 2014-2017 at 14 tertiary centers in Korea were included. Patients lacking imaging assessment data or insufficient drug exposure were excluded. The primary outcome was overall survival (OS). Secondary outcomes included performance rate of confirmatory bone scans in a real-world setting. Kaplan-Meier analysis and multivariate Cox regression analysis were performed.

RESULTS

Overall, 520 patients with mCRPC were enrolled (240 [26.2%] chemotherapy-naïve and 280 [53.2%] after chemotherapy). Among 352 responders, 92 patients (26.1%) showed new bone lesions in their early bone scan. Confirmatory bone scan was performed in 41 patients (44.6%), and it was associated with prolonged OS in the entire population (median, 30.9 vs. 19.7 months; p < 0.001), as well as in the chemotherapy-naïve (median, 47.2 vs. 20.5 months; p=0.011) and post-chemotherapy sub-groups (median, 25.5 vs. 18.0 months; p=0.006). Multivariate Cox regression showed that confirmatory bone scan performance was an independent prognostic factor for OS (hazard ratio 0.35, 95% confidence interval, 0.18 to 0.69; p=0.002).

CONCLUSION

Confirmatory bone scan performance was associated with prolonged OS. Thus, the premature discontinuation of enzalutamide without confirmatory bone scans should be discouraged.

Improved Outcomes with Enzalutamide in Biochemically Recurrent Prostate Cancer

BACKGROUND

Patients with prostate cancer who have high-risk biochemical recurrence have an increased risk of progression. The efficacy and safety of enzalutamide plus androgen-deprivation therapy and enzalutamide monotherapy, as compared with androgen-deprivation therapy alone, are unknown.

METHODS

In this phase 3 trial, we enrolled patients with prostate cancer who had high-risk biochemical recurrence with a prostate-specific antigen doubling time of 9 months or less. Patients were randomly assigned, in a 1:1:1 ratio, to receive enzalutamide (160 mg) daily plus leuprolide every 12 weeks (combination group), placebo plus leuprolide (leuprolide-alone group), or enzalutamide monotherapy (monotherapy group). The primary end point was metastasis-free survival, as assessed by blinded independent central review, in the combination group as compared with the leuprolide-alone group. A key secondary end point was metastasis-free survival in the monotherapy group as compared with the leuprolide-alone group. Other secondary end points were patient-reported outcomes and safety.

RESULTS

A total of 1068 patients underwent randomization: 355 were assigned to the combination group, 358 to the leuprolide-alone group, and 355 to the monotherapy group. The patients were followed for a median of 60.7 months. At 5 years, metastasis-free survival was 87.3% (95% confidence interval [CI], 83.0 to 90.6) in the combination group, 71.4% (95% CI, 65.7 to 76.3) in the leuprolide-alone group, and 80.0% (95% CI, 75.0 to 84.1) in the monotherapy group. With respect to metastasis-free survival, enzalutamide plus leuprolide was superior to leuprolide alone (hazard ratio for metastasis or death, 0.42; 95% CI, 0.30 to 0.61; P<0.001); enzalutamide monotherapy was also superior to leuprolide alone (hazard ratio for metastasis or death, 0.63; 95% CI, 0.46 to 0.87; P = 0.005). No new safety signals were observed, with no substantial between-group differences in quality-of-life measures.

CONCLUSIONS

In patients with prostate cancer with high-risk biochemical recurrence, enzalutamide plus leuprolide was superior to leuprolide alone with respect to metastasis-free survival; enzalutamide monotherapy was also superior to leuprolide alone. The safety profile of enzalutamide was consistent with that shown in previous clinical studies, with no apparent detrimental effect on quality of life. (Funded by Pfizer and Astellas Pharma; EMBARK ClinicalTrials.gov number, NCT02319837.).

The association between serum lipid profile and the prostate cancer risk and aggressiveness

Purpose

This study aims to evaluate the association of serum lipid profile on prostate cancer (PC) risk and aggressiveness.

Methods

Men who underwent prostate biopsy between January 2005 and December 2015 were retrospectively analyzed. The association between lipid profile and the risk, stage, and Gleason grade group (GG) of the PC were investigated. Sensitivity analysis was conducted using univariate and multivariate quantile analysis for lipide profile on the risk and stage of PC.

Results

Of the 1740 study populations, 720 men (41.4%) were diagnosed as PC. From multivariate logistic regression analysis, age, prostate specific antigen, triglyceride (odds ratio (OR):1.05, confidence interval (CI):1.03-1.07, p-value<0.001) significantly increased PC risk, while total cholesterol (OR:0.96, CI:0.92-0.99, p-value=0.011) significantly decreased the PC risk. The increase of serum triglyceride increased the risk of both of locally advanced (OR:1.03, CI:1.00-1.07, p-value=0.025) and metastatic PC (OR:1.14, CI:1.04-1.25, p-value=0.004). The increase of serum triglyceride increased the risk of GG2-3 (OR:1.03, CI:1.00-1.06, p-value=0.027) and GG4-5 (OR:1.04, CI:1.01-1.08, p-value=0.027). Univariate quartile analysis founded serum triglyceride increasing risk of locally advanced disease than organ confined disease. (OR: 1.00, 1.25, 2.04, 4.57 for 1^st, 2^nd, 3^rd and 4^th quartile, p-value<0.001). Adjusted multivariate quartile analysis confirmed statistically significant increasing PC risk of triglyceride (OR: 1.00, 1.25, 2.04, 4.57 for 1^st, 2^nd, 3^rd and 4^th quartile, p-value<0.001).

Conclusions

This study findings suggested increased in triglyceride level increased the risk PC. Increased in triglyceride level also associated with aggressive presentation of PC, with higher stage and GG.

Association of smoking status, duration and amount with the risk of head and neck cancer subtypes: a national population-based study

Smoking is positively associated with multiple cancer types including head and neck cancer (HNC). We sought to confirm the effect of smoking in HNC and subtypes through big data analysis. All data used in this study originated from the Korean National Health Insurance Service database. We analyzed subjects who had undergone health check-ups in 2009 with follow-up until 2018 (n=10,585,852). We collected data on smoking and other variables that could affect the risk of HNC. The overall incidence of HNC was highest in current smokers (HR: 1.822, 95% CI: 1.729-1.920), followed by ex-smokers (HR: 1.242, 95% CI: 1.172-1.317). Laryngeal cancer, hypopharynx cancer, oral cancer, oropharyngeal cancer, and salivary gland cancer showed increasing incidence rates from ex-smokers to current smokers. Smoking duration and amount showed a dose-dependent relationship with the occurrence of HNC. However, the incidence of HNC did not increase significantly when smoking duration was less than 10 years, or when the smoking amount was less than 10 pack-years in ex-smokers. Smoking is associated with the risk of HNC. Smoking cessation before 10 years or 10 pack-years can prevent the development of HNC.

Association of Estimated Glomerular Filtration Rate with Risk of Head and Neck Cancer: A Nationwide Population-Based Study

In this study, through a cohort study of 10 million people, we investigated the association between estimated glomerular filtration rate (eGFR) and head and neck cancer (HNC) incidence. This is an observational cohort study using data from the national health claims database established by the Korean National Health Insurance Service (NHIS). We selected 9,598,085 participants older than 20 years who had undergone health checkups in 2009. A health checkup involves the history of any diseases, current health status, and results of several physical and blood exams including eGFR. We investigated the presence of HNC diagnosis in their national health insurance data from 2010 to 2018. Of the 9,598,085 participants, 10,732 had been newly diagnosed with HNC in the 9-year follow-up. In the multivariate Cox proportional hazard model, participants with elevated eGFR were associated with a risk of HNC incidence (HR = 1.129; 95% CI = 1.075−1.186 for eGFR = 90−104 mL/min/1.73 m2 and HR = 1.129; 95% CI = 1.076−1.194 for eGFR ≥ 105 mL/min/1.73 m2) compared with those with eGFR 60−89 mL/min/1.73 m2. Among HNC, the incidences of oral cavity, oropharyngeal, hypopharyngeal, and laryngeal cancers were significantly increased in the elevated eGFR group. According to the subgroup analysis, participants with eGFR ≥ 60 mL/min/1.73 m2 were correlated with risk of HNC incidence in middle age, non/mild drinker, low BMI, no diabetes, and no hypertension patients compared with those with eGFR < 60 mL/min/1.73 m2. Elevated eGFR was associated with the risk of some type of HNC, even in individuals with adjusted hypertension and diabetes without chronic diseases. The results of this study have implications for etiological investigations and preventive strategies.

Association between gamma-glutamyltransferase and head and neck cancer in Korean population: A national population-based study

BACKGROUND

Gamma-glutamyltransferase (GGT) is positively associated with several cancer types. The objective of this study was to investigate the association between GGT and head and neck cancer (HNC) incidence in a cohort of 10 million people, considering effects of smoking and alcohol consumption.

METHODS

All data used in this study were obtained from the Korean National Health Insurance Service database. We analyzed subjects who underwent health check-ups in 2009 and monitored them until 2018 (n = 9,597,952). Using proportional hazards models, quartiles of GGT as independent predictors for HNC incidence were evaluated.

RESULTS

The overall incidence of HNC increased in the highest quartile (r-GPT ≥ 40 U/L) (hazards ratio [HR]: 1.452, 95% confidence interval [CI]: 1.354-1.557). Among HNC cases, the HR for hypopharyngeal cancer (HR: 2.364, 95% CI: 1.818-3.074) was significantly higher. HRs for HNC (larynx, sino-nasal, oropharynx, oral cavity, and nasopharynx, except salivary glands) were also significant.

CONCLUSIONS

Elevated GGT was associated with the risk of some types of HNCs such as hypopharyngeal, laryngeal, sinonasal, oropharyngeal, oral cavity, and nasopharyngeal cancer.

IMPACT

Results of this study have implications for etiological investigations and preventive strategies.

Sex Differences in the Prevalence of Head and Neck Cancers: A 10-Year Follow-Up Study of 10 Million Healthy People

Background: Descriptive epidemiologists have repeatedly reported that males are more susceptible to head and neck cancers. However, most published data are those of cross-sectional studies, and no population-based cohort study has yet been published. The aim of this study was to compare the prevalence of head and neck cancers in healthy males with females. Methods: A retrospective cohort study using the Korean National Health Insurance Service database on 9,598,085 individuals who underwent regular health checkups from 1 January to 31 December 2009. We sought head and neck cancers developed during the 10-year follow-up. Results: A total of 10,732 (incidence rate (IR) per 1000 person-years 0.25) individuals were newly diagnosed with head and neck cancer among the 9,598,085 individuals during the 10-year follow-up. The IR was 0.19 in males (8500 affected) and 0.06 in females (2232 affected). Notably, the male−female ratio increased with age below 70 years but decreased thereafter. The male−female difference was most apparent for laryngeal cancer; the male IR was 11-fold higher in the 40 s and 20-fold higher in the 60 s, followed by hypopharyngeal cancer (6.8- and 24.2-fold). Males smoked more and drank more alcohol than females (p < 0.0001 *, p < 0.0001 *). When never-smokers/-drinkers (only) were compared, males remained at a 2.9-fold higher risk of head and neck cancer than females. The hazard ratios for head and neck cancers in males tended to increase in the lower part of the upper aerodigestive tract: larynx (13.9) > hypopharynx (10.9) > oropharynx (4.4) > nasopharynx (2.9) > sinonasal region (1.8) > oral (1.6). Only the salivary gland cancer incidence did not differ between the sexes; the gland is not in the upper aerodigestive tract. Conclusion: Males are much more susceptible to head and neck cancers than females regardless of whether they drink alcohol or smoke tobacco. Sex differences in the incidence of head and neck cancer are most evident in the 60 s in the lower part of the upper aerodigestive tract, such as the larynx and hypopharynx.

Efficacy and Safety of Human Bone Marrow-Derived Mesenchymal Stem Cells according to Injection Route and Dose in a Chronic Kidney Disease Rat Model

Background and Objectives

We compared the efficacy and safety of human bone marrow-derived mesenchymal stem cells (hBMSC), delivered at different doses and via different injection routes in an animal model of chronic kidney disease.

Methods and Results

A total of ninety 12-week-old rats underwent 5/6 nephrectomy and randomized among nine groups: sham, renal artery control (RA-C), tail vein control (TV-C), renal artery low dose (RA-LD) (0.5×10⁶ cells), renal artery moderate dose (RA-MD) (1.0×10⁶ cells), renal artery high dose (RA-HD) (2.0×10⁶ cells), tail vein low dose (TV-LD) (0.5×10⁶ cells), tail vein moderate dose (TV-MD) (1.0×10⁶ cells), and tail vein high dose (TV-HD) (2.0×10⁶ cells). Renal function and mortality of rats were evaluated after hBMSC injection. Serum blood urea nitrogen was significantly lower in the TV-HD group at 2 weeks (p<0.01), 16 weeks (p<0.05), and 24 weeks (p<0.01) than in the TV-C group, as determined by one-way ANOVA. Serum creatinine was significantly lower in the TV-HD group at 24 weeks (p<0.05). At 8 weeks, creatinine clearance was significantly higher in the TV-MD and TV-HD groups (p<0.01, p<0.05) than in the TV-C group. In the safety evaluation, we observed no significant difference among the groups.

Conclusions

Our findings confirm the efficacy and safety of high dose (2×10⁶ cells) injection of hBMSC via the tail vein.

miR-96-5p targets PTEN to mediate sunitinib resistance in clear cell renal cell carcinoma

A multiple receptor tyrosine kinase inhibitor, sunitinib, is a first-line therapy for clear cell renal cell carcinoma (CCRCC). Unfortunately, it has the major challenges of low initial response rate and resistance after about one year of treatment. Here we evaluated a microRNA (miRNA) and its target responsible for sunitinib resistance. Using miRNA profiling, we identified miR-96-5p upregulation in tumors from sunitinib-resistant CCRCC patients. By bioinformatic analysis, PTEN was selected as a potential target of miR-96-5p, which showed low levels in tumors from sunitinib-resistant CCRCC patients. Furthermore, PTEN and miR-96-5p levels were negatively correlated in a large The Cancer Genome Atlas kidney renal clear cell carcinoma cohort and high miR-96 and low PTEN represented poor prognosis in this cohort. Additionally, four-week sunitinib treatment increased miR-96-5p and decreased PTEN only in tumors from a sunitinib-resistant patient-derived xenograft model. We found a novel miR-96-5p binding site in the PTEN 3′ UTR and confirmed direct repression by luciferase reporter assay. Furthermore, we demonstrated that repression of PTEN by miR-96-5p increased cell proliferation and migration in sunitinib-treated cell lines. These results highlight the direct suppression of PTEN by miR-96-5p and that high miR-96-5p and low PTEN are partially responsible for sunitinib resistance and poor prognosis in CCRCC.

Comparative oncological outcomes after radical prostatectomy or external beam radiation therapy plus androgen deprivation therapy in men with clinical T3b prostate cancer

OBJECTIVE

To compare oncological outcomes in men with clinical T3b prostate cancer who underwent radical prostatectomy or a combination of radiation therapy plus androgen deprivation therapy.

METHODS

Men with clinical T3b prostate cancer who underwent radical prostatectomy or radiation therapy plus androgen deprivation therapy between 2007 and 2014 were evaluated. All patients were relatively healthy, with Eastern Cooperative Oncology Group performance status of 0 or 1 without nodal or distant metastasis. Cancer-specific survival was analyzed. Age, Charlson Comorbidity Index, biopsy Gleason score and pretreatment prostate-specific antigen were adjusted by propensity score matching. The Cox proportional hazards model was used to assess factors prognostic of cancer-specific survival.

RESULTS

Of the 152 patients with clinical T3b prostate cancer, 45 underwent radical prostatectomy, and 107 underwent radiation therapy plus androgen deprivation therapy between 2007 and 2014. The mean cancer-specific survival was significantly longer in the radical prostatectomy than in the radiation therapy plus androgen deprivation therapy group (P = 0.029). Age, Charlson Comorbidity Index and pretreatment prostate-specific antigen were significantly higher in the radiation therapy plus androgen deprivation therapy group. In the propensity score matched population of 24 patients each, the median cancer-specific survival remained significantly longer in the radical prostatectomy than in the radiation therapy plus androgen deprivation therapy group (not reached vs 112.93 ± 11.94 months, P = 0.026). Multivariate analysis showed that undergoing radiation therapy plus androgen deprivation therapy was the only significant poor prognostic factor for cancer-specific survival (hazard ratio 6.694, 95% confidence interval 1.642-27.592, P = 0.008).

CONCLUSION

Cancer-specific survival was significantly longer in men with clinical T3b prostate cancer who underwent radical prostatectomy than radiation therapy plus androgen deprivation therapy, suggesting that radical prostatectomy can be a better treatment option for the initial definitive treatment for these patients.

Width of spared neurovascular bundle after robot-assisted laparoscopic prostatectomy in patients with prostate cancer: is it a reliable factor for predicting postoperative sexual outcome?

Purpose

To investigate the relationship between the width of spared neurovascular bundle (NVB) measured during robot-assisted laparoscopic prostatectomy and postoperative sexual outcomes.

Methods

Patients with localized prostate cancer with erectile hardness score ≥2 (N = 105) who underwent NVB-sparing robot-assisted laparoscopic prostatectomy were included. Patients were divided into three groups [first (Q1) vs. second and third (Q2-3) vs. fourth (Q4) quartile] according to width of spared NVB measured with a flexible ruler after prostate removal. Preoperative and postoperative sexual function was evaluated according to erectile hardness score and Expanded Prostate Cancer Index Composite questionnaires.

Results

The proportion of patients with postoperative erectile hardness score ≥2 at postoperative 6 months was as follows: 38.9% (Q1), 48.6% (Q2–3), and 83.3% (Q4) (P = 0.016). The preoperative/postoperative 6-month sexual function score was 40.7/16.9 (Q1), 48.1/19.0 (Q2–3), and 51.2/28.1 (Q4). Postoperative sexual function was significantly associated with preoperative sexual function in Q4 (P = 0.006) and Q2–3 (P = 0.030) but not in Q1. On multivariate analysis, the width of spared NVB was a significant predictor for postoperative 6-month erectile hardness score ≥2. Limitation includes selection bias and short follow-up duration.

Conclusions

Not only the performance but also the degree and quality of NVB sparing thought to be important for postoperative sexual function. Measurement of the width of NVB during surgery could be an easy intraoperative method for assessing the quality of NVB sparing.

Impact of positive surgical margin on biochemical recurrence in localized prostate cancer

BACKGROUND

We analyzed the relationship between biochemical recurrence (BCR) and the status of positive surgical margin (PSM) in patients with pT3a prostate cancer (PCa).

MATERIALS AND METHODS

Patients (n = 150) who underwent radical prostatectomy for pT3a PCa without nodal/distant metastasis were retrospectively reviewed between 2010 and 2013. The data regarding the status of PSM including the number, length, and margin Gleason score were collected. The predictors of BCR were analyzed using Cox regression hazard models. BCR-free survival was compared between the patients with negative surgical margin (NSM) and with PSM using Kaplan-Meier curves and log-rank tests.

RESULTS

PSM was noted in 74 patients (49.3%). Seventy-six patients (50.7%) had NSM and 38 patients (25.3%) had single PSM. Twenty patients (13.3%) had two PSMs and 16 patients (10.7%) had ≥3 PSMs. In total patients, the multivariate analysis demonstrated that a pathological Gleason score of ≥8 was significantly associated with BCR [hazard ratio (HR), 2.173; 95% confidence interval (CI), 1.244-3.797; P = 0.038]. In patients with PSM, the number of PSM more than two was significantly associated with BCR (HR, 2.723; 95% CI, 1.256-5.902; P = 0.011). PSM length of ≥3 mm was also a significant predictive factor (HR, 1.024; 95% CI, 0.994-1.055, P = 0.042). Patients with the highest margin Gleason score of ≥4 had poorer BCR-free survival than those with that of 3/no surgical margin.

CONCLUSIONS

Number (more than one), length (≥3 mm), and higher margin Gleason score (≥4) of PSM were significantly associated with an increased likelihood of BCR in patients with pT3a PCa.

Novel platinum bipolar electrode for irreversible electroporation in prostate cancer: preclinical study in the beagle prostate

The exposure of the prostate to high electric field strength during irreversible electroporation (IRE) has been extensively investigated. Multiple monopolar electrodes, however, have risks of organ piercing and bleeding when placing electrodes. A novel bipolar electrode made of pure platinum and stainless steel was developed for prostate cancer ablation. Voltages of 500 and 700 V were applied to the beagle prostate with this electrode to evaluate ablated tissues and their characteristics. IRE procedures were technically successful in all dogs without procedure-related complications. The current that flowed through the anode and cathode while applying 500 and 700 V were 1.75 ± 0.25 A and 2.22 ± 0.35 A, respectively. TUNEL assays showed that the estimated ablated areas when applying 500 and 700 V were 0.78 cm² and 1.21 cm², respectively. The minimum electric field strength threshold required for induction of IRE was 800 V/cm. The platinum electrode was resistant to corrosion. The IRE procedure for beagle prostates using a single bipolar electrode was technically feasible and safe. The novel bipolar electrode has great potential for treating human prostate cancer with fewer IRE-related complications.

The curative effect of androgen deprivation therapy alone is insufficient in high-risk prostate cancer

To compare the outcomes of patients with high-risk prostate cancer treated by primary radical prostatectomy (RP) and primary androgen deprivation therapy (ADT).The study included patients with high-risk or very high-risk prostate cancer. Patients treated with definitive radiation therapy and those with clinical N1 and M1 disease were excluded. The RP group was divided into sub-cohorts of patients treated with ADT and those who received ADT after biochemical recurrence post-RP. Cancer-specific survival (CSS) and overall survival (OS) were analyzed using the Kaplan-Meier method and the Cox proportional hazards model.The study analyzed 859 patients divided into the RP group (n = 654) and ADT group (n = 205). Castration-resistant prostate cancer was detected in 23 (3.5%) patients in the RP group and 43 (21.0%) patients in the ADT group. Mortality cases included 63 (9.6%) patients in the RP group and 91 (44.4%) patients in the ADT group. CSS (P = .0002) and OS (P < .0001) were significantly higher in the RP group than in the ADT group. In the sub-cohort, CSS did not differ significantly between the RP and ADT groups, whereas OS was significantly higher in the RP group than in the ADT group (P < .0001). In the multivariate analysis, primary ADT increased CSS (hazard ratio, 2.068; P = .0498) and OS (hazard ratio, 3.218; P < .0001) compared with RP.In clinically localized high-risk prostate cancer patients, primary RP was associated with better CSS and OS than primary ADT. Comprehensive counseling in this cohort of patients will help the selection of treatment.

Safety of autologous bone marrow-derived mesenchymal stem cells in erectile dysfunction: an open-label phase 1 clinical trial

BACKGROUND AIMS

The efficacy of phosphodiesterase type 5 inhibitors (PDE5Is), which are commonly used to treat erectile dysfunction (ED), is not satisfactory in patients with denervation of the cavernous nerve due to pelvic surgeries and diabetes mellitus (DM). Pre-clinical studies using bone marrow-derived mesenchymal stem cells (BMSCs) to treat ED have shown promising results. The authors conducted a phase 1 clinical trial with autologous BMSCs in patients with ED due to radical prostatectomy or DM.

METHODS

Ten patients (five with post-prostatectomy ED and five with DM-associated ED) who could not perform sexual activity despite taking the maximum dose of a PDE5I were enrolled. The brief clinical trial protocol was registered with the US National Institutes of Health on ClinicalTrials.gov (NCT02344849). The primary outcome was the safety of stem cell therapy, and the secondary outcome was the improvement of erectile function.

RESULTS

Of the 13 patients screened, 10 were registered in the clinical trial and received autologous BMSCs and nine completed the clinical trial. One patient with post-prostatectomy ED experienced two treatment-emergent adverse events (TEAEs) (pyrexia and back pain), and two patients with DM-associated ED experienced a total of five TEAEs (one case each of viral upper respiratory tract infection, prostatitis and pruritus and two cases of hyperglycemia). Of these patients, one with DM-associated ED experienced two serious TEAEs (two instances of hyperglycemia). All TEAEs were considered not to be related to autologous BMSC therapy. In addition, no clinical significance was identified related to other safety measures, such as laboratory tests and vital signs. The mean International Index of Erectile Function score increased significantly at 1 month versus baseline (24.9 versus 18.1, P = 0.0222).

CONCLUSIONS

This phase 1 clinical trial confirmed the safety and potential efficacy of autologous BMSC therapy in patients with ED. The authors' results need to be confirmed by a phase 2 clinical trial.

Hybrid ileal pouch with concomitant anti-refluxing and refluxing ureteroileal anastomosis

PURPOSE

We report our preliminary experience of using a hybrid ileal pouch, assessing oncologic outcomes, complications, voiding, and renal function.

METHODS

The study included 25 patients with bladder cancer treated with radical cystectomy with a hybrid ileal pouch with concomitant anti-refluxing and refluxing anastomosis, performed by a single surgeon. The patients were divided into two groups (first and last cases) according to the surgery date. Postoperative complications, separate renal function by renal scan, voiding function by uroflowmetry with residual urine, and oncologic outcomes were assessed.

RESULTS

The surgery duration was shorter in the last cases than the first cases. The voiding volume increased with time. There were 23 cases of grade 3 complication in 12 patients and one case of grade 4 complication (sepsis). In the first cases, ureterovesical stenosis occurred in five cases, whereas in the last cases, there were no cases of stenosis. In separate renal function, there was no difference between the left and right side or between the first and last cases.

CONCLUSIONS

The hybrid ileal pouch showed acceptable oncologic and functional outcomes and complications; therefore, it can be used according to the appropriate surgical situation with a relatively short bowel segment during neobladder construction.

Adjuvant Low-dose Statin Use after Radical Prostatectomy: The PRO-STAT Randomized Clinical Trial

PURPOSE

Statin use is reportedly associated with the risk of prostate cancer, outcomes after treatment, and prostate cancer-specific mortality. We sought to determine the efficacy of adjuvant atorvastatin in prostate cancer after radical prostatectomy.

PATIENTS AND METHODS

In this randomized, double-blind trial, we assigned patients with pathologic high-risk prostate cancer to receive either low-dose atorvastatin (20 mg/day, n = 183) or placebo (n = 181) for 1 year after radical prostatectomy. The primary endpoint was the 1-year biochemical recurrence rate. The secondary endpoints included the 5-year biochemical recurrence-free survival and changes in lipid, testosterone, and sex hormone binding globulin levels.

RESULTS

From October 2012 through January 2019, a total of 364 patients underwent randomization. Among 59 total primary end points, 30 (16.4%) and 29 (16.0%) occurred in the atorvastatin and placebo groups, respectively. Atorvastatin did not significantly reduce the primary endpoint of 1-year biochemical recurrence [HR, 0.96; 95% confidence interval (CI), 0.58-1.60]. During a median follow-up of 24 months, 131 patients experienced biochemical recurrence (68 in the atorvastatin group and 63 in the placebo group), representing Kaplan-Meier estimated event rates of 24.0% and 25.4% in the atorvastatin and placebo groups, respectively, at 24 months (HR, 1.00; 95% CI, 0.71-1.41). We observed no significant between-group differences in the testosterone and sex hormone binding globulin levels.

CONCLUSIONS

Among patients with high-risk pathologic features after radical prostatectomy for prostate cancer, 1-year adjuvant use of atorvastatin was not associated with a lower risk of disease recurrence compared with that for placebo. (ClinicalTrials.gov number, NCT01759836).See related commentary by Murtola and Siltari, p. 4947.

Biopsy-detected Gleason grade 5 tumor is an additional prognostic factor in metastatic hormone-sensitive prostate cancer

PURPOSE

A Gleason score ≥ 8, metastatic tumor burden, and visceral metastasis are known prognostic factors for patients with metastatic hormone-sensitive prostate cancer (mHSPC). Notably, however, these indicators have not been fully validated internationally. We aimed in this present study to further analyze the factors that influence the prognosis of mHSPC.

METHODS

In this retrospective study, we identified 201 patients with newly diagnosed mHSPC between 2008 and 2014 and collected their clinical information. Cox proportional hazard regression models were used to identify prognostic factors in mHSPC.

RESULTS

The mean age of the patients at presentation was 70 years (interquartile range (IQR), 64-76 years). The prostate-specific antigen level was 141 ng/mL (IQR, 58.8-464.5 ng/mL). Of the 201 study patients, 191 (94.5%) and 131 (65.2%) cases had a biopsy Gleason score ≥ 8 and grade 5, respectively. More than 4 metastases were detected in 134 patients. Castration-resistant prostate cancer (CRPC) was evident in 160 cases after a mean follow-up period of 46.6 months. By multivariable analysis, a Gleason grade of 5 and bone metastasis lesion count ≥ 4 were found to be significantly associated with CRPC-free survival (hazard ratio (HR), 1.45; 95% confidence interval (CI), 1.01-2.07) and (HR 2.02; 95% CI 1.39-2.92) and overall survival (HR 1.67 95%; CI 1.16-2.42) and (HR 1.67 95%; CI 1.16-2.41).

CONCLUSIONS

Bone metastases ≥ 4 and a Gleason grade 5 are independent prognostic factors for CRPC-free and overall survival in mHSPC. A Gleason grade 5 is therefore a new prognostic indicator in mHSPC.

Efficacy and tolerability of metallic stent in patients with malignant prostatic obstruction secondary to prostatic cancer

OBJECTIVE

To evaluate the efficacy and tolerability of a self-expandable covered metallic stent in patients with malignant prostatic obstruction secondary to prostate cancer (PC).

METHODS

We reviewed 22 cases of insertion of self-expandable covered metallic stents with barbs. Data were collected about PC status. Uroflowmetry variables, residual urine volume, International Prostate Symptom Score (IPSS), quality of life (QOL), and duration from stent insertion to removal were surveyed. These clinical parameters were compared before and after stent insertion.

RESULTS

The patients with PC showed a mean age of 75.5 ± 6.5 years and mean 5.1 ± 1.9 Charlson comorbidity index. The average flow rate (2.4 ± 1.9 vs 5.9 ± 2.4 mL/s, P = .005), peak flow rate (6.9 ± 6.2 vs 14.1 ± 5.5 mL/s, P = .003), flow time (54.6 ± 29.1 vs 23.6 ± 13.7 s, P = .002), residual urine volume (178.7 ± 195.5 vs 7.0 ± 7.1 mL, P = .004), IPSS (26.2 ± 8.1 vs 8.0 ± 6.5 points, P = .001), and QOL (4.7 ± 1.3 vs 2.4 ± 2.1 points, P = .030) improved between before and after stent insertion, respectively. Pain was the most common complication, but 60% of the patients were managed without any intervention. There were hematuria, urinary retention, urinary frequency, obstruction, and urinary incontinence. However, there was no urinary tract infection due to the stent. The median time to stent removal was 5.7 months.

CONCLUSIONS

The stent was maintained for about 6 months with improved objective and subjective outcomes. The patients with PC, who had a poor comorbidity index and advanced PC status showed a tolerable maintenance period. Self-expandable covered metallic stents can be used for PC patients with a short life expectancy and unsuitability for general anesthesia.

Antifibrotic effects of eupatilin on TGF-β1-treated human vocal fold fibroblasts

Vocal fold scarring is a major cause of dysphonia. Vocal fold fibroblasts (VFFs) and the TGF-β signaling pathway play important roles in scar formation. Eupatilin, a chromone derivative of the Artemisia species, is a traditional folk remedy for wound healing. However, until recently, few studies investigated the therapeutic effects of eupatilin. We investigated the antifibrogenic effects of eupatilin on TGF-β1-treated human vocal fold fibroblasts (hVFFs). The optimal concentration of eupatilin was determined by a cell viability assay. Western blotting was used to measure the expression of alpha-smooth muscle actin during myofibroblast differentiation, fibronectin (FN), collagen type I (Col I), and collagen type III (Col III) extracellular matrix proteins, and Smad2, Smad3, and p38 in the fibrotic pathway. Measurements were made before and after eupatilin treatment. Eupatilin at 100 nM was shown to be safe for use in hVFFs. TGF-β1 induced hVFFs to proliferate and differentiate into myofibroblasts and increased Col III and FN synthesis in a time- and dose-dependent manner. Eupatilin suppressed TGF-β1-induced hVFF proliferation and differentiation into myofibroblasts through the Smad and p38 signaling pathways. Furthermore, eupatilin inhibited TGF-β1-induced FN, Col I, and Col III synthesis in hVFFs. Our in vitro findings show that eupatilin effectively suppressed TGF-β1-induced fibrotic changes in hVFFs via the Smad and p38 signaling pathways. Thus, eupatilin may be considered a novel therapeutic agent for the treatment of vocal fold fibrosis.

Noninvasive Precision Screening of Prostate Cancer by Urinary Multimarker Sensor and Artificial Intelligence Analysis

Screening for prostate cancer relies on the serum prostate-specific antigen test, which provides a high rate of false positives (80%). This results in a large number of unnecessary biopsies and subsequent overtreatment. Considering the frequency of the test, there is a critical unmet need of precision screening for prostate cancer. Here, we introduced a urinary multimarker biosensor with a capacity to learn to achieve this goal. The correlation of clinical state with the sensing signals from urinary multimarkers was analyzed by two common machine learning algorithms. As the number of biomarkers was increased, both algorithms provided a monotonic increase in screening performance. Under the best combination of biomarkers, the machine learning algorithms screened prostate cancer patients with more than 99% accuracy using 76 urine specimens. Urinary multimarker biosensor leveraged by machine learning analysis can be an important strategy of precision screening for cancers using a drop of bodily fluid.

In vivo vocal fold augmentation using an injectable polyethylene glycol hydrogel based on click chemistry

It is important to focus on urgent needs in clinics and develop optimal materials. For successful augmentation of vocal folds, the ideal filler should be injectable through a syringe, and should stably maintain its volume for a long time without toxicity. To achieve these criteria, a click chemistry-based PEG (polyethylene glycol) hydrogel was developed and applied for vocal fold augmentation in vivo. The PEG hydrogel enables fast gelation in vivo after injection and provides long-term stability. Azide- and dibenzocyclooctyne (DBCO)-modified 4-arm PEG were cross-linked by chemical conjugation via click chemistry and yielded gelation within several minutes. After subcutaneous injection into mice and rats, the PEG hydrogel showed higher stability after 1 month compared to the traditionally used calcium hydroxyapatite-carboxymethyl cellulose (CaHA-CMC) filler. In rabbit models with vocal fold paralysis, the PEG hydrogel stably fixed the paralyzed vocal fold in 4 months and minimized the glottic gap. It was an improved therapeutic result compared to CaHA-CMC, demonstrating the potential of a click chemistry-based PEG hydrogel for vocal fold therapy.

Dr. Answer AI for Prostate Cancer: Predicting Biochemical Recurrence Following Radical Prostatectomy

OBJECTIVES

To develop a model to predict biochemical recurrence (BCR) after radical prostatectomy (RP), using artificial intelligence (AI) techniques.

PATIENTS AND METHODS

This study collected data from 7,128 patients with prostate cancer (PCa) who received RP at 3 tertiary hospitals. After preprocessing, we used the data of 6,755 cases to generate the BCR prediction model. There were 16 input variables with BCR as the outcome variable. We used a random forest to develop the model. Several sampling techniques were used to address class imbalances.

RESULTS

We achieved good performance using a random forest with synthetic minority oversampling technique (SMOTE) using Tomek links, edited nearest neighbors (ENN), and random oversampling: accuracy = 96.59%, recall = 95.49%, precision = 97.66%, F1 score = 96.59%, and ROC AUC = 98.83%.

CONCLUSION

We developed a BCR prediction model for RP. The Dr. Answer AI project, which was developed based on our BCR prediction model, helps physicians and patients to make treatment decisions in the clinical follow-up process as a clinical decision support system.

Does intraoperative frozen section really predict significant positive surgical margins after robot-assisted laparoscopic prostatectomy? A retrospective study

We investigated the relationship between positive surgical margin (PSM)-related factors and biochemical recurrence (BCR) and the ability of intraoperative frozen sections to predict significant PSM in patients with prostate cancer. The study included 271 patients who underwent robot-assisted laparoscopic prostatectomy with bilateral nerve sparing and maximal urethral preservation. Intraoperative frozen sections of the periurethra, dorsal vein, and bladder neck were analyzed. The ability of PSM-related factors to predict BCR and significant PSM was assessed by logistic regression. Of 271 patients, 108 (39.9%) had PSM and 163 (60.1%) had negative margins. Pathologic Gleason score ≥8 (18.9% vs 7.5%, P = 0.015) and T stage ≥T3a (51.9% vs 24.6%, P < 0.001) were significantly more frequent in the PSM group. Multivariate analysis showed that Gleason pattern ≥4 (vs <4; hazard ratio: 4.386; P = 0.0004) was the only significant predictor of BCR in the PSM cohort. Periurethral frozen sections had a sensitivity of 83.3% and a specificity of 84.2% in detecting PSM with Gleason pattern ≥4. Multivariate analysis showed that membranous urethra length (odds ratio [OR]: 0.79, P = 0.0376) and extracapsular extension of the apex (OR: 4.58, P = 0.0226) on magnetic resonance imaging (MRI) and positive periurethral tissue (OR: 17.85, P < 0.0001) were associated with PSM of the apex. PSM with Gleason pattern ≥4 is significantly predictive of BCR. Intraoperative frozen sections of periurethral tissue can independently predict PSM, whereas sections of the bladder neck and dorsal vein could not. Pathologic examination of these samples may help predict significant PSM in patients undergoing robot-assisted laparoscopic prostatectomy with preservation of functional outcomes.

Value of clinical parameters and MRI with PI-RADSV2 in predicting seminal vesicle invasion of prostate cancer

OBJECTIVE

To investigate the usefulness of magnetic resonance imaging (MRI) with Prostate Imaging Reporting and Data System version 2 (PI-RADS_V2) and clinical parameters in predicting seminal vesicle invasion (SVI).

MATERIAL AND METHODS

In this retrospective study, we identified 569 prostate cancer patients who underwent radical prostatectomy with MRI before surgery. SVI was interpreted with PI-RADS_V2. Clinical parameters such as the prostate-specific antigen (PSA) and Gleason score (GS) were analyzed for the prediction of SVI. Logistic regression models and receiver operating characteristic (ROC) curves were used to evaluate SVI based on clinical parameters and MRI with PI-RADS_V2.

RESULTS

The median age at presentation was 67 years (43-85 years). The median PSA level was 6.1 ng/mL (2.2-72.8 ng/mL). There were 113 patients with a biopsy GS of ≥ 8. A total of 34 patients (6.0%) were interpreted to have SVI by MRI of which 20 were true positive, and 52 patients (9.1%) had true SVI in the final pathologic analysis. In multivariable analysis, PSA (HR: 1.03, 95% CI: 1.00-1.07), biopsy GS ≥ 8 (HR: 4.14, 95% CI: 2.12-8.09), and MRI with PI-RADS_V2 (HR: 14.67, 95% CI: 6.34-33.93) were significantly associated with pathologic SVI. The area under the curve of the model based on the clinical parameters PSA and GS plus MRI (0.862) was significantly larger than that of the model based on clinical parameters alone (0.777, p < 0.001).

CONCLUSIONS

MRI with PI-RADS_V2 using the clinical parameters PSA and GS was effective in predicting SVI.

Differential contribution of the factors determining long-term renal function after partial nephrectomy over time

PURPOSE

To define how much of renal function was determined by the preserved renal parenchymal volume and the ischemic insult during partial nephrectomy (PN) long after surgery.

METHODS

We analyzed the data of 530 consecutive patients who had undergone PN. For all patients, renal function was measured preoperatively and again at 3 postoperative months, then annually using ^99mTc-diethylenetriaminepentaacetic acid renal scan. Perioperative variables potentially affecting the long-term ipsilateral glomerular filtration rate (GFR) and their time-varying contribution were assessed using a linear mixed model.

RESULTS

The mean preoperative ipsilateral GFR was 42.9 ml/min, which decreased by 27.3% at 3 months but began to recover thereafter continuing until 4 years (Δ% GFR at 1, 2, 3, 4, and 5 years: 22.3%, 18.5%, 14.7%, 10.0%, and 9.6%, respectively). Parenchymal volume reduction and ischemic time were significantly associated with postoperative ipsilateral GFR throughout observation period unvarying with time. Diabetes and proteinuria were not significant determinants of ipsilateral function at 3 months but became significant at 5 years. In multivariate analysis regarding recovery slope, volume reduction (β = -0.026, SE 0.006, P < 0.0001), preoperative ipsilateral GFR (β = -0.021, SE 0.007, P = 0.0012), proteinuria (β = -0.942, SE 0.372, P = 0.0116), and diabetes (β = -0.396, SE 0.197, P = 0.0447) were independently significant.

CONCLUSION

Ipsilateral renal function continued to improve until 5 years after PN. Parenchymal volume loss was the major determinant and its impact on long-term ipsilateral renal function remained constant while ischemic time affected early GFR reduction with its impact diminishing over time. Patient-related factors including diabetes and proteinuria gained significance over time and became independent determinants of recovery slope.

Pharmacological inhibition of androgen receptor expression induces cell death in prostate cancer cells

The androgen receptor (AR) plays an important role in the pathogenesis and development of prostate cancer (PCa). Mostly, PCa progresses to androgen-independent PCa, which has activated AR signaling from androgen-dependent PCa. Thus, inhibition of AR signaling may be an important therapeutic target in androgen-dependent and castration-resistant PCa. In this study, we determined the anticancer effect of a newly found natural compound, sakurasosaponin (S-saponin), using androgen-dependent and castration-resistant PCa cell lines. S-saponin induces mitochondrial-mediated cell death in both androgen-dependent (LNCaP) and castration-resistant (22Rv1 and C4-2) PCa cells, via AR expression. S-saponin treatment induces a decrease in AR expression in a time- and dose-dependent manner and a potent decrease in the expression of its target genes, including prostate-specific antigen (PSA), transmembrane protease, serin 2 (TMPRSS2), and NK3 homeobox 1 (NKX3.1). Furthermore, S-saponin treatment decreases B-cell lymphoma-extra large (Bcl-xL) and mitochondrial membrane potential, thereby increasing the release of cytochrome c into the cytosol. Moreover, Bcl-xL inhibition and subsequent mitochondria-mediated cell death caused by S-saponin were reversed by Bcl-xL or AR overexpression. Interestingly, S-saponin-mediated cell death was significantly reduced by a reactive oxygen species (ROS) scavenger, N-acetylcystein. Animal xenograft experiments showed that S-saponin treatment significantly reduced tumor growth of AR-positive 22Rv1 xenografts but not AR-negative PC-3 xenografts. Taken together, for the first time, our results revealed that S-saponin induces mitochondrial-mediated cell death in androgen-dependent and castration-resistant cells through regulation of AR mechanisms, including downregulation of Bcl-xL expression and induction of ROS stress by decreasing mitochondrial membrane potential.

Phase I/IIa trial of androgen deprivation therapy, external beam radiotherapy, and stereotactic body radiotherapy boost for high-risk prostate cancer (ADEBAR)

Background

To evaluate the clinical outcomes of combination of androgen deprivation therapy (ADT), whole pelvic radiotherapy (WPRT), and stereotactic body radiotherapy (SBRT) boost in high-risk prostate cancer patients.

Methods

This prospective phase I/IIa study was conducted between 2016 and 2017. Following WPRT of 44 Gy in 20 fractions, patients were randomized to two boost doses, 18 Gy and 21 Gy, in 3 fractions using the Cyberknife system. Primary endpoints were incidences of acute toxicities and short-term biochemical recurrence-free survival (BCRFS). Secondary endpoints included late toxicities and short-term clinical progression-free survival (CPFS).

Results

A total of 26 patients were enrolled. Twelve patients received a boost dose of 18 Gy, and the rest received 21 Gy. The Median follow-up duration was 35 months. There were no grade ≥ 3 genitourinary (GU) or gastrointestinal (GI) toxicities. Sixty-one and 4% of patients experienced grade 1–2 acute GU and GI toxicities, respectively. There were 12% late grade 1–2 GU toxicities and 8% late grade 1–2 GI toxicities. Patient-reported outcomes of urinary symptoms were aggravated after WPRT and SBRT boost. However, they resolved at 1 month and returned to the baseline level at 4 months. Three-year BCRFS was 88.1%, and CPFS was 92.3%.

Conclusions

The present study protocol demonstrated that the combination of ADT, WPRT, and SBRT boosts for high-risk prostate cancer is safe and feasible, and may reduce total treatment time to 5 weeks. Boost dose of 21 Gy in 3 fractions seems appropriate.

Trial registration

ClinicalTrials.gov, ID; NCT03322020 - Retrospectively registered on 26 October 2017.

External Validation of the Long Short-Term Memory Artificial Neural Network-Based SCaP Survival Calculator for Prediction of Prostate Cancer Survival

Purpose

Decision-making for treatment of newly diagnosed prostate cancer (PCa) is complex due to the multiple initial treatment modalities available. We aimed to externally validate the SCaP (Severance Study Group of Prostate Cancer) Survival Calculator that incorporates a long short-term memory artificial neural network (ANN) model to estimate survival outcomes of PCa according to initial treatment modality.

Materials and Methods

The validation cohort consisted of clinicopathological data of 4,415 patients diagnosed with biopsy-proven PCa between April 2005 and November 2018 at three institutions. Area under the curves (AUCs) and time-to-event calibration plots were utilized to determine the predictive accuracies of the SCaP Survival Calculator in terms of progression to castration-resistant PCa (CRPC)–free survival, cancer-specific survival (CSS), and overall survival (OS).

Results

Excellent discrimination was observed for CRPC-free survival, CSS, and OS outcomes, with AUCs of 0.962, 0.944, and 0.884 for 5-year outcomes and 0.959, 0.928, and 0.854 for 10-year outcomes, respectively. The AUC values were higher for all survival endpoints compared to those of the development cohort. Calibration plots showed that predicted probabilities of 5-year survival endpoints had concordance comparable to those of the observed frequencies. However, calibration performances declined for 10-year predictions with an overall underestimation.

Conclusion

The SCaP Survival Calculator is a reliable and useful tool for determining the optimal initial treatment modality and for guiding survival predictions for patients with newly diagnosed PCa. Further modifications in the ANN model incorporating cases with more extended follow-up periods are warranted to improve the ANN model for long-term predictions.

Association of Bacillus Calmette-Guerin shortages with bladder cancer recurrence: A single-center retrospective study

OBJECTIVE

To examine the association between Bacillus Calmette-Guerin (BCG) shortage and bladder cancer recurrence in high-risk non-muscle-invasive bladder cancer (NMIBC) patients.

MATERIALS AND METHODS

This retrospective study included 333 BCG-naive patients who underwent transurethral resection of bladder tumor for high-risk NMIBC between January 2014 and December 2017. The primary outcome was disease recurrence after operation. The secondary outcomes were trends in BCG shortages and differences in post-transurethral resection of bladder tumor intravesical treatments according to shortage. Multivariable Cox regression modeling was used to assess outcomes.

RESULTS

Among 333 patients (median age, 67 years; men, 270 [81.1%]), 94 (28.2%) experienced BCG shortage (BCG shortage group). Eleven episodes of BCG shortage occurred during the study period (median 10 days, range 2-97 days). Although we observed no statistically significant differences in clinical and pathological characteristics, there were significant differences in post-transurethral resection of bladder tumor intravesical treatments between the shortage and control groups (BCG: 28.7% vs. 68.1%, mitomycin/epirubicin: 27.7% vs. 1.7%, P < 0.001). The 3-year recurrence-free survival rate was significantly lower in the shortage group than that in the control group (38.0% vs. 60.2%, log-rank test, P = 0.010). In multivariable analysis, shortage (hazard ratio [HR] = 1.55, 95% confidence interval [CI] 1.09-2.21, P = 0.016) and tumor multiplicity (HR = 1.55, 95% CI 1.05-2.29, P = 0.028) were independent factors associated with the recurrence of bladder cancer.

CONCLUSIONS

High-risk NMIBC patients who experienced BCG shortage had a high risk of bladder cancer recurrence. Clinical trials of alternative treatment strategies and efforts to increase BCG supply are required.

Dr. Answer AI for prostate cancer: Clinical outcome prediction model and service

Objectives

The importance of clinical outcome prediction models using artificial intelligence (AI) is being emphasized owing to the increasing necessity of developing a clinical decision support system (CDSS) employing AI. Therefore, in this study, we proposed a “Dr. Answer” AI software based on the clinical outcome prediction model for prostate cancer treated with radical prostatectomy.

Methods

The Dr. Answer AI was developed based on a clinical outcome prediction model, with a user-friendly interface. We used 7,128 clinical data of prostate cancer treated with radical prostatectomy from three hospitals. An outcome prediction model was developed to calculate the probability of occurrence of 1) tumor, node, and metastasis (TNM) staging, 2) extracapsular extension, 3) seminal vesicle invasion, and 4) lymph node metastasis. Random forest and k-nearest neighbors algorithms were used, and the proposed system was compared with previous algorithms.

Results

Random forest exhibited good performance for TNM staging (recall value: 76.98%), while k-nearest neighbors exhibited good performance for extracapsular extension, seminal vesicle invasion, and lymph node metastasis (80.24%, 98.67%, and 95.45%, respectively). The Dr. Answer AI software consisted of three primary service structures: 1) patient information, 2) clinical outcome prediction, and outcomes according to the National Comprehensive Cancer Network guideline.

Conclusion

The proposed clinical outcome prediction model could function as an effective CDSS, supporting the decisions of the physicians, while enabling the patients to understand their treatment outcomes. The Dr. Answer AI software for prostate cancer helps the doctors to explain the treatment outcomes to the patients, allowing the patients to be more confident about their treatment plans.

Prostate cancer trajectory-map: clinical decision support system for prognosis management of radical prostatectomy

Purpose

Prostate cancer has a low mortality rate and requires persistent treatment; however, treatment decisions are challenging. Because prostate cancer is complex, the outcomes warrant thorough follow-up evaluation for appropriate treatment. Electronic health records (EHRs) do not present intuitive information. This study aimed to develop a Clinical Decision Support System (CDSS) for prognosis management of radical prostatectomy.

Methods

We used data from 5,199 prostate cancer patients from three hospitals' EHRs in South Korea, comprising laboratory results, surgery, medication, and radiation therapy. We used open source R for data preprocessing and development of web-based visualization system. We also used R for automatic calculation functionalities of two factors to visualize the data, e.g., Prostate-Specific Antigen Doubling Time (PSADT), and four Biochemical Recurrence (BCR) definitions: American Society of Therapeutic Radiology and Oncology (ASTRO), Phoenix, consecutive PSA > 0.2 ng/mL, and PSA > 0.2 ng/mL.

Results

We developed the Prostate Cancer Trajectory Map (PCT-Map) as a CDSS for intuitive visualization of serial data of PSA, testosterone, surgery, medication, radiation therapy, BCR, and PSADT.

Conclusions

The PCT-Map comprises functionalities for BCR and PSADT and calculates and visualizes the newly added patient data automatically in a PCT-Map data format, thus optimizing the visualization of patient data and allowing clinicians to promptly access patient data to decide the appropriate treatment.

Cause of Mortality after Radical Prostatectomy and the Impact of Comorbidity in Men with Prostate Cancer: A Multi-institutional Study in Korea

Purpose

This study aimed to examine the causes of death in Korean patients who underwent radical prostatectomy for prostate cancer and investigate the relationship between comorbidity and mortality.

Materials and Methods

We conducted a retrospective multicenter cohort study including 4,064 consecutive patients who had prostate cancer and underwent radical prostatectomy between January 1998 and June 2013. The primary endpoint of this study was all-cause mortality, and the secondary endpoints were cancer-specific mortality (CSM) and other-cause mortality (OCM). Charlson comorbidity index (CCI) was calculated to assess the comorbidities of each patient.

Results

Of 4,064 patients, 446 (11.0%) died during follow-up. The cause of death was prostate cancer in 132 patients (29.6%), other cancers in 121 patients (27.1%), and vascular disease in 57 patients (12.8%) in our cohort. The overall 10-year CSM rate was lower than the OCM rate (4.6% vs. 10.5%). The 10-year CSM rate was lower than the OCM rate in low- to intermediate-risk group patients (1.2% vs. 10.6%), whereas they were similar in high-risk group patients (11.8% vs. 10.1%). In the multivariable analysis, CCI was independently associated with all-cause mortality after radical prostatectomy, regardless of age and pathologic features.

Conclusion

Death from prostate cancer was rare in Korean men who underwent radical prostatectomy. Clinicians should be aware of the possibility of overtreatment of low-risk prostate cancer in men with significant comorbidity. Our findings may help to facilitate counseling and plan management in this patient group.

Circulating Tumor Cell Counts in Patients With Localized Prostate Cancer Including Those Under Active Surveillance

AIM

To evaluate the clinical efficacy of a circulating tumor cell (CTC) test by comparison between healthy volunteers and patients with localized prostate cancer including those under active surveillance.

MATERIALS AND METHODS

CTC counts in peripheral blood were compared between patients with prostate cancer (n=45) and healthy volunteers (n=17). CTCs were identified based on the expression of epithelial cell adhesion molecule (EpCAM) and counted using a SMART BIOPSY™ SYSTEM.

RESULTS

The number of EpCAM+ cells was significantly higher in patients with cancer than in healthy volunteers. Among the low-risk patients (n=9), two had up-staging and six had up-grading. Among those up-staged, there was one case which was EpCAM⁺ Among those cases up-graded, three were EpCAM⁺ In those with stage T2 tumors, the presence of Gleason pattern 5 was positively correlated with EpCAM positivity (rho=0.59, p<0.001).

CONCLUSION

CTC counts in localized prostate cancer were associated with Gleason pattern 5. Active treatment should be considered for patients with low-risk disease during active surveillance who are found to have EpCAM+ CTCs because of a risk of up-staging and up-grading.

Percent tumor volume vs American Joint Committee on Cancer staging system subclassification for predicting biochemical recurrence in patients with pathologic T2 prostate cancer

PURPOSE

Here, we re-checked the American Joint Committee on Cancer 7th edition subclassification and confirmed the possibility of percent tumor volume as a prognostic factor for biochemical recurrence in the 8th edition subclassification.

METHODS

A total of 1073 patients with pathologic T2 stage disease who underwent radical prostatectomy were included. Exclusion criteria were neoadjuvant therapy and pathologic T3 and N1 disease. Biochemical recurrence-free survival was estimated using the Kaplan-Meier method. Cox hazard regression was used to predict biochemical recurrence.

RESULTS

According to the 7th edition subclassification, 141 patients (13.1%) had T2a, 43 (4.0%) had T2b, and 889 (82.9%) had T2c disease. The 7th edition subclassification did not differ significantly on Kaplan-Meier analysis (p = 0.502). Mean percent tumor volume was 8.7 ± 8.0% (interquartile range, 5-10%). Percent tumor volume was positively correlated with initial prostate-specific antigen, grade group, surgical margin, and T2 subclassification (all p < 0.001). The 7th edition subclassification was not a significant factor, whereas percent tumor volume was (hazard ratio, 1.023; 95% confidence interval, 1.005-1.041; p = 0.0128) on multivariate analysis. On Kaplan-Meier analysis, percent tumor volume (> 7.5% vs ≤ 7.5%) differed significantly for biochemical recurrence-free survival (p < 0.001).

CONCLUSIONS

The 7th edition pathologic T2 subclassification had poor prognostic value for biochemical recurrence in our cohort. Elimination of the 8th edition subclassification was suitable. Percent tumor volume classified biochemical recurrence prognosis in pathologic T2 stage. Therefore, percent tumor volume can be a candidate factor for the next T2 subclassification.

Establishment of NOAEL for intracavernous injections of human bone marrow-derived mesenchymal stem cells in rats

Purpose

To assess the possible negative health effects of human bone marrow-derived mesenchymal stem cells (hBMSCs) on fertility and early embryonic development following intracavernous injections in rats.

Materials and Methods

A total of 88 Crl:CD(SD) male and female rats were equally divided into 4 groups in a random manner: control group (normal saline), low-dose group (2×10⁵ hBMSCs), moderate-dose group (1×10⁶ hBMSCs), and high-dose group (2×10⁶ hBMSCs). hBMSCs or normal saline was injected into the penis of the rats 3 times at 2-week-intervals prior to mating. We compared each group with respect to parameters of reproduction and histopathology.

Results

For male rats, various degrees of flushing and swelling were observed at the penile injection site in all the groups, although the severity increased in a dose-dependent manner in the hBMSC injection groups. There were no statistically significant differences in mean body weights and food consumption among all the groups of both sexes. There were no statistically significant differences in reproductive parameters among all the groups of both sexes. The absolute and relative organ weights did not significantly differ among the groups. At the time of necropsy, no remarkable findings were observed in gross examinations in all groups. On histopathological analysis, minimal mononuclear cell infiltration was observed in the right epididymis of each rat in the moderate- and high-dose groups.

Conclusions

The non-toxic amount of hBMSCs for male fertility and early embryogenesis in rats under the test conditions was determined to be 2×10⁶ cells/head.

Enzalutamide in chemotherapy-naive patients with metastatic castration-resistant prostate cancer: A retrospective Korean multicenter study in a real-world setting

Purpose

This study aimed to evaluate the clinical efficacy of enzalutamide in chemotherapy-naïve metastatic castration-resistant prostate cancer (mCRPC) patients using real-world data from Korean patients.

Materials and Methods

We retrospectively reviewed the medical records of 199 chemotherapy-naïve patients with mCRPC at 13 tertiary centers in Korea between 2014 and 2017. All patients received enzalutamide daily and 89 patients received concurrent androgen deprivation therapy (ADT).

Results

The median age of the patients was 74 years. Initial results showed that 81.5% of the patients had Gleason score ≥8 and 33.3% of the patients had European Cooperative Oncology Group Performance Status 0. The overall mortality rate was 12%. The median OS was not archieved and 76.7% of patients were alive at 30 months. Median time until PSA progression was 6 months. The overall survival rate at 2 years was significantly higher (84.6% vs. 71.7%, p=0.015) and the duration of PSA progression-free survival was significantly longer (8.0 vs. 4.6 months, p=0.008) in patients receiving concurrent ADT than in those receiving enzalutamide alone. The incidence of adverse events of grade 3 or higher was 1.7%. Multivariate Cox proportional hazard analysis indicated that ADT administered concurrently with enzalutamide significantly improved the overall survival (hazard ratio, 0.346; 95% confidence interval, 0.125-0.958).

Conclusions

Enzalutamide is effective and safe for chemotherapy-naïve patients with mCRPC. Furthermore, the overall survival was significantly higher in patients receiving enzalutamide and concurrent ADT than in patients receiving enzalutamide alone.

Determination of Ginsenosides (Ginseng Saponins) in Dry Root Powder from Panax ginseng, Panax quinquefolius, and Selected Commercial Products by Liquid Chromatography: Interlaboratory Study

Twelve collaborating laboratories assayed 4 products, namely, Panax ginseng, Panax quinquefolius, and 2 ginseng products, for 6 ginsenosides: Rb1, Rb2, Rc, Rd, Re, andRg1. Collaborators also received a negative control for the recovery study. Pure ginsenosides were provided as reference standards for the liquid chromatography (LC) analysis and the system suitability tests. The LC analyses were performed on the methanol extract using UV detection at 203 nm. For P. ginseng, individual ginsenosides were consistent in their means; repeatability standard deviations (RSDr)rangedfrom4.17to5.09% and reproducibility standard deviations (RSDR) ranged from 7.27 to 11.3%. For P. quinquefolius, the Rb1 and Rb2 ginsenosides were higher and lower in concentration than P. ginseng, with RSDr values of 3.44 and 6.60% and RSDR values of 5.91 and 12.6% respectively, and other analytes at intermediate precisions. For ginseng commercial products, RSDr values ranged from 3.39 to 8.12%, andRSDR values ranged from 7.65 to 16.5%. A recovery study was also conducted for 3 ginsenosides: Rg1, Re, andRb1. The average recoveries were 99.9, 96.2, and 92.3%, respectively. The method is not applicable for the determination of Rg1 and Re in ginseng product at levels &lt;300 mg/kg.

Stratification based on adverse laboratory/pathological features for predicting overall survival in patients undergoing radical prostatectomy: A K-CaP registry-based analysis

When making clinical decisions concerning additional treatment for patients who have undergone radical prostatectomy (RP), adverse laboratory/pathological features are considered major factors. We investigated and compared the prognostic efficacy of adverse laboratory/pathological features in predicting overall survival (OS) and biochemical failure (BCF) in these patients.The Korean Prostate Cancer Database was used to identify patients undergoing RP between May 2001 and April 2013. Patients with incomplete clinicopathological data or positive lymphadenectomy results were excluded. Finally, 4486 patients included in the final analysis were categorized based on their adverse laboratory/pathological features.Adverse pathological features and detectable prostate-specific antigen (PSA) levels 6 weeks after surgery were observed in 1977 (44.1%) and 634 (14.1%) patients, respectively. PSA levels, pathological Gleason score ≥8, adverse pathological features [positive surgical margin (PSM), seminal vesicle invasion (SVI), and extracapsular extension (ECE)], and adverse laboratory features (detectable PSA levels after 6 weeks) together were significant predictors of BCF-free survival (BCFFS). SVI was identified as a predictor of OS. Additionally, patients with ECE, PSM, and detectable PSA levels after 6 weeks, but without SVI, showed similar OS to those without ECE, PSM, and detectable PSA levels after 6 weeks and with SVI (log-rank test, P = .976).We successfully stratified patients based on adverse laboratory/pathological features after RP and demonstrated that these are important prognostic factors for OS and BCFFS. Additionally, we identified the criteria for selecting appropriate patients for undergoing additional treatment based on OS and BCFFS.

Utility of Multiparametric Magnetic Resonance Imaging With PI-RADS, Version 2, in Patients With Prostate Cancer Eligible for Active Surveillance: Which Radiologic Characteristics Can Predict Unfavorable Disease?

BACKGROUND

We investigated the utility of multiparametric magnetic resonance imaging (mpMRI) using Prostate Imaging Reporting and Data System, version 2 (PI-RADSv2), scoring in patients with prostate cancer eligible for active surveillance (AS).

MATERIALS AND METHODS

The medical records of the patients who had undergone mpMRI before radical prostatectomy from 2014 to 2018 were reviewed. All the patients had met the Prostate Cancer Research International AS criteria. PI-RADSv2 scores were assigned to 12 prostate regions. Unfavorable disease was stratified using the American Joint Committee on Cancer (AJCC) prognostic scale as stage IIB (Gleason score [GS], 3+4 and pathologic stage T2) and IIC-III (GS, ≥ 4+3 or pathologic stage T3).

RESULTS

Of 376 eligible patients, 184 (48.9%), 129 (34.3%), and 63 (16.8%) had AJCC stage I, IIB, and IIC-III disease, respectively. The patients with IIC-III disease were older and had a higher prostate-specific antigen density than those with stage I or IIB disease. PI-RADS 5 lesions were more frequent in patients with stage IIC-III than in patients with stage I or IIB disease. Multivariable analysis revealed that ≥ 2 lesions with a PI-RADS 5 score was an independent predictor for unfavorable disease (hazard ratio [HR], 3.612; P < .001 for IIB; HR, 6.562; P < .001 for IIC-III), and PI-RADS score of ≥ 4 was limited for predicting AJCC stage IIB disease (HR, 2.387; P = .01).

CONCLUSION

mpMRI with PI-RADSv2 showed high negative predictive value for patients with prostate cancer eligible for AS. Multiple PI-RADS 4-5 lesions were associated with unfavorable disease compared with solitary lesions. Multiple PI-RADS 5 lesions were strongly associated with GS ≥ 4+3 or pathologic T3 disease. Targeted biopsy or radical treatment should be considered for these patients.

Development of Integrated Data and Prediction System Platform for the Localized Prostate Cancer

In this study, we built a multi-center integrated database platform of localized prostate cancer and developed biochemical recurrence (BCR) prediction system with Gradient Boosted Regression model using Korean Prostate Cancer Registry (KPCR) database. This platform will facilitate clinical management of patients with prostate cancer, and it will also help develop appropriate treatment of prostate cancer.

The small molecule WNT/β-catenin inhibitor CWP232291 blocks the growth of castration-resistant prostate cancer by activating the endoplasmic reticulum stress pathway

Background

Androgen receptor (AR)-targeted treatments improve the survival of castration-resistant prostate cancer (CRPC) patients; however, secondary resistance to these agents ultimately occurs in virtually all patients. Therefore, alternative therapeutic targets are urgently needed. Since growing evidence demonstrates that WNT/β-catenin signaling plays an important role in CRPC, the antitumor activity and mechanism of action of CWP232291, a small molecule β-catenin inhibitor, were investigated in prostate cancer.

Methods

We assessed the antitumor activity of CWP232291 in prostate cancer cell lines and primary cells derived from CRPC patients. The effect of CWP232291 on apoptotic cell death, endoplasmic reticulum (ER) stress, cell viability, and WNT/β-catenin signaling was evaluated by flow cytometry, western blotting, luciferase reporter assay, and fluorescence microscopy. Antitumor efficacy was assessed in two CRPC xenograft mouse models.

Results

CWP232291 induced ER stress, resulting in upregulation of the proapoptotic protein CHOP and activation of caspase-3-dependent apoptosis. In addition, CWP232291 suppressed the expression of β-catenin by affecting WNT-dependent transcriptional activity, and downregulated AR and its splice variants in prostate cancer cells. Antitumor activity was observed in prostate cancer cells in vitro and ex vivo, and antitumor efficacy was observed in vivo.

Conclusions

Beyond providing preclinical evidence of therapeutic efficacy for the novel small molecule β-catenin inhibitor CWP232291 in CRPC, our results show that inducing ER stress and targeting WNT/β-catenin signaling may be a novel strategy against CRPC.

Electronic supplementary material

The online version of this article (10.1186/s13046-019-1342-5) contains supplementary material, which is available to authorized users.

Effects of an antiadhesive agent on functional recovery of the greater auricular nerve after parotidectomy: a double-blind randomized controlled trial

PURPOSE

Periauricular sensory deficit occurs frequently after parotidectomy even in cases with preservation of the greater auricular nerve (GAN). This study was performed to evaluate the effects of antiadhesive agent in functional recovery of the GAN after parotidectomy.

METHODS

Ninety-eight patients undergoing partial parotidectomy for benign parotid tumors were prospectively enrolled in this multicenter, double-blind randomized controlled study and randomly assigned to either the study or control group. Antiadhesive agent was applied in the study group. The results of sensory tests (tactile, heat, and cold sensitivity) and a questionnaire on quality of life (QoL) were acquired at postoperative 1, 8, and 24 weeks after surgery. Clinical parameters, and the results of the sensory tests and the questionnaire, were compared between the two groups.

RESULTS

A total of 80 patients were finally enrolled. On sensory evaluation, tactile sensation and warm sensation in the ear lobule, and warm sensation in the mastoid area, showed significant improvement at 24 weeks postoperatively in the study group. There were no significant differences between the two groups on any questions in the QoL questionnaire, at any follow-up time point.

CONCLUSIONS

Antiadhesive agents have some positive effects on functional recovery of the GAN after parotidectomy. Therefore, applying antiadhesive agents after parotidectomy can reduce discomfort in patients.