Robotic SBRT in Prostate Cancer Patients Younger Than 50 Years Old-Updated Results

PURPOSE/OBJECTIVE(S)

Stereotactic Body Radiation Therapy (SBRT) is a standard therapeutic option for men with prostate adenocarcinoma. The median age of prostate cancer in the US is 66 but patients as young as 35 have been reported. Many younger patients will have surgery rather than SBRT for localized prostate cancer but some will be treated with SBRT. There is a paucity of data on the outcomes of this younger subset. This study reports updated outcomes on patients younger than 50 treated with SBRT at a single institution and compares outcomes to older patients.

MATERIALS/METHODS

Between April 2006 and December 2022, 6,130 patients with prostate cancer were treated with inhomogeneous-dosed SBRT using a robotic linear accelerator. Information was available for 4,143 patients. 3568 (86.12%) of patients were treated with a median dose of 3500cGY (3500-3625) delivered over 5 consecutive fractions prescribed to the 83-85% isodose line, and the remaining 575 (13.88%) other patients receiving a median dose of 4500cGY (4500-5400) to the pelvis in conventional fractionation followed by a 3 fraction SBRT boost of 2100 cGY (1950-2100) over 3 consecutive fractions. Androgen deprivation Therapy (ADT) was prescribed in 1,035 (24.98%) of these cases. The mean age was 67.4 years old. 48 patients were younger than 50 years old (mean age 46.6). 4,095 patients were 50 or older. Patients were divided into prognostic D'Amico risk groups with 43.75%, 50.00%, 6.25% of patients falling in the low, intermediate, and high-risk stratifications in the younger cohort and 23.88%, 57.05%, 19.07% in the older cohort respectively. Pretreatment PSA was 1.72 - 43.2 (median: 5.4) in the younger group and 0.3 - 661 (median: 6.5) in the older group. In the younger group, Gleason scores were 6 in 47.92%, 7 in 47.92%, and 8-10 in 4.16%. 44 younger patients were treated with SBRT alone. 4 patients also received supplemental external beam radiation (median dose 4500cGY) and 5 patients (10.42%) received Androgen Deprivation Therapy (ADT) as part of their treatment regimen. In the older group, Gleason scores were 6 in 29.84%, 7 in 54.14%, and 8-10 in 16.02%. 3522 were treated with SBRT alone. 573 patients also received supplemental external beam radiation (median dose 4500cGY) and 1030 patients (25.15%) received Androgen Deprivation Therapy (ADT) as part of their treatment.

RESULTS

At 75 months the 6-year biochemical relapse free survival was 95.83% in younger patients compared to 98.41% in older patients using the Phoenix definition of biochemical failure. The 6-year median post treatment PSA was 0.3 in younger patients and 0.2 in the older patients. There were no significant differences in the risk stratification between the 2 groups.

CONCLUSION

This represents the largest series evaluating outcomes in very young patients treated with definitive SBRT for prostate cancer. With updated 6-year follow up, SBRT remains an effective treatment for this younger subset of patients. Continued follow up will be required to see if these results remain durable.

Minority participation in phase 1 gynecologic oncology clinical trials: Three decades of inequity

OBJECTIVES

It is important to develop effective therapies in minorities to ensure equity in cancer care. Underrepresentation of minorities in early phase trials may cause therapies that are effective only in majority populations. We evaluated minority participation in gynecologic oncology phase 1 clinical trials.

METHODS

In peer-reviewed published articles of gynecologic oncology phase 1 clinical trials from years 1985 to 2018, we manually abstracted racial distribution of enrolled participants, cancer type, and year published. We calculated expected and observed ratios of racial participation on the basis of age-adjusted cancer incidence for race from the United States Centers for Disease Control and Prevention.

RESULTS

We identified 357 articles of phase 1 trials (total, 9492 participants), including 213 articles on ovarian cancer (60%). Racial distribution of participants was available in 84 articles (23%) that included 2483 participants (26%): 1950 white (79%), 140 black (5%), and 393 other participants (16%). Other nonwhite races exceeded black enrollment in 46 of 84 trials (55%) that listed race. Enrollment of black participants was less than expected from disease incidence for ovarian (incidence-to-enrollment ratio, 18.5; P < .001), endometrial (3.6; P < .001), and cervical cancer (6.8; P < .001). No phase 1 study met expected enrollment for black participants. Frequency of black participants decreased 1.8-fold from 1995 to 1999 (8 of 70 participants [11%]) to 2015-2018 (55 of 892 participants [6%]; P < .025).

CONCLUSIONS

Major racial underrepresentation exists in gynecologic oncology phase 1 clinical trials. Enrollment of more black participants is needed to achieve racial equity.

Use of lupin, Lupinus perennis, mango, Mangifera indica, and stinging nettle, Urtica dioica, as feed additives to prevent Aeromonas hydrophila infection in rainbow trout, Oncorhynchus mykiss (Walbaum)

Feeding rainbow trout, Oncorhynchus mykiss (Walbaum), with 1% lupin, Lupinus perennis, mango, Mangifera indica, or stinging nettle, Urtica dioica, for 14 days led to reductions in mortality after challenge with Aeromonas hydrophila. In addition, there was significant enhancement in serum bactericidal activity, respiratory burst and lysozyme activity in the treatment groups compared to the controls. Use of lupin and mango led to the highest number of red blood and white blood cells in recipient fish, with use of stinging nettle leading to the highest haematocrit and haemoglobin values; the highest value of mean corpuscular volume and haemoglobin was in the control groups and those fed with stinging nettle.

Increased lithium serum and red blood cell concentrations during ketorolac coadministration

Case reports of a lithium-ketorolac drug interaction have been published, but no formal investigation of this interaction has been conducted. The objective of the study presented here was to determine significant changes in lithium serum and red blood cell (RBC) concentrations after lithium and ketorolac (oral formulation) coadministration at steady-state conditions. Five healthy men participated in the study and received lithium 900 mg/day (300 mg in the morning and 600 mg at bedtime) for 13 days. Ketorolac 40 mg/day (10 mg four times a day) was added on days 8 through 12. Ten blood samples were obtained on days 7 and 13 to determine area under the concentration-time curve (AUC) lithium serum and RBC concentrations. Serum and RBC lithium concentrations were assayed by atomic absorption spectrophotometry with an intra-assay coefficient of variation (CV) of 1.2% on day 1 (range 0-1.0 microg/mL) and 4.9% (range 0-1.0 microg/mL) on day 2 and an interassay CV of 2.9% (range 0-1.0 microg/mL) on days 1 and 2 of serum analysis and a CV of 5.3% (range 0-0.3 microg/mL) of RBC concentrations. Total serum AUC lithium and RBC AUC values significantly increased by 24% (p < 0.02) and by 27% (p < 0.05) with the ketorolac coadministration, respectively. An increased incidence and severity of lithium-associated side effects were reported during concomitant administration. A clinically significant drug interaction can occur when ketorolac is added to lithium therapy.

The effect of comprehensive outpatient pulmonary rehabilitation on dyspnea

To evaluate the effect of outpatient pulmonary rehabilitation (OPR) on dyspnea, we measured this symptom using a visual analogue scale during graded treadmill exercise testing and with baseline and transitional dyspnea indices (TDI). The latter measure overall dyspnea in three spheres: functional impairment, magnitude of task, and magnitude of effort. Twenty patients with COPD referred for OPR were randomly assigned to either a treatment group (T, n = 10), with dyspnea evaluated at baseline then shortly following a 6-week OPR program, or a control group (C, n = 10), with dyspnea evaluated at baseline then following a 6-week waiting period. No significant change in maximal exercise performance from baseline to repeated testing was observed in either group. Dyspnea at maximum treadmill workload (Dmax), which did not significantly change in C, decreased from 74.4 +/- 18.9 percent at baseline to 50.5 +/- 23.2 percent post-OPR in T (p = 0.006). The Dmax related to minute ventilation (Dmax/VEmax) and oxygen consumption (Dmax/VO2max) also significantly decreased following OPR. The reduction in exertional dyspnea was apparent by the second minute of exercise. Additionally, TDI focal scores were significantly higher in T than C (2.3 +/- 1.06 vs 0.2 +/- 1.75 units, p = 0.006), indicating decreased overall dyspnea following OPR. These results point to significant improvements in both exertional and clinically assessed dyspnea following OPR.

Characteristics of cancer patients under the age of 20 at medical centers in Israel and the West Bank: a preliminary study

This paper describes the demographic experience on 373 young cancer patients (less than 20 years of age) at two oncology centers initiated in Israel by one medical team in 1975-1977. These units are the Assaf Harofeh Medical Center (AHMC), which predominantly serves a Jewish population (103 cases); and the West Bank Cancer Unit (WBCU), which provides similar care services to the Arab population of the West Bank (270 cases). The two centers have the unique feature of serving two populations residing in close relationship but still differing in many cultural and socioeconomic characteristics. The Arab patients at WBCU tended to be younger than the Jewish children at AHMC. The five most common diagnostic sites for both AHMC and WBCU included hematopoietic system, bones and joints, soft tissue, urinary tract, and brain and nervous system, although not in the same order of occurrence. These tumor sites accounted for approximately 80% of the cases at each center. The experience with WBCU patients was also compared with data for all Jews in Israel. This comparison identified for both sexes combined statistically significant differences in relative frequency of tumors of soft tissue, eye and orbit, brain and nervous system, and thyroid gland. If confirmed by additional data, reasons for the suggested excess risks should be pursued through more definitive epidemiological studies.

Thrombotic thrombocytopenic purpura in systemic lupus erythematosus and antiphospholipid antibodies: effective treatment with plasma exchange and immunosuppression

We describe 2 patients with systemic lupus erythematosus (SLE) with neurological complications and thrombocytopenia, who, upon further investigation, were found to have thrombotic thrombocytopenic purpura. While neither patient responded to treatment with corticosteroids, both responded to plasma exchange and intravenous cyclophosphamide. This highlights the need to carefully consider this diagnosis in patients with SLE presenting with neurological complications and thrombocytopenia.

Miller Fisher syndrome in systemic lupus erythematosus

We describe the first case of Miller Fisher syndrome, a Guillain Barré variant, complicating systemic lupus erythematosus. The symptoms and signs mimicked a brainstem syndrome. Despite treatment with high dose gamma globulin, our patient worsened and required mechanical ventilation. After plasma exchange, the patient improved.

Detrusor muscle and sphincteric response to anorectal stimulation in spinal cord injury

Twelve patients with spinal cord injuries were studied to determine whether the anal sphincter could be used as an index of urethral sphincter activity and to determine the bladder and striated sphincter response to anal and rectal stimulation. Electromyogram (emg) needle electrodes were placed in the external urethral sphincter, external anal sphincter and levator ani. The output of a cystometer was simultaneously recorded on the printout so that the relationship of the striated muscle response to distension of the bladder could be observed. The response to inserting a finger into the external anal canal, external anal sphincter stretch and rectal balloon distension was also observed. The external urethral and anal sphincter activity was closely linked during bladder contraction and anorectal stimulation. The levator ani showed divergent activity. Stretch of the external anal sphincter caused an initial period of increased striated muscle activity, then in 10 of 12 patients abrupt and often marked inhibition of both sphincters and levator ani developed with continued stretch. Ongoing bladder contractions were inhibited and a decrease in bladder tone developed in 7 of 12. Stretch of the rectum produced results similar to those with anal stretch except that bladder facilitation was seen in 4 of 12 patients.