PEACE V - Salvage Treatment of OligoRecurrent nodal prostate cancer Metastases (STORM): a study protocol for a randomized controlled phase II trial

BACKGROUND

Pelvic nodal recurrences are being increasingly diagnosed with the introduction of new molecular imaging techniques, like choline and PSMA PET-CT, in the restaging of recurrent prostate cancer (PCa). At this moment, there are no specific treatment recommendations for patients with limited nodal recurrences and different locoregional treatment approaches are currently being used, mostly by means of metastasis-directed therapies (MDT): salvage lymph node dissection (sLND) or stereotactic body radiotherapy (SBRT). Since the majority of patients treated with MDT relapse within 2 years in adjacent lymph node regions, with an estimated median time to progression of 12-18 months, combining MDT with whole pelvic radiotherapy (WPRT) may improve oncological outcomes in these patients. The aim of this prospective multicentre randomized controlled phase II trial is to assess the impact of the addition of WPRT to MDT and short-term androgen deprivation therapy (ADT) on metastasis-free survival (MFS) in the setting of oligorecurrent pelvic nodal recurrence.

METHODS & DESIGN

Patients diagnosed with PET-detected pelvic nodal oligorecurrence (≤5 nodes) following radical local treatment for PCa, will be randomized in a 1:1 ratio between arm A: MDT and 6 months of ADT, or arm B: WPRT added to MDT and 6 months of ADT. Patients will be stratified by type of PET-tracer (choline, FACBC or PSMA) and by type of MDT (sLND or SBRT). The primary endpoint is MFS and the secondary endpoints include clinical and biochemical progression-free survival (PFS), prostate cancer specific survival, quality of life (QoL), toxicity and time to castration-resistant prostate cancer (CRPC) and to palliative ADT. Estimated study completion: December 31, 2023.

DISCUSSION

This is the first prospective multicentre randomized phase II trial assessing the potential of combined WPRT and MDT as compared to MDT alone on MFS for patients with nodal oligorecurrent PCa.

TRIAL REGISTRATION

ClinicalTrials.gov Identifier: NCT03569241, registered June 14, 2018, ; Identifier on Swiss National Clinical Trials Portal (SNCTP): SNCTP000002947, registered June 14, 2018.

Transurethral microwave hyperthermia for benign prostatic hyperplasia: preliminary clinical and pathological results

Transurethral microwave hyperthermia is a new conservative treatment modality for benign prostatic hyperplasia. We treated 15 patients with 915 MHz. microwaves delivered transurethrally by a helical applicator. Of the patients 12 showed substantial objective and subjective improvement of obstructive outflow parameters. Significant improvement in objective study parameters included increased mean flow rate (p less than 0.00021), decreased mean residual volume (p less than 0.00001) and decreased mean prostatic volume (p less than 0.0077). Analysis of patterns of failure showed chronic bladder atony, prostate asymmetry and middle lobe configuration as important factors that could explain the failure of hyperthermia in 3 patients. Toxicity was mild, consisting of bladder spasms, perineal pain, dysuria and hematuria. Hyperthermia-induced pathological changes in prostatic tissues, causing periurethral shrinking and secondary dilatation of the prostatic urethra, are described. The reported clinical results of this phase I study are preliminary due to the short followup. A phase II study to optimize transurethral hyperthermia currently is underway. A phase III study is to be phased in comparing hyperthermia with transurethral resection of the prostate.

Accuracy of combined computerized tomography and fine needle aspiration cytology in lymph node staging of localized prostatic carcinoma

The sensitivity and accuracy rate of computerized tomography (CT) in lymph node staging of localized prostatic carcinoma is commonly considered to be low. Fine needle aspiration cytology of pathological lymph nodes seen on radiological staging can enhance this low accuracy rate. We prospectively investigated the accuracy of CT and fine needle aspiration cytology in lymph node evaluation of 285 patients with clinically locally confined prostatic carcinoma. The sensitivity, specificity and accuracy rates of this combined method were 77.8%, 100% and 96.5%, respectively. False-negative staging results were found in only 10 patients with minimal nodal disease. Although in contrast with previous reports, combined CT and fine needle aspiration cytology in our hands seems to be a highly efficient staging method for lymph node involvement. This method could be considered as an alternative to surgical lymphadenectomy in the preoperative evaluation of the nodal status of patients with localized prostatic carcinoma who are scheduled for radical prostatectomy or curative radiotherapy.

Heating characteristics of a helical microwave applicator for transurethral hyperthermia of benign prostatic hyperplasia

A new applicator for intraurethral hyperthermic treatment of benign prostatic hyperplasia is described. The applicator uses an insulated helical antenna wound on the outer surface of a silicone urological (Foley) balloon catheter. The balloon catheter assures rapid and reproducible localization of the antenna in the prostatic urethra. Two small cannulae are fixed to the exterior surface of the applicator. One holds a temperature control sensor at a fixed location, the other is used to map temperature along the applicator. Two-dimensional SAR and steady-state temperature distributions measured in a plane tangent to the applicator in a tissue-equivalent phantom are presented, as well as longitudinal temperature distributions measured in situ at the applicator-urethral interface. Prostatic temperatures were also measured intraoperatively. The applicator appears to be capable of elevating temperature to greater than 42 degrees C in a cylindrically symmetric volume of about 4 cm length and about 0.5 cm radial penetration surrounding the antenna. The heating characteristics of this applicator are similar to an earlier design that employed an array of three dipoles. The helical applicator is narrower, more flexible and simpler to use than the earlier design.

Interstitial temperature measurements during transurethral microwave hyperthermia

Microwave hyperthermia is presently being investigated as a treatment for alleviating the symptoms of urinary outlet obstruction associated with benign prostatic hyperplasia. Two clinical techniques using intracavitary microwave applicators are being evaluated for safety and efficacy at various institutions. The transrectal technique uses a directional microwave radiator that is inserted into the rectum adjacent to the prostate. The transurethral approach uses a symmetrically radiating applicator located within the prostatic urethra. Transrectal prostatic heating techniques require surface cooling to prevent hazardous temperatures in the intervening rectal mucosa. Since transurethral applicators radiate from within the prostatic urethra, heating is confined to the obstructive tissue immediately surrounding the applicator. Concern has been expressed regarding the possibility of thermal injury to the prostate and adjacent rectum during transurethral hyperthermia treatment. In this report we present interstitial temperature measurements of prostatic and rectal temperatures in 5 patients. Temperature was observed to decrease at a rate of about 6C/cm. outward from the applicator. No clinically significant temperature increase was observed beyond 1 cm, outside the prostatic capsule or in the rectal mucosa.

Chromosome abnormalities in benign prostatic hyperplasia

We combined conventional cytogenetic analysis and fluorescence in situ hybridization of short-term cultures of 28 samples from benign prostatic hyperplasia. Loss of the Y chromosome was the most common chromosome change, followed by trisomy 7. Trisomy 7, however, may be unrelated to the origin of benign prostate hyperplasia, in which the only and not very specific change seems to be the loss of the Y chromosome.

Transurethral hyperthermia for benign prostatic hyperplasia patients with retention

From 1989 to 1990, 32 poor surgical risk patients with urinary retention were treated with transurethral microwave hyperthermia at the department of urology, University of Leuven in Belgium. Mean patient age was 73 years (range 58 to 90 years) and mean duration of retention was 4 weeks (range 3 to 12 weeks). Followup ranged from 13 to 82 weeks, with a mean of 31 weeks. Bilobar or trilobar hyperplasia was diagnosed in 25 patients (78%), while 7 (22%) had median lobe or median bar hypertrophy. The mean prostatic volume was 52 cc (range 25 to 150 cc). Transurethral microwave hyperthermia was given with a helical antenna at 915 MHz. once or twice per week. The mean number of transurethral microwave hyperthermia sessions was 8.9 (range 5 to 10). Each session consisted of a 60-minute treatment at a mean maximum temperature of 45.4C (range 43.7 to 47.2C), average temperature 43.9C (range 42.7 to 45.5C) and minimum temperature 42.0C (range 40.2 to 43.0C). The temperature was continuously monitored, including thermal mapping in all patients. Of the 25 patients who presented with bilobar or trilobar hyperplasia 18 (72%) were catheter-free for the duration of followup. Of the 7 median lobe or median bar patients 1 (14%) showed sufficient improvement to warrant catheter removal. This patient, however, had recurrent retention 4 months after transurethral microwave hyperthermia. In patients with bilobar and trilobar hyperplasia a strong correlation was observed among maximum temperature (p = 0.0006), average temperature (p = 0.0033) and treatment response. As expected, no such correlation existed between minimum temperature and response to treatment (p = 0.56). Our study has again demonstrated therapeutic activity in patients with benign prostatic hyperplasia treated with transurethral microwave hyperthermia. A new finding was a strong correlation between temperature and response.

Temperature steering in prostate by simultaneous transurethral and transrectal hyperthermia

Localized hyperthermia (HT) is presently under investigation as a treatment for benign prostatic hyperplasia and carcinoma of the prostate (CaP). One popular approach employs a transrectal (TR) device, a directional microwave (MW) applicator inserted into the rectum and aimed at the prostate. Alternatively, in the transurethral (TU) technique, a symmetrically radiating MW antenna is placed directly within the prostatic urethra. Used individually, TR applicators are capable of effectively heating (> 42 degrees C) the prostate up to 2 cm from the rectum, whereas TU applicators selectively heat the periurethral tissue with effective radial penetration of about 0.6 cm. Neither technique is of much value in heating the anterior prostate. In general, the highest temperatures are produced in the tissue immediately adjacent to the surface of intracavitary microwave devices. However, when MW antennas are used in arrays, the resulting heating pattern can differ significantly from that of the individual antennas. Heating at depth can be selectively enhanced and "steered" by adjusting the phase relationship between the devices. Prostatic temperature profiles were measured in 6 patients treated with TR alone, TU alone, and simultaneous TR and TU heating. In the combined treatments different phase relationships between the antennas were applied. We found that a higher temperature could be produced in the center of the prostate than on the surface of either applicator for certain phase relationships, and that the temperature profiles could be changed by shifting phase. The results of these measurements are in agreement with those of a computer simulation. Based on the above data we feel the combined use of TU and TR hyperthermia may be justified in Phase I-II trials for patients with locally advanced CaP.

New trends in the treatment of benign prostatic hyperplasia and carcinoma of the prostate

Benign prostatic hyperplasia (BPH) is a very common condition affecting over 800,000 American males each year. A standard, effective, and well-proven therapy is prostatectomy. This surgical procedure is used to treat, in the United States, approximately 400,000 BPH patients annually. Major treatment benefit is expected in 70% to 80% of patients. Complications are seen in 20% of the surgically treated patients. Due to the advanced age of BPH patients and the presence of other serious coexisting medical problems, surgical therapy may be difficult to utilize. These patients, who present a high risk for surgery, are in need of alternative treatments. Alternative therapy in BPH patients with clinically important symptoms and signs of urinary outflow obstruction include treatment with pharmacological agents, balloon dilatation, laser beam therapy, transurethral thermal therapy, transrectal microwave hyperthermia, and transurethral microwave hyperthermia. These alternative treatment modalities are currently under intensive study. These new treatment modalities ultimately must be compared with the standard treatment, which is prostatectomy. Due to the unpredictable natural history of BPH, it is desirable that each Phase III study should contain a no-treatment observation-only arm. Adenocarcinoma of the prostate (CaP) has become a tumor, which first in frequency, and second in importance in cancer mortality statistics of American males. Local tumor control rates and long-term survivals, with radical prostatectomy or radiation therapy, have been excellent. There was, however, recent concern regarding a high incidence of microscopic local tumor recurrence following a definitive course of irradiation. Deep regional or intracavitary hyperthermia (HT) with phase steering may be of value as an adjuvant treatment to radiotherapy. This HT may increase the incidence of local tumor control obtained with radiotherapy. Phase I-II clinical studies are currently underway.

Treatment response with transurethral microwave hyperthermia in different forms of benign prostatic hyperplasia: a preliminary report

During a 7-month period, 79 patients with benign prostatic hyperplasia (BPH) were treated with 915 MHz transurethral hyperthermia (TUHT). All patients had obstructive and irritative signs and symptoms which warranted surgical treatment considerations. Of the 79 patients treated, 31 had follow-ups of 12 months or longer and seven additional patients experienced treatment failure requiring surgical management. These 38 patients were studied to evaluate the relationship of treatment response to the pretreatment prostatic morphology assessed during cystoscopy. There was a well-balanced distribution of patients regarding the important pretreatment characteristics in different morphological types of prostatic hypertrophy. These important characteristics included: prostate volume, postvoiding residual volume, mean peak flow rate, and mean symptom score on the FDA scale. The study patients were scheduled to receive five 60-min TUHT sessions with temperature controlled on the urethral surface at 45.5 degrees C. The treatment were well tolerated and administered on an outpatient basis without sedation or anesthesia. There was a significant difference in the incidence of major improvement in patients with lateral lobe hyperplasia and those with median lobe enlargement, 73 vs. 30%, P = 0.018. From this study, it appears that BPH patients who are found at cystoscopy to have a predominance of median lobe hypertrophy should, perhaps, be selected for treatment other than TUHT. A Phase I study utilizing a modified transurethral applicator to accommodate the specific problem of patients with median lobe hyperplasia is currently being planned.

Transurethral microwave hyperthermia: an alternative treatment for prostadynia?

A total of 15 patients with severe symptoms of prostadynia who were refractory to therapy were treated with transurethral microwave hyperthermia (TUHT) in a phase I trial. All patients had pain as the predominant symptom, 9 (60%) patients gave a history of psychological problems while frequency, urgency, dysuria, nocturia, and impotence were less common symptoms. Treatment consisted of TUHT at 915 MHz given weekly for 5 weeks with a total of 68 treatment sessions and a mean of 4.5 treatments per patient. Each treatment lasted for 60 minutes. The aim was to increase the temperature measured on the urethral surface to greater than or equal to 44 degrees C. T mean for all sessions was 45.5 degrees C. In 91% of treatments, the temperature was greater than or equal to 44 degrees C. Treatment was well tolerated in 87% patients and acute toxicity was mild. Of the 15 patients treated, 2 (13%) did not complete the treatment course due to discomfort during TUHT. Good treatment response, manifested by complete pain relief and a decrease in dysuria, was noted in 7 (47%) patients. A higher (greater than or equal to 46 degrees C) treatment temperature correlated well with good response, P less than .01. Similarly, relief of pain correlated well with the absence of a history of psychological problems, P less than .01. A decrease of obstructive micturition problems was noted in 5 of the 7 patients who had this upon presentation. This study showed evidence of therapeutic activity with the use of TUHT in patients with prostadynia refractory to therapy. The response obtained was limited to less than one-half of the patients. Complete pain relief was obtained in 4 (27%) patients. It is of interest to note that patients who had major benefit did not show evidence of psychological problems and were able to tolerate higher treatment temperatures. The latter could suggest a temperature-related response.

A case of imported melioidosis presenting as prostatitis

We report a case of melioidosis in a previously healthy Belgian man. He presented with septicemia and prostatic abscesses 1 week after a trip to Vietnam. Burkholderia pseudomallei was isolated from multiple hemocultures. He was treated successfully with intravenous ceftazidime and trimethoprim-sulfamethoxazole, followed by a per-oral maintenance therapy of amoxicillin-clavulanate with supplementary amoxicillin. There was no need for surgical drainage. This is the second reported case of melioidosis in Belgium.

Relationship of response to transurethral hyperthermia and prostate volume in BPH patients

A response to transurethral microwave hyperthermia (TUHT) at 915 MHz and its relationship to prostate volume was examined in 63 poor surgical risk benign prostatic hyperplasia (BPH) patients. All patients had moderate-to-severe obstructive signs and symptoms, and received > or = 5 TUHT one-hour sessions. Treatment temperature was controlled on the urethral surface at 45 degrees C +/- 1 degree C. Follow-up ranged from twelve to forty-four months (mean 18 months). The mean prostate volume was 57 cc (range 10-301 cc). There were 40 patients (63%) with prostate volume < or = 50 cc and 23 (37%) with a volume > 50 cc. Treatment failure was seen in 6 patients (10%). It was 10 percent in 40 patients with smaller glands and 9 percent for those 23 with larger prostates, N.S. at p = 0.49. Subjective treatment response was seen in 58 patients (92%). It was 90 percent for the 40 patients with < or = 50 cc prostates vs. 96 percent for the 23 with > 50 cc prostates, N.S. at p = 0.75. This study suggests that the initial prostate volume is not an important parameter predicting response to TUHT.

Transurethral microwave hyperthermia for benign prostatic hyperplasia: the Leuven clinical experience

Local microwave hyperthermia, delivered transurethrally or transrectally, is a new treatment modality for benign prostatic hyperplasia. We started transurethral application, delivering 915-MHz microwaves at the prostatic urethra using a helical microwave antenna incorporated in a Foley catheter. This hyperthermia was given without a urethral surface cooling system. Thermophysical testing of the applicator proved therapeutic efficacy in vitro and in vivo. Pathologic studies demonstrated hyperthermia-induced lesions in the periurethral prostatic tissues and permitted us to hypothesize a working mechanism of transurethral hyperthermia. Clinical Phase I and II studies showed clinical efficacy in patients with urinary retention or prostatism secondary to benign hyperplasia, especially in bilobar or trilobar prostatic configurations. While awaiting results of further pathologic and thermophysical experimental work and ongoing Phase II and III studies, we consider transurethral hyperthermia an investigational but promising conservative treatment modality for benign prostatic hyperplasia.

Bilateral pneumothorax after emergency tracheotomy: two case reports and a review of the literature

Bilateral pneumothorax may occur after emergency tracheotomy, if a significant upper airway obstruction with a large negative intrathoracic pressure exists.

Concordance Between Biopsy and Radical Prostatectomy Gleason Scores: Evaluation of Determinants in a Large-Scale Study of Patients Undergoing RARP in Belgium

To determine whether Gleason scores were concordant between prostate biopsies (bGS) and the definitive resection specimen (pGS) excised with robot-assisted radical prostatectomy (RARP); to identify clinical and pathological factors that might predict upgrading; and to evaluate how upgrading affected outcome. Between 2009 and 2016, 25 Belgian centers participated in collecting prospective data for patients that underwent RARP. We analyzed the concordance rate between the bGS and the pGS in 8021 patients with kappa statistics, and we compared concordance rates from different centers. We assessed the effect of several clinical and pathological factors on the concordance rate with logistic regression analysis. The concordance rate for the entire population was 62.9%. Upgrading from bGS to pGS occurred in 27.3% of patients. The number of biopsies was significantly associated with concordance. Older age (>60 y), a higher clinical T stage (≥cT2), a higher PSA value at the time of biopsy (>10 ng/ml), and more time between the biopsy and the radical prostatectomy were significantly associated with a higher risk of upgrading. Positive margins and PSA relapse occurred more frequently in upgraded patients. Center size did not significantly affect the concordance rate (p = 0.40).This prospective, nationwide analysis demonstrated a Gleason score concordance rate of 62.9%. Upgrading was most frequently observed in the non-concordant group. We identified clinical and pathological factors associated with (non)-concordance. Upgrading was associated with a worse oncological outcome. Center volume was not associated with pathological accuracy.

Optimization of transurethral hyperthermia: number of treatments

OBJECTIVE

The optimal number of transurethral microwave hyperthermia (TUHT) treatments in patients with moderate to severe symptoms of benign prostatic hyperplasia (BPH) is not known. This study was designed to compare TUHT efficacy with the use of three versus six treatments.

METHODS

In a Phase II prospective trial during a three-month period, 28 poor surgical risk patients with moderate to severe prostatism were randomized to receive three or six TUHT sessions. TUHT treatments were given on an outpatient basis without sedation or anesthesia for sixty minutes at 915 MHz with the temperature controlled on the urethral surface at 45 degrees C.

RESULTS

Subjective improvement was obtained in 7 (50%) patients receiving three TUHT treatments and in 12 (86%) patients receiving six treatments. A greater degree of improvement in total symptom score (P = 0.01) and obstructive (P = 0.01) and irritative (P = 0.04) symptoms was also recorded in the 14 patients receiving six treatments compared to those treated with three TUHT sessions (P = 0.01). A posttreatment improvement in objective study parameters was recorded for both treatment groups. The 14 patients treated with six TUHT sessions, however, showed a better improvement in peak flow rates (51% vs. 8.4%, P = 0.003) and postvoiding residual volume compared to the 14 patients treated with three TUHT sessions (P = 0.10). Treatments were very well tolerated and no clinically significant toxicity was recorded. Of the 9 study patients who failed to respond to treatment, 1 patient was successfully retreated with TURP while 8 patients required an indwelling catheter.

CONCLUSIONS

In TUHT in poor surgical risk patients with BPH with the temperature controlled at 45 degrees C, six treatments were superior to three treatments, based on a higher incidence of subjective and objective improvement.

Treatment of patients with newly diagnosed metastatic hormone sensitive prostate cancer (mHSPC) in Belgium: a real world data analysis

INTRODUCTION

Abiraterone acetate + prednisone (AAP) and docetaxel have proven their efficacy in the treatment of patients with newly diagnosed metastatic hormone-sensitive prostate cancer (mHSPC) in clinical trials. However, real-world data are scarce. The goal of this study is to evaluate real-world data on the efficacy and safety of these therapies in mHSPC patients.

PATIENTS AND METHODS

Records of 93 patients from 21 different centres were retrospectively reviewed. Primary and secondary endpoints were radiographic and PSA progression-free survival (RPFS - PSA-PFS) and cancer specific and overall survival (CSS - OS), respectively. Adverse events (AEs) were evaluated according to the Common Terminology Criteria for Adverse Events version 5.0. Differences in oncological outcome and AEs were evaluated between three treatment groups: ADT only (N=26) - ADT + AAP (N=48) - ADT + docetaxel (N=19). Survival analysis was performed using Kaplan-Meier statistics.

RESULTS

Median RPFS was 13 months (95% confidence interval [CI]: 9-17) for ADT only, 21 months (95% CI: 19-23) for ADT + AAP and 12 months (95% CI: 11-14) for ADT + docetaxel (p = 0.004). The 1-year PSA-PFS, CSS and OS were 73.5%, 90.7% and 88.7%, respectively, with no significant differences between the three groups. Adverse events of grade 3 or higher were not observed more frequently.

CONCLUSION

Retrospective real-world data show a significantly longer RPFS for mHSPC patients treated with ADT + AAP compared to ADT only or ADT + docetaxel at short-term follow-up. This can aid in counselling of mHSPC patients in daily clinical practice.

[The significance of focal hypoechoic lesions in the peripheral zone of the prostate]

Hypoechoic lesions in the peripheral zone of the prostate gland are one of the commonest abnormalities at transrectal ultrasonography (TRUS). 90% of all carcinomas originating in the peripheral zone present as a hypoechoic lesion. Hypoechogenicity though is not specific, as many benign lesions are also hypoechoic. In this retrospective study, based on TRUS alone 57% of the hypoechoic lesions showed carcinoma in the biopsy core (43% of the biopsy cores were benign). The number of positive biopsies increased up to 75% when the hypoechoic lesion was palpable at digital rectal examination. 5.2% of the hypoechoic cancers would have been missed when non-palpable lesions would not have had a biopsy. When the hypoechoic lesion was associated with increased serum concentration of prostate specific antigen (PSA > 4 ng/ml) 74% of the biopsies were positive. 20% to 25% of all hypoechoic cancers would not have had a biopsy. The positive predictive value was 85% when the hypoechoic lesion was palpable at digital rectal examination and the PSA-concentration was > 4 ng/ml (and 90% when volume-adjusted PSA-parameter would have been applied).

Radical prostatectomy for localized prostate cancer

A retrospective analysis of 70 patients, undergoing a radical prostatectomy in 1989 and 1990 is reported. The value of computed tomography (CT) scanning in preoperative lymph node staging should be reconsidered. Evaluation of the resection margins is of utmost importance as is the distinction between capsular invasion, penetration and transgression. The etiology of local failure and its treatment are discussed.