The Rate of Prostatic Involvement in Men Treated With Radical Cystectomy for Muscle Invasive Bladder Cancer.

PURPOSE: Radical cystoprostatectomy (RC) is one standard treatment for muscle-invasive bladder cancer (MIBC) in male patients. Another therapeutic option is trimodal therapy. Including the prostate in the trimodal therapy radiation therapy volume is based on MIBC surgical series showing prostatic stromal (PS) involvement. Our aim was to establish the rate of pathologic PS involvement by preoperative T stage in men treated with RC for MIBC. METHODS AND MATERIALS: We conducted a retrospective review of men with MIBC treated with RC between 2006 and 2019. Electronic medical records were reviewed, and preoperative clinical staging data were collected. χ2 test was done to test for a statistically significant difference in the rate of prostatic involvement between clinical tumor (cT) stages. Preoperatively identified carcinoma in situ, lymph node involvement, tumor location, and urethral involvement were also analyzed to see if they conferred a higher risk of PS involvement. Multivariate analysis using multiple logistic regression was performed. RESULTS: We identified 283 men with bladder cancer treated with RC. Patients with non-MIBC or incomplete medical data were excluded (n = 72). We analyzed 211 patients, and 46 (22%) had pathologic PS involvement. PS involvement by preoperative T stage was cT2 = 18%, cT3 = 23%, and cT4 = 48%. Twenty-nine (12%) patients had clinical lymph node involvement, of whom 19 (76%) had PS involvement. Thirty-four (16%) had urethral involvement, of whom 17 (50%) had PS involvement. Sixteen percent and 17% of percent of clinical T2 and T3 patients had bladder neck/trigone tumors, of whom 57% and 50% had prostatic involvement. Clinical T2 and T3 were not statistically different with regards to PS involvement (P = .385). Preoperative urethral involvement, lymph node involvement, cT4, and bladder neck/trigone location were statistically significant predictors of pathologic PS involvement (all P < .05). On multivariate analysis, only clinical urethral involvement was significant (P < .0001). CONCLUSIONS: The high rate of pathologic PS involvement seen in cT2 patients and the lack of ability of cT stage to predict PS involvement support routinely treating the prostate in trimodal therapy. Patients with preoperatively identified bladder neck/trigone tumors, urethral involvement, positive lymph nodes, or prostatic involvement are a subset at even higher risk of having pathologic PS involvement.

Creation and Pilot-testing of Virtual Patients for Learning Oncologic Emergency Management.

Purpose or objective Management of oncologic emergencies becomes critical at the start of the second year of a radiation oncology residency. Considering the limited exposure to oncology in the medical school curriculum, this knowledge gap needs to be filled prior to managing real patients. The aim of this project was to create virtual patients (VPs) to ease this transition and improve learner readiness for independently managing oncologic emergencies on call. Material and methods A curriculum mapping exercise was done to identify gaps. The main oncologic emergencies that needed to be addressed were selected for development of the modules. Review of the key concepts for management was elucidated and validated. These included history, physical examination, imaging interpretation, staging, as well as anatomy, epidemiology, pertinent literature, differential diagnosis, prognostication, radiation treatment planning, summarizing, and patient- and peer-communication skills. Clinical vignettes were then designed, in collaboration with a virtual patient education expert, to mimic the clinical presentation and evolution of a typical patient for three common oncologic emergencies: spinal cord compression, superior vena cava syndrome, and tumor-induced hemorrhage. Results Three virtual modules were developed: spinal cord compression, superior vena cava syndrome, and tumor-induced hemorrhage. Each case included 25 to 30 vignettes that participants progressed through, with a total estimated completion time of 30 to 45 minutes. Each node branched out to provide a detailed answer and explanation of the key concept. Figures were included to mimic real patients and to provide a more authentic learning experience. The modules also included quantitative pre- and post-testing assessments, including multiple-choice questions, true or false, fill in the blank, short answers, and text response. The cases were then transcribed onto a virtual patient simulation platform. Following completion of the module, a report was generated for each individual learner to track all responses and used as the assessment tool. The pilot test showed an increase of 28% in the pre-to-post-test results in a cohort of nine residents. The mean pre-test result of 58% increased to a mean post-test result of 86% (range: 70-100%) after completing the three modules. Conclusion VPs can be used for learning the management of oncologic emergencies and can be done on a simulation-based learning platform. The modules can be used as both, a learning and an assessment tool for junior residents. The results of the pilot test show a significant improvement in knowledge acquisition between pre- and post-test scores after completion of the three modules.

Long-term Outcomes and Late Effects of Definitive Chemoradiotherapy in Patients with Cervical Cancer in Nova Scotia.

PURPOSE:  To determine the long-term oncologic outcomes and toxicity of patients treated with definitive chemo-radiotherapy for cervical cancer.  METHODS AND MATERIALS:  The study period was January 1, 2000 to December 31, 2009. All patients diagnosed with cervical cancer who received curative-intent chemoradiotherapy were included. Patients were excluded if they resided out of the province, received surgery as an initial treatment, or were treated with palliative intent. A retrospective chart review was performed. RESULTS: Four hundred and eighty-six patients were diagnosed with cervical cancer; 190 met eligibility criteria. Median follow-up for all patients was 3.2 years (interquartile range 1.1-5.6 years). Clinical stage was FIGO IIB or higher in 139 of 190 patients (73.2%). One hundred and fifty-eight (82.7%) received concurrent cisplatin chemotherapy (mean # cycles = 4.8). The most common external beam radiotherapy (EBRT) dose/fractionation schedule was 45 Gray (Gy) in 25 fractions (149 pts, 78.0%). One hundred and thirty-six (71.2%) received low-dose-rate (LDR) brachytherapy (BT: most common dose = 35 Gy). High-dose-rate (HDR) BT was implemented in 2008; the most common HDR dose was 24 Gy in 8 fractions over five days.  Five-year overall survival (OS) and progression-free survival (PFS) were 69.4% and 61.4%, respectively. OS and PFS were significantly higher in patients who received chemotherapy vs. radiotherapy alone. For those receiving HDR-BT, there was a significantly higher OS, but not PFS. The rate of late RTOG Grade 3/4 toxicity at five years was 23.3% (gastrointestinal - 26 events, 13% of patients; genitourinary - 13 events, 8% of patients). Fourteen patients had Grade 3 radiation proctitis as the only late toxicity. EBRT dose above 45 Gy was the only factor associated with late toxicity on multivariate analysis. CONCLUSION:  Outcomes of patients treated with chemoradiotherapy for cervical cancer are in keeping with those reported in other series. Chemotherapy improved OS and PFS. External beam radiotherapy dose above 45 Gy was the only predictor of late toxicity.