BACKGROUND:Grade group 5 (GG5) prostate cancer (PCa) carries a less favorable prognosis after standard-of-care (SOC) therapy, necessitating novel therapeutic approaches. High-dose rate brachytherapy (HDRBT) and androgen deprivation therapy (ADT) may modulate immune response in GG5 PCa, particularly in tumors with increased immune content. This study evaluated whether the addition of nivolumab to SOC was associated with improved disease control in patients with high-volume GG5 PCa, including those with oligometastatic disease. METHODS:In this non-randomized phase II trial, 31 patients with localized or oligometastatic GG5 PCa and >30% positive biopsy cores were evaluated between September 2018 and April 2021. Patients received four doses of nivolumab (240 mg every 2 weeks) beginning 4 weeks prior to HDRBT, alongside ADT, HDRBT, and external beam radiation. The primary endpoint was to evaluate whether the 2-year freedom from biochemical recurrence (FFBR) rate would exceed a prespecified historical control rate of 75%. RESULTS:Among the 31 patients, the median follow-up was 38.8 months (IQR 31.0-46.5 months). The addition of nivolumab to SOC RT with ADT was associated with a 2-year FFBR rate of 90.3% (95% CI 74.3% to 98.0%) (median FFBR not reached), exceeding the prespecified historical control rate of 75% (one-sided p value from binomial test=0.024). Definitive and probable nivolumab-related toxicity included 6.3% acute grade 2 and 6.3% acute grade 3 adverse events (AEs), with no grade 4+ AEs observed. A higher Decipher immunosuppression score at diagnosis correlated with early pathologic response (p=0.005) and was independently associated with time to metastatic failure (p=0.044). CONCLUSIONS:Nivolumab combined with SOC was associated with encouraging FFBR in this high-risk GG5 PCa population and may represent a promising therapeutic intensification strategy. The Decipher immunosuppression score may serve as a predictive biomarker for response. These findings warrant further investigation in randomized trials.

Prostate Artery Embolization (PAE) is a novel minimally invasive angiographic technique that has been used effectively to treat men with lower urinary tract symptoms (LUTS) from benign prostatic hyperplasia (BPH). However, applications of PAE for men with prostate cancer have been minimally studied. This review serves as an update on the status of PAE in men with prostate cancer, as well as a discussion of emerging indications.

Pain from spinal metastases can result in significant impact to patients' quality of life. Conventional external beam radiation therapy (cEBRT) has long been shown to be effective in the pain control of patients with spinal metastases. With the advancement in radiation therapy, stereotactic body radiation therapy (SBRT) has been increasingly adopted for the treatment of spinal metastases. Multiple randomised controlled trials (RCT) have been performed to evaluate whether SBRT provides better pain relief compared to cEBRT. Previous meta-analyses showed that SBRT have significantly better complete pain response at 3 months compared to cEBRT. This report updates meta-analyses by incorporating the complete pain response data obtained from personal communication with the NRG Oncology Radiation Therapy Oncology Group (RTOG) 0631 principal investigator and the recently published RCT by Guckenberger et al. The results demonstrate that the results for complete pain response at 3 months have now changed and no longer favour SBRT. It is postulated that inconsistent definitions and reporting of study endpoints, specifically regarding vertebral compression fractures induced by radiation therapy, could be possible reasons for the difference in meta-analyses results. A consensus for standardizing study endpoints for future clinical trials in SBRT for painful bone metastases is needed to allow for better interpretation of study results.

Background: HPV infection is implicated in approximately half of global penile squamous cell carcinoma (PSCC) cases. Previous studies on HPV DNA and p16INK4a status in PSCC have yielded inconclusive prognostic findings. This meta-analysis aims to elucidate the prognostic role of HPV in PSCC by pooling data on disease-free survival (DFS), disease-specific survival (DSS), and overall survival (OS). Methods: We systematically searched Medline and Embase up to January 2023 for relevant human studies. Data from eligible publications reporting HPV DNA or p16INK4a status, along with and DFS, DSS, or OS outcomes, were extracted. A random-effects meta-analysis model was used to synthesize data, with study weights based on size and significance. The study protocol was registered with PROSPERO (CRD42019131355). Results: Out of 544 studies screened, 34 publications were included, comprising a pooled sample size of 3,944 patients. p16INK4a-positive status was associated with improved OS (hazard ratio [HR], 0.54; 95% CI, 0.39-0.75; I 2=31%), DFS (HR, 0.52; 95% CI, 0.29-0.94; I 2=20%), and DSS (HR, 0.34; 95% CI, 0.23-0.50; I 2=18%). HPV DNA positivity was significantly associated with improved DFS (HR, 0.63; 95% CI, 0.46-0.87; I 2=13%) and DSS (HR, 0.46; 95% CI, 0.29-0.75; I 2=47%) but not OS (HR, 0.92; 95% CI, 0.74-1.11; I 2=0%). Conclusions: This meta-analysis, comprising the largest number of patients with PSCC to date, shows a notable correlation between p16INK4a immunohistochemistry positivity and survival outcomes. These findings support the understanding that penile cancer cases not associated with HPV tend to behave more aggressively. We support p16INK4a immunohistochemistry testing as part of the initial diagnostic evaluation of patients with PSCC.

Background:Radiation therapy (RT) for prostate cancer has gastrointestinal and genitourinary toxicities, greater with baseline lower urinary tract symptoms (LUTS) and larger prostate volume (PV). Prostate artery embolization (PAE) improves LUTS and PV before RT. This study evaluates the durability of LUTS improvement from neoadjuvant PAE before prostate RT and oncologic outcomes. Methods:We retrospectively identified patients receiving definitive prostate RT following PAE from a prospective database, including International Prostate Symptom Scores (IPSS), pre- and post-PAE MRI PV, and toxicity per CTCAEv5.0. Primary objective was LUTS by IPSS. Secondary objectives included biochemical recurrence-free survival (bRFS), local recurrence, and distant metastasis. Results:From 9/2017-5/2024, 82 patients underwent PAE before RT, with 30.5 % having unfavorable intermediate risk. RT consisted of conventional fractionation (n = 21), moderate hypofractionation (n = 42), SBRT (n = 11), and EBRT/brachytherapy boost (n = 8); a subset of patients received androgen deprivation therapy. Pelvic lymph nodes were treated in 28 (34 %) patients. Median pre-PAE IPSS was 18 (range 2-34), PV 90 cc (14.2-240), and PSA 8.4 ng/mL (0.02-125.5). Post-PAE, mean IPSS reduction was 10.7 points (-13-30). Mean PV reduction was 30.9 cc (-9-136) or 32 %. PAE converted 52 % of patients contraindicated by size/IPSS for brachytherapy/SBRT. Post-RT, mean IPSS changes at 3, 6, 12, 18 and 24 months were -8.7, -8.5, -9.5, -8.9, and -7.6, respectively (p < 0.001). At 24.2-month median follow-up, 1 local recurrence occurred. Two-year bRFS was 92 % for non-metastatic patients. Conclusion:Urinary improvement is durable after RT in men with large prostates and/or high LUTS burden with neoadjuvant PAE, and no increased risk of recurrence at intermediate-term follow-up. Further investigation is warranted.

It is well recognized that melanoma has a predilection for brain involvement; however, its propensity of causing an intracerebral hemorrhage (ICH) has yet to be determined. The purpose of this current study was to describe the natural history of metastatic melanoma-associated ICH, and to evaluate its occurrence in the setting of prior whole-brain radiation therapy (WBRT) and stereotactic radiosurgery (SRS). Following institutional review board approval, a retrospective chart review was performed, including all patients with malignant melanoma treated at our institution, who suffered a secondary, tumor-associated brain hemorrhage. 1,120 patients with brain metastases secondary to melanoma were identified, and of those, 182 (16.3 %) were diagnosed with a tumor-associated brain hemorrhage. Of these 182 patients, 81 (44.5%) underwent testing for the presence of a BRAF mutation. In these patients, neither the type of radiation therapy (X2=3.03, p=0.082) nor BRAF mutation (X2=6.30, p=0.39) related to the development of ICH post radiation. Forty two (51.8%) of these patients experienced a brain bleed after radiation treatment; 31 (73.8%) had a BRAF mutation while 11 (26.2%) did not. BRAF status, mutant versus wild type (p<0.001, 95% CI 0.34-0.47), and the use of a BRAF inhibitor (p<0.001, CI 0.49-0.62) were both significantly associated with the time between radiation therapy and hemorrhage. Post-treatment ICH developed sooner in BRAF mutant patients (87.81 days versus 99.1 days) and in patients were treated with a BRAF inhibitor (71.92±1.66 days versus 125.00±2.80 days). While the frequency of tumor-associated ICH is likely not impacted by delivery of WBRT, the time between tumor-associated ICH and radiation therapy is associated with BRAF mutation and BRAF inhibitor treatment. Future studies ought to examine how BRAF mutation and other tumor and treatment-related factors contribute to post-treatment ICH.

Penile cancer is a rare neoplasm with heterogeneous prevalence influenced by risk factors such as smoking, poor hygiene and human papillomavirus (HPV) infection. Southern Africa, South America and Southeast Asia have the highest incidence of this disease. Penile squamous cell carcinomas (PSCCs) account for the majority of instances of penile cancer, with HPV-related carcinogenesis implicated in up to half of them. Increases in PSCC incidence in industrialized nations parallel the rising high-risk HPV infection rates, particularly HPV-16. Early-stage, localized PSCC is often manageable, but treatment options in advanced disease remain limited, with poor survival outcomes. Emerging evidence suggests that HPV-positive PSCC might exhibit unique therapeutic responses, including increased sensitivity to radiotherapy and chemotherapy, as has been observed in HPV-driven head and neck squamous cell carcinoma. Results of studies in HPV-positive PSCC demonstrate improved responses to chemoradiotherapy and immunotherapy, underscoring the potential for tailored treatments and de-escalation. Additionally, incorporating immunotherapy with radiotherapy in HPV-driven PSCC might provide greater oncological benefits than standard chemotherapy. These observations suggest that treatment strategies for HPV-positive PSCC might benefit from de-escalated chemoradiotherapy regimens or immunotherapy incorporation, potentially optimizing efficacy while minimizing toxic effects. Furthermore, biomarkers such as tumour mutational burden, programmed cell death ligand 1 expression, and genetic alterations could be crucial for predicting treatment response. Comprehensive biomarker assessment and accurate HPV status determination are essential for developing patient-tailored therapeutic strategies. These data provide evidence of the potential benefits of individualized approaches based on tumour biology and biomarker profiles. In this Review, the authors describe the intricate interplay of chemo-radio-immuno-sensitization in advanced penile squamous cell carcinoma with human papillomavirus (HPV) co-infections. By drawing parallels with other HPV-driven tumours, they provide arguments for the development of effective therapeutic strategies tailored to the unique characteristics of advanced penile squamous cell carcinoma with HPV co-infection.

PURPOSE:Radical cystectomy and trimodality therapy (TMT) are efficacious treatments for muscle invasive bladder cancer. Novel methods for post-treatment surveillance are needed to detect recurrence. This study assesses the value of plasma circulating tumor DNA (ctDNA) for detection of post-TMT recurrence. MATERIALS AND METHODS:We performed a retrospective ctDNA analysis in 32 patients with at least one post-TMT ctDNA measurement before any disease recurrence. Patients were stratified as post-TMT ctDNA (+) or ctDNA (-) and assessed for metastasis-free survival and recurrence-free survival (RFS) using Kaplan-Meier and Cox regression methods. RESULTS:At a median follow-up of 181 days (range: 24-522) after the first post-TMT ctDNA measurement, 4 patients (12.5%) were ctDNA (+) and 28 patients (87.5%) were ctDNA (-); 3 of 4 ctDNA (+) patients developed radiographic evidence of metastasis. All 28 ctDNA (-) patients were without metastasis. ctDNA positivity correctly identified all metastatic progression with 100% sensitivity and 93% specificity at 6-month post-TMT ctDNA surveillance. Furthermore, ctDNA-based detection preceded clinical detection of metastasis with a median lead time of 138 days. ctDNA (+) status was associated with worse metastasis-free survival (P < .0001) and RFS (P < .0001). In univariable analysis, ctDNA (+) status was the only variable significantly associated with worse RFS (HR 3.53, 95% CI: 1.11-11.53, P = .03). CONCLUSIONS:Plasma ctDNA is a potential biomarker for early detection of metastatic progression after TMT. Our hypothesis-generating findings provide a basis for larger studies to evaluate the utility of ctDNA-guided post-TMT surveillance.

To evaluate if the presence of penile intraepithelial neoplasia (PeIN) at the final surgical margin increases the risk of local recurrence in men with penile squamous cell carcinoma (PSCC) undergoing penile sparing surgery (PSS), we performed an analysis of our contemporary PSS database. After IRB approval, data was retrieved from our organizational PSS database. Surgical margin status was verified by a genitourinary pathologist and patients were divided into groups with negative margins and patients with PeIN at the final surgical margins. The primary endpoint of the study was local recurrence free survival. A total of 62 patients, including 34 with PeIN positive margins (55

Soft tissue sarcomas (STS) are radioresistant with a low α/β, which may have a biologic benefit with hypofractionation. For unresectable STS, the dose escalation required to achieve durable control is often limited by long-term toxicity risk. We sought to compare an isotoxic approach utilizing hypofractionated accelerated radiation dose-painting (HARD) versus standard fractionated radiation therapy (SFT) in patients with unresected STS. We conducted a retrospective analysis of patients with unresected STS who received either HARD (n = 49) or SFT (n = 43) with photon-based therapy between 1990 and 2022. The 2 HARD regimens each use 3 dose levels based on risk of disease burden. The gross disease, intermediate risk, and low-risk clinical target volumes were treated with either 20-22 fractions of 3/2.5/2-2.2 Gy or 28 fractions of 2.5/2.2/1.8 Gy. SFT included patients treated with definitive intent, receiving ≥ 50 Gy in 1.8-2 Gy per fraction. Clinical endpoints included 3-year local control (LC), overall survival (OS), and progression-free survival (PFS), along with treatment-related toxicity. With a median age of 67 and tumor size of 7 cm, most patients were stage IV (37 %), grade 3 (67 %), had no concurrent systemic therapy (70 %), and were lower extremity tumors (24 %). HARD cohort consisted of higher age, stage, recurrent disease, and median BED4 (p < 0.05), when compared to SFT. With a median follow-up of 35.9 months, HARD demonstrated significant improvement in 3-year LC (96.4 % vs. 48.4 %, p < 0.001), compared to SFT overall, with a median PFS benefit (16 vs. 10 months, p = 0.037) for non-distantly metastatic patients at baseline. On multivariate analysis, HARD was significantly associated with improved LC (HR 0.058, 95 % CI 0.005-0.682, p = 0.024). The HARD regimen found no significant increase in toxicity, with limited acute grade 3 (24 %, all dermatitis) and late grade 3 toxicity (6 %) observed, with no grade 4 or 5 events. HARD regimen significantly improves LC for unresectable STS without a significant increase in toxicity, when compared to a standard fractionated approach, supporting further prospective investigation of this treatment approach.

Objectives Stereotactic body radiotherapy (SBRT) is widely used for localized prostate cancer and implementation of MR-guided radiotherapy has the advantage of tighter margins and improved sparing of organs at risk. Here we evaluate outcomes and time required to treat using non-adaptive MR-guided SBRT (MRgSBRT) for localized prostate cancer at our institution. Methods From 9/2019 to 11/2021 we conducted a retrospective review of 80 consecutive patients who were treated with MRgSBRT to the prostate. Patients included low (LR) (5%), favorable intermediate (FIR) (40%), unfavorable intermediate (UIR) (49%), and high risk (HR) (6%). Short-term androgen deprivation therapy was used in 32% of patients. Target volumes included prostate gland and proximal seminal vesicles with an isotropic 3 mm margin. Treatment was prescribed to 36.25 Gy in 5 fractions every other day with urethral sparing. Hydrogel spacer was used in 18% of patients. Time on the linac was recorded as beam on time (BOT) plus total treatment time (TTT) including gating. Analyzed outcomes included PSA response and patient reported outcomes scored by the American Urological Association (AUA) questionnaire and toxicity per CTCAE v5. General linear regression model was used to analyze factors affecting PSA and AUA in longitudinal follow up, and chi-square test was used to assess factors affecting toxicity. Results Median follow up was 19.3 months (3.8 – 36.6). Median BOT was 4.6 min (2.6 – 7.2) with a median TTT of 11 min (7.6 – 15.8). Pre-treatment vs post-RT median PSA was 6.36 (2.20 – 19.6) vs 0.85 (0.19 – 3.6), respectively ( P < 0.001). PSA decrease differed significantly when patients were stratified by risk category, favoring LR/FIR vs UIF/HR group ( P = 0.019). Four (5%) patients experienced a biochemical failure (BCF), with a median time to BCF of 20.4 months (7.9 – 34.5). Median biochemical failure free survival (BCFFS) was not reached, with 2-yr and 4-yr BCFFS of 97.1% and 72.1%, respectively. Patients with LR/FIR disease had 100% 2-yr and 4-yr BCFFS, whereas patients with UIF/HR had 95% and 41% 2-yr and 4-yr BCFFS ( P = 0.05). Mean pre-treatment AUA was 7.3 (1 - 25) vs 11.3 (1 - 26) at first follow-up; however, AUA normalized to baseline over time. Urethral Dmax ≥35 Gy trended to lower AUA score at all follow-ups ( P = 0.07). Forty-one (51%) patients reported grade 1-2 genitourinary toxicities at the 1 month follow up. Grade 3 toxicity (proctitis) was noted in 1 patient. There was no decrease in any grade rectal toxicity with use of hydrogel spacer (3 vs 6, P = 0.2). No grade ≥4 toxicities was observed. Conclusions MRgSBRT has the potential for treatment adaptation but this comes at the cost of increased resource utilization. Our experience with non-adaptive MRgSBRT of the prostate highlights its short treatment times as well as efficacy with good PSA control and low toxicity profile.

Purpose/Objective(s) Stereotactic body radiation therapy (SBRT) represents a paradigm shift in the precision oncologic management of spinal metastases, leveraging advanced image-guidance and motion management techniques to deliver ablative doses with sub-millimetric accuracy. This study assesses the comparative efficacy and safety of various SBRT regimens for spinal metastases using a network meta-analysis (NMA) approach, integrating both direct and indirect evidence from randomized controlled trials (RCTs). Materials/Methods A comprehensive search of Ovid MEDLINE, Embase, and the Cochrane Central Register of Controlled Trials was conducted through March 1, 2023 to identify RCTs comparing SBRT with conventional external beam radiotherapy (cEBRT) in treating spinal metastases. The primary outcomes included overall and complete pain response, local tumor progression, and overall survival. Risk ratios (RR) and hazard ratios (HR) with 95% confidence intervals (CI) were estimated using a random-effects model. Heterogeneity was assessed with the Cochran Q and I² statistics, and the P-score method was employed to rank treatment efficacy. Results Three RCTs involving 642 patients were included. The SBRT regimens were 24 Gy in a single fraction, 24 Gy in 2 daily fractions, and 16 or 18 Gy in a single fraction, all compared against cEBRT. The regimen of 16 or 18 Gy in a single fraction showed a statistically significant lower overall pain response at 3 months compared to 24 Gy in 2 daily fractions (RR 0.58, 95% CI, 0.37–0.89; P = 0.013), with no significant differences at 6 months. Complete pain response at 3 and 6 months did not significantly differ across SBRT dose-fractionations, with data missing from one trial. Side effects were rare and similar across regimens, although 24 Gy in 2 fractions was associated with fewer compression fractures compared to 24 Gy in a single fraction (RR 0.11, 95% CI, 0.01–0.98; P = 0.047). There were no significant differences in local progression and overall survival at 6 months across fractionation regimens. Conclusion This NMA suggests that different SBRT regimens offer comparable safety profiles and efficacy for the treatment of spinal metastases, with specific dose-fractionations showing advantages in certain outcomes. These findings underscore the necessity of tailored treatment strategies to optimize patient outcomes. Future research should prioritize elucidating patient and disease characteristics that predict the most benefit from specific SBRT protocols, thereby enhancing personalized care in spinal metastases management.

With improving rates of survival among patients with metastatic malignancies, the request for palliative re-irradiation and re-re-irradiation continues to grow despite an absence of standardized guidelines. With only limited data regarding extra-cranial third-course palliative radiation, many radiation oncologists may feel uncomfortable proceeding with third-course irradiation of the same site. The review explores the available modern data regarding re-re-irradiation. A literature review identified four modern peer-reviewed studies investigating palliative, extra-cranial third-course irradiation with external beam radiation. These studies were retrospective, small, and heterogenous. While they reported comparable rates of pain palliation to first course irradiation and low rates of acute toxicity, interpretation is complicated by heterogeneous treatment parameters and insufficient reporting of cumulative dose equivalents and time intervals. With limited data available, it is critical to prioritize patient safety and quality of life in palliative radiotherapy. Patient selection should be meticulous, considering factors such as initial treatment response and predicted life expectancy. Conformal radiation techniques, strict immobilization, and daily image guidance should be employed to minimize toxicity to organs at risk (OARs). Long-term follow-up is essential for identifying and managing late toxicities effectively. Despite the scarcity of data, retrospective series suggest that extra-cranial third course irradiation can provide effective pain palliation comparable to first-course irradiation with tolerable rates of toxicity. However, careful consideration of patient prognosis and adherence to established principles of palliative radiotherapy are essential in decision-making. Further research and long-term follow-up are needed to refine treatment strategies and ensure safe and efficacious care delivery in this complex clinical scenario.

Centralization of care for penile cancer has been underscored in the 2023 updated EAU-ASCO guidelines. Expertise consolidation enhances patient care, addressing penile cancer complexities from diagnosis to treatment. Centralization initiatives, like the European Reference Networks, and dedicated scientific societies have crucial roles in guiding centralized care pathways to ultimately improve patient outcomes.

Penile squamous cell carcinoma (PSCC) is a rare and deadly malignancy. Therapeutic advances have been stifled by a poor understanding of disease biology. Specifically, the immune microenvironment is an underexplored component in PSCC and the activity of immune checkpoint inhibitors observed in a subset of patients suggests immune escape may play an important role in tumorigenesis. Herein, we explored for the first time the immune microenvironment of 57 men with PSCC and how it varies with the presence of human papillomavirus (HPV) infection and across tumor stages using multiplex immunofluorescence of key immune cell markers. We observed an increase in the density of immune effector cells in node-negative tumors and a progressive rise in inhibitory immune players such as type 2 macrophages and upregulation of the PD-L1 checkpoint in men with N1 and N2-3 disease. There were no differences in immune cell densities with HPV status.

Purpose/Objective(s) Survival outcomes of grade group 5 (GG5) prostate cancer (PCa) after standard of care therapy (SOC) remain poor. Evidence suggests that high-dose rate brachytherapy (HDR) and androgen deprivation therapy (ADT) can serve as immune modulators. We determine whether the addition of a checkpoint inhibitor (ICI) to SOC would synergize to improve disease control for GG5 PCa patients with or without oligometastatic disease. Materials/Methods The single-arm phase 2 trial accrued 34 patients between September 2018 and April 2021 with a data cutoff date of December 6, 2023. Patients had to have GG5 PCa with > 30% positive cores and receive ICI plus SOC regimen (ADT, HDR, and external beam RT [EBRT]). ICI (240 mg) was given every 2 weeks for 4 doses beginning 4 weeks prior to HDR. HDR consisted of 2 implants (1150 cGy). EBRT (4500 cGy/25 fractions) followed HDR. Biopsies were taken at time of diagnosis, HDR, and 1-month post HDR. Biopsy tumor samples underwent transcriptome profiling using the Decipher® Affymetrix platform. Major pathologic response (MPR) was defined as ≤ 1 positive cores. The primary endpoint was a 2-year freedom from biochemical recurrence (FFBR; as defined by NCCN) improvement to ≥ 90% from 75% with a one-sided alpha of 0.05 (binomial exact test). A separate contemporary control cohort consisted of all GG5 patients treated with trimodality between January 2013 and April 2021 that met study enrollment criteria. Additional statistical analyses consisted of Wilcoxon tests for transcriptome data, and Kaplan Meier log-rank (KM) and Cox univariable (UVA)/multivariable (MVA) analysis for clinical data. Results The primary endpoint was reached with a 2-year FFBR of 90.3% (P = 0.031). Median follow up and ADT length was 38 and 18 months, respectively. The addition of nivolumab resulted in a median KM FFBR of 58.6 months (95% CI not reached) and there were no disease or treatment related deaths. Compared to contemporary controls (n = 45), nivolumab demonstrated a 21.6% improvement in 3-year FFBR (90.4% vs. 68.8%, P = 0.032). Nivolumab (P = 0.009), > 18 months of ADT (0.037), and stage IVB (P = 0.030) were significant on 3-year FFBR MVA with control cohort. A higher Decipher® Ricketts Immunosuppression biomarker was associated with both early MPR (P = 0.012) and 3-month radiographic response (P = 0.021) for patients with intermediate/high Decipher® scores. Two patients (6.3%) experienced an acute grade 3 (autoimmune hepatitis and QT prolongation) toxicity related to nivolumab. Conclusion Nivolumab plus SOC for GG5 PCa demonstrated an improvement in 2-year FFBR to historic rate and was well tolerated. It was also associated with a 3-year FFBR improvement over a strictly defined external control cohort. Ricketts Immunosuppression was identified as a potential biomarker to predict favorable treatment response, contributing to the ongoing effort to optimize patient selection for ICI-based approaches. Our findings support further investigation with a larger randomized phase 2/3 study. Trial information: NCT03543189.

Background In graduate medical education (GME) residency programs, teaching interprofessional teaming is a desired skill for Radiation Oncology (RO) trainees. However, traditional curricula in RO centers around packed weekly schedules incorporating clinical oncology, radiation biology and radiation physics. A recent systematic review of Interprofessional Education (IPE) initiatives in RO was found to be lacking, suggesting novel and efficient ways of offering such activities are needed. Methods During the past 12 months, the Radiation Oncology Department designed a teamwork activity. Each staff member was asked to take a short survey to determine their "True Color" (TC) as an indicator of those preferred styles and traits that best characterize their working persona. At the Town Hall meeting following completion, colleagues from the Patient Experience Department came to debrief our group on the aggregate TC data. Our leadership curriculum development faculty wanted to then incorporate the TC diversity into a novel teaming class. The challenge, however, was how to package this efficiently in a one-hour time slot without pre-work that would be burdensome to our residents. Our leadership faculty reviewed the TC results and partnered with the Chairman of the GI Oncology Department to create a novel teaming exercise. Results After extensive thought ideation and iteration, we designed a one-hour class that was both didactic and interactive. We started with an introduction to teaming, reviewing data to explain why teaming is important in healthcare with respect to enhancing team performance, decreasing medical errors, and facilitating staff resilience. An 8-minute video describing the forming/storming/norming/performing stages of team evolution was then shown. Following this, the room was divided into two groups. One medical and one physics resident were picked as team captains. The leadership course director then created a scenario for each group, with instructions that each captain had to pick the best team for the assigned problem. Using the TC assessments, each captain then selected their team to brainstorm solutions with a faculty coach, one of whom was the surgical oncology Chairman of the GI Department and the other was the leadership course director. The entire course was completed in one hour with outstanding verbal attendee feedback. Discussion IPE to develop teaming and collaborative skills is needed in radiation oncology residency education. By incorporating a hybrid didactic/interactive one hour session with coaching, residents responded favorably to a RO team exercise. Further study and implementation are needed to evaluate the effectiveness of such activities.