Treatment Option For Older Patients Research Articles

EFFICACY OF NERVE ROOT BLOCK FOR THE TREATMENT OF LUMBAR SPINAL CANAL STENOSIS IN ADULTS OLDER THAN 80 YRS OF AGE

Background: Patients with advanced lumbar spinal canal stenosis (LCS) often prefer non-operative treatment owing to decreased physiological function and comorbidities. Although the therapeutic value ofselective nerve root block (SNRB) for LCS is confirmed, there are few reports of its effectiveness in theelderly. We investigated the efficacy of SNRB for LCS in patients over 80 years of age. Methods: The subjects were 112 patients aged over 80 years (mean age: 84 years 45 men and 67 women)with medication-resistant LCS without cauda equina syndrome who underwent SNRB. Cases with acute-onset lumbar disc herniation were excluded. We retrospectively investigated and compared the presence orabsence of surgery, effect of SNRB, number of procedures, duration of disease, and magnetic resonanceimaging findings. Patients who could avoid the surgery by SNRB were defined as the effective group. Patientswhose symptoms were not relieved by SNRB and who underwent surgery and those whose symptoms werenot relieved but who continued conservative treatment were defined as the ineffective group. A total of oneto seven SNRBs were performed in both groups, and the same spine surgeon performed the entire procedurefrom SNRB to surgery. Results: There were 86 nonoperative patients (69 effective cases) and 26 operative patients the overall rateof effectiveness was 61% (69/112 patients). The area of the spinal canal at the responsible level was 108.63mm2in the effective group compared with 77.06 mm 2 in the ineffective group. This was significantlynarrower in the ineffective group (p=0.0094). There was no significant difference in the duration of illness,number of blocks, or hernia complication rate between the groups. No patient experienced severe neuralgiathat may have been caused by neuropathy during SNRB. Discussion: Our outcome showed that more than 60% of older patients with LCS showed symptomatic improvement with SNRB. SNRB can be performed relatively safely in the elderly and appears to be afavourable treatment option for older patients with various risks, such as poor general condition. Conclusions: Multiple sessions of SNRB may provide older patients with symptomaticimprovement and maybe an option for treatment.

A comparison of quality-adjusted life years in older adults after heart transplantation versus long-term mechanical support: Findings from the SUSTAIN-IT study

BackgroundThe quality-adjusted life year (QALY) measures disease burden and treatment, combining overall survival and health-related quality of life (HRQOL). We estimated QALYs in three groups of older patients (60-80 years) with heart failure (HF) who underwent heart transplantation (HT, with pre-transplant mechanical circulatory support [HT MCS] or HT without pre-transplant MCS [HT Non-MCS]) or long-term MCS (destination therapy). We also identified factors associated with gains in QALYs through 24 months follow-up. MethodsOf 393 eligible patients enrolled (10/1/15-12/31/18) at 13 U.S. sites, 161 underwent HT (n=68 HT MCS, n=93 HT Non-MCS) and 144 underwent long-term MCS. Survival and HRQOL data were collected through 24 months. QALY health utilities were based on patient self-report of EQ-5D-3L dimensions. Mean-restricted QALYs were compared among groups using generalized linear models. ResultsFor the entire cohort, mean age in years closest to surgery was 67 (standard deviation, SD: 4.7), 78% were male, and 83% were White. By 18 months post-surgery, sustained significant differences in adjusted average+SD QALYs emerged across groups, with the HT Non-MCS group having the highest average QALYs (24-month window: HT Non-MCS=22.58+1.1, HT MCS=19.53+1.33, Long-term MCS=19.49+1.3, p=0.003). At 24 months post-operatively, a lower gain in QALYs was associated with HT MCS, long-term MCS, a lower pre-operative LVEF, NYHA class III or IV before surgery, and an ischemic or other etiology of HF. ConclusionsDetermination of QALYs may provide important information for policy makers and clinicians to consider regarding benefits of HT and long-term MCS as treatment options for older patients with HF.

Abstract RF02-04: A phase III study comparing trastuzumab emtansine with trastuzumab, pertuzumab, and docetaxel in older patients with metastatic HER2-positive breast cancer. (JCOG1607 HERB TEA study)

Abstract Background A combination of trastuzumab, pertuzumab, and docetaxel (HPD) is recommended as first-line treatment for patients with HER2-positive metastatic breast cancer. For older patients, it is difficult to maintain a relative dose intensity, which often impairs their quality of life. A new standard treatment option for older patients is required with less toxicity and non-inferior efficacy compared to HPD. Methods The eligibility criteria were as follows: age 65 years and older, HER2-positive metastatic breast cancer, no previous systemic treatment with chemotherapy and anti-HER2 targeted drugs, ECOG PS 0–2 for 65–74 years or 0–1 for 75 years or older, and adequate organ function. Treatment consisted of trastuzumab emtansine (T-DM1) 3.6 mg/kg every 3 weeks or HPD (trastuzumab 8 mg/kg, then 6 mg/kg, pertuzumab 840 mg, then 420 mg/body, and docetaxel 60 mg/m2, could be escalated to 75 mg/m2 if there were no unmanageable toxicity) every 3 weeks after a 1:1 ratio randomization. The trial was designed to achieve 70% power to confirm the non-inferiority of T-DM1 to HPD at a one-sided alpha of 5% with a non-inferiority margin of 1.35 in terms of the hazard ratio (HR) for overall survival (OS) as the primary endpoint. With a median OS of 30 months in both arms, 6.5 years of accrual, and 5 years of follow-up, the planned sample size was 250. Secondary endpoints were progression-free survival (PFS), response rate (RR), adverse events, cumulative breast cancer-specific mortality (BCSM), safety, and deterioration of activities of daily living. (Clinical Trial Information: UMIN000030783). Results In total, 148 patients were enrolled between January 2018 and March 2023. A total of 135 patients were assessed in the preplanned first interim analysis. The median patient age was 72 years (range 65-88) in the T-DM1 arm and 71 (65-84) in the HPD arm. The proportion of estrogen receptor-positive (10%) patients was well balanced between both arms (49.3 and 55.6%, respectively). Of these patients, 64.8% had stage IV disease and 35.2% had recurrent disease. T-DM1 was not non-inferior to HPD (HR 1.487; 99.9% CI, 0.288 to 7.678) in terms of OS. The median PFS was 9.8 months in the T-DM1 arm and 18.4 months in the HPD arm (HR 1.749; 95%CI, 1.124-2.723). Response rates were lower in the T-DM1 arm than that of the HPD arm (52.7% [95% CI, 38.8-66.4] and 76.8% [95% CI, 63.6-87.0], respectively) (p=0.099). BCSM was higher in the T-DM1 arm than that of the HPD arm (HR 1.617; 95% CI, 0.764-3.425). Grade 3 and higher neutropenia were less common in the T-DM1 arm than in the HPD arm (0 vs. 30.4%); however, thrombocytopenia was more common in the T-DM1 arm than in the HPD arm (16.9 vs. 0%). Grade 3 or more non-hematological adverse events were less common and lower in the T-DM1 arm (35.2%) than in the HPD arm (58.6%), including fatigue (5.6% vs. 22.9%), diarrhea (0% vs. 11.4%), appetite loss (8.5% vs. 11.4%), and febrile neutropenia (0% vs. 10.0%), which reduced the quality of life in older patients with HER2-positive metastatic breast cancer. Conclusion T-DM1 was not non-inferior to HPD in terms of OS. However, T-DM1 showed better tolerability in terms of frequency and severity of adverse events. HPD will continue to be the standard of care as the first-line treatment for older patients with HER2-positive metastatic breast cancer. Older patients with breast cancer have heterogeneous health conditions. A subset analysis according to age or geriatric assessment may identify the subpopulation of older patients with HER2-positive metastatic breast cancer for whom T-DM1 is an optional treatment. Citation Format: Akihiko Shimomura, Kenji Tamura, Keita Sasaki, Ryo Sadate, Akihiko Suto, Masataka Sawaki, Naohito Yamamoto, Tomoyuki Yoshiyama, Takako Hayashi, Eriko Tokunaga, Takashi Yamanaka, Chikako Shimizu, Tadahiko Shien, Hiroji Iwata. A phase III study comparing trastuzumab emtansine with trastuzumab, pertuzumab, and docetaxel in older patients with metastatic HER2-positive breast cancer. (JCOG1607 HERB TEA study) [abstract]. In: Proceedings of the 2023 San Antonio Breast Cancer Symposium; 2023 Dec 5-9; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2024;84(9 Suppl):Abstract nr RF02-04.

Mechanisms of glutamate metabolic function and dysfunction in vascular dementia

AbstractAs the global population ages, research on the pathogenesis and treatment options for older patients with dementia has become increasingly important. Vascular dementia (VaD), the second most frequent type of dementia, is characterized by vascular impairment caused by inadequate blood supply to the brain. VaD is a complex neurological disorder involving multiple cells and signaling pathways, and its prevention and treatment pose clinical challenges with significant behavioral implications. Glutamate, the most abundant amino acid in the brain, plays a critical role as an excitatory neurotransmitter, impacting cognitive function, learning, and memory. Abnormal glutamate metabolism has been closely linked to dementia, and reduced blood flow to the brain can lead to excessive glutamate accumulation, resulting in neuronal death. This article highlights the connection between VaD and glutamate metabolism, aiming to identify better methods for preventing and treating VaD via regulating glutamate metabolism.

A nationwide analysis of the treatment patterns, survival, and medical costs in Korean patients with relapsed or refractory diffuse large B-cell lymphoma.

Approximately one-third of patients with diffuse large B-cell lymphoma (DLBCL) are refractory to treatment or experience relapse after initial therapy. Unfortunately, treatment options for older patients and those who experience relapse or become refractory to hematopoietic stem cell transplantation (HSCT) are limited. This nationwide population-based study aimed to identify treatment patterns, survival times, and treatment costs in patients with relapsed/refractory DLBCL (R/R DLBCL). Between 2011 and 2020, data on patients with R/R DLBCL were retrieved from the Korean Health Insurance Review & Assessment Service, encompassing the entire population. We identified the treatment patterns for each treatment line using a Sankey diagram and calculated the median time to the subsequent treatment in line. Median overall and progression-free survival times were estimated using the Kaplan-Meier survival curves. Finally, the medical costs incurred during DLBCL treatment were calculated for each treatment line and the costs related to HSCT were summarized at the episode level. A total of 864 patients with R/R DLBCL who received second-line treatment were identified, and a regimen of ifosfamide, carboplatin, and etoposide (ICE) was administered the most. Among them, 353 were refractory or relapsed cases that were treated with third-line treatments. The median times for second-line to third-line, third-line to fourth-line, fourth-line to fifth-line, and fifth-line to sixth-line treatment failures gradually decreased (3.93, 2.86, 1.81, and 1.38 months, respectively). The median overall survival time was 8.90 and 4.73 months following the second-line and third-line treatments, respectively. In the third-line treatment setting, the patients did not show a significant difference in survival time after HSCT. The median medical cost was $39,491 across all treatment lines including the cost of HSCT which was $22,054. The treatment patterns in patients with R/R DLBCL, especially at third-line treatments and thereafter, were complicated, and their prognosis was poor despite the high medical costs. Novel and effective treatment options are expected to improve the prognosis and alleviate the economic burden of patients with R/R DLBCL.

Older versus younger patients in robot-assisted radical cystectomy with intracorporeal ileal conduit comparing safety and clinical outcomes.

To evaluate the safety and efficacy of robot-assisted radical cystectomy using an intracorporeal ileal conduit in older compared to younger patients. We retrospectively analyzed 122 patients who underwent robot-assisted radical cystectomy with an intracorporeal ileal conduit at Fujita Health University Hospital and Fujita Health University Okazaki Medical Center between 2012 and 2022. Patients were categorized into two groups: older (age ≥ 75 years; n = 53) and younger (age < 75 years; n = 69). Perioperative outcomes, complications, recurrence-free survival, cancer-specific survival, and overall survival were compared between the cohorts. The groups had no significant differences in perioperative outcomes, such as estimated blood loss, operative time, and blood transfusion rate. However, hospital stay was longer in the older patients than in the younger group (19 vs. 16 days; p < 0.001). The 30-day minor and major complication rates were 33.3% and 13.0%, respectively, for the younger group and 50.9% and 9.4% for the older group (p = 0.11). Urinary tract infection and bowel ileus were the most common complications in both groups. No significant differences were observed in recurrence-free survival, cancer-specific survival, and overall survival between the groups (p = 0.58, p = 0.75, and p = 0.78), and subgroup analysis in ≥cT3 revealed the older group tended to have poorer cancer-specific survival and overall survival (p = 0.07 and p = 0.01). Multivariate analysis indicated that older age was not associated with high-grade complications and cancer-specific survival. Robot-assisted radical cystectomy with an intracorporeal ileal conduit is a safe and effective treatment option for older patients.

Utility and safety of robot-assisted radical cystectomy in older patients with bladder cancer

Introduction: This study aimed to investigate the efficacy and safety of robot-assisted radical cystectomy (RARC) in older patients with bladder cancer (BCa). Material and methods: We reviewed the clinical and pathological records of 110 patients with BCa who underwent RARC at Gifu University Hospital between February 2019 and January 2023. Older patients were defined as those with BCa aged ≥ 75 years. The enrolled patients were divided into two groups: those aged < 75 years (Group I) and those aged ≥ 75 years (Group II). Oncological outcomes, including overall survival (OS) and recurrence-free survival (RFS), were the primary endpoints of the study; the secondary endpoints were the surgical and pathological outcomes. Results: A shorter console time, less blood loss, and reduced time to postoperative fluid and food intake in Group II may be attributed to the fact that more patients opted for ureterocutaneostomy in Group II than in Group I. In all patients, the three-year OS and RFS rates were 84.7% and 88.5%, respectively. There were no significant differences in OS or RFS between the two groups. (p = .403, p = .963, respectively). Conclusions: RARC appears to be a safe and useful treatment option for older patients with BCa.

Primary Versus Secondary Total Knee Arthroplasty for Tibial Plateau Fractures in Patients Aged 55 or Over—A Systematic Review and Meta-Analysis

BackgroundTotal knee arthroplasty allows immediate postoperative weight-bearing and is increasingly recognized as a suitable treatment option for older patients who have tibial plateau fractures (TPFs). This systematic review evaluated the clinical and functional outcomes associated with primary versus secondary TKA for the treatment of TPFs in patients aged ≥55 years. MethodsVarious databases were searched from inception to December 2021. Studies investigating outcomes of primary TKA (pTKA) as the initial treatment for TPFs in patients of mean age ≥55 years or those investigating outcomes of secondary TKA (sTKA) following any other primary treatment for TPFs were included. Quality of included studies was assessed using a methodological scale. Of 767 potentially relevant studies, 12 studies comprising 341 patients were included: 121 patients underwent (pTKA) and 220 patients underwent sTKA. There were 3 high-quality studies. Patients in the sTKA cohort were significantly younger at the time of TKA compared with those undergoing pTKA (mean 61.3 versus 72.2 years, P < .001, 95% confidence interval (CI) 8.2 to 13.6). ResultsIntraoperative and postoperative complication rates were lower with pTKA; in particular, sTKA was associated with a significantly increased rate of stiffness requiring reintervention and patella tendon rupture. Functional outcome was greater after pTKA, but this did not reach statistical significance (85.2 versus 79.9%, P = .359, 95% CI -16.7 to 6.1). ConclusionPrimary TKA was associated with lower complication rates than secondary TKA after TPF. In appropriate cases of TPF in older adults, it may be preferable to proceed with TKA as primary treatment rather than delaying until after fracture union or malunion.

Safety and Efficacy of [177Lu]-PSMA-I&T Radioligand Therapy in Octogenarians with Metastatic Castration-Resistant Prostate Cancer: Report on 80 Patients over the Age of 80 Years.

177Lu-labeled prostate-specific membrane antigen (PSMA) radioligand therapy (RLT) is a new treatment option for metastatic castration-resistant prostate cancer (mCRPC). Its low toxicity profile favors use in elderly patients or in patients with critical comorbidities. The purpose of this analysis was to evaluate the efficacy and safety of [177Lu]-PSMA RLT in mCRPC patients at least 80 y old. Methods: Eighty mCRPC patients at least 80 y old underwent [177Lu]-PSMA-I&T RLT and were retrospectively selected. The patients were previously treated by androgen receptor-directed therapy, received taxane-based chemotherapy, or were chemotherapy-ineligible. The best prostate-specific antigen (PSA) response was calculated, as well as clinical progression-free survival (cPFS) and overall survival (OS). Toxicity data were acquired until 6 mo after the last treatment cycle. Results: Of 80 patients, 49 (61.3%) were chemotherapy-naïve and 16 (20%) had visceral metastases. The median number of previous mCRPC treatment regimens was 2. In total, 324 cycles (median, 4 cycles; range, 1-12) with a median cumulative activity of 23.8 GBq (interquartile range, 14.8-42.2) were applied. A PSA decline of 50% was achieved in 37 (46.3%) patients. Chemotherapy-naïve patients showed higher 50% PSA response rates than chemotherapy-pretreated patients (51.0% vs. 38.7%, respectively). Overall, median cPFS and OS were 8.7 and 16.1 mo, respectively. The median cPFS and OS of chemotherapy-naïve patients were significantly longer than those of chemotherapy-pretreated patients (10.5 vs. 6.5 mo and 20.7 vs. 11.8 mo, respectively, P < 0.05). A lower hemoglobin level and higher lactate dehydrogenase level at baseline were independent predictors of shorter cPFS and OS. Treatment-emergent grade 3 toxicities were anemia in 4 patients (5%), thrombocytopenia in 3 patients (3.8%), and renal impairment in 4 patients (5%). No nonhematologic grade 3 and no grade 4 toxicities were observed. The most frequent clinical side effects were grade 1-2 xerostomia, fatigue, and inappetence. Conclusion: [177Lu]-PSMA-I&T RLT in mCRPC patients at least 80 y old is safe and effective, comparable to previously published data on non-age-selected cohorts with a low rate of high-grade toxicities. Chemotherapy-naïve patients showed a better and longer response to therapy than taxane-pretreated patients. [177Lu]-PSMA RLT seems to be a meaningful treatment option for older patients.

Bisphosphonate use for glucocorticoid-induced osteoporosis in older patients with immune thrombocytopenia: a clinical perspective.

Prednisolone, used as a standard initial treatment for immune thrombocytopenia (ITP), is an important risk factor for osteoporosis. Recently, we found that prescription of bisphosphonate during initial loading of prednisolone may prevent reduction in bone mineral density and development of glucocorticoid-induced osteoporosis (GIO) in older patients with ITP receiving prolonged steroid therapy. In this review, I describe the treatment options for older patients with ITP, and present the best practices for screening, evaluating, and diagnosing ITP. I also summarize the literature from 2017 to 2022 on the treatment options for ITP, including discussions on the contraindications and side effects, with an emphasis on GIO, and the relative merits of bisphosphonates as a co-treatment for prevention of GIO. Finally, I present a perspective and an expert recommendation on how older patients with ITP would best be served in the future.

Rezum: a novel transurethral water vapor therapy for benign prostatic hyperplasia

Rezum: a novel transurethral water vapor therapy for benign prostatic hyperplasia

A comparison of the functional results and costs of functional cast and volar-flexion ulnar deviation cast at 2-year follow-up in 105 patients aged 65 and older with dorsally displaced distal radius fracture: A randomized controlled trial.

Non-operative treatment is the most common treatment option for older patients with distal radius fracture (DRF). Traditionally, wrists have been placed in volar-flexion and ulnar deviation position (VFUDC). In recent years, there has been a trend towards using a functional position cast (FC). However, long-term results for these different casting positions are lacking. This randomized, controlled, prospective study evaluates the functional results and costs of the 2 casting positions in patients 65 and older with DRF. Primary end point in this study was Patient-Reported Wrist Evaluation (PRWE) at 24 months, and secondary end points were cost-effectiveness of treatment, health-related quality of life measurement (15D), short version of Disabilities of arm, shoulder and hand score (QuickDASH), and VAS at 24 months. The trial was registered in ClinicalTrials.gov (NCT02894983, https://clinicaltrials.gov/ct2/show/NCT02894983). We enrolled 105 patients, of which 81 (77%) continued until 24-month follow-up. 8 patients (18%) were operated in the VFUDC group and 4 (11%) in the FC group. Patients in the VFUDC group also received more frequent physical therapy. The difference in PRWE score between the VFUDC and FC groups at 24 months was -4.31. The difference in the cost of treatment per patient was €590. Both findings favored FC. We found a slight, but consistent difference in the functional results between groups. These results suggest that VFUDC is not superior to FC when treating Colles' type DRF. Cost analysis revealed overall costs in the VFUDC group are nearly double those in the FC group, mostly due to more physical therapy, additional visits to hospital, and additional examinations. Therefore, we recommend FC in older patients with Colles' type DRF.

Factors associated with dose reduction of pirfenidone in patients with idiopathic pulmonary fibrosis: A study based on real-world clinical data.

Although pirfenidone slows disease progression in patients with idiopathic pulmonary fibrosis (IPF), in clinical practice, patients often cannot tolerate the recommended dose because of several adverse events. This study aimed to investigate adverse events associated with pirfenidone and factors associated with dose reduction. This single-center retrospective cohort study included 156 consecutive patients with IPF who received pirfenidone. Demographic characteristics, pulmonary function, and pirfenidone-related adverse events were investigated. We compared patients who received standard and reduced doses of pirfenidone. The mean patient age was 69.7 years. The median follow-up duration was 243 days. The low-dose group (n = 73) included older patients (71.0 years vs. 67.4 years, p = 0.016), fewer smokers (80.8% vs. 96.4%, p = 0.008), and patients with a lower body mass index (BMI; 24.1 kg/m2 vs. 25.7 kg/m2, p = 0.027) than the standard dose group (n = 57). Multivariate logistic regression analysis revealed that older age (odds ratio = 1.066, p = 0.016) was significantly associated with dose reduction of pirfenidone after adjusting for sex, smoking history, emphysema, and BMI. No significant difference was found in the rates of a reduced forced vital capacity and diffusing capacity for carbon monoxide between the two groups. Although older patients are more likely to undergo dose reduction of pirfenidone, low-dose pirfenidone might be effective for treating patients with IPF. Low-dose pirfenidone could be considered an effective treatment option for older patients with IPF.

S98 Ozanimod Efficacy and Safety in Older Patients With Ulcerative Colitis: A Post Hoc Analysis From True North

Background: Ozanimod is approved for the treatment of moderately to severely active ulcerative colitis (UC) in the US and EU. Older patients are understudied in IBD. This post hoc analysis from the phase 3 True North (TN) trial examined the efficacy and safety of ozanimod in patients aged < 60 y and ≥60 y. Methods: Patients were randomized to double-blind ozanimod 0.92 mg or placebo (Cohort 1) or received open-label ozanimod (Cohort 2) during the 10-week induction period. Clinical responders to ozanimod at Week (W) 10 were rerandomized to ozanimod or placebo for maintenance through W52. Efficacy endpoints were assessed at W10 and W52; adjusted treatment differences for ozanimod vs placebo were calculated using the Cochran-Mantel-Haenszel test. Treatment-emergent adverse events (TEAEs) and adverse events of special interest (AESIs) were also assessed. Results: Overall, 562 patients 2 x ULN. One death from acute respiratory distress syndrome due to viral pneumonia occurred during induction in an older patient (64 y) on ozanimod but was unrelated to treatment. Conclusion(s): Ozanimod is a safe, tolerable oral treatment option for older patients with UC without concerning serious AEs. Efficacy in older patients was comparable to younger patients. A key limitation of this study is the small sample size, warranting future studies with larger, real-world cohorts.

“EFFICACY OF NERVE ROOT BLOCK FOR THE TREATMENT OF LUMBAR SPINAL CANAL STENOSIS IN ADULTS OLDER THAN 60 YEARS OF AGE”

Background:- Patients suffering from Lumbar spinal canal stenosis usually complain severe low back pain with Radiculopathy that warrants immediate treatment. Decompression of the Lumbar spine for stenosis is a classical procedure that amiably responds by relieving the patient from the neurogenic claudication and radiculopathy. Patients suffering from lumbar spinal canal stenosis usually prefer conservative management due to diminished function and other associated comorbidities. Selective nerve root block or Transforaminal epidural injection for lumbar spinal canal stenosis is a well-known conservative treatment since a long time but only a handful of the cases conrm its effectiveness in the elderly patients. Our investigation was carried out to nd the efcacy of Selective nerve root block for lumbar spinal canal stenosis in elderly patients above age of 60 years. The research is prospective study been conducted from August 2020 to July 2022 a Methodology:- t the Orthopaedics Unit, Maheshwara Medical College &amp; Hospital, Chitkul, Patancheru, Telangana state. A total of 60 patients of both genders aged over 60 years with medicationresistant lumbar spinal canal stenosis without cauda equina syndrome were included in the study. Patients with acute lumbar disc herniation were excluded. We investigated the effectiveness of selective nerve root block, number of procedures, MRI ndings and duration of disease. Depending on duration &amp; severity of disease, we performed 1 to 7 selective nerve root blocks by same spine surgeon. Patients who responded well are termed as effective group and Patients whose symptoms were not relieved by selective nerve root block and went for surgery were named as ineffective group. Out of total 60 patients, there were 22 (36.6%) male and 38 (63.3%) Female patients Results:- in the study group with a male to female ratio of 1:7. 35 patients were satised with selective nerve root block documented by reduction in pain in Visual Analogue Scale. In our study the effectiveness of selective nerve root block was 58%. The cross-sectional area of lumbar canal stenosis in the effective group was 108.63 mm2 whereas ineffective group had 77 mm2. This shows statistically signicant narrower area of lumbar canal in ineffective group with P value of 0.001. Our patients didn't have severe neuralgia after selective nerve root block. Our Discussion: - study outcome revealed that more than 58% of elderly patients with lumbar spinal canal stenosis showed symptomatic relief with selective nerve root block. Selective nerve root block can be performed in a safer way in the elderly and is likely to be a preferable treatment option for older patients with various risks like poor general condition. Conclusions:- Transforaminal epidural injection or Selective nerve root block can be tried in multiple settings which provides symptomatic improvement in elderly patients above 60 years of age and may be an option for conservative treatment.

Long-Term Outcome of a Prospective Randomized Trial Comparing Continuous Lenalidomide/Dexamethasone with Lenalidomide/Dexamethasone Induction, MEL140 with Autologous Blood Stem Cell Transplantation and Single Agent Lenalidomide Maintenance in Patients of Age 60-75 Years with Newly Diagnosed Multiple Myeloma

Background: Lenalidomide/dexamethasone has been approved as a standard treatment in multiple myeloma and is applied preferentially in older patients with comorbidities. The addition of daratumumab to this therapy is the best treatment option today for patients who are not transplant eligible. Intensity-reduced high-dose melphalan (MEL140) with autologous transplantation also is an effective treatment option for older patients who are transplant eligible but may not tolerate full dose high-dose melphalan (MEL200). A combination of MEL140 with lenalidomide/dexamethasone potentially could produce a better outcome compared with lenalidomide/dexamethasone alone. Methods: In this trial (DSMM XIII; EudraCT-No: 2008-004083-39) patients of age 60-75 years with newly diagnosed multiple myeloma who had symptomatic and measurable disease were randomly assigned to either (A1) 3 cycles of lenalidomide (25 mg po d1-21/28d) with low-dose dexamethasone (40 mg po d1, d8, d15, d22/28d), followed by stem cell mobilization and then further lenalidomide/dexamethasone cycles until progression or (A2) 3 cycles of lenalidomide/dexamethasone as induction, followed by stem cell mobilization, intensity-reduced high-dose melphalan 140 mg/m2 (MEL140) (single or double) with autologous blood stem cell transplantation and lenalidomide maintenance with 10 mg daily until progression. At randomization, patients were stratified according to age (60-70 years vs 71-75 years) and ISS stage (I, II vs III). The primary endpoint was progression-free survival, and secondary endpoints included safety, response rates and overall survival. Here, we report the long-term outcome. Results: 348 patients were included into the study and 339 patients could be analysed per intention-to-treat (ITT). Patient characteristics were well balanced between treatment arms. For all patients, median age was 68 years (range 60 - 75), 29% were older than 70 years, 36.5% had ISS stage I, 35.6% ISS stage II, and 27.9% ISS stage III. After a median follow-up of 68 months, the median progression-free survival (PFS) was 40 months for A1 (169 patients) and 33 months for A2 (170 patients) (HR 1.16; p=0.19) in the ITT analysis. The median overall survival (OS) was 87 months for A1 and 96 months for A2 (HR 1.04; p=0.81). A prespecified per-protocol (PP) analysis was defined to include patients who received at least 6 months of study treatment (also including patients with progressive disease or death during this time period). In this PP analysis the median PFS was 42 months for A1 (139 patients) and 36 months for A2 (131 patients) (HR 1.15; p=0.27); the median OS was 89 months for A1 and 96 months for A2 (HR 1.01; p=0.96). In arm A2, 115 patients (68%) received one or two transplants. For transplanted patients, median PFS was 40 months and median OS was 114 months. Second primary malignancies (SPMs) were observed in 24 patients in arm A1 (skin 12, solid tumor 11, hematologic 1) and in 20 patients in arm A2 (skin 5, solid tumor 11, hematologic 4). Conclusion: In the intention-to-treat population, the combination of MEL140 with lenalidomide/dexamethasone induction and lenalidomide single agent maintenance was not superior to continuous lenalidomide/dexamethasone treatment. Subgroup analyses with a focus on the role of transplant will be presented at the meeting. Sponsor: Gesellschaft für Medizinische Innovation in der Hämatologie/Onkologie - GMIHO

An evaluation based on relative treatment intensity in older patients treated with reduced-dose R-THP-COP therapy for diffuse large B-cell lymphoma: A multicenter retrospective cohort study

IntroductionThe number of older patients with diffuse large B-cell lymphoma (DLBCL) is increasing. Although the standard treatment for newly diagnosed younger patients with DLBCL has been established, no consensus has been reached regarding the optimal chemotherapy intensity and regimen for older patients with DLBCL. In addition, no method for evaluating treatment intensity in retrospective studies when different numbers of chemotherapy courses are administered has been elucidated. Materials and MethodsA multicenter retrospective analysis was conducted to evaluate the outcomes of a reduced-dose R-THP-COP regimen, which included 30 mg/m2 of pirarubicin, in 54 patients with DLBCL who were aged ≥75. To assess treatment intensity, we defined the relative treatment intensity (RTI) as the number of courses administered multiplied by the relative dose intensity (RDI). ResultsThe estimated four-year overall survival rates (OS) of the patients aged 75–80 and ≥ 80 were 55.1% and 60.6%, respectively. There was no significant difference in four-year OS between these age groups. In our cohort, there was no significant difference in the estimated four-year OS between the patients who received reduced-dose R-THP-COP at an RDI of ≥61% and those that received it at an RDI of <61% (P = 0.35). On the other hand, the patients who received reduced-dose R-THP-COP at an RTI of ≥2.7 exhibited a significantly higher estimated four-year OS than those treated at an RTI of <2.7 (68.5% vs. 28.7%; P < 0.001). Multivariate analysis revealed that the RTI was a significant independent predictor of OS. The cumulative incidence of treatment-related mortality (TRM) at one year was 4.2% and 3.4% in the 75–80 and ≥ 80 age groups, respectively. The cumulative incidence of TRM was significantly worse among the patients with Charlson Comorbidity Index (CCI) scores of ≥2 than among those with CCI scores of 0 or 1. DiscussionOur study suggests that the reduced-dose R-THP-COP regimen is a suitable treatment option for older patients with DLBCL, especially those with CCI scores of <2. Our study also showed that the RTI may be a valuable tool for assessing treatment intensity in retrospective studies involving older patients.

Real-world Treatment Sequencing in Patients with Metastatic Castration-resistant Prostate Cancer: Results from the Prospective, International, Observational Prostate Cancer Registry

BackgroundProstate cancer has a multifaceted treatment pattern. Evidence is lacking for optimal treatment sequences for metastatic castration-resistant prostate cancer (mCRPC). ObjectiveTo increase the understanding of real-world treatment pathways and outcomes in patients with mCRPC. Design, setting, and participantsA prospective, noninterventional, real-world analysis of 3003 patients with mCRPC in the Prostate Cancer Registry (PCR; NCT02236637) from June 14, 2013 to July 9, 2018 was conducted. InterventionPatients received first- and second-line hormonal treatment and chemotherapy as follows: abiraterone acetate plus prednisone (abiraterone)-docetaxel (ABI-DOCE), abiraterone-enzalutamide (ABI-ENZA), abiraterone–radium-223 (ABI-RAD), docetaxel-abiraterone (DOCE-ABI), docetaxel-cabazitaxel (DOCE-CABA), docetaxel-enzalutamide (DOCE-ENZA), and enzalutamide-docetaxel (ENZA-DOCE). Outcome measurements and statistical analysisBaseline patient characteristics, quality of life, mCRPC treatments, and efficacy outcomes (progression and survival) were presented descriptively. Results and limitationsData from 727 patients were eligible for the analysis (ABI-DOCE n = 178, ABI-ENZA n = 99, ABI-RAD n = 27, DOCE-ABI n = 191, DOCE-CABA n = 74, DOCE-ENZA n = 116, and ENZA-DOCE n = 42). Demographics and disease characteristics among patients between different sequences varied greatly. Most patients who started on abiraterone or enzalutamide stopped therapy because of disease progression. No randomisation to allow treatment/sequence comparisons limited this observational study. ConclusionsThe real-world PCR data complement clinical trial data, reflecting more highly selected patient populations than seen in routine clinical practice. Baseline characteristics play a role in mCRPC first-line treatment selection, but other factors, such as treatment availability, have an impact. Efficacy observations are limited and should be interpreted with caution. Patient summaryBaseline characteristics appear to have a role in the first-line treatment selection of metastatic castration-resistant prostate cancer in the real-world setting. First-line abiraterone acetate plus prednisone seems to be the preferred treatment option for older patients and those with lower Gleason scores, first-line docetaxel for younger patients and those with more advanced disease, and first-line enzalutamide for patients with fewer metastases and more favourable performance status. The benefit to patients from these observations remains unknown.

Efficacy of Nerve Root Block for the Treatment of Lumbar Spinal Canal Stenosis in Adults Older Than 80 Years of Age.

Background: Patients with advanced lumbar spinal canal stenosis (LCS) often prefer non-operative treatment owing to decreased physiological function and comorbidities. Although the therapeutic value of selective nerve root block (SNRB) for LCS is confirmed, there are few reports of its effectiveness in the elderly. We investigated the efficacy of SNRB for LCS in patients over 80 years of age.Methods: The subjects were 112 patients aged over 80 years (mean age: 84 years; 45 men and 67 women ) with medication-resistant LCS without cauda equina syndrome who underwent SNRB. Cases with acute-onset lumbar disc herniation were excluded. We retrospectively investigated and compared the presence or absence of surgery, effect of SNRB, number of procedures, duration of disease, and magnetic resonance imaging findings. Patients who could avoid the surgery by SNRB were defined as the effective group. Patients whose symptoms were not relieved by SNRB and who underwent surgery and those whose symptoms were not relieved but who continued conservative treatment were defined as the ineffective group. A total of one to seven SNRBs were performed in both groups, and the same spine surgeon performed the entire procedure from SNRB to surgery.Results: There were 86 nonoperative patients (69 effective cases) and 26 operative patients; the overall rate of effectiveness was 61% (69/112 patients). The area of the spinal canal at the responsible level was 108.63 mm2 in the effective group compared with 77.06 mm2 in the ineffective group. This was significantly narrower in the ineffective group (p=0.0094). There was no significant difference in the duration of illness, number of blocks, or hernia complication rate between the groups. No patient experienced severe neuralgia that may have been caused by neuropathy during SNRB.Discussion: Our outcome showed that more than 60% of older patients with LCS showed symptomatic improvement with SNRB. SNRB can be performed relatively safely in the elderly and appears to be a favorable treatment option for older patients with various risks, such as poor general condition.Conclusions: Multiple sessions of SNRB may provide older patients with symptomatic improvement and may be an option for treatment.

Efficacy and safety of reperfusion treatments in middle-old and oldest-old stroke patients

IntroductionIntravenous thrombolysis (IT) and mechanical thrombectomy (MT) have significantly changed the clinical outcome of acute ischaemic stroke (AIS). Concerns about possible complications often reduce the use of these treatment options for older patients, preferentially managed with antiplatelet therapy (AT). Aim of this study was to evaluate, in a population of middle-old (75–84 years) and oldest-old (≥ 85 years) subjects, the efficacy and safety of different treatments for AIS (IT, IT + MT, MT or AT), mortality and incidence of serious complications.Patients and methodsAll patients aged over 75 years admitted for AIS in two Stroke Units were enrolled. The physician in each case considered all treatment options and chose the best approach. NIHSS and modified Rankin Scale (mRS) were obtained and differences between admission and discharge scores, defined as delta(NIHSS) and delta(mRS), were calculated. The relationship between delta(NIHSS), delta(mRS) and type of procedure was analysed with a GLM/Multivariate model. Differences in mortality and incidence of serious complications were analysed with the chi-square test.ResultsA total of 273 patients, mean age 84.07 (± 5.47) years, were included. The Delta(NIHSS) was significantly lower in patients treated with AT than in those treated with IT and MT (p < 0.009 and p < 0.005, respectively). Haemorrhagic infarction occurrence was significantly lower (p < 0.0001) among patients treated with AT (10.6%) or IT (16.7%) compared to MT (34.9%) or MT + IT (37.0%). No significant difference was observed for in-hospital mortality. Age did not influence the outcome.ConclusionsOur results suggest that IT and AT are effective and relatively safe approaches in middle-aged and older patients.