Thomas Zilli

The etiopathogenesis of prostate cancer (PCa) is complex and involves multiple hormonal and environmental factors. Among these, the role of infectious agents remains controversial. Human papillomavirus (HPV) is known to promote carcinogenesis in epithelial tumors and has also been detected, albeit inconsistently, in PCa tissues. This systematic review, meta-analysis, and real-world cohort study aimed to clarify the prevalence and the prognostic role of intratumoral (IT)-HPV detection in locally advanced and metastatic PCa. We performed a systematic literature search including studies reporting IT-HPV detection in locally advanced (LA-PCa) and metastatic PCa (mPCa). Pooled prevalence estimates were calculated using random-effects models. In parallel, HPV DNA was analyzed using archival tissue in a single-center real-world retrospective cohort of 196 metastatic PCa patients. Twenty-three records met the inclusion criteria, comprising 22 full-text publications and one Nineteen datasets, encompassing 837 patients, contributed to the quantitative synthesis of stage III–IV disease. Pooled IT-HPV prevalence in mPCa was 18.5% (95% CI, 6.4–34%), while including also LA-PCa was 14.6% (95% CI, 5.2–26.8). Eastern countries showed higher IT-HPV prevalence in both mPCa and LA-PCa (40% and 34.3%, respectively) compared with Western regions (0.8% and 0.3%; p < 0.0001). HPV-positive PCa was associated with a higher Gleason score (>7) in advanced stage (pooled OR 6.32, 95% CI, 3.13–12.78) compared with IT-HPV-negative PCa; however, no studies reported data on its association with survival outcomes. Within our retrospective cohort, IT-HPV DNA was detected in 3.1% of cases (6/196) and exhibited typical PCa driver alterations, such as TP53, SPOP, PIK3CA, and AR amplification. IT–HPV seems to be infrequent in metastatic and locally advanced PCa in Western populations and more prevalent in Asian cohorts and might be associated with a higher Gleason score. IT–HPV-positive advanced PCa seems to exhibit typical PCa driver alterations. Data on the association between IT–HPV status and survival outcomes in PCa are lacking. Standardized molecular assays and multicenter prospective studies are needed to delineate its significance in PCa.

Purpose: To evaluate the impact of PSMA PET versus conventional imaging for staging, and the effect of dose escalation (DE) to metastatic lymph nodes in cN1 prostate cancer patients treated with EBRT and ADT. Methods: A retrospective multicenter analysis included 197 propensity score-matched patients (77 staged with PSMA PET, 120 with conventional imaging) treated with EBRT and ADT, with or without DE to lymph node metastases. Matching criteria were T stage, nodal involvement, imaging modality, Gleason score, and ADT duration. Primary endpoint was metastasis-free survival (MFS); secondary endpoints included overall survival (OS), locoregional control (LRC), and toxicity. Results: Median follow-up was 42 months (IQR: 25–59). Median EQD2 (alpha/beta=1.5) to elective nodes was 46 Gy, and to metastatic nodes, 66 Gy (PSMA PET) and 63 Gy (conventional imaging). The 3-year MFS was 80.5% (95% CI: 71.3–90.8%) for PSMA PET and 77.2% (95% CI: 69.5–85.8%) for conventional imaging; 5-year MFS was 59.3% versus 65.8% ( P =0.57). OS at 5 years was 82.2% (PSMA PET) and 77.4% (conventional imaging) ( P =0.72). On multivariable analysis, ISUP grade group 3–5 predicted earlier metastasis (HR: 4.03, 95% CI: 1.61–10.06; P =0.003); higher prostate dose (EQD2 ≥113 Gy) improved MFS (HR: 0.53, 95% CI: 0.30–0.95; P =0.033); long-term ADT (≥24 mo) improved OS (HR: 0.38, 95% CI: 0.19–0.78; P =0.009). No significant difference in toxicity was observed between groups. Conclusions: PSMA PET staging and nodal dose escalation >60 Gy were safe but did not improve MFS, OS, or LRC. ISUP grade group 3–5 and higher prostate dose significantly influenced outcomes.

Background: Large Language Models (LLMs) have demonstrated expert-level performance across many medical domains, suggesting potential utility in clinical practice. However, their reliability in the highly specialized domain of moderate hyperthermia (HT) remains unknown. We therefore evaluated the performance of three modern LLMs in answering HT-related questions. Methods: We conducted an evaluation study by posing 40 open-ended questions—22 clinical and 18 physics-related—to three modern LLMs (DeepSeek-V3, Llama-3.3-70B-Instruct, and GPT-4o). Responses were blinded, randomized, and evaluated by 19 international experts with either a clinical or physics background for quality (5-point Likert scale: 1=very bad, 2=bad, 3=acceptable, 4=good to 5=very good) and for potential harmfulness in clinical decision-making. Results: A total of 1144 quality evaluation responses were collected. Overall reported mean quality scores were similar across models, with DeepSeek scoring 3.26, Llama 3.18, and GPT-4o 3.07, corresponding to an “acceptable” rating. Across expert evaluations, responses were considered potentially harmful in 17.8% of cases for DeepSeek, 19.3% for Llama, and 15.3% for GPT-4o. Notably, despite “acceptable” mean scores, approximately 25% of responses were rated “bad” to “very bad,” and potentially harmful answers occurred in ∼15–19% of evaluations, indicating a non-trivial risk if used without domain expertise. Conclusion: Our findings indicate that the performance of LLMs in HT in versions available at the time of investigation is only partially satisfactory. The proportion of poor-quality responses is too high and may lead non-domain experts to misinterpret the available clinical evidence and draw inappropriate clinical conclusions.