Moderate hypofractionated radiotherapy for prostate cancer: 3-year toxicity results of a multicentre randomized phase 3, non-inferiority trial

BACKGROUND AND PURPOSE

Moderate hypofractionated radiotherapy (HFRT) is a standard treatment for prostate cancer patients. We compared 2 moderate HFRT regimens, with a biologically equivalent dose of 80 Gy in 2 Gy fractions, with a modest simultaneous integrated boost to the dominant intraprostatic lesion.

MATERIAL AND METHODS

This is a multicenter, non-inferiority, randomized phase 3 trial with acute toxicity as the primary endpoint, comparing: 56 Gy in 4 weeks (16x3.5 Gy, 4 days/week, Arm A) with 67 Gy in 5 weeks (25x2.68 Gy, 5 days/week, Arm B). The H0 hypothesis is that both regimens are equivalent in terms of acute grade ≥ 2 gastro-intestinal toxicity, defined as a difference in acute grade ≥ 2 gastro-intestinal toxicity of ≤ 10 %. Here we report on acute and late toxicity.

RESULTS

We included 170 patients in Arm A and 172 patients in Arm B. The median follow-up time for all patients was 42 months. Acute grade ≥ 2 gastrointestinal toxicity was reported by 24 % of patients in both groups. Acute grade 2 and 3 urinary toxicity was observed in 52 % and 9 % of patients in Arm A and 53 % and 7 % in Arm B. Late grade 2 and grade ≥ 3 gastrointestinal toxicity occurred in 19 % and 4 % of patients in Arm A compared with 15 % and 4 % in Arm B. Late grade 2 and grade ≥ 3 urinary toxicity was observed in 37 % and 10 % of patients in Arm A and 36 % and 6 % in Arm B.

CONCLUSION

This analysis confirms that both HFRT regimens are safe and equivalent in terms of acute grade ≥ 2 gastrointestinal toxicity.

No difference in cumulative live birth rates between cleavage versus blastocyst transfer in patients with four or fewer zygotes: results from a retrospective study

STUDY QUESTION

Is the cumulative live birth rate (CLBR) per oocyte collection cycle (OCC) comparable after cleavage-stage or blastocyst-stage transfer in combination with supernumerary blastocyst vitrification on Day 5 (D5) in patients with four or fewer zygotes on Day 1?

SUMMARY ANSWER

The CLBR in a fresh blastocyst-transfer or cleavage-stage transfer policy followed by vitrification on D5 is comparable in patients with four or fewer zygotes.

WHAT IS KNOWN ALREADY

Blastocyst transfer enhances the self-selection of the embryo and shortens the time to pregnancy in patients with normal or high ovarian response. Whether these advantages are also present in patients with a low ovarian response and/or a limited number of available zygotes is a continuous debate.

STUDY DESIGN, SIZE, DURATION

This was a retrospective, observational cohort study of 2359 consecutive OCCs between January 2014 and December 2018. According to a shift in transfer policy in our center, 571 OCCs had been scheduled for a fresh transfer on Day 3 (D3) and 1788 on D5. The D5 group was matched to the D3 group by propensity score (PS) matching according to multiple maternal baseline covariates. After PS matching, there were 571 OCCs in each group.

PARTICIPANTS/MATERIALS, SETTING, METHODS

OCCs scheduled for a D3 transfer (n = 571) or for a D5 transfer (n = 1788) were matched by PS matching in a 1:1 ratio accounting for potential confounding factors associated with CLBR. The model included patient characteristics, such as maternal age and cycle rank, as well as treatment characteristics such as GnRH analog regimen and ovarian response. Embryological variables included the number of zygotes and the number of 6- to 7- and 8-cell embryos on D3. The delivery outcomes of the fresh treatment cycle and the consecutive vitrified-warmed embryo transfers were analyzed up to the first live birth. The primary endpoint of this study was CLBR per OCC. Secondary outcomes were live birth rate per fresh transfer and embryo implantation rate per transferred embryo.

MAIN RESULTS AND THE ROLE OF CHANCE

The CLBR per OCC was comparable between the D5 and D3 groups (16.8% versus 17.7%, respectively, P = 0.600). Live birth rates per OCC did not differ between a cleavage-stage transfer and blastocyst-stage transfer policy (15.2% versus 12.4%, respectively, P = 0.160). In the D5 group, 201 cycles did not result in a blastocyst to perform an embryo transfer or cryopreservation; in the D3 group, only 59 cycles did not have an embryo transfer because of poor embryo quality (35.2% versus 10.3%, respectively; P < 0.001). A significantly higher number of fresh double embryo transfers were performed in the D3 group compared to D5 (23.8% versus 7.0%, respectively, P < 0.001).

LIMITATIONS, REASONS FOR CAUTION

Although adjusted for important confounders in the PS matching, BMI and embryo quality of the transferred embryo(s) were not taken into account. This study is limited by its retrospective design and is a single-center study, which may limit the generalizability of our findings.

WIDER IMPLICATIONS OF THE FINDINGS

The CLBR in a fresh blastocyst-transfer or cleavage-stage transfer policy followed by vitrification on D5 is comparable. A fresh embryo transfer on D3 can still be considered in patients with a poor ovarian response and/or limited number of zygotes when combined with blastocyst vitrification without impacting the overall CLBR of the cycle.

STUDY FUNDING/COMPETING INTEREST(S)

No external funding was obtained for this study. There are no conflicts of interest to declare.

TRIAL REGISTRATION NUMBER

This retrospective study was approved by the local ethical committee at Ghent University Hospital (B 670201731234).

Anti-adhesion Gel versus No gel following Operative Hysteroscopy prior to Subsequent fertility Treatment or timed InterCourse (AGNOHSTIC), a randomised controlled trial: protocol

STUDY QUESTIONS

Does the application of anti-adhesion gel, compared to no gel, following operative hysteroscopy to treat intrauterine pathology in women wishing to conceive increase the chance of conception leading to live birth?

WHAT IS KNOWN ALREADY

Intrauterine adhesions (IUAs) following operative hysteroscopy may impair reproductive success in women of reproductive age. Anti-adhesion barrier gels may decrease the occurrence of IUAs, but the evidence on their effectiveness to improve reproductive outcomes is sparse and of low quality.

STUDY DESIGN SIZE DURATION

This multicentre, parallel group, superiority, blinded and pragmatic randomised controlled trial is being carried out in seven participating centres in Belgium. Recruitment started in April 2019. Women will be randomly allocated to treatment with anti-adhesion gel (intervention group) or no gel (control group). Sterile ultrasound gel will be applied into the vagina as a mock-procedure in both treatment arms. The patient, fertility physician and gynaecologist performing the second-look hysteroscopy are unaware of the allocated treatment. Power analysis, based on a target improvement of 15% in conception leading to live birth using anti-adhesion gel, a power of 85%, a significance level of 5%, and a drop-out rate of 10%, yielded a number of 444 patients to be randomised. The baseline rate of conception leading to live birth in the control group is expected to be 45%.

PARTICIPANTS/MATERIALS SETTING METHODS

Women of reproductive age (18-47 years), wishing to conceive (spontaneously or by fertility treatment) and scheduled for operative hysteroscopy to treat intrauterine pathology (endometrial polyps, myomas with uterine cavity deformation, uterine septa, IUAs or retained products of conception) are eligible for recruitment. Women may try to conceive from 3 to 6 weeks after receiving allocated treatment with follow-up ending at 30 weeks after treatment. If the woman fails to conceive within this timeframe, a second-look hysteroscopy will be scheduled within 2-6 weeks to check for IUAs. The primary endpoint is conception leading to live birth, measured at 30 weeks after randomisation. The secondary endpoints are time to conception, clinical pregnancy, miscarriage and ectopic pregnancy rates, measured at 30 weeks after receiving allocated treatment. The long-term follow-up starts when the patient is pregnant and she will be contacted every trimester.

STUDY FUNDING/COMPETING INTERESTS

This work is funded by the Belgian Healthcare Knowledge Centre (KCE). The anti-adhesion gel is supplied at no cost by Nordic Pharma and without conditions. Dr. Tomassetti reports grants and non-financial support from Merck SA, non-financial support from Ferring SA, personal fees and non-financial support from Gedeon-Richter, outside the submitted work. None of the other authors have a conflict of interest.

Blastocyst transfer for all? Higher cumulative live birth chance in a blastocyst-stage transfer policy compared to a cleavage-stage transfer policy

BACKGROUND

In an unselected patient population, what is the cumulative live birth rate per oocyte collection cycle in a blastocyst-stage transfer policy compared to a cleavage-stage transfer policy?

METHODS

A retrospective cohort analysis of 1656 IVF and ICSI cycles was performed in two timeframes between January 2010 and December 2016. Transfer was scheduled, either on day 3 (n=729) or on day 5 (n=927). In this study, the main outcome measure was cumulative live birth rate per oocyte collection cycle including fresh and frozen embryo transfers in both groups.

RESULTS

The cumulative live birth rates per oocyte collection cycle were comparable between patients with cleavage-stage transfers (day 3 group) and those with blastocyst-stage transfers (day 5 group) (23.7% versus 25.5%, respectively; p = 0.42). After controlling for confounders, there was a 34% increased chance of live birth with blastocyst-stage transfer policy compared with cleavage-stage transfer policy (odds ratio (OR) =1.34; 95% confidence interval (CI), 1.051 to 1.704; p = 0.018).

CONCLUSION

In an unselected patient cohort, the cumulative live birth chance per oocyte collection cycle is higher in a blastocyst-stage transfer policy compared to a cleavage-stage transfer policy.

Assay of Some Thromboplastin Generation Factors

A method for measuring six plasma or serum factors required for intrinsic thromboplastin formation is described by which various dilutions of normal serum are used to correct the abnormal TGT obtained with specifically deficient blood. When the arithmetic product of the minimum clotting time and the corresponding incubation time are plotted against the logarithm of the concentration of the particular factor in question, a rectilinear relationship is obtained for factors V, VIII, IX, XI and XII, and a hitherto unrecognized new serum factor (Thorium Vulnerable Factor, TVF). This correlation does not hold for factor X. Thus far no mathematical or biochemical equation could be formulated to explain the empiric observations.

Other reported assay procedures are discussed.

Immunoglobulin subclass determines ability of immunoglobulin (Ig)G to capture and activate neutrophils presented as normal human IgG or disease-associated anti-neutrophil cytoplasm antibody (ANCA)-IgG

Immunoglobulin G (IgG) is a potent neutrophil stimulus, particularly when presented as anti-neutrophil cytoplasm antibody (ANCA) in ANCA-associated vasculitis. We assessed whether IgG subclasses had differential effects on neutrophil activation and whether differences were dependent on specific Fc-receptor engagement. Using a physiologically relevant flow model, we compared adhesion of neutrophils to different subclasses of normal IgG coated onto solid surfaces, with adhesion of neutrophils treated with different subclasses of soluble ANCA IgG to P-selectin surfaces or endothelial cells (EC). Normal IgG captured flowing neutrophils efficiently in the order IgG3 > IgG1 > IgG2 > IgG4. Fc-receptor blockade reduced capture, IgG3 being more dependent on CD16 and IgG1/2 on CD32. Blockade of the integrin CD18 reduced neutrophil spreading, while inhibition of calcium-dependent signalling reduced both capture and spreading, suggesting that both were active processes. Neutrophils treated with ANCA IgG subclasses 1, 3 and 4 showed stabilization of adhesion to P-selectin surfaces and EC. ANCA changed neutrophil behaviour from rolling to static adhesion and the potency of the subclasses followed the same pattern as above: IgG3 > IgG1 > IgG4. Blockade of Fc receptors resulted in neutrophils continuing to roll, i.e. they were not ANCA-activated; differential utilization of Fc receptor by particular IgG subclasses was not as apparent as during neutrophil capture by normal IgG. IgG3 is the most effective subclass for inducing neutrophil adhesion and altered behaviour, irrespective of whether the IgG is surface bound or docks onto neutrophil surface antigens prior to engaging Fc receptors. Engagement of Fc receptors underpins these responses; the dominant Fc receptor depends on IgG subclass.

Altered Glut-2 accumulation and beta-cell function in mice lacking the exocrine-specific transcription factor, Mist1

Mist1 is an exocrine-specific transcription factor that is necessary for the establishment of cell organization and function of pancreatic acinar cells. While Mist1 is not expressed in the endocrine pancreas, the disorganized phenotype of the exocrine component may affect endocrine function. Therefore, we examined endocrine tissue morphology and function in Mist1-knockout (Mist1(KO)) mice. Endocrine function was evaluated using a glucose-tolerance test on 2-10-month-old female mice and revealed a significant reduction in glucose-clearing ability in 10-month-old Mist1(KO) mice compared with wild-type mice. Immunohistochemical analysis of islet hormone expression indicated that the decreased endocrine function was not due to a decrease in insulin-, glucagon- or somatostatin-expressing cells. However, a decrease in the size of islets in 10-month-old Mist1(KO) mice was observed along with a decrease in Glut-2 protein accumulation. These results suggest that the islets in Mist1(KO) mice are functionally compromised, likely accounting for the decreased glucose tolerance. Based on these findings, we have identified that the loss of a regulatory gene in the exocrine compartment can affect the endocrine component, providing a possible link between susceptibility for various pancreatic diseases.

Anti-endothelial cell antibodies from lupus patients bind to apoptotic endothelial cells promoting macrophage phagocytosis but do not induce apoptosis

OBJECTIVE

Anti-endothelial cell antibodies (AECA) have been reported to induce apoptosis. We investigated the induction of apoptosis by these autoantibodies and their involvement in the removal of apoptotic cells.

METHODS

AECA isolated from patients with active systemic lupus erythematosus (SLE) were incubated with human umbilical vein endothelial cells (HUVECs). AECA-positive sera were identified using a cell-based ELISA. Apoptosis was measured by morphology and phosphatidylserine externalization using flow cytometry with fluorescein isothiocyanate (FITC)-conjugated annexin V. Flow cytometry was used to investigate AECA binding to apoptotic cells using FITC-conjugated anti-human immunoglobulin G (IgG). Apoptotic endothelial cells were stained with a red dye (PKH26) and co-cultured with macrophages, and phagocytosis was visualized under phase contrast microscopy.

RESULTS

AECA from patients with SLE did not induce apoptosis compared with normal IgG (nIgG) at any time point, as assessed by morphology (at 24 h, P = 0.167) or phosphatidylserine externalization (at 24 h, P = 0.098). However, there was increased binding of AECA to apoptotic endothelial cells (48.8 +/- 11.9 compared with 25.8 +/- 6.7% AECA binding to freshly isolated cells, P< 0.001). These opsonized endothelial cells showed greater phagocytosis by macrophages (mean phagocytic index 24.9 +/- 4.5%) when cells opsonized with nIgG were compared with AECA (34.8 +/- 3.4% n = 5, P = 0.01).

CONCLUSION

In conclusion, AECA bind to apoptotic endothelial cells but do not induce endothelial cell apoptosis. Macrophage phagocytosis is increased by opsonization of apoptotic endothelial cells by AECA, a proinflammatory mechanism of cell removal.

Psychosocial variables, age, and angiographically-determined coronary artery disease in women

The present study explored the relationship between psychosocial measures and the degree of coronary stenosis in a sample of 59 women between the ages of 39 and 84. Coronary occlusion was correlated with elevated cholesterol and marginally correlated with age and was inversely associated with years of education. Based on hierarchical multiple regression, an interview-based measure of hostility was associated with coronary stenosis after controlling for traditional risk factors, and age moderated the hostility-stenosis relationship. Further, a second regression model suggested that trait anxiety was inversely correlated with degree of occlusion, perhaps because low-anxious women are referred for catheterization later in the course of the disease. Contrary to hypotheses, there was no evidence that repression of interview-based hostility or anxiety predicted coronary occlusion. Given the small sample size, results should be considered preliminary. Future studies should explore the degree to which anxiety and hostility are associated with coronary heart disease (CHD) in larger samples of women and the degree to which age moderates the hostility-occlusion association.

An ultrasensitive chemiluminoenzyme immunoassay for the quantification of human tissue kininogens: application to synovial membrane and cartilage

A sandwich enzyme immunoassay using a chemiluminescent detection has been developed for the quantification of total human (high and low molecular weight) kininogens in tissue extracts. This assay uses monospecific polyclonal IgG labelled with alkaline phosphatase and the commercially available dioxetane derivatives as substrates, for the detection of immune complexes. This method exhibits a sensitivity level of 1 fmol/ml and allows a precise quantification of total kininogens in synovium and cartilage extracts. When characterized by Western blot, the immunoreactive material reveals the presence of both high and low molecular weight kininogens.

Interpretation of Snow-Climate Feedback as Produced by 17 General Circulation Models

Snow feedback is expected to amplify global warming caused by increasing concentrations of atmospheric greenhouse gases. The conventional explanation is that a warmer Earth will have less snow cover, resulting in a darker planet that absorbs more solar radiation. An intercomparison of 17 general circulation models, for which perturbations of sea surface temperature were used as a surrogate climate change, suggests that this explanation is overly simplistic. The results instead indicate that additional amplification or moderation may be caused both by cloud interactions and longwave radiation. One measure of this net effect of snow feedback was found to differ markedly among the 17 climate models, ranging from weak negative feedback in some models to strong positive feedback in others.

Low incidence of thrombocytopenia with porcine mucosal heparin. A prospective multicenter study

We treated 193 patients either intravenously (94) or subcutaneously (99) for at least 5 days with porcine intestinal mucosal heparin and followed them up prospectively with frequent platelet counts to determine the incidence of heparin-related thrombocytopenia and arterial thrombosis. None of the patients in the study developed severe thrombocytopenia (platelet count, less than 100 x 10(9)/L) or arterial thrombosis. Eight patients had a platelet count of 100 to 140 X 10(9)/L on one occasion, with a count of greater than 140 x 10(9)/L on the subsequent measurement. The mean (+/- SD) values of the initial and lowest platelet counts during therapy in all patients were 288 +/- 100 x 10(9)/L and 253 +/- 88 x 10(9)/L, respectively, with the lowest counts occurring on day 4.1 +/- 4.2. A least-squares line was computed for each patient to fit the day and counts; the slopes were significantly different from zero and negative in 7.8% of patients and positive in 14.5%. This multicenter study confirms the reports that the incidence of heparin-related severe thrombocytopenia and arterial thrombosis is distinctly low in patients treated with porcine-mucosal heparin.

Activation of bovine factor VII by hageman factor fragments

During the early events of coagulation of human blood by the intrinsic pathway, factor XII is activated to a form which can activate factor XI, and is proteolytically fragmented to smaller species (30,000 daltons and 70,000 daltons) which have lost most of the ability to activate factor XI but which can activate prekallikrein rapidly. The effect of these fragments on factor VII was studied. It was found that these Hageman factor fragments promoted rapid proteolysis of one-chain factor VII to a more active two-chain form. The amino-terminal sequences of the chains of activated factor VII were found to be Ala-Asx-Gly- and Ile-Val-Gly-, the same as were earlier observed after activation of factor VII by activated factor X. This finding indicates that initiation of coagulation by the intrinsic pathway also primes the extrinsic pathway.

Germination of spores of Bacillus stearothermophilus induced by analogues of dipicolinate di-anion

The structural specificity required for induction of germination of spores of Bacillus stearothermophilus by analogues of dipicolinate in buffer at pH 5.5 is similar to that found previously with spores of Bacillus megaterium and calcium chelate salts at pH 8. 4H-pyran-2,6-dicarboxylate, but no other analogue tested, is as effective as dipicolinate di-anion.