P-477 Ovarian stimulation and PGT-A outcomes with random start letrozole protocol for fertility preservation in breast cancer patients

Study question

Data on random start letrozole ovarian stimulation (RSL) in breast cancer patients is scant. We studied RSL outcomes from a single-center with fertility preservation expertise.

Summary answer

RSL appears to result in high oocyte and embryo/blastocyst yield, with an age-appropriate aneuploidy rate.

What is known already

With increasing utility of neoadjuvant chemotherapy regimens in breast cancer, young women have limited time to undergo fertility preservation (FP) by oocyte or embryo cryopreservation. Random start stimulation protocols were developed to complete an ovarian stimulation cycle in the shortest time possible before cancer patients started chemotherapy. In addition, letrozole protocols were developed to mitigate the potential risks of high estrogen levels during ovarian stimulation in breast cancer patients. Even though both random start and letrozole supplemented ovarian stimulation have been studied individually, there is limited data on combining both strategies in random start letrozole (RSL) protocols.

Study design, size, duration

We reviewed our records from 2014 to 2021. We included the first FP cycle of all breast cancer patients undergoing RSL ovarian stimulation for oocyte or embryo cryopreservation. Cancer stages were grouped as 0-4, 0 being ductal carcinoma in situ (DCIS). Twenty-eight cycles met the criteria. Main outcome measures were number of oocytes retrieved and embryos cryopreserved. Secondary outcome measures were fertilization, blastocyst, and euploidy rates for the embryo cryopreservation group.

Participants/materials, setting, methods

Ovarian stimulation began on cycle days 3-26 with letrozole 5 mg/day initiated simultaneously with rFSH. The rFSH dose was based on age and antral follicle counts (AFC). Oocyte maturation was triggered with leuprolide acetate, rhCG or both 35h prior to retrieval.

Main results and the role of chance

The mean age was 33.5±4.9 years (range 26-40) and BMI 22.3±2.9(18.4-30.3). The mean breast cancer stage at FP was 1.7±0.9 (0-4), with 42.3% being stage-I disease. 77% of cases were estrogen receptor positive. AMH was 2.7±2.4 (0.16-7.9) and AFC 18.5±8.9(4-42). Ovarian stimulation began on cycle-day 13.7±7.3(2-26). 15(54%) cycles were started in the follicular and 13(46%) in the luteal-phase. The mean total rFSH dose was 3880±1615.4 IU(1275-8325) with a stimulation length of 11.8±2.4 days(8-19).

Mean oocytes retrieved were 16.4±6.9(1-36) with a maturity rate of 71.4±17.9%(35.7-94.4). From 13 patients, 10.4±4.7(1-22) oocytes were cryopreserved. Among the 15 patients proceeding to embryo cryopreservation, the fertilization rate was 96.9±6.8%(80-100), resulting in 7.1±4.4(1-15) embryos. 24 embryos were cryopreserved on day-3 and 82 as blastocysts. PGT-A was performed in 72% of the cases, with euploidy rate of 37.7±24.4%(0-63.6). There was no difference in oocyte or embryo yield between follicular and luteal start patients. Likewise, fertilization rates and euploidy rates were similar. The comparative results are summarized in Table 1.

To date, two patients conceived utilizing cryopreserved embryos. Both pregnancies resulted in healthy term babies.

Limitations, reasons for caution

Though our report is one of the largest series of RSL, it can be strengthened with longer follow up that includes pregnancy outcomes in a greater proportion of patients.

Wider implications of the findings

This is the first detailed report of the RSL protocol utility with PGT-A results in a breast-cancer population. RSL appears to result in high oocyte-yield, fertilization, and blastocyst formation rates, with age-appropriate euploidy. Additionally, the outcomes appear to be similar between patients undergoing follicular and luteal phase start RSL.

Trial registration number

not applicable

Individual-oocyte transcriptomic analysis shows that genotoxic chemotherapy depletes human primordial follicle reserve in vivo by triggering proapoptotic pathways without growth activation

Gonadotoxic chemotherapeutics, such as cyclophosphamide, can cause early menopause and infertility in women. Earlier histological studies showed ovarian reserve depletion via severe DNA damage and apoptosis, but others suggested activation of PI3K/PTEN/Akt pathway and follicle ‘burn-out’ as a cause. Using a human ovarian xenograft model, we performed single-cell RNA-sequencing on laser-captured individual primordial follicle oocytes 12 h after a single cyclophosphamide injection to determine the mechanisms of acute follicle loss after gonadotoxic chemotherapy. RNA-sequencing showed 190 differentially expressed genes between the cyclophosphamide- and vehicle-exposed oocytes. Ingenuity Pathway Analysis predicted a significant decrease in the expression of anti-apoptotic pro-Akt PECAM1 (p = 2.13E-09), IKBKE (p = 0.0001), and ANGPT1 (p = 0.003), and reduced activation of PI3K/PTEN/Akt after cyclophosphamide. The qRT-PCR and immunostaining confirmed that in primordial follicle oocytes, cyclophosphamide did not change the expressions of Akt (p = 0.9), rpS6 (p = 0.3), Foxo3a (p = 0.12) and anti-apoptotic Bcl2 (p = 0.17), nor affect their phosphorylation status. There was significantly increased DNA damage by γH2AX (p = 0.0002) and apoptosis by active-caspase-3 (p = 0.0001) staining in the primordial follicles and no change in the growing follicles 12 h after chemotherapy. These data support that the mechanism of acute follicle loss by cyclophosphamide is via apoptosis, rather than growth activation of primordial follicle oocytes in the human ovary.

Comparison of 1-year results of single transforaminal epidural steroid injection among patients with different spinal pathologies-related radicular pain

Aims

This study aims to investigate the effectiveness of transforaminal epidural steroid injection (TFESI) in patients with lumbar radicular pain or radiculopathy caused by different spinal pathologies.

Methods

One hundred and seventy seven patients who underwent single transforaminal epidural steroid injection were included in the study group and divided into 3 subgroups (central spinal stenosis + lateral recess stenosis, foraminal stenosis, lumbar disc herniation) according to existing spinal pathology. Patients' visuel analogue scale (VAS) measures and Oswestry Disability Index (ODI) scores were recorded and the patients who give favourable response to treatment were called respondents and who were not called as non-respondents. Subgroups were compared statistically at the end of 12 months.

Results

Sixty patients (33.9%) were considered as respondents and 117 patients (66.1%) were non-respondents in the entire study group. Patients with foraminal stenosis included the vast majority of the respondents and showed better results of pain relief as opposed to patients of other groups at the end of 12 months (P < 0.001).

Conclusion

TFESI was an effective treatment modality for pain relief and functional improvement in patients with foraminal stenosis. However, it could not produce the same results in patients with central spinal stenosis and lumbar disc herniations.

A Computational Statistics Approach to Evaluate Blood Biomarkers for Breast Cancer Risk Stratification

Breast cancer is the second leading cause of cancer mortality among women. Mammography and tumor biopsy followed by histopathological analysis are the current methods to diagnose breast cancer. Mammography does not detect all breast tumor subtypes, especially those that arise in younger women or women with dense breast tissue, and are more aggressive. There is an urgent need to find circulating prognostic molecules and liquid biopsy methods for breast cancer diagnosis and reducing the mortality rate. In this study, we systematically evaluated metabolites and proteins in blood to develop a pipeline to identify potential circulating biomarkers for breast cancer risk. Our aim is to identify a group of molecules to be used in the design of portable and low-cost biomarker detection devices. We obtained plasma samples from women who are cancer free (healthy) and women who were cancer free at the time of blood collection but developed breast cancer later (susceptible). We extracted potential prognostic biomarkers for breast cancer risk from plasma metabolomics and proteomics data using statistical and discriminative power analyses. We pre-processed the data to ensure the quality of subsequent analyses, and used two main feature selection methods to determine the importance of each molecule. After further feature elimination based on pairwise dependencies, we measured the performance of logistic regression classifier on the remaining molecules and compared their biological relevance. We identified six signatures that predicted breast cancer risk with different specificity and selectivity. The best performing signature had 13 factors. We validated the difference in level of one of the biomarkers, SCF/KITLG, in plasma from healthy and susceptible individuals. These biomarkers will be used to develop low-cost liquid biopsy methods toward early identification of breast cancer risk and hence decreased mortality. Our findings provide the knowledge basis needed to proceed in this direction.

Abstract PD6-06: Impact of BRCA mutations on chemotherapy-induced loss of ovarian reserve: A prospective longitudinal study

Background: The BRCA1/2 genes are key members of the ataxia-telangiectasia mutated (ATM)-mediated DNA double strand break (DSB) repair pathway. Recent research showed that germline mutations in these genes result in DNA repair deficiency in oocytes, leading to accelerated ovarian aging as manifested by lower ovarian reserve and earlier age at natural menopause. Because we discovered that oocyte DNA repair is similarly critical in chemotherapy-induced ovarian follicle loss, we hypothesized that women with pathogenic mutations in BRCA1/2 genes may experience larger declines in ovarian reserve after chemotherapy. To gauge the degree of the chemotherapy-induced ovarian damage, we utilized serum anti-mullerian hormone (AMH), which is the most reliable current marker for assessing oocyte reserve.

Methods: Women with early stage breast cancer were enrolled before chemotherapy (Trial registration number: NCT00823654) between January 2009 and November 2017. Sera were obtained at baseline, before the initiation of treatment, and 18 to 24 months after the completion of chemotherapy. Stored sera were assayed at once for anti-mullerian hormone (AMH) and the results were adjusted for the women's age at sample collection. Of the 235 enrolled, 117 evaluable women were stratified into three groups, those never tested (based on NCCN Guidelines V 1.2018 ; n=38) and those negative (n=65) or positive (n=14) for a pathogenic BRCA mutation. Ovarian recovery was defined as the geometric mean of the post chemotherapy age-adjusted AMH levels compared to baseline.

Results: Compared to the lower risk (BRCA-untested) control group, AMH levels averaged 76% and 66% in those negative or positive for BRCA mutations (p=0.078). The geometric mean recoveries for the three groups (not tested, BRCA negative and BRCA positive) were 3.7%, 5.2% and 1.6%, respectively. The mean recovery in the BRCA mutation positive group was about one-third the 4.6% recovery in the other two groups combined (two group ANOVA, p=0.034, F=4.89). Given the potential of the ovarian recovery to be dependent on type of chemotherapy, the data were reanalyzed for all three BRCA groups after restriction to those treated with the AC-T (doxorubicin and cyclophosphamide followed by paclitaxel) regimen. Of the 108 women in the previous analysis, 83 (77%) were treated with AC-T; 25, 46 and 12 women in the three groups, respectively. The geometric mean AMH recoveries for these new groups were 3.2%, 4.7% and 1.3%. When the BRCA mutation positive group was compared with other two groups, the former had significantly worse recovery of serum AMH levels (ANOVA, p=0.044, F=4.2).

Conclusions: These data show that women with breast cancer and pathogenic BRCA mutations have striking liability to chemotherapy-induced ovarian reserve loss and may have to be preferentially counselled on fertility preservation methods. In addition, taken together with the previous data showing that women with BRCA mutations may have accelerated ovarian aging, even unaffected reproductive age individuals may have to be proactive about family building or early preservation of their fertility (Supported by NIH R01HD053112).

Citation Format: Oktay K, Bedoschi G, Goldfarb SB, Taylan E, Titus S, Palomaki GE, Cigler T, Robson M, Dickler MN. Impact of BRCA mutations on chemotherapy-induced loss of ovarian reserve: A prospective longitudinal study [abstract]. In: Proceedings of the 2018 San Antonio Breast Cancer Symposium; 2018 Dec 4-8; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2019;79(4 Suppl):Abstract nr PD6-06.

Oocyte cryopreservation for fertility preservation in postpubertal female children at risk for premature ovarian failure due to accelerated follicle loss in Turner syndrome or cancer treatments

OBJECTIVE

To preliminarily study the feasibility of oocyte cryopreservation in postpubertal girls aged between 13 and 15 years who were at risk for premature ovarian failure due to the accelerated follicle loss associated with Turner syndrome or cancer treatments.

DESIGN

Retrospective cohort and review of literature.

SETTING

Academic fertility preservation unit.

PARTICIPANTS

Three girls diagnosed with Turner syndrome, 1 girl diagnosed with germ-cell tumor. and 1 girl diagnosed with lymphoblastic leukemia.

INTERVENTIONS

Assessment of ovarian reserve, ovarian stimulation, oocyte retrieval, in vitro maturation, and mature oocyte cryopreservation.

MAIN OUTCOME MEASURE

Response to ovarian stimulation, number of mature oocytes cryopreserved and complications, if any.

RESULTS

Mean anti-müllerian hormone, baseline follical stimulating hormone, estradiol, and antral follicle counts were 1.30 ± 0.39, 6.08 ± 2.63, 41.39 ± 24.68, 8.0 ± 3.2; respectively. In Turner girls the ovarian reserve assessment indicated already diminished ovarian reserve. Ovarian stimulation and oocyte cryopreservation was successfully performed in all female children referred for fertility preservation. A range of 4-11 mature oocytes (mean 8.1 ± 3.4) was cryopreserved without any complications. All girls tolerated the procedure well.

CONCLUSIONS

Oocyte cryopreservation is a feasible technique in selected female children at risk for premature ovarian failure. Further studies would be beneficial to test the success of oocyte cryopreservation in young girls.

Fertility preservation options in women with endometriosis

Endometriosis is a common, chronic condition in reproductive age women. Although some women may be asymptomatic, most women present with dysmenorrhea, dyspareunia, pelvic pain and/or infertility. Despite the fact that a causal relationship between endometriosis and infertility has not been clearly established, the fecundity rate of untreated women with endometriosis is lower than normal couples. However, suppressive medical therapy for endometriosis has not been shown to improve fecundity rates and may only result in a delay in the use of more effective treatments to achieve pregnancy. In the other hand, surgery for severe endometriosis can be useful to treat infertile women, but several studies reported a lower ovarian reserve after excision of ovarian endometriomas, due to incidental excision of normal ovarian tissue together with the endometrioma wall. Therefore, fertility preservation procedures should be considered to reproductive-age women at risk of impaired fertility related to endometriosis progression or endometriosis surgical treatment. The purpose of this document was to review the current literature regarding fertility preservation techniques for patients diagnosed with endometriosis.

Ovarian cryopreservation

Cryopreservation of ovarian tissue and future autotransplantation are new promising strategies for fertility preservation in various malignant and non-malignant diseases facing the risk of ovarian failure. Ovarian cortrical tissue pieces or intact whole ovary can be removed by laparoscopy without any significant delay in chemotherapy. Slow freezing and vitrification methods are developed to avoid damage to follicles. Ovarian tissue can be transplanted in an orthotopic or heterotopic location when the patient is cured from the disease. Autotransplantation can be performed if absence of malignant cells in the graft is confirmed. Although the procedures are still experimental, ovarian cryopreservation is the single option in prepubertal girls who have not sexual maturity. Earlier team approach of oncologists and reproductive endocrinologists may provide a more successful and professional way of fertility preservation.

Abstract P2-14-01: A Prospective Controlled Analysis of Fertility Preservation by Oocyte and Embryo Cryopreservation Using an Aromatase Inhibitor-Gonadotropin Protocol: Treatment Outcomes and Safety in Young Women with Breast Cancer

Objective: Breast Cancer (BCa) is the most common malignancy in reproductive age women and letrozole, an aromatase inhibitor, has been used to reduce estrogen exposure in women undergoing embryo/oocyte cryopreservation prior to chemotherapy. Our aim was to determine the long-term outcomes and safety of letrozole-FSH protocol. Design: Prospective

Materials and Methods: Women with stage 0-3 BCa underwent ovarian stimulation with letrozole 5-mg starting menstrual cycle day (CD)-2 and gonadotropins 150-450 IU, starting CD-4. Oocyte maturation was triggered either with human chorionic gonadotropin (hCG) or a Gonadoropin Releasing Hormone Agonist (GnRHa).

Results: Of the 129 women with mean age of 35.2±4.6, 13 vs. 91 underwent oocyte vs. embryo freezing, and 9 underwent both. Ovarian trigger with GnRHa (n=37/115, 32.2%) resulted in higher number of mature oocytes (10.9±6.6 vs. 8.4±6.0, p=0.045,). Of those, 21 underwent 25 frozen embryo transfers (mean age 35.5±4.5) with a clinical pregnancy (CP) rate of 68% and y per ET. CP rates were similar between the self-transfer and gestational carrier groups (7/9 vs. 10/16, p=0.37). No birth defects are encountered. Relapse rates were compared to a similar group of women with BCa (n=141, mean age 35.7±4.7, similar projected 10-year relapse rate at the outset by! adjuvant online) who elected to not to undergo ovarian stimulation. After a mean follow up of 2.4±1.6 vs. 2.9±1.7 years (range 8 mo - 5.6y vs. 4m-6.8y) women who had undergone ovarian stimulation with letrozole and FSH had a significantly lower recurrence rate [2.0% vs. 25.0%, Hazard ratio 0.08, 95%C.I. (0.06, 0.48), p=0.01]. Conclusions: This long term follow up of LF protocol for up to 7 years indicates that the protocol is safe, efficient and is associated with age-appropriate pregnancy success rates. Whether pretreatment with letrozole improves BCa treatment outcomes should be further investigated. Women with BCa can be safely offered this protocol when undergoing fertility preservation prior to chemotherapy.

Citation Information: Cancer Res 2010;70(24 Suppl):Abstract nr P2-14-01.