Achievement of Target Gain Larger than Unity in an Inertial Fusion Experiment

On December 5, 2022, an indirect drive fusion implosion on the National Ignition Facility (NIF) achieved a target gain G_{target} of 1.5. This is the first laboratory demonstration of exceeding "scientific breakeven" (or G_{target}>1) where 2.05 MJ of 351 nm laser light produced 3.1 MJ of total fusion yield, a result which significantly exceeds the Lawson criterion for fusion ignition as reported in a previous NIF implosion [H. Abu-Shawareb et al. (Indirect Drive ICF Collaboration), Phys. Rev. Lett. 129, 075001 (2022)PRLTAO0031-900710.1103/PhysRevLett.129.075001]. This achievement is the culmination of more than five decades of research and gives proof that laboratory fusion, based on fundamental physics principles, is possible. This Letter reports on the target, laser, design, and experimental advancements that led to this result.

Ten-Year Outcomes of Stereotactic Body Radiotherapy for Oligometastatic Breast Cancer: Does Synchronous Oligometastatic Breast Cancer Benefit?

AIMS

The benefit of stereotactic body radiotherapy (SBRT) in metachronous oligometastatic breast cancer (OMBC) has previously been described and its use in current clinical practice is established. The role of SBRT in the management of synchronous OMBC remains uncertain. The aim of this study was to compare outcomes of SBRT-treated synchronous OMBC with those of SBRT-treated metachronous OMBC.

MATERIALS AND METHODS

This was a retrospective analysis of consecutive extracranial OMBC patients treated with SBRT at a single institution between 2011 and 2022. Kaplan-Meier methods were used to calculate progression-free survival (PFS), overall survival, local control and distant control. Log-rank tests were used to test any differences. Cox regression was used for univariate and multivariate analyses to identify predictive factors. Toxicity was assessed using Common Terminology Criteria for Adverse Events (CTCAE) version 5.

RESULTS

In total, 74 OMBC patients with 113 lesions were analysed. The median follow-up was 20 months (range 0-98). Seventy per cent of patients presented metachronously and 30% synchronously. 30 Gy in three fractions was most commonly prescribed, resulting in a median biologically effective dose (BED at α/β = 10) of 60 Gy (range 35.7-112.5 Gy). Forty-nine per cent of patients switched systemic therapy post-SBRT (median time to switch: 14 months, range 0-79). Two patients (2%) experienced grade 3 acute toxicities with no grade ≥4 toxicities. At 2 years overall survival was 92.4% and PFS 39.0%, local control 85.9% and distant control 37.0%. For metachronous and synchronous disease, respectively, 2-year local control rates were 86.5% and 85.8% and PFS rates were 35.3% and 48.3%. The median PFS of metachronous and synchronous disease were 18 months and 17 months, respectively (P = 0.86). Predictive factors on multivariate analysis were treated site for overall survival, change in systemic therapy post-SBRT for PFS and BED for local control.

CONCLUSION

Our data confirm SBRT as a well-tolerated treatment for OMBC with excellent local control rates regardless of metachronous or synchronous presentation. There is no suggestion that survival outcomes are inferior for synchronous disease. Further prospective studies are required to validate this finding.

Predicting spontaneous preterm birth in asymptomatic high-risk women with cervical cerclage

OBJECTIVE

To determine the performance of the predictive markers of spontaneous preterm birth, cervicovaginal quantitative fetal fibronectin (fFN) and cervical length, in asymptomatic high-risk women with transabdominal, history-indicated or ultrasound-indicated cervical cerclage.

METHODS

This was a secondary analysis of a prospective cohort of asymptomatic high-risk women with cervical cerclage and no other prophylactic intervention (including progesterone), who attended the preterm birth clinic at a central London teaching hospital between October 2010 and September 2016. Women had either transabdominal cerclage, placed prior to conception, history-indicated cerclage, placed before 14 weeks' gestation, or ultrasound-indicated cerclage for a short cervix (< 25 mm), placed before 24 weeks. All women underwent serial cervical length assessment on transvaginal ultrasound in the second trimester (16-28 weeks), and quantitative fFN testing from 18 weeks onward. Test performance was analyzed for the prediction of spontaneous preterm birth before 30 weeks (cerclage failure), 34 weeks and 37 weeks, using receiver-operating-characteristics (ROC)-curve analysis.

RESULTS

Overall, 181 women were included in the analysis. Cervical length and fFN were strong predictors of spontaneous preterm birth before 30 weeks in women with cerclage, with areas under the ROC curve (AUC) of 0.86 (95% CI, 0.79-0.94) and 0.84 (95% CI, 0.75-0.92), respectively. Cervical length was a better predictor of preterm birth before 30 weeks in women with history-indicated compared to those with ultrasound-indicated cerclage, although both showed clinical utility (AUC, 0.96 (95% CI, 0.91-1.00) vs 0.79 (95% CI, 0.66-0.91); P = 0.01). Quantitative fFN was a strong predictor of spontaneous preterm birth before 30 weeks in women with history-indicated cerclage (AUC, 0.91 (95% CI, 0.75-1.00)) and retained clinical utility in those with ultrasound-indicated cerclage (AUC, 0.76 (95% CI, 0.64-0.89)). There were no spontaneous deliveries before 34 weeks in women with a transabdominal cerclage, so AUC was not calculated. Delivery was delayed significantly in this group (P < 0.01).

CONCLUSIONS

Cervical length and quantitative fFN retain clinical utility for the prediction of spontaneous preterm birth in women with cervical cerclage, and prediction is best in women with a history-indicated stitch. These tests can be relied upon to discriminate risk and have utility when planning clinical management with regard to treatment failure. © 2023 The Authors. Ultrasound in Obstetrics & Gynecology published by John Wiley & Sons Ltd on behalf of International Society of Ultrasound in Obstetrics and Gynecology.

Lawson Criterion for Ignition Exceeded in an Inertial Fusion Experiment

For more than half a century, researchers around the world have been engaged in attempts to achieve fusion ignition as a proof of principle of various fusion concepts. Following the Lawson criterion, an ignited plasma is one where the fusion heating power is high enough to overcome all the physical processes that cool the fusion plasma, creating a positive thermodynamic feedback loop with rapidly increasing temperature. In inertially confined fusion, ignition is a state where the fusion plasma can begin "burn propagation" into surrounding cold fuel, enabling the possibility of high energy gain. While "scientific breakeven" (i.e., unity target gain) has not yet been achieved (here target gain is 0.72, 1.37 MJ of fusion for 1.92 MJ of laser energy), this Letter reports the first controlled fusion experiment, using laser indirect drive, on the National Ignition Facility to produce capsule gain (here 5.8) and reach ignition by nine different formulations of the Lawson criterion.

Clinical characteristics with inflammation profiling of long COVID and association with 1-year recovery following hospitalisation in the UK: a prospective observational study

BACKGROUND

No effective pharmacological or non-pharmacological interventions exist for patients with long COVID. We aimed to describe recovery 1 year after hospital discharge for COVID-19, identify factors associated with patient-perceived recovery, and identify potential therapeutic targets by describing the underlying inflammatory profiles of the previously described recovery clusters at 5 months after hospital discharge.

METHODS

The Post-hospitalisation COVID-19 study (PHOSP-COVID) is a prospective, longitudinal cohort study recruiting adults (aged ≥18 years) discharged from hospital with COVID-19 across the UK. Recovery was assessed using patient-reported outcome measures, physical performance, and organ function at 5 months and 1 year after hospital discharge, and stratified by both patient-perceived recovery and recovery cluster. Hierarchical logistic regression modelling was performed for patient-perceived recovery at 1 year. Cluster analysis was done using the clustering large applications k-medoids approach using clinical outcomes at 5 months. Inflammatory protein profiling was analysed from plasma at the 5-month visit. This study is registered on the ISRCTN Registry, ISRCTN10980107, and recruitment is ongoing.

FINDINGS

2320 participants discharged from hospital between March 7, 2020, and April 18, 2021, were assessed at 5 months after discharge and 807 (32·7%) participants completed both the 5-month and 1-year visits. 279 (35·6%) of these 807 patients were women and 505 (64·4%) were men, with a mean age of 58·7 (SD 12·5) years, and 224 (27·8%) had received invasive mechanical ventilation (WHO class 7-9). The proportion of patients reporting full recovery was unchanged between 5 months (501 [25·5%] of 1965) and 1 year (232 [28·9%] of 804). Factors associated with being less likely to report full recovery at 1 year were female sex (odds ratio 0·68 [95% CI 0·46-0·99]), obesity (0·50 [0·34-0·74]) and invasive mechanical ventilation (0·42 [0·23-0·76]). Cluster analysis (n=1636) corroborated the previously reported four clusters: very severe, severe, moderate with cognitive impairment, and mild, relating to the severity of physical health, mental health, and cognitive impairment at 5 months. We found increased inflammatory mediators of tissue damage and repair in both the very severe and the moderate with cognitive impairment clusters compared with the mild cluster, including IL-6 concentration, which was increased in both comparisons (n=626 participants). We found a substantial deficit in median EQ-5D-5L utility index from before COVID-19 (retrospective assessment; 0·88 [IQR 0·74-1·00]), at 5 months (0·74 [0·64-0·88]) to 1 year (0·75 [0·62-0·88]), with minimal improvements across all outcome measures at 1 year after discharge in the whole cohort and within each of the four clusters.

INTERPRETATION

The sequelae of a hospital admission with COVID-19 were substantial 1 year after discharge across a range of health domains, with the minority in our cohort feeling fully recovered. Patient-perceived health-related quality of life was reduced at 1 year compared with before hospital admission. Systematic inflammation and obesity are potential treatable traits that warrant further investigation in clinical trials.

FUNDING

UK Research and Innovation and National Institute for Health Research.

The Impact of ApoE and FOXO3 Genotype on the Risk of Intracerebral Hemorrhage Among American Men of Japanese Ancestry

This study assessed the impact of APOE e2, e4 minor alleles and the FOXO3 longevity-associated genotype (carrier of SNP rs2802292 “G” allele) on 34-year incidence of intracerebral hemorrhage (ICH). Cox regression models were performed to assess the impact of the APOE e2, e4 and FOXO3 G alleles on the incidence of ICH. A total of 6483 participants were eligible for the analyses. 213 participants developed ICH. Cox-regression model showed neither APOE minor allele vs. common genotype (APOE e3/e3: RR 0.89, 95% CI: 0.64-1.22, p=0.46) nor FOXO3 G carrier status (RR 0.97, 95% CI: 0.72-1.29, p=0.82) was associated with incident ICH. Conversely, both hypertension (RR: 1.46, 95% CI: 1.07-2.00, p=0.02) and low cholesterol level (RR: 0.99, 95% CI: 0.99-1.00, p=0.001) were associated with incident ICH. Carriage of APOE e2 or E4 alleles and the FOXO3 G allele do not appear to impact risk of ICH over 34 years in this cohort.

What Can Proton Beam Therapy Achieve for Patients with Pectus Excavatum Requiring Left Breast, Axilla and Internal Mammary Nodal Radiotherapy?

AIMS

Exposure of the heart to radiation increases the risk of ischaemic heart disease, proportionate to the mean heart dose (MHD). Radiotherapy techniques including proton beam therapy (PBT) can reduce MHD. The aims of this study were to quantify the MHD reduction achievable by PBT compared with volumetric modulated arc therapy in breath hold (VMAT-BH) in patients with pectus excavatum (PEx), to identify an anatomical metric from a computed tomography scan that might indicate which patients will achieve the greatest MHD reductions from PBT.

MATERIALS AND METHODS

Sixteen patients with PEx (Haller Index ≥2.7) were identified from radiotherapy planning computed tomography images. Left breast/chest wall, axilla (I-IV) and internal mammary node (IMN) volumes were delineated. VMAT and PBT plans were prepared, all satisfying target coverage constraints. Signed-rank comparisons of techniques were undertaken for the mean dose to the heart, ipsilateral lung and contralateral breast. Spearman's rho correlations were calculated for anatomical metrics against MHD reduction achieved by PBT.

RESULTS

The mean MHD for VMAT-BH plans was 4.1 Gy compared with 0.7 Gy for PBT plans. PBT reduced MHD by an average of 3.4 Gy (range 2.8-4.4 Gy) compared with VMAT-BH (P < 0.001). PBT significantly reduced the mean dose to the ipsilateral lung (4.7 Gy, P < 0.001) and contralateral breast (2.7 Gy, P < 0.001). The distance (mm) at the most inferomedial extent of IMN volume (IMN to heart distance) negatively correlated with MHD reduction achieved by PBT (Spearman's rho -0.88 (95% confidence interval -0.96 to -0.67, P < 0.001)).

CONCLUSION

For patients with PEx requiring left-sided breast and IMN radiotherapy, a clinically significant MHD reduction is achievable using PBT, compared with the optimal photon technique (VMAT-BH). This is a patient group in whom PBT could have the greatest benefit.

Field comparison of a roof bolter dry dust collection system with an original designed wet collection system for dust control

Dust collectors for roof bolting machines generally use a dry box to collect the roof bolting material. Recently, an underground mining operation converted a dry box dust collector to a wet box dust collector with a unique exception from MSHA for testing purposes. Water is routed to the roof bolter from the main water line of the continuous miner. The wet box utilizes a water spray to wet the incoming material. Testing was conducted comparing the two different collector types. Respirable dust concentrations surrounding the roof bolter with the different collection boxes were similar. The main difference in respirable dust concentrations occurred when cleaning the dust boxes. The average respirable dust concentration during cleaning of the wet box was 0.475 mg/m3, and during the cleaning of the dry box, the average respirable dust concentration was 1.188 mg/m3, a 60% reduction in respirable dust concentration. The quartz content of the roof material was high, ranging from 28.9 to 52.7% during this study. The results from this study indicate that using the wet box as a collector reduced exposure to respirable dust up to 60% when cleaning the collector boxes.

Field investigation to measure airflow velocities of a ram dump car using circular routing at a Midwestern underground coal mine: a case study

Due to the successful application of roof bolter canopy air curtains (CACs) to protect roof bolter operators from high levels of coal mine respirable dust, a shuttle car CAC is currently being developed. Since a shuttle car consistently trams from the continuous miner to the feeder and back at a speed up to 9.66 kph (6 mph) or 2.68 m/s (528 fpm), it is thought that the shuttle car may encounter very high air velocities (mine ventilation air velocity + max shuttle speed (2.68 m/s (528 fpm)). Past research and preliminary lab testing showed that CAC protection in high interference air velocities is difficult to achieve. Therefore, testing was conducted at a Midwestern US coal mine to determine the air velocities their shuttle car actually encounters. This mine used ram dump cars as their shuttle cars. Results showed that coal mine dust exposure is generally very low at the feeder and when tramming. Elevated concentrations are encountered at the ram dump car operator position when the car is being loaded by the continuous miner. Recorded air velocities while tramming did not reach the max air velocity of mine ventilation air velocity + 2.68 m/s (528 fpm) calculated as 3.32 m/s (653 fpm). High velocities, while encountered, were of low frequency and associated with low respirable coal mine dust concentrations. Therefore, using this new information, designing the shuttle car CAC for maximum interference air velocity may not be as important as previously thought.

Field investigation to measure airflow velocities of a shuttle car using independent routes at a central Appalachian underground coal mine

Canopy air curtains on roof bolting machines have been proven to protect miners from respirable dust, preventing their overexposure to dust. Another desired application for canopy air curtains is in the compartments of shuttle cars. The challenges faced in developing the design of canopy air curtains for shuttle cars include mine ventilation rates in tandem with the shuttle car tram speeds. The resulting cab airspeeds may exceed 182 m/min (600 fpm), as found in the present study conducted in a central Appalachian underground coal mine by U.S. National Institute for Occupational Safety and Health (NIOSH) researchers. Prior research and laboratory testing had indicated that successfully protecting a miner in high air velocities is difficult, because the clean air from the canopy air curtain is unable to penetrate through the high-velocity mine air. In this study, the dust concentrations to which a shuttle car operator was exposed were measured, and air velocities experienced by the operator were measured as well using a recording vane anemometer. The results indicate that the highest exposure to respirable dust, 2.22 mg/m³, occurred when the shuttle car was loading at the continuous miner, where the average airspeed was 48 m/min (157 fpm). While tramming, the operator was exposed to 0.77 mg/m³ of respirable dust with an average airspeed of 62 m/min (203 fpm). This study indicates that a canopy air curtain system can be designed to greatly reduce an operator's exposure to respirable dust by providing clean air to the operator, as the majority of the operator's dust exposure occurs in air velocities slower than 61 m/min (200 fpm).

Complete excision with narrow margins provides equivalent local control to wider excision in breast conservation for invasive cancer

Background

Society of Surgical Oncology and American Society for Radiation Oncology guidelines define clear margins in breast-conserving therapy (BCT) as 'no ink on tumour', in contrast to the attainment of margins of at least 1 mm widely practised in the UK. The primary aim of this study was to explore clinical, surgical and tumour-related factors associated with local recurrence after BCT, with a secondary aim of assessing the impact of margin re-excision on the risk of local recurrence.

Methods

Patient demographics, surgical details, tumour characteristics and local recurrence were recorded for consecutive women with BCT undergoing surgery between January 1997 and January 2007. Margins were defined as clear (greater than 1 mm), close (less than 1 mm but no ink on tumour), reaches (ink on tumour) and clear after re-excision.

Results

A total of 1045 women of median age 54 (range 18-86) years were studied. Median follow-up was 89 (range 4-196) months. Local recurrence occurred in 52 patients (5·0 per cent). Ink on tumour was associated with local recurrence (hazard ratio (HR) 4·86, 95 per cent c.i. 1·49 to 15·79; P = 0·009). Risk of local recurrence was the same for close and clear margins (HR 1·03, 0·40 to 2·62; P = 0·954). In women with involved margins, re-excision was still associated with an increased local recurrence risk (HR 2·50, 1·32 to 4·72; P = 0·005). Oestrogen receptor negativity increased risk (HR 2·28, 1·28 to 4·06; P = 0·005).

Conclusion

Adequately excised margins, even when under 1 mm, provide equivalent outcomes to wider margins in BCT. Achieving complete excision at primary surgery achieves the lowest rates of local recurrence.

Laboratory testing of a shuttle car canopy air curtain for respirable coal mine dust control

Canopy air curtain (CAC) technology has been developed by the National Institute for Occupational Safety and Health (NIOSH) for use on continuous miners and subsequently roof bolting machines in underground coal mines to protect operators of these machines from overexposure to respirable coal mine dust. The next logical progression is to develop a CAC for shuttle cars to protect operators from the same overexposures. NIOSH awarded a contract to Marshall University and J.H. Fletcher to develop the shuttle car CAC. NIOSH conducted laboratory testing to determine the dust control efficiency of the shuttle car CAC. Testing was conducted on two different cab configurations: a center drive similar to that on a Joy 10SC32AA cab model and an end drive similar to that on a Joy 10SC32AB cab model. Three different ventilation velocities were tested-0.61, 2.0, 4.3 m/s (120, 400, and 850 fpm). The lowest, 0.61 m/s (120 fpm), represented the ventilation velocity encountered during loading by the continuous miner, while the 4.3 m/s (850 fpm) velocity represented ventilation velocity airflow over the shuttle car while tramming against ventilation airflow. Test results showed an average of the dust control efficiencies ranging from 74 to 83% for 0.61 m/s (120 fpm), 39%-43% for 2.0 m/s (400 fpm), and 6%-16% for 4.3 m/s (850 fpm). Incorporating an airflow spoiler to the shuttle car CAC design and placing the CAC so that it is located 22.86 cm (9 in.) forward of the operator improved the dust control efficiency to 51%-55% for 4.3 m/s (850 fpm) with minimal impact on dust control efficiencies for lower ventilation velocities. These laboratory tests demonstrate that the newly developed shuttle car CAC has the potential to successfully protect shuttle car operators from coal mine respirable dust overexposures.

Lipid-Lowering Effects of Fluvastatin in Renal Transplant Patients. A Clinical Observation

A Atherosclerosis-related cardiovascular disease remains an important cause of morbidity and mortality in renal transplant patients. We assessed the efficacy and safety of the newer synthetic HMG-CoA reductase inhibitor, fluvastatin, in 12 renal transplant patients who remained hypercholesterolemic, despite having been on the American Heart Association (AHA) Step I diet for 6 weeks. At 8 weeks, compared to the control phase, fluvastatin therapy, 20 mg/day, reduced the total cholesterol (TC) from 321 ± 57 [± SD] to 301 ± 123 mg/dl (p=0.3); low-density lipoprotein cholesterol (LDL-C), from 209 ± 56 to 176 ± 81 mg/dl (p=0.2); and the triglyceride (TG) levels from 343 ± 119 to 277 ± 117 mg/dl (p=0.06); all these changes were statistically insignificant. However, the therapy significantly increased the high-density lipoprotein cholesterol (HDL-C) from 37 ± 11 to 46 ± 13 mg/dl (p=0.006). During this short-term treatment period no adverse biochemical effects were noted with the therapy.

ATGAM Associated Coagulopathy in Renal Transplant Patients: A Report of Two Unusual Cases

Polyclonal antibodies, used for both induction and rejection therapy in renal transplant recipients, are associated with such side effects as chills and fever. We describe two patients who developed a coagulopathy during antithymocyte globulin (ATGAM) therapy, a previously unknown complication. The laboratory tests revealed prolonged prothrombin and partial thromboplastin times and thrombocytopenia. Discontinuation of ATGAM therapy resulted in correction of these abnormalities.

De novo Membranous Glomerulopathy in a Renal Transplant Patient Treated with FK 506. The First Reported Case

We describe a case of de novo membranous glomerulopathy in the renal allograft of a diabetic patient, treated with the newer immunosuppressive agent FK 506. Twenty-two months later this patient developed nephrotic range proteinuria.

Goodpasture's Syndrome Superimposed on Membranous Nephropathy. A Case Report

We describe a patient with idiopathic membranous glomerulopathy who developed acute deterioration in renal function; this was associated with hemoptysis, severe hypertension, and anti-glomerular basement membrane (anti-GBM) antibody in the serum. Despite aggressive therapy with plasmapheresis, cyclophosphamide and prednisone, the patient progressed to end-stage renal failure and is on maintenance hemodialysis.

Effects of dietary therapy on post renal transplant hyperlipidemia. A prospective study

Hyperlipidemia often occurs after renal transplantation and may contribute to increased cardiovascular morbidity. The National cholesterol education program guidelines (NCEP) recommend dietary modification as the initial therapeutic intervention. We evaluated the effects of the AHA Step I and Step II diets on the serum total cholesterol (TC) and the triglyceride (TG) levels in nondiabetic renal transplant patients. Both the AHA Step I (TC 296 ± 7 vs 294 ± 9 mg/dL, p = ns) and Step II diets (TC 282 ± 8 vs 292 ± 16 mg/dL, p = ns) failed to significantly lower the serum total cholesterol and the triglycerides levels. During this dietary intervention, the patients' body weight and serum creatinine level remained stable. Our data suggest that neither the AHA Step 1 nor the Step II diet are effective in significantly lowering elevated serum lipids in nondiabetic renal transplant recipients.

Involvement of Male-Specific Minor Histocompatibility Antigen H-Y in Epidermal Equivalent Allograft Rejection

This study describes the involvement of male-specific minor histocompatibility antigen H-Y in vitro cultured epidermal equivalent (EE) rejection. Male and female Balb/c or C3H/HeN keratinocytes were isolated and cultured separately. Male EE were grafted onto adult male (isografts) and adult female (H-Y allografts) mice. As controls, Balb/c EE were grafted onto adult C3H/HeN (complete allografts) mice. Fourteen, 21, and 30 days postgrafting, histological studies showed well-organized cutaneous tissues with complete basement membranes (laminin and type IV collagen deposition) in H-Y allografts compared to the isografts. This cutaneous organization was altered 150 days postgrafting, which is a sign of the H-Y EE allograft rejection. Complete allografts were totally rejected 21 days postgrafting. Immunological studies revealed leucocyte infiltration of H-Y allografts. Significant infiltration was detected even 150 days postgrafting. Leucocyte phenotyping revealed the presence of Mac-1+, CD8+ and CD4+ cells in the H-Y allografts. Humoral immune analysis revealed the presence of circulating anti-H-Y allogeneic keratinocyte cytotoxic antibodies in female recipient sera. Our data suggest that male-specific minor histocompatibility antigen H-Y induces cellular and humoral activation of the recipient immune system even after grafting EE free of cutaneous active immune cells such as T lymphocytes and Langerhans cells.

Initial UK Experience of Stereotactic Body Radiotherapy for Extracranial Oligometastases: Can We Change the Therapeutic Paradigm?

AIMS

To retrospectively review the toxicity and early outcome data from patients who have received stereotactic body radiotherapy (SBRT) for extracranial oligometastases at a single UK institution.

MATERIALS AND METHODS

Eligible patients had ≤3 extracranial metastases and performance status ≤2. Prior systemic therapy and radical treatment of oligometastastic relapse with any standard treatment modality was permitted. Patients with synchronous metastatic disease were excluded unless they had evidence of controlled primary disease after radical therapy. Follow-up consisted of clinical examination, biochemical and radiological assessments in accordance with standard clinical care. Progression events were defined using RECIST. Toxicity was evaluated using CTCAE v4.0. Local control, progression-free survival (PFS), freedom from widespread distant metastasis (defined as disease not amenable to further radical salvage therapy) and overall survival were calculated.

RESULTS

Between July 2011 and April 2014, 73 patients with 87 metastases received SBRT (range 1-3 per patient). The median follow-up was 14.5 months (range 0-26.4). The median PFS was 14.5 months (1 year PFS 57%, 2 year 28%); 1 year overall survival 96%, 2 year 79.8%; 2 year local control 88%. At 2 years, 46% of patients were free from widespread distant metastases. No ≥ grade 3 acute or late toxicity was observed.

CONCLUSION

At this time point, observed toxicity is minimal with excellent local control rates. This promising treatment paradigm requires further investigation in the context of a randomised controlled trial to establish if the addition of SBRT to standard care improves survival outcomes.

Urine homogentisic acid and tyrosine: simultaneous analysis by liquid chromatography tandem mass spectrometry

Alkaptonuria (AKU) is a rare debilitating autosomal recessive disorder of tyrosine metabolism. Deficiency of homogentisate 1,2-dioxygenase results in increased homogentisic acid (HGA) which although excreted in gram quantities in the urine, is deposited as an ochronotic pigment in connective tissues, especially cartilage. Ochronosis leads to a severe, early-onset form of osteoarthritis, increased renal and prostatic stone formation and hardening of heart vessels. Treatment with the orphan drug, Nitisinone, an inhibitor of the enzyme 4-hydroxyphenylpyruvate dioxygenase has been shown to reduce urinary excretion of HGA, resulting in accumulation of the upstream pre-cursor, tyrosine. Using reverse phase LC-MS/MS, a method has been developed to simultaneously quantify urinary HGA and tyrosine. Using matrix-matched calibration standards, two product ion transitions were identified for each compound and their appropriate isotopically labelled internal standards. Validation was performed across the AKU and post-treatment concentrations expected. Intrabatch accuracy for acidified urine was 96-109% for tyrosine and 94-107% for HGA; interbatch accuracy (n=20 across ten assays) was 95-110% for tyrosine and 91-109% for HGA. Precision, both intra- and interbatch was <10% for tyrosine and <5% for HGA. Matrix effects observed with acidified urine (12% decrease, CV 5.6%) were normalised by the internal standard. Tyrosine and HGA were proved stable under various storage conditions and no carryover, was observed. Overall the method developed and validated shows good precision, accuracy and linearity appropriate for the monitoring of patients with AKU, pre and post-nitisinone therapy.

Abstract P4-12-10: Safety of pertuzumab (P) with trastuzumab (T) and docetaxel (D) in patients (pts) from Asia with HER2-positive metastatic breast cancer (MBC): Results from the phase III trial CLEOPATRA

Background: CLEOPATRA is a phase III study of placebo (Pla)+T+D and P+T+D in HER2-positive first-line MBC. The combination of both HER2-targeted antibodies, P+T, with D resulted in significantly improved progression-free survival (PFS) and overall survival (OS). The incidence of febrile neutropenia (FN) was higher with P+T+D versus Pla+T+D. We present analyses of adverse events (AEs) and treatment patterns for pts from Asia.

Methods: Pts were from Asia, Europe, North and South America. Study drugs were given intravenously, q3w: P/Pla, 840 mg initial dose, then 420 mg; T, 8 mg/kg initial dose, then 6 mg/kg; D, 75 mg/m2 with escalation to 100 mg/m2 if tolerated. Treatment was given until disease progression or unacceptable toxicity; 6 cycles of D were recommended, &gt;6 cycles were at investigator's discretion. Dose modifications of P or T were not permitted. Two D dose reductions by 25% to 75 mg/m2 and 55 mg/m2 were allowed in order to manage toxicities; re-escalation was not permitted.

Results: The safety population comprised 253 pts from Asia (Pla+T+D: 128; P+T+D: 125) and 551 pts from other regions (Pla+T+D: 269; P+T+D: 282). The incidences of neutropenia, FN, diarrhea, mucosal inflammation, grade ≥3 AEs overall, and serious AEs were higher with P+T+D versus Pla+T+D. In the P arm, the largest increase in AEs in pts from Asia versus other regions was observed for FN and mucosal inflammation. D dose was more frequently reduced in pts from Asia; however, the incidence of AEs leading to discontinuation of all study treatment was balanced between pts from Asia and other regions. PFS and OS were improved with P+T+D in pts from all regions. In the whole study population, the hazard ratios (HR) for PFS and OS were 0.63 (95% CI 0.52-0.76) and 0.66 (0.52-0.84), respectively. In pts from Asia, the HR was 0.68 (0.48-0.95) for PFS and 0.64 (0.41-1.00) for OS. These efficacy analyses were unstratified.

Pts with event, n (%)Other regionsAsia Pla+T+DP+T+DPla+T+DP+T+D n = 269n = 282n = 128n = 125Neutropenia123 (46)141 (50)74 (58)74 (59)FN15 (6)24 (9)15 (12)32 (26)Diarrhea118 (44)179 (63)66 (52)93 (74)Mucosal inflammation56 (21)67 (24)23 (18)46 (37)Grade ≥3 AEs194 (72)199 (71)95 (74)103 (82)Serious AEs69 (26)82 (29)35 (27)58 (46)AEs leading to discontinuation of all study treatment15 (6)21 (7)6 (5)4 (3)D dose escalation to 100 mg/m256 (21)47 (17)5 (4)1 (1)D dose reduction to &lt;75 mg/m232 (12)42 (15)57 (45)62 (50)Use of granulocyte colony-stimulating factor (G-CSF) to treat FN8 (3)11 (4)12 (9)30 (24)Subsequent G-CSF prophylaxis in pts with FN6 (2)3 (1)1 (1)11 (9)Study treatment cycles, median15181520D cycles, median8799

Conclusions: AEs did not result in reduction of the median number of cycles administered in pts from Asia compared with other regions. However, given that 47% of pts from Asia had D dose reductions &lt;75 mg/m2 with comparable survival benefits to pts from other regions, a reduction in the D starting dose should be considered in these pts. Based on the efficacy and safety profile of P+T+D, this regimen is the preferred treatment option for pts with HER2-positive first-line MBC from all geographic regions.

Citation Information: Cancer Res 2013;73(24 Suppl): Abstract nr P4-12-10.

Measurement of high-pressure shock waves in cryogenic deuterium-tritium ice layered capsule implosions on NIF

The first measurements of multiple, high-pressure shock waves in cryogenic deuterium-tritium (DT) ice layered capsule implosions on the National Ignition Facility have been performed. The strength and relative timing of these shocks must be adjusted to very high precision in order to keep the DT fuel entropy low and compressibility high. All previous measurements of shock timing in inertial confinement fusion implosions [T. R. Boehly et al., Phys. Rev. Lett. 106, 195005 (2011), H. F. Robey et al., Phys. Rev. Lett. 108, 215004 (2012)] have been performed in surrogate targets, where the solid DT ice shell and central DT gas regions were replaced with a continuous liquid deuterium (D2) fill. This report presents the first experimental validation of the assumptions underlying this surrogate technique.

Health-related quality-of-life assessment in CLEOPATRA, a phase III study combining pertuzumab with trastuzumab and docetaxel in metastatic breast cancer

BACKGROUND

The phase III CLEOPATRA study demonstrated that combining pertuzumab with trastuzumab plus docetaxel significantly improves progression-free and overall survival in previously untreated HER2-positive metastatic breast cancer. Here, we report health-related quality-of-life (HRQoL) results from CLEOPATRA.

PATIENTS AND METHODS

Participants were randomly assigned to pertuzumab or placebo, each given with trastuzumab plus docetaxel every 3 weeks. Pertuzumab and trastuzumab were administered until progression and six or more docetaxel cycles were recommended. Time from randomization to a ≥ 5-point decrease in Trial Outcome Index-Physical/Functional/Breast (TOI-PFB) of the Functional Assessment of Cancer Therapy-Breast (FACT-B) questionnaire was analyzed as a prespecified secondary end point. A post hoc exploratory analysis investigated time to ≥ 2-point deterioration in Breast Cancer Subscale (BCS) score.

RESULTS

Time to ≥ 5-point decline in TOI-PFB did not differ significantly between the pertuzumab and placebo arms [hazard ratio (HR), 0.97; P = 0.7161]. The median times to TOI-PFB deterioration were 18.4 and 18.3 weeks, respectively (approximately six cycles). The mean TOI-PFB declined slightly until week 18 and recovered thereafter. Pertuzumab increased time until BCS deterioration versus placebo (median 26.7 versus 18.3 weeks; HR, 0.77; P = 0.0061).

CONCLUSIONS

Combining pertuzumab with trastuzumab and docetaxel had no adverse impact on HRQoL and may prolong time to worsening of breast cancer-specific symptoms.

Abstract P5-18-01: Pertuzumab (P) in combination with trastuzumab (T) and docetaxel (D) in elderly patients with HER2-positive metastatic breast cancer in the CLEOPATRA study

Background: The incidence of cancer increases with age as does the risk of treatment-related adverse events (AEs) due to underlying comorbidities. A better understanding of cancer therapy-related AEs in elderly pts may help identify the optimal therapy by balancing treatment benefit and risk. CLEOPATRA, a double-blind Phase III trial, compared placebo (Pla)+T+D with P+T+D in pts with HER2-positive 1L MBC (Baselga 2012). Here we report safety and efficacy by age group.

Methods: P/Pla: 840 mg initial dose, 420 mg q3w iv; T: 8 mg/kg initial dose, 6 mg/kg q3w iv; D: 75 mg/m2 q3w iv, escalating to 100 mg/m2 if tolerated. P/Pla+T were given until progressive disease (PD) or unacceptable toxicity. At least 6 cycles of D were recommended; &lt;6 cycles were allowed for PD or unacceptable toxicity, &gt;6 cycles were allowed at investigators' discretion. At baseline, pts were required to have ECOG PS of 0 or 1, LVEF ≥50% and no decline to &lt;50% during or following prior T therapy. The cumulative exposure to prior doxorubicin must not have exceeded 360 mg/m2 or its equivalent. The primary endpoint was independently assessed PFS; secondary endpoints included overall survival, objective response, safety.

Results: In the safety population, 678 pts (332 Pla arm, 346 P arm) were &lt;65 yrs and 126 pts (65 Pla arm, 61 P arm) were ≥65 yrs. In pts &lt;65 yrs, the median number of D cycles was 8 (1–41) in the Pla arm (median D dose intensity: 24.8 mg/m2/week) and 8 (1–35) in the P arm (24.5 mg/m2/week). The median number of D cycles was lower in pts ≥65 yrs, with 6.5 (1–26) in the Pla arm (24.8 mg/m2/week) and 6 (1–16) in the P arm (24.8 mg/m2/week). In elderly pts, the incidence of diarrhea, fatigue, and dysgeusia appeared to be higher in both arms, whereas neutropenia and febrile neutropenia were reported less frequently. Grade ≥3 diarrhea was reported in 4.8% (Pla arm) and 6.6% (P arm) of pts &lt;65 yrs and in 6.2% (Pla arm) and 14.8% (P arm) of pts ≥65 yrs. In a univariate Cox regression analysis, age had no statistically significant association with the development of asymptomatic or symptomatic left ventricular systolic dysfunction (LVSD); however, due to the low number of LVSD events overall this analysis has limited sensitivity to detect differences in time to event by age group. An exploratory post hoc analysis of independently assessed PFS in the ITT population showed a median PFS of 12.5 months in the Pla arm and 17.2 months in the P arm (HR = 0.65, 95% CI 0.53–0.80) in pts &lt;65 yrs. In pts ≥65 yrs, the median PFS was 10.4 months in the Pla arm and 21.6 months in the P arm (HR = 0.52, 95% CI 0.31–0.86).

A randomized phase II study evaluating the combination of carboplatin-based chemotherapy with pertuzumab versus carboplatin-based therapy alone in patients with relapsed, platinum-sensitive ovarian cancer

BACKGROUND

Pertuzumab, a humanized monoclonal antibody targeting human epidermal growth factor receptor (HER)-mediated signalling, has shown activity in ovarian cancer in preclinical models and in the clinic. This randomized phase II study evaluated efficacy and safety of pertuzumab in combination with carboplatin-based chemotherapy in patients with platinum-sensitive, recurrent advanced ovarian cancer.

PATIENTS AND METHODS

Patients were randomized to receive six cycles of chemotherapy (carboplatin and either paclitaxel (Taxol) or gemcitabine) with or without pertuzumab. The primary end point was progression-free survival (PFS) as determined by Response Evaluation Criteria in Solid Tumors and/or by CA 125 measurements. Secondary end points evaluated the response rate, safety profile, duration of response, time to progression and overall survival for both treatment arms.

RESULTS

A total of 149 patients received either chemotherapy with pertuzumab (arm A, n=74) or chemotherapy alone (arm B, n=75). There was no significant difference either in median PFS or in the secondary end points between the two arms. No differences were seen in an exploratory biomarker analysis of HER3 mRNA expression between the two arms. Pertuzumab was well tolerated, with no increase in cardiac adverse events compared with chemotherapy alone.

CONCLUSIONS

The addition of pertuzumab to carboplatin-based chemotherapy did not substantially prolong PFS in unselected patients with platinum-sensitive ovarian cancer.

BRCA1 testing should be offered to individuals with triple-negative breast cancer diagnosed below 50 years

BACKGROUND

Triple-negative (TN) tumours are the predominant breast cancer subtype in BRCA1 mutation carriers. Recently, it was proposed that all individuals below 50 years of age with TN breast cancer should be offered BRCA testing. We have evaluated the BRCA1 mutation frequency and the implications for clinical practice of undertaking genetic testing in women with TN breast cancer.

METHODS

We undertook BRCA1 mutation analysis in 308 individuals with TN breast cancer, 159 individuals from unselected series of breast cancer and 149 individuals from series ascertained on the basis of young age and/or family history.

RESULTS

BRCA1 mutations were present in 45 out of 308 individuals. Individuals with TN cancer <50 years had >10% likelihood of carrying a BRCA1 mutation in both the unselected (11 out of 58, 19%) and selected (26 out of 111, 23%) series. However, over a third would not have been offered testing using existing criteria. We estimate that testing all individuals with TN breast cancer <50 years would generate an extra 1200 tests annually in England.

CONCLUSION

Women with TN breast cancer diagnosed below 50 years have >10% likelihood of carrying a BRCA1 mutation and are therefore eligible for testing in most centres. However, implementation may place short-term logistical and financial burdens on genetic services.

Pooled analysis of cardiac safety in patients with cancer treated with pertuzumab

BACKGROUND

Pertuzumab, a human epidermal growth factor receptor (HER) 2 dimerization inhibitor, has demonstrated promising efficacy in combination with trastuzumab in patients with metastatic breast cancer. As HER signaling pathways are not only involved in oncogenesis, but also in myocardial homeostasis, an analysis of cardiac safety data was undertaken in a large group of patients treated with pertuzumab.

PATIENTS AND METHODS

A complete database of patients treated with full-dose pertuzumab was used to describe the incidence of asymptomatic left ventricular systolic dysfunction (LVSD) and symptomatic heart failure (HF).

RESULTS

Information for 598 unique patients was available for the current analysis. Of the patients treated with pertuzumab alone (n = 331) or pertuzumab in combination with a non-anthracycline-containing cytotoxic (n = 175) or trastuzumab (n = 93), 23 (6.9%), 6 (3.4%), and 6 (6.5%), respectively, developed asymptomatic LVSD and 1 (0.3%), 2 (1.1%), and 1 (1.1%), respectively, displayed symptomatic HF. None of the 15 patients receiving both pertuzumab and erlotinib demonstrated LVSD.

CONCLUSIONS

Patients treated with pertuzumab experienced relatively low levels of asymptomatic LVSD or symptomatic HF. There was no notable increase in cardiac side-effects when pertuzumab was given in combination with other anticancer agents.

OT1-02-04: Adjuvant Pertuzumab and Herceptin IN IniTial TherapY of Breast Cancer: APHINITY (BIG 4–11/BO25126/TOC4939g)

Background

Approximately 20% of breast cancer (BC) patients (pts) have HER2−positive tumors. While the adjuvant use of the anti-HER2 humanized monoclonal antibody trastuzumab (T) has been shown to improve disease-free (DFS) and overall survival (OS), not all pts treated with this agent benefit from this therapy. Pertuzumab (P) is a humanized monoclonal antibody that inhibits HER2 dimerization and induces ADCC with a complementary mechanism of action to T. In HER2−positiveadvanced BC, T and P is active in pts who have progressed to T. In the neoadjuvant setting, T and P in combination with chemotherapy (CT) nearly doubled the pathological complete response rate compared to either T or P administered in combination with CT (45.8% vs 29% vs 24%, respectively). Therefore, comprehensive HER2 blockade with two anti-HER2 monoclonal antibodies warrants further investigation in the adjuvant setting.

Trial Design: APHINITY is a prospective, randomized, multicenter, double-blind, placebo-controlled study in pts with HER2−positive primary BC who have had an excision of their tumor. Pts will be randomized to one of 2 arms (1:1 ratio). The investigational arm will comprise of a course of adjuvant CT (investigators choice) consisting of either an anthracycline-taxane or taxane-platin containing regimens and T and P for 1 year. The comparator arm will consist of the same adjuvant CT backbone with T and placebo for 1 year.

Major Eligibility Criteria:

1. Non-metastatic primary BC histologically confirmed and adequately excised

2. Node-positive or node-negative: for patients with node-positive disease (pN ≥1), any pT except T0; for patients with node-negative disease (pN0), tumor size must be &gt;1.0 cm OR for tumor size between &gt;0.5 cm and ≤1.0 cm, at least one of the following features will be required: histologic grade 3 OR negative for ER and PgR OR age &lt;35 years

3. The interval between definitive surgery for BC and randomization must be at least 3 weeks but no more than 7 weeks

4. Baseline LVEF ≥55%

5. HER2−positive BC confirmed by a central laboratory and defined as: IHC 3+ in &gt;10% immunoreactive cells OR HER2 gene amplification by in situ hybridization [ISH] (ratio of HER2 gene signals to centromere 17 signals ≥2)

Aims: The primary objective is to compare invasive disease-free survival (IDFS) between both treatment arms. Secondary objectives include comparing IDFS including second non-BC, DFS, OS, recurrence-free interval (RFI), distant RFI, cardiac safety, overall safety and health-related quality of life in the two treatment arms.

Statistical Methods: Pts will be stratified based on nodal status, type of adjuvant CT regimen, hormone receptor status and geographical region. The study is designed to have an 80% power to test the null hypothesis of no true difference in risk of an IDFS event (HR = 1) versus the alternative hypothesis of a difference (HR = 0.75) in hazard rates with a 5%, 2-sided significance level.

Target accrual: 3806; Present accrual: Start Q4 2011

Citation Information: Cancer Res 2011;71(24 Suppl):Abstract nr OT1-02-04.