Adjuvant chemotherapy in upper tract urothelial carcinoma (the POUT trial): a phase 3, open-label, randomised controlled trial

BACKGROUND

Urothelial carcinomas of the upper urinary tract (UTUCs) are rare, with poorer stage-for-stage prognosis than urothelial carcinomas of the urinary bladder. No international consensus exists on the benefit of adjuvant chemotherapy for patients with UTUCs after nephroureterectomy with curative intent. The POUT (Peri-Operative chemotherapy versus sUrveillance in upper Tract urothelial cancer) trial aimed to assess the efficacy of systemic platinum-based chemotherapy in patients with UTUCs.

METHODS

We did a phase 3, open-label, randomised controlled trial at 71 hospitals in the UK. We recruited patients with UTUC after nephroureterectomy staged as either pT2-T4 pN0-N3 M0 or pTany N1-3 M0. We randomly allocated participants centrally (1:1) to either surveillance or four 21-day cycles of chemotherapy, using a minimisation algorithm with a random element. Chemotherapy was either cisplatin (70 mg/m2) or carboplatin (area under the curve [AUC]4·5/AUC5, for glomerular filtration rate <50 mL/min only) administered intravenously on day 1 and gemcitabine (1000 mg/m2) administered intravenously on days 1 and 8; chemotherapy was initiated within 90 days of surgery. Follow-up included standard cystoscopic, radiological, and clinical assessments. The primary endpoint was disease-free survival analysed by intention to treat with a Peto-Haybittle stopping rule for (in)efficacy. The trial is registered with ClinicalTrials.gov, NCT01993979. A preplanned interim analysis met the efficacy criterion for early closure after recruitment of 261 participants.

FINDINGS

Between June 19, 2012, and Nov 8, 2017, we enrolled 261 participants from 57 of 71 open study sites. 132 patients were assigned chemotherapy and 129 surveillance. One participant allocated chemotherapy withdrew consent for data use after randomisation and was excluded from analyses. Adjuvant chemotherapy significantly improved disease-free survival (hazard ratio 0·45, 95% CI 0·30-0·68; p=0·0001) at a median follow-up of 30·3 months (IQR 18·0-47·5). 3-year event-free estimates were 71% (95% CI 61-78) and 46% (36-56) for chemotherapy and surveillance, respectively. 55 (44%) of 126 participants who started chemotherapy had acute grade 3 or worse treatment-emergent adverse events, which accorded with frequently reported events for the chemotherapy regimen. Five (4%) of 129 patients managed by surveillance had acute grade 3 or worse emergent adverse events. No treatment-related deaths were reported.

INTERPRETATION

Gemcitabine-platinum combination chemotherapy initiated within 90 days after nephroureterectomy significantly improved disease-free survival in patients with locally advanced UTUC. Adjuvant platinum-based chemotherapy should be considered a new standard of care after nephroureterectomy for this patient population.

FUNDING

Cancer Research UK.

Adding abiraterone or docetaxel to long-term hormone therapy for prostate cancer: directly randomised data from the STAMPEDE multi-arm, multi-stage platform protocol

Background

Adding abiraterone acetate with prednisolone (AAP) or docetaxel with prednisolone (DocP) to standard-of-care (SOC) each improved survival in systemic therapy for advanced or metastatic prostate cancer: evaluation of drug efficacy: a multi-arm multi-stage platform randomised controlled protocol recruiting patients with high-risk locally advanced or metastatic PCa starting long-term androgen deprivation therapy (ADT). The protocol provides the only direct, randomised comparative data of SOC + AAP versus SOC + DocP.

Method

Recruitment to SOC + DocP and SOC + AAP overlapped November 2011 to March 2013. SOC was long-term ADT or, for most non-metastatic cases, ADT for ≥2 years and RT to the primary tumour. Stratified randomisation allocated pts 2 : 1 : 2 to SOC; SOC + docetaxel 75 mg/m2 3-weekly×6 + prednisolone 10 mg daily; or SOC + abiraterone acetate 1000 mg + prednisolone 5 mg daily. AAP duration depended on stage and intent to give radical RT. The primary outcome measure was death from any cause. Analyses used Cox proportional hazards and flexible parametric models, adjusted for stratification factors. This was not a formally powered comparison. A hazard ratio (HR) <1 favours SOC + AAP, and HR > 1 favours SOC + DocP.

Results

A total of 566 consenting patients were contemporaneously randomised: 189 SOC + DocP and 377 SOC + AAP. The patients, balanced by allocated treatment were: 342 (60%) M1; 429 (76%) Gleason 8-10; 449 (79%) WHO performance status 0; median age 66 years and median PSA 56 ng/ml. With median follow-up 4 years, 149 deaths were reported. For overall survival, HR = 1.16 (95% CI 0.82-1.65); failure-free survival HR = 0.51 (95% CI 0.39-0.67); progression-free survival HR = 0.65 (95% CI 0.48-0.88); metastasis-free survival HR = 0.77 (95% CI 0.57-1.03); prostate cancer-specific survival HR = 1.02 (0.70-1.49); and symptomatic skeletal events HR = 0.83 (95% CI 0.55-1.25). In the safety population, the proportion reporting ≥1 grade 3, 4 or 5 adverse events ever was 36%, 13% and 1% SOC + DocP, and 40%, 7% and 1% SOC + AAP; prevalence 11% at 1 and 2 years on both arms. Relapse treatment patterns varied by arm.

Conclusions

This direct, randomised comparative analysis of two new treatment standards for hormone-naïve prostate cancer showed no evidence of a difference in overall or prostate cancer-specific survival, nor in other important outcomes such as symptomatic skeletal events. Worst toxicity grade over entire time on trial was similar but comprised different toxicities in line with the known properties of the drugs.

Trial registration

Clinicaltrials.gov: NCT00268476.

TRAPEZE: a randomised controlled trial of the clinical effectiveness and cost-effectiveness of chemotherapy with zoledronic acid, strontium-89, or both, in men with bony metastatic castration-refractory prostate cancer

BACKGROUND

Bony metastatic castration-refractory prostate cancer is associated with a poor prognosis and high morbidity. TRAPEZE was a two-by-two factorial randomised controlled trial of zoledronic acid (ZA) and strontium-89 (Sr-89), each combined with docetaxel. All have palliative benefits, are used to control bone symptoms and are used with docetaxel to prolong survival. ZA, approved on the basis of reducing skeletal-related events (SREs), is commonly combined with docetaxel in practice, although evidence of efficacy and cost-effectiveness is lacking. Sr-89, approved for controlling metastatic pain and reducing need for subsequent bone treatments, is generally palliatively used in patients unfit for chemotherapy. Phase II analysis confirmed the safety and feasibility of combining these agents. TRAPEZE aimed to determine the clinical effectiveness and cost-effectiveness of each agent.

METHODS

Patients were randomised to receive six cycles of docetaxel plus prednisolone: alone, with ZA, with a single Sr-89 dose after cycle 6, or with both. Primary outcomes were clinical progression-free survival (CPFS: time to pain progression, SRE or death) and cost-effectiveness. Secondary outcomes were SRE-free interval (SREFI), total SREs, overall survival (OS) and quality of life (QoL). Log-rank test and Cox regression modelling were used to determine clinical effectiveness. Cost-effectiveness was assessed from the NHS perspective and expressed as cost per additional quality-adjusted life-year (QALY). An additional analysis was carried out for ZA to reflect the availability of generic ZA.

RESULTS

PATIENTS

757 randomised (median age 68.7 years; Eastern Cooperative Oncology Group scale score 0, 40%; 1, 52%; 2, 8%; prior radiotherapy, 45%); median prostate-specific antigen 143.78 ng/ml (interquartile range 50.8-353.9 ng/ml). Stratified log-rank analysis of CPFS was statistically non-significant for either agent (Sr-89, p = 0.11; ZA, p = 0.45). Cox regression analysis adjusted for stratification variables showed CPFS benefit for Sr-89 [hazard ratio (HR) 0.845, 95% confidence interval (CI) 0.72 to 0.99; p = 0.036] and confirmed no effect of ZA (p = 0.46). ZA showed a significant SREFI effect (HR 0.76; 95% CI 0.63 to 0.93; p = 0.008). Neither agent affected OS (Sr-89, p = 0.74; ZA, p = 0.91), but both increased total cost (vs. no ZA and no Sr-89, respectively); decreased post-trial therapies partly offset costs [net difference: Sr-89 £1341; proprietary ZA (Zometa(®), East Hanover, NJ, USA) £1319; generic ZA £251]. QoL was maintained in all trial arms; Sr-89 (0.08 additional QALYs) and ZA (0.03 additional QALYs) showed slight improvements. The resulting incremental cost-effectiveness ratio (ICER) for Sr-89 was £16,590, with £42,047 per QALY for Zometa and £8005 per QALY for generic ZA.

CONCLUSION

Strontium-89 improved CPFS, but not OS. ZA did not improve CPFS or OS but significantly improved SREFI, mostly post progression, suggesting a role as post-chemotherapy maintenance therapy. QoL was well maintained in all treatment arms, with differing patterns of care resulting from the effects of Sr-89 on time to progression and ZA on SREFI and total SREs. The addition of Sr-89 resulted in additional cost and a small positive increase in QALYs, with an ICER below the £20,000 ceiling per QALY. The additional costs and small positive QALY changes in favour of ZA resulted in ICERs of £42,047 (Zometa) and £8005 for the generic alternative; thus, generic ZA represents a cost-effective option. Additional analyses on the basis of data from the Hospital Episode Statistics data set would allow corroborating the findings of this study. Further research into the use of ZA (and other bone-targeting therapies) with newer prostate cancer therapies would be desirable.

STUDY REGISTRATION

Current Controlled Trials ISRCTN12808747.

FUNDING

This project was funded by the NIHR Health Technology Assessment programme and will be published in full in Health Technology Assessment; Vol. 20, No. 53. See the NIHR Journals Library website for further project information.

Abiraterone for Prostate Cancer Not Previously Treated with Hormone Therapy

BACKGROUND

Abiraterone acetate plus prednisolone improves survival in men with relapsed prostate cancer. We assessed the effect of this combination in men starting long-term androgen-deprivation therapy (ADT), using a multigroup, multistage trial design.

METHODS

We randomly assigned patients in a 1:1 ratio to receive ADT alone or ADT plus abiraterone acetate (1000 mg daily) and prednisolone (5 mg daily) (combination therapy). Local radiotherapy was mandated for patients with node-negative, nonmetastatic disease and encouraged for those with positive nodes. For patients with nonmetastatic disease with no radiotherapy planned and for patients with metastatic disease, treatment continued until radiologic, clinical, or prostate-specific antigen (PSA) progression; otherwise, treatment was to continue for 2 years or until any type of progression, whichever came first. The primary outcome measure was overall survival. The intermediate primary outcome was failure-free survival (treatment failure was defined as radiologic, clinical, or PSA progression or death from prostate cancer).

RESULTS

A total of 1917 patients underwent randomization from November 2011 through January 2014. The median age was 67 years, and the median PSA level was 53 ng per milliliter. A total of 52% of the patients had metastatic disease, 20% had node-positive or node-indeterminate nonmetastatic disease, and 28% had node-negative, nonmetastatic disease; 95% had newly diagnosed disease. The median follow-up was 40 months. There were 184 deaths in the combination group as compared with 262 in the ADT-alone group (hazard ratio, 0.63; 95% confidence interval [CI], 0.52 to 0.76; P<0.001); the hazard ratio was 0.75 in patients with nonmetastatic disease and 0.61 in those with metastatic disease. There were 248 treatment-failure events in the combination group as compared with 535 in the ADT-alone group (hazard ratio, 0.29; 95% CI, 0.25 to 0.34; P<0.001); the hazard ratio was 0.21 in patients with nonmetastatic disease and 0.31 in those with metastatic disease. Grade 3 to 5 adverse events occurred in 47% of the patients in the combination group (with nine grade 5 events) and in 33% of the patients in the ADT-alone group (with three grade 5 events).

CONCLUSIONS

Among men with locally advanced or metastatic prostate cancer, ADT plus abiraterone and prednisolone was associated with significantly higher rates of overall and failure-free survival than ADT alone. (Funded by Cancer Research U.K. and others; STAMPEDE ClinicalTrials.gov number, NCT00268476 , and Current Controlled Trials number, ISRCTN78818544 .).

Randomized Phase II Study Investigating Pazopanib Versus Weekly Paclitaxel in Relapsed or Progressive Urothelial Cancer

Purpose Two previous single-arm trials have drawn conflicting conclusions regarding the activity of pazopanib in urothelial cancers after failure of platinum-based chemotherapy. Patients and Methods This randomized (1:1) open-label phase II trial compared the efficacy of pazopanib 800 mg orally with paclitaxel (80 mg/m2 days 1, 8, and 15 every 28 days) in the second-line setting. The primary end point was overall survival (OS). Results Between August 2012 and October 2014, 131 patients, out of 140 planned, were randomly assigned. The study was terminated early on the recommendation of the independent data monitoring committee because of futility. Final analysis after the preplanned number of deaths (n = 110) occurred after a median follow-up of 18 months. One hundred fifteen deaths had occurred at the final data extract presented here. Median OS was 8.0 months for paclitaxel (80% CI, 6.9 to 9.7 months) and 4.7 months for pazopanib (80% CI, 4.2 to 6.4 months). The hazard ratio (HR) adjusted for baseline stratification factors was 1.28 (80% CI, 0.99 to 1.67; one-sided P = .89). Median progression-free survival was 4.1 months for paclitaxel (80% CI, 3.0 to 5.6 months) and 3.1 months for pazopanib (80% CI, 2.7 to 4.6 months; HR, 1.09; 80% CI, 0.85 to 1.40; one-sided P = .67). Discontinuations for toxicity occurred in 7.8% and 23.1% for paclitaxel and pazopanib, respectively. Conclusion Pazopanib did not have greater efficacy than paclitaxel in the second-line treatment of urothelial cancers. There was a trend toward superior OS for paclitaxel.

Cost-effectiveness of zoledronic acid and strontium-89 as bone protecting treatments in addition to chemotherapy in patients with metastatic castrate-refractory prostate cancer: results from the TRAPEZE trial (ISRCTN 12808747)

OBJECTIVE

To evaluate the cost-effectiveness of adding zoledronic acid or strontium-89 to standard docetaxel chemotherapy for patients with castrate-refractory prostate cancer (CRPC).

PATIENTS AND METHODS

Data on resource use and quality of life for 707 patients collected prospectively in the TRAPEZE 2 × 2 factorial randomised trial (ISRCTN 12808747) were used to assess the cost-effectiveness of i) zoledronic acid versus no zoledronic acid (ZA vs. no ZA), and ii) strontium-89 versus no strontium-89 (Sr89 vs. no Sr89). Costs were estimated from the perspective of the National Health Service in the UK and included expenditures for trial treatments, concomitant medications, and use of related hospital and primary care services. Quality-adjusted life-years (QALYs) were calculated according to patients' responses to the generic EuroQol EQ-5D-3L instrument, which evaluates health status. Results are expressed as incremental cost-effectiveness ratios (ICERs) and cost-effectiveness acceptability curves.

RESULTS

The per-patient cost for ZA was £12 667, £251 higher than the equivalent cost in the no ZA group. Patients in the ZA group had on average 0.03 QALYs more than their counterparts in no ZA group. The ICER for this comparison was £8 005. Sr89 was associated with a cost of £13 230, £1365 higher than no Sr89, and a gain of 0.08 QALYs compared to no Sr89. The ICER for Sr89 was £16 884. The probabilities of ZA and Sr89 being cost-effective were 0.64 and 0.60, respectively.

CONCLUSIONS

The addition of bone-targeting treatments to standard chemotherapy led to a small improvement in QALYs for a modest increase in cost (or cost-savings). ZA and Sr89 resulted in ICERs below conventional willingness-to-pay per QALY thresholds, suggesting that their addition to chemotherapy may represent a cost-effective use of resources.

Addition of docetaxel, zoledronic acid, or both to first-line long-term hormone therapy in prostate cancer (STAMPEDE): survival results from an adaptive, multiarm, multistage, platform randomised controlled trial

BACKGROUND

Long-term hormone therapy has been the standard of care for advanced prostate cancer since the 1940s. STAMPEDE is a randomised controlled trial using a multiarm, multistage platform design. It recruits men with high-risk, locally advanced, metastatic or recurrent prostate cancer who are starting first-line long-term hormone therapy. We report primary survival results for three research comparisons testing the addition of zoledronic acid, docetaxel, or their combination to standard of care versus standard of care alone.

METHODS

Standard of care was hormone therapy for at least 2 years; radiotherapy was encouraged for men with N0M0 disease to November, 2011, then mandated; radiotherapy was optional for men with node-positive non-metastatic (N+M0) disease. Stratified randomisation (via minimisation) allocated men 2:1:1:1 to standard of care only (SOC-only; control), standard of care plus zoledronic acid (SOC + ZA), standard of care plus docetaxel (SOC + Doc), or standard of care with both zoledronic acid and docetaxel (SOC + ZA + Doc). Zoledronic acid (4 mg) was given for six 3-weekly cycles, then 4-weekly until 2 years, and docetaxel (75 mg/m(2)) for six 3-weekly cycles with prednisolone 10 mg daily. There was no blinding to treatment allocation. The primary outcome measure was overall survival. Pairwise comparisons of research versus control had 90% power at 2·5% one-sided α for hazard ratio (HR) 0·75, requiring roughly 400 control arm deaths. Statistical analyses were undertaken with standard log-rank-type methods for time-to-event data, with hazard ratios (HRs) and 95% CIs derived from adjusted Cox models. This trial is registered at ClinicalTrials.gov (NCT00268476) and ControlledTrials.com (ISRCTN78818544).

FINDINGS

2962 men were randomly assigned to four groups between Oct 5, 2005, and March 31, 2013. Median age was 65 years (IQR 60-71). 1817 (61%) men had M+ disease, 448 (15%) had N+/X M0, and 697 (24%) had N0M0. 165 (6%) men were previously treated with local therapy, and median prostate-specific antigen was 65 ng/mL (IQR 23-184). Median follow-up was 43 months (IQR 30-60). There were 415 deaths in the control group (347 [84%] prostate cancer). Median overall survival was 71 months (IQR 32 to not reached) for SOC-only, not reached (32 to not reached) for SOC + ZA (HR 0·94, 95% CI 0·79-1·11; p=0·450), 81 months (41 to not reached) for SOC + Doc (0·78, 0·66-0·93; p=0·006), and 76 months (39 to not reached) for SOC + ZA + Doc (0·82, 0·69-0·97; p=0·022). There was no evidence of heterogeneity in treatment effect (for any of the treatments) across prespecified subsets. Grade 3-5 adverse events were reported for 399 (32%) patients receiving SOC, 197 (32%) receiving SOC + ZA, 288 (52%) receiving SOC + Doc, and 269 (52%) receiving SOC + ZA + Doc.

INTERPRETATION

Zoledronic acid showed no evidence of survival improvement and should not be part of standard of care for this population. Docetaxel chemotherapy, given at the time of long-term hormone therapy initiation, showed evidence of improved survival accompanied by an increase in adverse events. Docetaxel treatment should become part of standard of care for adequately fit men commencing long-term hormone therapy.

FUNDING

Cancer Research UK, Medical Research Council, Novartis, Sanofi-Aventis, Pfizer, Janssen, Astellas, NIHR Clinical Research Network, Swiss Group for Clinical Cancer Research.

Osteonecrosis of the Jaw and Oral Health–Related Quality of Life After Adjuvant Zoledronic Acid: An Adjuvant Zoledronic Acid to Reduce Recurrence Trial Subprotocol (BIG01/04)

Purpose

In patients with early breast cancer, adjuvant zoledronic acid (zoledronate) may reduce recurrence and improve survival. However, zoledronate is associated with the occasional development of osteonecrosis of the jaw (ONJ). We report on the frequency of ONJ and investigate oral health–related quality of life (Oral-QoL) in a large randomized trial (Adjuvant Zoledronic Acid to Reduce Recurrence [AZURE]).

Patients and Methods

Three thousand three hundred sixty women with stage II or III breast cancer were randomly assigned to receive standard adjuvant systemic therapy alone or with zoledronate administered at a dose of 4 mg for 19 doses over 5 years. All potential occurrences of ONJ were reported as serious adverse events and centrally reviewed. Additionally, we invited 486 study participants to complete the Oral Health Impact Profile-14 (OHIP-14) to assess Oral-QoL around the time the patients completed 5 years on study. Multivariable linear regression was used to calculate mean scores and 95% CIs in addition to identifying independent prognostic factors.

Results

With a median follow-up time of 73.9 months (interquartile range, 60.7 to 84.2 months), 33 possible cases of ONJ were reported, all in the zoledronate-treated patients. Twenty-six cases were confirmed as being consistent with a diagnosis of ONJ, representing a cumulative incidence of 2.1% (95% CI, 0.9% to 3.3%) in the zoledronate arm. Three hundred sixty-two patients (74%) returned the OHIP-14 questionnaire. Neither the prevalence nor severity of impacts on Oral-QoL differed significantly between zoledronate patients and control patients.

Conclusion

Adjuvant zoledronate used in the intensive schedule studied in the AZURE trial is associated with a low incidence of ONJ but does not seem to adversely affect Oral-QoL.

Abstract 4356: Finding the genetic determinants of response to radiotherapy

Radiotherapy is very effective at local control of tumours but leads to adverse reactions in a minority of patients. This project aimed to predict which breast cancer patients will show radiation toxicity, allowing them to be offered alternative treatment (e.g. mastectomy). Previously, studies have focussed on single nucleotide polymorphisms (SNP) for association with adverse reactions, but there is growing evidence that genomic copy number variation (CNV) are frequent and significantly contribute to genetic variation and human diseases. The aim of this candidate gene association study was to determine copy number variants (CNVs) that influence radiation toxicity in cancer patients, and combine these with clinical indicators to contribute to a predictive algorithm. CNV data for 88 candidate genes were ranked based on CNV position, size and frequency. Paralogue ratio test (PRT) assays were designed for the top-ranked 13 genes. Typing of the CNVs in the analysed samples was performed using PRT method because it is cheap, simple and fast and requiring a small amount of genomic DNA. Copy number typing was carried out on 69 control samples (comprising 30 random DNA and 39 CEPH [Centre de ‘Etude du Polymorphisme Humain] specimens of three multigenerational reference families); and 401 samples from a breast cancer cohort (i.e. test samples) with good clinical characterisation and scored for late effects of radiotherapy. Two PRT assays in the DNA ligase 1 (LIG1) gene were used for typing. PRT amplification products were electrophoresed on agarose gel (PRT2 assay) and ABI 3031xl genetic analyser (PRT3 assay) respectively. Quantification of DNA bands was performed using Syngene and Genescan software respectively and statistical analysis in SPSS. The result of this study showed that 5.2 % of the CEPH samples and 0.3% of the breast cancer cohorts showed consistent evidence of raised copy numbers which suggest duplication of LIG1 gene in those samples. The result also showed moderate correlation between the two assays used (r=0.56). The findings from this study have re-inforced the need for future research to focus on further characterisation of this studied CNV either by using more PRT over a wider region around LIG1 or an array or sequence based approach. Future work would also attempt to establish whether cells from the breast cancer patients show changed expression of LIG1. Lastly, CNV typing would be repeated in further cohorts, though with a frequency of 0.3%, many more cohorts in the range of thousands might be required. With multiple patients with the variant, then it might be possible to detect significant differences in radiation toxicity phenotypes.

Citation Format: {Authors}. {Abstract title} [abstract]. In: Proceedings of the 103rd Annual Meeting of the American Association for Cancer Research; 2012 Mar 31-Apr 4; Chicago, IL. Philadelphia (PA): AACR; Cancer Res 2012;72(8 Suppl):Abstract nr 4356. doi:1538-7445.AM2012-4356

Abstract P4-11-17: Can We Specifiy the Minimum Breast Size at Which Therapeutic Mammoplasty Should Be Considered To Mitigate Radiotherapy Toxicity in Patients Undergoing Breast Conserving Surgery for Breast Cancer?

Background

For breast cancer patients undergoing breast conserving surgery, local complications after breast radiotherapy have in the past been shown to be proportional to breast size. Therapeutic mammoplasty is an option to extend the role of breast conserving surgery. In our units, it has been used in larger breasted women undergoing breast conserving surgery to reduce the risk of local radiotherapy complications.

Aim

The aim of this multicentre study was to determine, with modern radiotherapy dosing schedules, if it is possible to specify a minimum bra cup size at which therapeutic mammoplasty should be considered.

Methods

Recurrence free breast cancer patients (at least 3 years post conservative surgery and radiotherapy) were identified from three oncology follow up clinics in the United Kingdom.

50Gy in 25 fractions over 5 weeks prescribed to the 100% isodose at the ICRU reference point, on the central outline of the breast had been a typical dosing schedule. Radiotherapy effects were graded using the Late Effects of Normal Tissue-Subjective Objective Management Analytical (LENT-SOMA) score. A score of two or above was taken as representing that the particular toxicity variable was present. The relationship between radiotherapy toxicity variables was calculated using the Pearson correlation co-efficient.

Results

479 breast cancer patients were assessed. Increasing cup size correlated with oedema (Pearson correlation co-efficient r=0.30, p=&lt;0.0001), induration (r=0.31, p=&lt;0.0001), telangiectasia (r=0.24, p=&lt;0.0001), breast retraction (r=0.15, p=0.002) and pain (r=0.10, p=0.030). 2.3% of patients with cup size AA/A exhibited fibrosis, 6.6% with cup size B or C, 11.8% cup size D and 25.5% with cup size DD and above. Conclusion

Local radiotherapy complications following breast conserving surgery for breast cancer remain proportional to breast size even with modern radiotherapy equipment and dosing schedules. This effect is most pronounced in women with a bra cup size D and above. For these women, therapeutic mammoplasty should be considered. Further work to identify the genetic determinants of normal-tissue radiation damage is underway to optimise the surgical decision.

Citation Information: Cancer Res 2010;70(24 Suppl):Abstract nr P4-11-17.

Changes in the Allergenicity during Different Preparations of Pomfret, Hilsa, Bhetki and Mackerel Fish as Illustrated by Enzyme-Linked Immunosorbent Assay and Immunoblotting

BACKGROUND

Although the identification and characterization of several fish allergens have already been reported, there is almost no data on Indian fish allergens and the effect of thermal processing on their allergenicity. This study aimed at the evaluation of the changes in the level of allergenicity of 4 highly consumed Indian fishes, i.e. pomfret, hilsa, bhetki and mackerel, that occurred after boiling and frying.

METHODS

In this study 110 patients with fish hypersensitivity as evidenced by clinical history and symptoms were recruited based on their positive skin prick test results. The raw, boiled and fried muscle extracts of the 4 fishes were prepared, and each extract was tested by ELISA and immunoblotting with patients' sera.

RESULTS

ELISA and immunoblotting studies demonstrated that the raw muscle extracts of pomfret, hilsa, bhetki and mackerel were allergenic. While the allergenicity of boiled and fried extracts of pomfret and hilsa was considerably reduced, maximum allergenicity of bhetki was demonstrated in the fried extract. The degree of allergenicity of bhetki was demonstrated in the order fried>boiled>raw while that of mackerel followed the order raw>boiled approximately fried.

CONCLUSION

The specific IgE-binding activity and immunoblot profile clearly showed that pomfret and hilsa fish allergens are heat-labile, while allergens of bhetki and mackerel maintained strong reactivity even after thermal treatment.

Effect of thyroid hormone on the development and gene expression of hormone receptors in rat testes in vivo

Thyroid hormone is known to play a pivotal role in the regulation of prepuberal rat testes development and function with specific influence on the differentiation of Sertoli cells, the only cell type that expresses thyroid hormone receptors in testes. To explore in vivo effects of thyroid hormone on testes development and the regulation of testicular gene expression, the hyper- and hypothyroid rat models were established by T3 injection to pups (ip 100 microg/kg bw) and by oral administration of 6-N-propyl-2-thiouracil (PTU) to the lactating mother from days 1 to 21 post-delivery. Half of the rats from each group were sacrificed at 21 days of age, and the other half were allowed to recover with discontinued treatments from day 22 to day 50. At 21 days of age, a significantly elevated serum T3 level was observed in hyperthyroid rats (179.5 ng/dl) vs controls (97.5 ng/dl), and in hypothyroid rats a significantly lower level of T3 was detected (26.1 ng/dl). However, serum T4 concentration was significantly lower in both hyper- (0.105 microg/dl) and hypothyroid (0.058 microg/dl) rats compared to the controls (2.48 microg/dl). In recovered rats in which the serum T3 and T4 were restored to normal, the serum T levels remained remarkably lower in both hyper- and hypothyroid rats. The significantly decreased body and testes weights observed in both hyper- and hypothyroid rats at 21 days of age were not restored by the time they were 50 days old. Histological analyses of testes of 21-day-old hypothyroid rats revealed smaller-sized seminiferous tubules, incomplete lumen formation and delayed germ cell differentiation and in hyperthyroid rats an increased number of early stage spermatocytes was found. Testicular mRNA levels of follicle-stimulating hormone receptor (FSH-R), luteinizing hormone receptor (LH-R) and androgen binding protein (ABP) were studied by Northern blot hybridization. At 21 days of age data showed that FSH-R mRNA levels were significantly higher in both hyper- and hypothyroid rat testes compared to controls, but no differences were detected in recovered 50-day-old rats. Significantly decreased ABP mRNA levels were detected only in hypothyroid rat testes compared to those in both the hyperthyroid and control groups at 21 days of age, but no significant change was observed in recovered 50-day-old rats. To further evaluate the effect of thyroid hormone on the Leydig cell function, the 2.3/2.6 kb specific LH-R hybridization bands were detected with rat LH-R cRNA probe. Significant suppression of LH-R mRNA levels was only observed in the hypothyroid rat testes at 50 days of age. The testicular thyroid hormone receptors (TRs) and the regulation of TR by thyroid hormone were investigated using semi-quantitative reverse transcription-polymerase chain reaction (RT-PCR) assays. Both TRalpha and TRbeta mRNAs were identified in the testes from 21- and/or 50-day-old rats. TRalpha mRNA levels were significantly increased in hypothyroid rat testes and were suppressed in hyperthyroid rats at 21 days of age and no changes of TRalpha mRNA were found in recovered animals. Our in vivo data strongly suggest that the thyroid hormone directly affects the development of prepuberal testes and the regulation of FSH-R and ABP gene expression in Sertoli cells, as well as the LH-R mRNA levels in Leydig cells, which may lead to further modulating the effect of gonadotropins on testes function.

Effects of prolactin and fish pituitary extract on plasma calcium levels in common carp, Cyprinus carpio

The effects of prolactin (PRL) from both mammalian and piscine sources on plasma calcium levels in common carp, Cyprinus carpio, were investigated. Injections of ovine prolactin (oPRL) or homologous fish pituitary extract or partially purified prolactin of murrel, Channa punctatus pituitary (mPRL), caused significant increases in total and ultrafiltrable plasma calcium. Larger hypercalcemic responses were observed in fish kept in high-calcium fresh water and normal tap water than in fish in low-calcium fresh water. Injections of oPRL caused dose-dependent increases in plasma calcium level. The highest dose (1 mg/kg body wt) of oPRL had a reduced hypercalcemic effect. Administration of EGTA (200 microM/kg body wt) reduced the stimulatory effects of daily injections of oPRL or mPRL on plasma calcium in freshwater common carp under laboratory conditions. These results indicate that PRL may be involved in regulating plasma calcium levels in fish.

Effect of mercuric chloride and cadmium chloride on gonadal function and its regulation in sexually mature common carp Cyprinus carpio

Gonadal function in fish, Cyprinus carpio was significantly affected by sublethal doses of mercuric chloride (HgCl2) and cadmium chloride (CdCl2) in chronic (45 days) exposure. Parameters investigated were nonesterified (NE) and esterified (E) cholesterol of ovary, liver and serum and ovarian 3 beta-Hydroxysteroid and 17 beta-Hydroxysteroid dehydrogenase enzyme activity and serum and pituitary gonadotropin (GtH) levels. Both the pollutants were able to reduce the hypothalamic extract (HE) or gonadotropin releasing hormone (GnRH) induced pituitary GtH release in vitro. Short term (96h) exposure of the fish to the pollutants had no significant effect on the gonadal function. In addition to the deleterious effect of pollutants on the gonadal steroidogenesis and pituitary gonadotropin release, using [4-14C] cholesterol as a tracer it was found that for 45 days exposure, HgCl2 had an adverse effect on the transport of cholesterol from circulation to ovary.

The cyanogen bromide fragment I of asialoorosomucoid is transported more efficiently than asialoorosomucoid in rat hepatocytes

Cultured rat hepatocytes internalized and degraded 125I-labeled asialoorosomucoid (125I-ASOR) through asialoglycoprotein receptor at rates about half that of its cyanogen bromide fragment I (125I-ASCNBr-I). Reduction and carboxymethylation of the fragment resulted in decreased rates of internalization and degradation which were still greater than those of 125I-ASOR. In the presence of 5 microM colchicine, degradation of all three ligands was inhibited. However, the intracellular level of 125I-ASOR at steady state remained unchanged, while those of the fragments increased continuously. Study of the binding of these ligands to hepatocytes at 4 degrees C indicated that there was no significant difference in binding parameters between ASOR, ASCNBr-I and RC-ASCNBr-I (reduced and carboxymet ASCNBr-I). Studies of the fate of these ligands preloaded in the cell at 37 degrees C indicated that a higher fraction of the internalized ASOR than of the fragments was released by diacytosis. In contrast to ASOR, diacytosis of the fragments was not enhanced by colchicine. Studies of the distribution of intracellular ligands by Percoll density gradient centrifugation indicated that they were internalized initially into two early endosomal compartments of d = 1.037 g/ml and d = 1.045 g/ml. In the presence of colchicine, accumulation of the ligands in a third endosomal compartment of d = 1.08-1.095 g/ml was revealed, while in the presence of leupeptin accumulation of the ligands in lysosomes was observed. The results of a kinetic analysis indicated that both cyanogen bromide fragments were transported to all these compartments more rapidly than was ASOR. It appears that they are internalized and degraded more rapidly than ASOR due to a more efficient sorting of the internalized ligand into the pathway of lysosomal degradation.

Binding of thyroid hormone to isolated ovarian nuclei from a freshwater perch, Anabas testudineus

High affinity, low capacity 3,5,3'-triiodo-L-thyronine (T3) specific binding was detected in the pure nuclei preparation from ovarian tissue of freshwater perch by employing an in vitro thyroid hormone binding assay. Under standardized assay conditions of pH 7.0 at 30 degrees and 1 hr incubation time, the binding in the ovarian nuclei was saturable with a Kd 9.1 X 10(-9) M. For comparison, a Scatchard analysis of T3 binding to perch hepatic nuclei was done and a higher Kd value (16.89 X 10(-9) M) with twofold increase in maximum binding capacity (MBC 8.882 and 4.312 pmol/mg DNA in liver and ovary, respectively) was observed. Competitive inhibition studies showed ovarian T3 binding to be hormone specific with relative binding affinities comparable to T3 binding in other systems. T3 binding to the nuclear preparation from tail kidney and brain tissue of perch was considerably lower in comparison to liver and ovarian nuclei. Functional relevance of T3 binding to perch ovarian nuclei was tested by incubating ovarian tissue in vitro with T3. T3 significantly (P less than 0.001) increased protein synthesis in comparison to control.

Plasma thyroxine levels in freshwater perch: influence of season, gonadotropins, and gonadal hormones

Plasma thyroxine (T4) of a freshwater female perch Anabas testudineus (Bloch) has been measured by specific radioimmunoassay (RIA). Monitoring of plasma T4 throughout the year showed that July to early September (spawning stage) had the highest T4 and late September to January (postspawning stage) had the lowest T4. The plasma T4 cycle was coincident with the ovarian cycle. Treatment of intact perch with salmon gonadotropin (SG-G100) or ovine LH (500 ng/100 g body wt) markedly enhanced plasma T4 levels. Ovine FSH was without any effect. Ovarian steroids, estrone and 17 beta-estradiol (100 ng/100 g body wt), also significantly augmented T4 level whereas estriol or progesterone had no such effect. There was a striking fall of plasma T4 in ovariectomized fish. The drop of T4 due to ovariectomy could not be reversed by SG-G100 but administration of estrone or 17 beta-estradiol to ovariectomized fish effectively reversed the drop of plasma T4 level. These findings suggest that gonadotropin's stimulatory effect on perch thyroid is mediated via the release of ovarian steroids.

Influence of gonadotropins and gonadal hormones on climbing perch thyroid nucleic acids

Climbing perch thyroidal RNA content fluctuated in different phases of the reproductive cycle, highest at spawning (36.08 +/- 3.69 micrograms/mg tissue) and lowest at postspawning (6.88 +/- 0.76 microgram/mg tissue) whereas DNA remained unaltered. Treatment of intact perch with salmon gonadotropin (SG-G100) or ovine LH for 15 days significantly stimulated thyroidal RNA content. Stimulatory effect of SG-G100 was greater (p less than 0.001) than LH (p less than 0.005). FSH had no such effect. Gonadotropin (GtH) treatment could not alter thyroidal DNA. Ovarian steroids, 17 beta-estradiol (E2) and estrone (E1) remarkably elicited RNA content. Ovariectomy of perch caused striking depletion of RNA. Administration of GtH to ovariectomized perch had no effect on thyroid RNA but E1 and E2 supplementation resulted in significant stimulation in comparison to ovariectomized control. Findings indicate that GtH mediated its stimulatory effect on perch thyroidal RNA via the release of ovarian steroids.

Bovine TSH-stimulation of fish thyroid peroxidase activity and role of thyroxine thereon

bTSH augmented the fish thyroid peroxidase activity in a dose-response manner. Thyroxine could not modulate the effect of exogenous bTSH, but it decreased the peroxidase activity in a control system when administered alone. The data therefore suggest similar negative feedback control system for TSH-regulation as operative in the case of mammals.