Towards an optimal luteal support modality in agonist triggered cycles: a randomized clinical trial.

STUDY QUESTION: In ICSI patients with high risk of ovarian hyperstimulation syndrome (OHSS), are antagonist cycles triggered by gonadotropin releasing hormone (GNRH) agonist with a specialized luteal support regimen associated with comparable ongoing pregnancy rate (OPR) and less OHSS than those triggered by hCG? SUMMARY ANSWER: In antagonist ICSI cycles, GnRH agonist triggering with a specialized luteal support regimen is associated with comparable OPR to those triggered by hCG but may be less likely to be associated with OHSS. WHAT IS KNOWN ALREADY: In IVF/ICSI protocols, exogenous hCG was used for years as a substitute of the endogenous LH surge. However, because of its longer half life, hCG is associated with more risk of OHSS, especially in high risk women. For this reason, GnRH agonist triggering was introduced. There is, however, no consensus on the best protocol for luteal support on agonist triggered cycles. STUDY DESIGN, SIZE, DURATION: Randomized controlled open label trial including 190 participants recruited from June 2015 to March 2016 in a private fertility center. Participants were divided into 2 equal groups; GnRH agonist trigger and hCG trigger. Randomization was done using identical sealed envelope technique. PARTICIPANTS/MATERIALS, SETTING, METHODS: One hundred ninety women, predicted to have high response, were randomized on the day of final oocyte maturation into two equal groups: group (A), GnRH agonist trigger followed by specialized regimen (1500 IU hCG) at time of oocyte retrieval plus oral estradiol and intramuscular progesterone during luteal phase; and group (B), 5000 IU of hCG with luteal support (oral estradiol and vaginal progesterone). MAIN RESULTS AND THE ROLE OF CHANCE: The 2 groups were comparable in baseline characteristics. OPR per randomized patient was comparable in the 2 groups {49/95 (51.6%) in group A, and 50/95 (52.6%) in group B ((P = 0.88); RR = 0.980, 95% CI: 0.75-1.29)}. Considerable (moderate + severe) OHSS was higher in group B (13/95 [14%] versus 5/95 [5%] P = 0.047; uncorrected Chi-square test). Upon performing multivariate regression analysis for predicting OHSS, number of follicles ≥11 mm on trigger day was the only independent predictor (P = 0.0004). LIMITATIONS, REASONS FOR CAUTION: Strict selection criteria limit generalization of results. The study was powered for pregnancy rate not OHSS, so that the strength of evidence on OHSS prediction is weak. WIDER IMPLICATIONS OF THE FINDINGS: We recommend the use of GnRH agonist plus the specialized luteal phase support in high responders with high risk of OHSS undergoing IVF/ICSI cycles. This protocol achieved a similar ongoing pregnancy to hCG triggering and may be less likely to result in moderate to severe OHSS. STUDY FUNDING/COMPETING INTEREST(S): None. TRIAL REGISTRATION NUMBER: PACTR 201506001132105. TRIAL REGISTRATION DATE: 24/6/2015. DATE OF FIRST PATIENT'S ENROLLMENT: 26/6/2015.

Neoadyuvancia en cáncer de mama: papel del patólogo / Neoadjuvant therapy in breast cancer: the role of the pathologist

El tratamiento neoadyuvante ha sido utilizado en el carcinoma de mama localmente avanzado y en casos de carcinoma inicialmente inoperable. Más recientemente, esta estrategia se ha extendido a casos de cáncer de mama operable estadio ii/iii, especialmente para aumentar las posibilidades de tratamiento quirúrgico conservador. La neoadyuvancia permite además valorar la respuesta del tumor primario a un determinado tipo de quimioterapia y proporciona la oportunidad de cambiar el tratamiento en caso de falta de respuesta. Si bien la respuesta patológica completa es un factor predictivo de supervivencia, no hay consenso en la metodología de evaluación de este importante parámetro patológico y pueden aplicarse diferentes criterios de valoración. Finalmente, la biopsia con aguja gruesa puede proporcionar importante información que ayude a determinar la indicación y tipo de tratamiento neoadyuvante(AU)

Neoadjuvant therapy was first used for locally advanced breast carcinoma and in cases in which the carcinoma is initially inoperable. More recently, it has been extended to include operable, stage II/III carcinomas of the breast to increase the possibility of conservative surgery. Neoadjuvant therapy also allows the response of the primary tumour to a particular type of chemiotherapy to be evaluated and, if necessary, changed, in the absence of tumour response. Although the overall pathological response is a prognositic factor, no consensus has been reached as to the method of evaluation of this important pathological parameter and different criteria may be used in its assessment. Finally, core needle biopsy can provide important information which helps determine the indication for and the type of neoadjuvant therapy(AU)

Relaçäo entre tipo histológico e dosagem bioquímica dos receptores de estradiol e progesterona em mulheres com carcinoma primário da mama / Relation into histopatological type and biochemical determination of estradiol receptors and progesterone in women with primary breast neoplasms

Estudaram-se 100 pacientes com carcinoma primário da mama näo tratadas. Analisaram-se o grau de diferenciaçäo tumoral e a dosagem bioquímica dos receptores de estradiol e de progesterona em pacientes, tanto na pré como na pós-menopausa. Utilizou-se o método de carväo dextran, tendo como limites de positividade 10 fmoles/mg para os receptores de estradiol e 20 fmoles/mg para os de progesterona. Näo houve diferença na distribuiçäo do grau histológico na pré e na pós-menopausa. A positividade dos receptores de estradiol foi de 60,0%, sendo 50,0% na pré e 66,7% na pós-menopausa. Para os receptores de progesterona, a positividade foi de 44,0%, sendo 45,0% na pré e 43,3% na pós-menopausa. Nos tumores indiferenciados os receptores de estradiol tiveram menor positividade e concentraçöes inferiores do que em tumores diferenciados na pós-menopausa. Os receptores de progesterona näo variaram significativamente, tanto na pré como na pós-menopausa. Os parâmetros estudados, isto é, positividade e concentraçäo de receptores, näo substituem o valor prognóstico dos graus de diferenciaçäo histológica. Näo säo, pois, intersubstituíveis; porém, quando o tumor for diferenciado e possuir mais do que 50,4 fmoles/mg de estradiol, é possível predizer um prognóstico mais favorável da moléstia