Chemoprevention of Prostate Cancer by Natural Agents: Evidence from Molecular and Epidemiological Studies

BACKGROUND/AIM

Prostate cancer is one of the most common cancers in men which remains a global public health issue. Treatment of prostate cancer is becoming increasingly intensive and aggressive, with a corresponding increase in resistance, toxicity and side effects. This has revived an interest in nontoxic and cost-effective preventive strategies including dietary compounds due to the multiple effects they have been shown to have in various oncogenic signalling pathways, with relatively few significant adverse effects.

MATERIALS AND METHODS

To identify such dietary components and micronutrients and define their prostate cancer-specific actions, we systematically reviewed the current literature for the pertinent mechanisms of action and effects on the modulation of prostate carcinogenesis, along with relevant updates from epidemiological and clinical studies.

RESULTS

Evidence from various recent experimental, clinical and epidemiological studies indicates that select dietary micronutrients (i.e., lycopene, epigallocatechin gallate, sulforaphane, indole-3-carbinol, resveratrol, quercetin, curcumin & piperine) and zinc play a key role in prostate cancer prevention and progression and therefore hold great promise for the future overall management of prostate cancer.

CONCLUSION

A formulation that comprises these micronutrients using the optimal, safest form and dosing should be investigated in future prostate cancer chemoprevention studies and as part of standard prostate cancer therapy.

Correlation of TERT and Stem Cell Markers in the Context of Human Breast Cancer

BACKGROUND

Telomerase reverse transcriptase (TERT) has a well-known role in carcinogenesis due to its functions in inducing cell immortality and preventing senescence. In this study, the relationships between TERT and a panel of known stem cell markers was examined in order to direct future enquiries into the role of 'stem-ness' in human breast cancer.

MATERIALS AND METHODS

Breast cancer tissues (n=124) and adjacent normal tissues (n=30) underwent reverse transcription and quantitative polymerase chain reaction. Transcript levels were analyzed for the correlation with that of TERT.

RESULTS

A significant direct correlation was found in cancerous tissue between TERT and BMI1 proto-oncogene polycomb ring finger 4 (BMI1; n=88, p<0.001), nestin (NES; n=88, p<0.001), POU domain, class 5, transcription factor 1 (POU5F1; n=88, p<0.001), aldehyde dehydrogenase 1 family member A2 (ALDH1A2; n=87, p=0.0298), cyclin-dependent kinase inhibitor 1A (CDKN1A; n=88, p<0.001), integrin subunit beta 1 (ITGNB1; n=88, p<0.001), integrin subunit alpha 6 (ITGA6; n=88, p<0.001), cluster of differentiation antigen 24 (CD24; n=88, p=0.0114), MET proto-oncogene (MET; n=78, p<0.001) and noggin (NOG; n=88, p<0.001).

CONCLUSION

The evidence presented in this article of possible interactions between TERT and a discrete subset of known stem cell markers would significantly contribute to further enquiries regarding clonal dynamics in the context of human breast cancer.

A Study of the Relation Between Mastectomy Specimen Weight and Volume With Implant Size in Oncoplastic Reconstruction

BACKGROUND

There is no general consensus regarding the best and most accurate method for assessing the size of implant required for achieving the best symmetry in oncoplastic reconstruction.

MATERIALS AND METHODS

Breast weight, volume and size of implant were recorded prospectively on patients undergoing immediate reconstruction over a 3-year period. Cases with specimen size greater than 2,000 g were excluded. The primary endpoint was size of implant used in relation to specimen weight and volume. Secondary endpoints were the influence of age and histology on specimen weight, volume and breast density.

RESULTS

A total of 278 mastectomies were performed. Correlation of implant size with volume was marginally stronger than that with weight (r=81%, p<0.001 vs. r=78.9%, p<0.001 respectively). Women aged 50 years and above had lower breast weight for the same breast volume than women under 50 years. The difference was merely 4%, but was statistically significant (p=0.001). Histology had no statistically significant influence on breast density.

CONCLUSION

Specimen weight and volume were found to be closely correlated. Weight can be measured more accurately and easily with reproducible readings compared to volume.

Can Complete Axillary Node Dissection Be Safely Omitted in Patients with Early Breast Cancer When the Sentinel Node Biopsy Is Positive for Malignancy? An Update for Clinical Practice

The sentinel lymph node biopsy (SLNB) has become the new standard-of-care for patients with clinically node-negative invasive breast cancer. The focused examination of fewer lymph nodes in addition to improvements in histopathological and molecular analysis have increased the rate at which micrometastases and isolated tumor cells are identified. We reviewed the literature and summarized the evidence regarding the need for complete axillary lymph node dissection (ALND) following the finding of a positive sentinel node biopsy through the identification of the most important outcomes and evaluation of quality of evidence. The article focuses on the safe omission of complete ALND when the axillary lymph nodes contain macrometastases and provides an overview of the topic primarily based on level 1 evidence derived from randomized clinical trials with a critical appraisal of the ACOSOG Z0011 trial.

The Evolving Role of Pre-pectoral ADM-assisted Approach in Implant-based Immediate Breast Reconstruction Following Conservative Mastectomy: An Overview of the Literature and Description of Technique

BACKGROUND/AIM

The recent development of acellular dermal matrix (ADM) devices has enhanced implant-based breast reconstruction surgery following conservative mastectomy for therapeutic and risk-reducing purposes leading to improved aesthetics. In the traditional sub-pectoral approach, coverage of the implant is provided by the pectoral muscles superiorly and the ADM inferiorly. The need to eliminate breast animation, reduce post-operative dysfunctional pain and the risk of capsular contracture, have stimulated surgeons to investigate the feasibility of placing the implant over the pectoralis major muscle with complete coverage with ADM thus inventing a novel pre-pectoral approach.

MATERIALS AND METHODS

We reviewed the literature regarding this evolving technique of muscle sparing ADM-assisted implant-based immediate breast reconstruction. Also, we describe our technique, and present pictures of the post-operative result.

RESULTS AND CONCLUSION

The early reported results of the pre-pectoral breast reconstruction approach are encouraging and confirmed the potential benefits of eliminating breast animation and reducing postoperative pain. However, most of these studies had a small sample size (<100 patients) and were retrospective in nature with a limited follow-up duration and lack of data regarding the objective aesthetic assessment and oncological outcome. Nevertheless, suitable patients undergoing conservative mastectomy and implant-based reconstruction should be offered this option while further evaluation is being performed.

mRNA Expression of CDK2AP1 in Human Breast Cancer: Correlation with Clinical and Pathological Parameters

BACKGROUND

Cyclin-dependent kinase 2-associated protein 1 (CDK2AP1) interacts with CDK2AP2, modulates the actions of transforming growth factor-B1, cyclin-dependent kinase 2 and retinoblastoma protein, and closely interacts with micro-RNA21 and micro-RNA25. Our objective was to determine if CDK2AP1 mRNA expression levels were consistent with tumour-suppressive functions in breast cancer.

MATERIALS AND METHODS

A total of 134 samples were analysed. CDK2AP1 mRNA levels were measured using quantitative polymerase chain reaction (RT-PCR) and normalised against glyceraldehyde 3-phosphate dehydrogenase mRNA. Levels in breast cancer and adjacent non-cancerous breast tissue were analysed against pathological and clinical parameters (TNM staging, survival over a 10-year follow-up period).

RESULTS

Normalised CDK2AP1 expression was 38-fold higher in adjacent non-cancerous breast tissue than in breast cancer. CDK2AP1 expression in disease-free patients at 10 years was more than threefold that of patients who died of breast cancer. However, neither of these differences in expression levels reached statistical significance. CDK2AP1 mRNA levels were higher in TNM1 compared to TNM3 (p=0.016) and with TNM4 (p=0.016). There were no significant associations between CDK2AP1 expression and estrogen receptor status, tumour grade and tumour type. There was no significant difference in overall survival between patients with high and those with low CDK2AP1 mRNA levels after a median follow-up of 10 years (Kaplan-Meier analysis, p=0.872).

CONCLUSION

To our knowledge, this is the first study in the literature to examine the mRNA expression of CDK2AP1 in human breast cancer over a long-term follow-up period. A compelling relationship exists between high CDK2AP1 mRNA expression and lower TNM classification of breast cancer, which is consistent with CDK2AP1 having a tumour-suppressive function.

Optimizing adjuvant endocrine therapy for early ER+ breast cancer: An update for surgeons

INTRODUCTION

The optimal duration of adjuvant endocrine therapy in early ER + breast cancer has been controversial. This article aims to provide an overview of the evidence.

METHODS

A search of the literature was conducted via MEDLINE using appropriate keywords. Eligible studies were screened and relevant articles were selected for this report.

RESULTS

Studies investigating the role of extended adjuvant tamoxifen beyond 5 years have revealed mixed results depending on the proportion of node positivity. In postmenopausal women, aromatase inhibitors (AIs) for 5 years are superior to tamoxifen. Extending the use of AIs beyond 5 years seem to reduce the risk of relapse in postmenopausal women with node positive disease. The addition of bisphosphonates to counteract AI-related osteopenia may further improve overall and disease-free survival. Women younger than 40 years seem to benefit from ovarian suppression combined with tamoxifen or exemestane.

CONCLUSIONS

An individualised approach is required for every patient. The adverse effects of endocrine therapy should be weighed against the potential benefits of extended therapy to better inform decision-making.

The Impact of EndoPredict Clinical Score on Chemotherapy Recommendations in Women with Invasive ER+/HER2- Breast Cancer Stratified as Having Moderate or Poor Prognosis by Nottingham Prognostic Index

BACKGROUND

The Nottingham Prognostic Index (NPI) was developed using tumour pathological features to guide decisions regarding adjuvant therapy in breast cancer. Recent breakthroughs in molecular biology aided development of genomic assays such as EndoPredict, which have been shown to provide excellent prognostic information. The current study investigated the impact of EndoPredict Clinical (EPClin), a composite of clinicopathological data and EndoPredict score, on chemotherapy recommendations based on NPI.

PATIENTS AND METHODS

A total of 120 patients with oestrogen receptor-positive (ER⁺)/human epidermal growth factor receptor 2-negative (HER2^-) breast cancer who were candidates for post-operative adjuvant chemotherapy at a single tertiary centre were included. Both NPI and EPClin were applied to all patients. NPI differentiated patients into groups with excellent/good prognosis (N=41; NPI≤3.4) or moderate/poor prognosis (N=79; NPI >3.4). The latter were considered for adjuvant chemotherapy.

RESULTS

There was discordance in results of 31% of cases; 35% of the patients/candidates for adjuvant chemotherapy according to NPI were reclassified as being at low risk of recurrence by EPClin.

CONCLUSION

Genomic profiling using EPClin reduces the potential need for adjuvant chemotherapy in women with ER⁺/HER2^- breast cancer who are candidates for chemotherapy according to the NPI.

Is Adjuvant Endocrine Therapy Indicated for DCIS Patients After Complete Surgical Excision?

Data derived from pathological analysis, natural history, radiological characteristics, genomic profiling, and clinical outcome indicate that ductal carcinoma in situ (DCIS) is a heterogeneous disease; meaning that no single therapeutic strategy is best, but rather that treatment should be personalised and entail a rigorous multidisciplinary approach. The role of adjuvant endocrine therapy after surgical excision has been the subject of scientific debate in view of the in situ nature of this neoplasm. We reviewed the literature and summarised the evidence regarding the need for adjuvant endocrine therapy following complete surgical excision of DCIS through the identification of the most important outcomes, evaluation of quality of evidence, and assessment of the trade-offs involved. There is no scientific evidence that adjuvant endocrine therapy reduces the incidence of ipsilateral breast invasive recurrence or breast cancer mortality in the context of adequate local treatment of DCIS in the form of breast conserving surgery with clear surgical margins plus adjuvant radiotherapy or total mastectomy. Therefore, its routine use is not indicated. However, adjuvant endocrine therapy can be considered after a rigorous multidisciplinary discussion and patient counselling in a carefully selected subgroup of patients with high-risk estrogen receptor-positive DCIS.

Abstract P6-05-04: mRNA expression of PTK6V1 and PTKV2 in human breast cancer

BACKGROUND:

Protein tyrosine kinase 6 (PTK6) is an intracellular protein that is upregulated in several human cancers and its localization to the plasma-membrane facilitates its various oncogenic roles in breast cancer cell proliferation, survival, and migration. The full length protein (PTK6V1) and alternative splice variant (PTK6V2) seem to play different roles with the latter being negative regulator of the former.

In this study, the level of mRNA expression of PTK6V1 and PTK6V2 were assessed in normal and malignant breast tissue using real time Q-PCR in a cohort of women with breast cancer and correlated to conventional clinico-pathological parameters and clinical outcome.

MATERIALS AND METHODS:

Breast cancer tissues (n = 127) and normal background tissues (n = 33) were collected immediately after excision during surgery. Following RNA extraction, reverse transcription was carried out and transcript levels were determined using real-time quantitative PCR and normalized against beta-actin expression. Transcript levels within the breast cancer specimens were compared to the normal background tissues and analysed against TNM stage, nodal involvement, tumour grade and clinical outcome over a 10 year follow-up period.

RESULTS:

The median copy number of transcripts of PTK6V1 were higher in malignant compared with normal breast tissue (23 vs.7) and overall increased with advancing tumour stage (374 vs. 13 for TNM3 vs. TNM1 respectively p=0.019 and 374 vs.23 for TNM3 vs. TNM2 p=0.0244). however these associations did reach statistical significance. PTK6V1 levels were associated with oestrogen receptor (ER) positivity (p = 0.061). The transcript levels were significantly higher in patients who developed recurrence (p=0.03) or died of breast cancer (p=0.003). PTK6V2 transcript levels were generally higher in normal breast tissue than in malignant tissues and decreased with increasing tumour stage and grade however these associations did not reach stastical significance. After a median follow up of 10 years, there was a trend for higher PTK6V2 expression to be associated with longer overall survival (OS) and disease free survival (DFS). PTK6V2/PTK6V1 ratio was a significant predictor of OS.

Conclusions

Our observations suggest that the two variants of PTK6 play opposing roles in mammary oncogenesis. These findings could have prognostic and therapeutic implications.

Citation Format: El Hage Chehade H, Harvey A, Wazir U, Jiang WG, Mokbel K. mRNA expression of PTK6V1 and PTKV2 in human breast cancer [abstract]. In: Proceedings of the 2017 San Antonio Breast Cancer Symposium; 2017 Dec 5-9; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2018;78(4 Suppl):Abstract nr P6-05-04.

Abstract P4-13-13: The correlation between mastectomy specimen weight and volume- a guide to the choice of implant size in breast reconstruction

Introduction: The concept of “conservative” mastectomy with breast reconstruction has led to a huge positive impact on the quality of life of breast cancer survivors. In 2015, 106,338 breast reconstructions were performed with implant-based reconstruction (IBR) constituting 86,013 (80.9%) of those procedures. Technically speaking, there is still no consensus on the most accurate method of assessing the size of implant used to achieve the desirable aesthetic results and symmetry. Some surgeons use the volume of the mastectomy specimen, believing that the volume of the implant replacing the volume of breast tissue removed is a logical way of thinking. Others prefer to depend on the weight of the specimen owing to the presumption that a mixture of fat and fibroglandular tissue will give an approximate overall density of 1.0g/cm3. To the authors' knowledge, the correlation between the mastectomy specimen volume and weight has been scarcely reported in the literature.

Materials and Methods: Patients undergoing nipple or skin-sparing mastectomy with immediate IBR at the London Breast Institute between January 2014 and December 2016 were included in this study. They were under the care of two senior Oncoplastic breast surgeons. Data on breast weight and volume as well as the size of implants used were prospectively collected. The volume of the breast tissue was assessed by volume displacement method while the weight was measured on a scale in grams. The exclusion criteria included patients with mastectomy specimen weighing more than 2000 grams. Further subgroups were divided into patients younger and those older than 50 years old. The presence or absence of cancer was also reviewed to assess whether the tumor tissue would have heavier weight when compared with volume.

Results: Between January 2014 and December 2016, a total of 236 mastectomies were performed, of which 144 were accompanied with IBR. The mean age of the patients was 45 years (range= 25-74). There were 79 right and 65 left breast specimens. Among these cases, 36 were bilateral. Tissue volume and weight had a strong direct correlation (N=144, R=0.99, P&lt;0.00). Mastectomy volume had a marginally stronger correlation with implant volume/size (N=144, R=0.82, P=&lt;0.00) than weight (N=144, R=0.79, P=&lt;0.00). Further subgroup analysis showed that neither the presence of cancer nor the variation in breast density with age or menopausal status seemed to affect the correlation between the weight and volume of the breast tissue. 75% of reconstructions had implant size within 100 mls or grams of the mastectomy specimen.

Conclusions: Our study has shown that mastectomy specimen weight and volume have close enough correlation. The volume measurement was best estimated to the nearest 25 to 50 mls. On the other hand, the weight assessment was more accurate, objective, easier, and more reproducible with minimal inter-observer error. Hence, we believe that the breast weight can be reliably used to estimate the size of the implant. However, there are many other factors that should be taken into consideration when choosing an implant. For instance, the woman's wish for smaller or larger size, the width and height of the breast base, and the availability of a wide range of implants.

Citation Format: Wazir U, El Hage Chehade H, Choy C, Kasem A, Mokbel K. The correlation between mastectomy specimen weight and volume- a guide to the choice of implant size in breast reconstruction [abstract]. In: Proceedings of the 2017 San Antonio Breast Cancer Symposium; 2017 Dec 5-9; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2018;78(4 Suppl):Abstract nr P4-13-13.

Abstract P1-07-27: Prognostic value of programmed death 1/Programmed death ligand 1/ mammalian target of rapamycin/Rictor/Tuberin in human breast cancer

Background:The Mammalian Target of Rapamycin (mTOR) regulates a multitude of cellular processes including metabolism, proliferation and growth. It is known to form two multi-protein complexes - complex 1 (mTORC1) and complex 2 (mTORC2) with Raptor and Rictor being their core proteins vital for their integrity.

Tuberin, the product of the Tuberous Sclerosis Complex gene 2, TSC2, has been characterized as a tumour suppressor and negatively regulates the mTOR pathway.

Programmed Death 1 (PD-1), a transmembrane protein particularly expressed on the surface of tumour cells, acts as an immune checkpoint receptor. Together with its ligand Programmed Death Ligand 1 (PDL-1) they form a pathway which when activated influences anti-tumour immunity and supresses anti-tumour adaptive responses. The expression of PD1/PDL-1 is lightly regulated by the mTOR pathway.

We investigated the value of expression patterns of all these molecules in breast cancer as potential prognostic factors.

Materials and Methods: Quantitative PCR (qPCR) analysis was used to determine the transcript expression profile of the five genes of interest (PD-1, PDL-1, mTOR, Rictor and Tuberin) in 128 breast cancer specimens.The correlation between PD-1 or PDL-1 with mTOR, Rictor and Tuberin was assessed using the Spearman Rank Order Correlation. Subsequently, a combined analysis was performed, where the influence of favourable expression in relation to patient overall (OS) and disease free survival (DFS) using the Kaplan Meier survival curves and multivariate analysis.

Results: The mRNA expression of the molecules showed a varying degree of association with the clinicopathological parameters. PD-1 transcript expression showed a significant correlation with mTOR expression (p &lt; 0.001). PDL-1 transcript expression was seen to correlate with mTOR (p &lt; 0.001), Rictor (p &lt; 0.001) and Tuberin (p &lt; 0.01) transcript expression. However, when the expression profile was analysed using an integrated expression score, the combined predictive value for the clinical outcome of the five genes was highly significant in terms of OS (p &lt; 0.001) and DFS (p = 0.001), and was found to be an independent prognostic factor (p&lt;0.001) for breast cancer related death using a multivariate analysis.

Conclusions: Our study identifies a molecular signature of 5 genes as a powerful prognostic predictor of OS and DFS in patients with breast cancer.

Citation Format: Uhercik M, Sanders AJ, Owen S, Davies EL, Sharma AK, Jiang WG, Mokbel K. Prognostic value of programmed death 1/Programmed death ligand 1/ mammalian target of rapamycin/Rictor/Tuberin in human breast cancer [abstract]. In: Proceedings of the 2017 San Antonio Breast Cancer Symposium; 2017 Dec 5-9; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2018;78(4 Suppl):Abstract nr P1-07-27.

Does the Use of Hair Dyes Increase the Risk of Developing Breast Cancer? A Meta-analysis and Review of the Literature

BACKGROUND/AIM

Hair dye may contain mutagenic compounds which could be associated with an increased incidence of breast cancer in women who use it. The aim of this study was to examine the association between the personal use of hair dyes and the risk of breast cancer.

MATERIALS AND METHODS

We conducted a literature review of epidemiological studies reporting breast cancer-specific risks among hair dye users versus non-users. The data for the incidence of breast cancer following the 'ever' use of hair dye in studies which met the inclusion criteria was analysed using a meta-analysis. The relative risk ratio (RR) and 95% confidence intervals (CI) were determined.

RESULTS

A total of eight case-control studies published between 1980 and 2017 met the selection criteria and were included in the meta-analysis. Compared to non-users, using a random effects model and the Duval and Tweedie's trim and fill procedure to adjust for publication bias in the presence of between studies heterogeneity, the adjusted RR for women using hair dyes was 1.1885 (95% CI=1.03228-1.36835). This indicates an 18.8% increased risk of future development of breast cancer among hair dye users.

CONCLUSION

Although further work is required to confirm our results and clarify potential mechanisms, our findings suggest that exposure to hair dyes may contribute to an increased breast cancer risk.

The evolving role of pre-pectoral ADM-assisted implant-based immediate breast reconstruction following skin-sparing mastectomy

INTRODUCTION

The increasing use of acellular dermal matrix (ADM) and fat transfer in the context of breast reconstruction, following skin sparing mastectomy (SSM) for therapeutic and risk reducing purposes, combined with the need to eliminate animation deformities, reduce post-operative dysfunctional pain and the risk of capsular contracture, has prompted surgeons to investigate the possibility of placing the mammary implant over the pectoralis major muscle with complete coverage with ADM thus reviving the pre-pectoral approach which was previously abandoned due to high complications rates and poor aesthetics in the pre-ADM era.

METHODS

We reviewed the literature regarding this evolving technique of muscle sparing ADM-assisted implant-based immediate breast reconstruction.

RESULTS AND CONCLUSIONS

Several authors have recently reported positive early results confirming the potential benefits of eliminating breast animation and reducing postoperative pain, however, most of these reports contain insufficient numbers of patients (<100) and were retrospective in nature with a very short-term follow-up and lack of data regarding objective aesthetic assessment. Prospective data are required for more definitive recommendations.

A Comparison of the Performance of EndoPredict Clinical and NHS PREDICT in 120 Patients Treated for ER-positive Breast Cancer

BACKGROUND

Computational algorithms, such as NHS PREDICT, have been developed using cancer registry data to guide decisions regarding adjuvant chemotherapy. They are limited by biases of the underlying data. Recent breakthroughs in molecular biology have aided the development of genomic assays which provide superior clinical information. In this study, we compared the performance in risk stratification of EndoPredict Clinical (EPClin, a composite of clinical data and EndoPredict) and PREDICT in a cohort of patients with breast cancer considered potential candidates for chemotherapy by the clinicians.

MATERIALS AND METHODS

One hundred and twenty patients with biopsy-proven oestrogen receptor positive (ER⁺)/human epidermal growth factor receptor 2-negative (HER2^-) breast cancer who underwent surgery were included. EPClin and PREDICT were determined for every tumour, and the results were compared.

RESULTS

Using EPClin scores performed on 120 tumours, the cohort was stratified into low- (n=60) and high-risk (n=60) groups leading to 50% reduction in total chemotherapy prescriptions. PREDICT differentiated the patients into low- (n=45), intermediate- (n=33), and high-risk groups (n=42). Discordance between scores was demonstrated for 50 (41.66%) tumours. Nine (20%) out of 45 patients with low PREDICT scores had high EPClin scores and would otherwise not have received chemotherapy if the NHS PREDICT tool had been used alone. Eight (19%) out of 42 patients at high risk by PREDICT were reclassified as being at low risk by EPClin and avoided adjuvant chemotherapy. The sensitivity, specificity, positive predictive value and negative predictive value for NHS PREDICT to predict the potential need for chemotherapy as determined by EPClin were 85%, 51%, 68% and 80%, respectively.

CONCLUSION

To our knowledge, this is the first clinical study to compare EPClin and PREDICT. The data indicate that computational algorithms such as NHS PREDICT may not accurately predict the need for chemotherapy leading to overtreatment, undertreatment or uncertainty and anxiety in a significant proportion of patients. This underscores the importance of more personalized prognostic tools.

Are online prediction tools a valid alternative to genomic profiling in the context of systemic treatment of ER-positive breast cancer?

Background

Clinicians use clinical and pathological parameters, such as tumour size, grade and nodal status, to make decisions on adjuvant treatments for breast cancer. However, therapeutic decisions based on these features tend to vary due to their subjectivity. Computational and mathematical algorithms were developed using clinical outcome data from breast cancer registries, such as Adjuvant! Online and NHS PREDICT. More recently, assessments of molecular profiles have been applied in the development of better prognostic tools.

Methods

Based on the available literature on online registry-based tools and genomic assays, we evaluated whether these online tools could be valid and accurate alternatives to genomic and molecular profiling of the individual breast tumour in aiding therapeutic decisions, particularly in patients with early ER-positive breast cancer.

Results and conclusions

Early breast cancer is currently considered a systemic disease and a complex ecosystem with behaviour determined by the complex genetic and molecular signatures of the tumour cells, mammary stem cells, microenvironment and host immune system. We anticipate that molecular profiling will continue to evolve, expanding beyond the primary tumour to include the tumour microenvironment, cancer stem cells and host immune system. This should further refine therapeutic decisions and optimise clinical outcome.

This article was specially invited by the editors and represents work by leading researchers.

Clinical Significance of PD1 and PDL1 in Human Breast Cancer

BACKGROUND/AIM

Programmed death 1 (PD1) and its ligand programmed death ligand 1 (PDL1) form a pathway which when activated is thought to result in suppression of antitumor adaptive responses, influencing antitumor immunity. With potential targeted therapies emerging against PDL1, we investigated the clinical significance of mRNA expression levels of PD1 and PDL1 in our breast cancer cohort to explore its association with disease progression and prognosis. Previous studies evaluating the expression of PD1 and PDL1 (mRNA or protein) and its association with prognosis in breast cancer showed both positive and negative correlations and hence remain controversial.

MATERIALS AND METHODS

Quantitative polymerase chain reaction was used to determine transcript expression levels of PD1 and PDL1 in a cohort consisting of primary breast cancer tissues (n=127) and matching non-neoplastic background tissues (n=33) with available clinical and pathological information. Two-sample two-tailed t-test, Kaplan-Meier survival analysis and Wilcoxon tests were performed.

RESULTS

Significant PDL1 transcript level reductions were seen in patients who developed metastases, as well as those who had local recurrence, compared to patients who remained disease-free. Higher PDL1 transcript levels were also associated with better overall and disease-free survival. Significantly higher transcript expression levels of PD1 were found in tumor tissue, whilst a general increase in PDL1 expression was found in tumor tissues, although this did not reach statistical significance.

CONCLUSION

Our study demonstrates higher levels of expression of PDL1 are associated with favorable clinical outcome.

Do online prognostication tools represent a valid alternative to genomic profiling in the context of adjuvant treatment of early breast cancer? A systematic review of the literature

INTRODUCTION

Decision-making regarding adjuvant chemotherapy has been based on clinical and pathological features. However, such decisions are seldom consistent. Web-based predictive models have been developed using data from cancer registries to help determine the need for adjuvant therapy. More recently, with the recognition of the heterogenous nature of breast cancer, genomic assays have been developed to aid in the therapeutic decision-making.

METHODS

We have carried out a comprehensive literature review regarding online prognostication tools and genomic assays to assess whether online tools could be used as valid alternatives to genomic profiling in decision-making regarding adjuvant therapy in early breast cancer.

RESULTS AND CONCLUSIONS

Breast cancer has been recently recognized as a heterogenous disease based on variations in molecular characteristics. Online tools are valuable in guiding adjuvant treatment, especially in resource constrained countries. However, in the era of personalized therapy, molecular profiling appears to be superior in predicting clinical outcome and guiding therapy.

Abstract P3-17-08: The role of sentinel lymph node biopsy in patients with ductal carcinoma in situ. An updated meta-analysis involving 9803 patients

Background: Ductal carcinoma in situ (DCIS) is the predominant pre-invasive neoplasia of the breast. It was observed that omission of axillary dissection in those with pure DCIS had no adverse effect on survival or recurrence. Therefore, axillary dissection typically does not feature in the management of DCIS. However, it has recently been purported that in some cases of DCIS, the axillary lymph nodes may show evidence of invasive disease. Consequently, there may be a role for sentinel lymph node biopsy (SLNB) in patients with DCIS with a high risk of invasion.

Materials and Methods: Systematic literature review identified 48 studies (9803 DCIS patients who underwent SLNB). Separate analyses for patients diagnosed preoperatively by core sampling and patients diagnosed postoperatively by specimen pathology were conducted to determine the percentage of patients with axillary nodal involvement. Patient factors were analysed for associations with risk of nodal involvement.

Results: The mean percentage of positive SLNBs was higher in the pre-operative group (5.95% vs. 3.02%; p=0.0201). Meta-regression analysis showed a direct association with tumour size (p=0.0333) and grade(p=0.00839), but not median age nor tumour upstage rate.

Conclusions: SLNB should be considered in patients with a pre-operative diagnosis of extensive and/or high-grade DCIS after a careful multidisciplinary discussion in order to identify those patients who have unrecognised axillary spread.

Citation Format: Chehade HEH, Headon H, Wazir U, El Tokhy O, Kasem A, Mokbel K. The role of sentinel lymph node biopsy in patients with ductal carcinoma in situ. An updated meta-analysis involving 9803 patients [abstract]. In: Proceedings of the 2016 San Antonio Breast Cancer Symposium; 2016 Dec 6-10; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2017;77(4 Suppl):Abstract nr P3-17-08.

Abstract P3-14-03: Does fat transfer increase the risk of breast cancer recurrence? A meta-analysis involving 2382 patients

Introduction: Lipofilling is an increasingly popular technique for breast reconstruction following both mastectomy and breast conserving surgery. However, concerns remain over its oncological safety and its effect on cancer recurrence.

Methods: A systematic literature review and meta-analysis was carried out. Patients who had undergone mastectomy and patients who had undergone breast conserving surgery (BCS) were looked at separately in order to investigate whether the addition of lipofilling had a significant effect on locoregional recurrence rate.

Results: Eleven studies were used in the analysis yielding a total of 2382 patients. For patients undergoing mastectomy (mean follow up = 36.2 months: range=12-90) or BCS (mean follow up = 30.2 months: range = 12-60) , the addition of lipofilling was not found to significantly affect the locoregional recurrence rate.

Conclusion: This meta-nalysis demonstrates that lipofilling is an oncologically safe procedure to be incorporated into breast reconstruction following either mastectomy or BCS for breast cancer. However a careful oncological follow up is recommended. In the future, more adequately- powered controlled clinical trials are needed in order to fully understand long term outcomes after lipofilling.

Citation Format: Wazir U, Chehade HEH, Headon H, Oteifa M, Kasem A, Mokbel K. Does fat transfer increase the risk of breast cancer recurrence? A meta-analysis involving 2382 patients [abstract]. In: Proceedings of the 2016 San Antonio Breast Cancer Symposium; 2016 Dec 6-10; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2017;77(4 Suppl):Abstract nr P3-14-03.

Abstract P2-01-29: In the era of conservative surgery, can patients presenting with node positive breast cancer be spared axillary node dissection post neoadjuvant chemotherapy? A meta-analysis and review of literature

Background:The use of sentinel lymph node biopsy (SLNB) following neoadjuvant chemotherapy (NAC) in patients presenting with clinically positive lymph nodes remains controversial.

Methods: A computer-aided search of the literature regarding SLNB in clinically node-positive breast cancer treated with NAC was carried out to identify the false negative rate (FNR), sentinel lymph node identification rate (IR), and axillary pathological complete response (pCR).

Results: Nineteen articles were used in the analysis yielding 3398 patients. The pooled estimate of the FNR was 13% and that of the IR was 91%. The adjusted pCR rate was 47%.

Conclusions: SLNB after NAC in biopsy-proven node positive patients results in reasonably acceptable FNR and IR making it a valid alternative management strategy to axillary dissection. Although the results are not matched with those in clinically node negative patients, a FNR of 13% is very unlikely to adversely affect overall survival. Its impact on locoregional recurrence should be evaluated in adequately powered future studies. More refined patient selection and optimal techniques can improve the FNR and IR in this patient population.

Citation Format: Headon H, Chehade HEH, El Tokhy O, Wazir U, Heeney J, Kasem A, Mokbel K. In the era of conservative surgery, can patients presenting with node positive breast cancer be spared axillary node dissection post neoadjuvant chemotherapy? A meta-analysis and review of literature [abstract]. In: Proceedings of the 2016 San Antonio Breast Cancer Symposium; 2016 Dec 6-10; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2017;77(4 Suppl):Abstract nr P2-01-29.

Oncological Safety of Lipofilling in Patients with Breast Cancer: A Meta-analysis and Update on Clinical Practice

BACKGROUND

Lipofilling is an increasingly popular technique for breast reconstruction following both mastectomy and breast-conserving surgery (BCS). However, concerns remain over its oncological safety and its effect on cancer recurrence.

MATERIALS AND METHODS

A systematic literature review and meta-analysis was carried out. Patients who had undergone mastectomy or BCS were investigated separately in order to find out whether the addition of lipofilling had a significant effect on locoregional recurrence rate.

RESULTS

Eleven studies were used in the analysis, yielding a total of 2,382 patients. For patients undergoing mastectomy (mean follow-up=36.2 months, range=12-90 months) or BCS (mean follow-up=30.2 months, range=12-60 months), the addition of lipofilling was not found to significantly affect the locoregional recurrence rate.

CONCLUSION

This meta-analysis demonstrates that lipofilling is an oncologically safe procedure to be incorporated into breast reconstruction following either mastectomy or BCS for breast cancer. However, a careful oncological follow-up is recommended. In the future, more adequately powered controlled clinical trials are needed in order to fully understand long-term outcomes after lipofilling.

Pleomorphic lobular carcinoma in situ: Current evidence and a systemic review

Pleomorphic lobular carcinoma in situ (PLCIS) has only recently been identified as a distinct pathological entity within classic lobular carcinoma in situ (CLCIS). As such, there is currently no consensus among clinicians regarding the optimal treatment of this disease. The present study determined the risk of concomitant invasive disease and ductal carcinoma in situ (DCIS) if PLCIS is observed on core needle biopsy (CNB) and collated the evidence regarding the risk of recurrence in relation to surgical margins and adjuvant therapy. In addition, the pertinent literature available through MedLine, PubMed, the WHO Clinical Trials Registry Platform and Google Scholar using appropriate keywords was reviewed. The pooled results of studies in the literature demonstrated a concomitant presence of invasive disease of 40%, and 15% for DCIS. The studies that examined recurrence rates indicated that the risk is reduced with ample resection margins (>2 mm) and adjuvant radiotherapy. However, recent studies raise concerns regarding breast conservation when pursuing clear margins. No level 1 evidence from prospective studies, randomized controlled trials (RCTs), or meta-analyses based on such RCTs was identified. This is a clinical issue that warrants investigation in appropriately powered well designed prospective studies for a satisfactory resolution of all concerns.

Is sentinel lymph node biopsy indicated in patients with a diagnosis of ductal carcinoma in situ? A systematic literature review and meta-analysis

BACKGROUND

Recent discussion has suggested that some cases of ductal carcinoma in situ (DCIS) with high risk of invasive disease may require sentinel lymph node biopsy (SLNB).

METHODS

Systematic literature review identified 48 studies (9,803 DCIS patients who underwent SLNB). Separate analyses for patients diagnosed preoperatively by core sampling and patients diagnosed postoperatively by specimen pathology were conducted to determine the percentage of patients with axillary nodal involvement. Patient factors were analyzed for associations with risk of nodal involvement.

RESULTS

The mean percentage of positive SLNBs was higher in the preoperative group (5.95% vs 3.02%; P = .0201). Meta-regression analysis showed a direct association with tumor size (P = .0333) and grade (P = .00839) but not median age nor tumor upstage rate.

CONCLUSIONS

The SLNB should be routinely considered in patients with large (>2 cm) high-grade DCIS after a careful multidisciplinary discussion. In the context of breast conserving surgery, the SLNB is not routinely indicated for low- and intermediate-grade DCIS, high-grade DCIS smaller than 2 cm, or pure DCIS diagnosed by definitive surgical excision.

Is sentinel lymph node biopsy a viable alternative to complete axillary dissection following neoadjuvant chemotherapy in women with node-positive breast cancer at diagnosis? An updated meta-analysis involving 3,398 patients

BACKGROUND

The use of sentinel lymph node biopsy (SLNB) following neoadjuvant chemotherapy (NAC) in patients presenting with clinically positive lymph nodes remains controversial.

METHODS

A computer-aided search of the literature regarding SLNB in clinically node-positive breast cancer treated with NAC was carried out to identify the false negative rate (FNR), sentinel lymph node identification rate (IR), and axillary pathological complete response (pCR).

RESULTS

Nineteen articles were used in the analysis yielding 3,398 patients. The pooled estimate of the FNR was 13% and that of the IR was 91%. The adjusted pCR rate was 47%. A trend toward significance was observed with only clinical stage N1 (cN1) disease whereby clinical stage N1 was associated with an increased pCR rate when compared to N2 or N3 disease (P = .06).

CONCLUSIONS

SLNB after NAC in biopsy-proven node-positive patients results in reasonably acceptable FNR and IR, making it a valid alternative management strategy to axillary dissection. More refined patient selection and optimal techniques can improve the FNR and IR in this patient population.

Improvement of survival with postmastectomy radiotherapy in patients with 1-3 positive axillary lymph nodes: A systematic review and meta-analysis of the current literature

In breast cancer with >4 positive axillary lymph nodes, it is common practice to deliver radiotherapy to the affected site following mastectomy. However, less is known regarding the benefits this may confer on women with 1-3 positive lymph nodes. In this meta-analysis, we aimed to assess whether post-mastectomy radiotherapy (PMRT) was beneficial for such patients. A literature review was conducted using the PubMed and Ovid databases. Selected studies were analysed and data regarding overall survival (OS) and locoregional recurrence (LRR) rates were extracted. Statistical analysis was then conducted in order to develop a combined risk ratio (RR) for both OS and LRR in the setting of PMRT in women with breast cancer with 1-3 positive lymph nodes. PMRT in women with 1-3 positive lymph nodes significantly reduced the risk of LRR, with a RR of 0.3 [95% confidence interval (CI): 0.23-0.38] and also showed a minor benefit in terms of OS (RR=1.03, 95% CI: 1.00-1.07). Therefore, in breast cancer patients with 1-3 positive lymph nodes, PMRT significantly reduced the risk of LRR and was associated with a minor OS benefit. Until the results of ongoing randomised controlled trials are published, PMRT should be recommended in this group of patients following a careful multidisciplinary discussion.

Refining the Performance of Sentinel Lymph Node Biopsy Post-neoadjuvant Chemotherapy in Patients with Pathologically Proven Pre-treatment Node-positive Breast Cancer: An Update for Clinical Practice

BACKGROUND

Neoadjuvant chemotherapy (NAC) has become the standard treatment regimen for locally advanced breast cancer and has recently been incorporated into the treatment of early breast cancer. It allows down-staging of tumors favoring breast-conservative surgery over mastectomy. Furthermore, NAC results in nodal conversion in about 40% of patients. This favorable outcome has complicated the decision-making regarding the best approach in managing the axilla post-treatment; especially in pathologically proven nodal disease prior to NAC. Axillary lymph node clearance is still the standard-of-care for this group of patients; however, it is clearly an over-treatment in a substantial number of patients. Given the high accuracy of sentinel lymph node biopsy (SLNB) post-NAC in clinically node-negative cases prior to treatment, substantial research has been carried out in order to validate the feasibility of post-NAC SLNB in pathologically proven node-positive cases. The results so far are still inconclusive, yet promising.

MATERIALS AND METHODS

We performed a computer-aided review of the literature for relevant articles on the performance of SLNB post-NAC in pathologically proven node-positive patients prior to chemotherapy. We also targeted studies on important factors that can refine the accuracy of SLNB in this group of patients, as well as elements favoring pathological complete response. All studies focusing on post-NAC SLNB in pre-treatment node-positive cases including randomized controlled trials, retrospective and prospective series, review articles, and two meta-analyses were included.

RESULTS

The review established a false-negative rate of 14-15.1% and an IR of 89-92.3%. Several technical enhancements, as well as imaging modalities, may be incorporated to improve the performance of SLNB. Furthermore, selected patients with more likelihood of pathological complete response represent the best candidates for this technique.

CONCLUSION

SLNB is a valid option after NAC in patients with pathologically proven node-positive breast cancer, given the high node-conversion rate. The literature demonstrated a false-negative rate that is slightly higher than that of patients initially node-negative which although might increase the locoregional recurrence in theory, has no effect on chemotherapy-decision making, and will most probably have no impact on overall survival. We identified several measures to refine its accuracy.

Clinical outcome and patient satisfaction with the use of bovine-derived acellular dermal matrix (SurgiMend™) in implant based immediate reconstruction following skin sparing mastectomy: A prospective observational study in a single centre

INTRODUCTION

The advent of acellular dermal matrix devices (ADMs) has enhanced both the scope of implant-based immediate breast reconstruction (IBR) following skin sparing mastectomy (SSM) for the treatment or risk reduction of breast cancer. Currently, there are a wide range of options available for the use of ADMs.

METHODS

This is a prospective observational single institution study of 118 consecutive patients undergoing a total of 164 SSM and IBR procedures either for treatment for breast cancer or for risk reduction, between 2012 and 2014. IBR was performed using an implant and bovine-derived ADM (SurgiMend™). Nipple sparing mastectomy (NSM) accounted for 103 procedures. IBR was performed as a single stage procedure in 23% of patients. The primary endpoint of this prospective study was the explantation rate and secondary endpoints included quality of life, patient satisfaction, aesthetic outcome assessed objectively, surgical complications, overall and disease free survival.

RESULTS

Forty-six patients (39%) had a bilateral and 72 underwent a unilateral SSM. Of those who underwent a unilateral SSM, 25 had a contralateral adjustment procedure. Out of 164 procedures, 117 (71%) were for the treatment of breast cancer. Sixty-one patients received chemotherapy (52%) and 32 (27%) had radiotherapy. In this study 27 patients underwent post-mastectomy radiotherapy. At a mean follow of 21 months, the explantation rate was 1.2%, 4% (6 patients) developed wound complications. The patient satisfaction with the procedure was found to be very high. The mean Breast Q Score was 85 and the mean overall patient satisfaction rating was 9 out of a possible 10. The mean objective assessment score was 8.9 out of a possible 10 and the mean subjective capsular contracture severity score was 2.9 out of 10. There were two cases of local recurrence (1.7%), one distant recurrence (0.8%) and one patient died of metastatic breast cancer (0.8%). Overall survival was 99.2% and locoregional disease free survival (LRFS) was 98.3%. One patient (0.8%) developed a mild inflammatory reaction secondary to the underlying mesh.

CONCLUSIONS

SurgiMend™ is an effective adjunct to implant based IBR following SSM. It is associated with a very low rate of implant loss and a high level of patient satisfaction and is associated with a very low incidence of inflammatory reaction. Neither prior radiotherapy nor post-mastectomy radiotherapy (PMRT) represents a contraindication to its use.

Surgical treatment of the primary tumour improves the overall survival in patients with metastatic breast cancer: A systematic review and meta-analysis

Traditionally, stage IV metastatic breast cancer has been treated with systemic therapy and/or radiotherapy in order to decrease cancer-associated symptoms, maintain quality of life and control disease burden. Previous research suggests that surgical treatment of the primary tumour may prolong survival, as well achieve local control of disease. Using the PubMed and Ovid SP databases, a literature review and meta-analysis was performed in order to assess whether surgical resection of the primary tumour in metastatic breast cancer prolongs survival. In this meta-analysis, a pooled hazard ratio of 0.63 (95% confidence interval, 0.58-0.7; P<0.0001) was revealed, equating to a 37% reduction in risk of mortality in patients that underwent surgical resection of the primary tumour. Therefore, it was concluded that surgery of the primary tumour in stage IV breast cancer appears to offer a survival benefit in metastatic patients.

Abstract P2-13-08: Breast lipofilling: A systematic review of current practice and oncological safety

Background: Lipofilling is a reconstructive and aesthetic technique that has recently grown in popularity and is increasingly being used in breast surgery. Concerns had been raised regarding its safety when used for remodelling and reconstruction of the breast.

Methods: We reviewed the current literature by systematically searching PubMed and Google Scholar databases regarding the current evidence regarding the oncological safety of the procedure in patients seeking aesthetic breast enhancement and in patients requiring oncoplastic reconstruction.

Results: Among the 864 patients included in the currently available studies on breast cancer patients who underwent lipofilling, only 14 (1.6%) recurrences were identified. However, evidence has emerged suggestive that the use of lipofilling in the background of ductal carcinoma in situ (DCIS) may be associated with an increased risk of neoplasia.

Conclusions: Over the subsequent two decades, little evidence has been found to support these early theoretical concerns, and growing numbers of proponents of the procedure are confident in its safety. Further study is required to better delineate the effect of lipofilling on DCIS.

Citation Format: Wazir U, Kasem A, Headon H, Mokbel K. Breast lipofilling: A systematic review of current practice and oncological safety. [abstract]. In: Proceedings of the Thirty-Eighth Annual CTRC-AACR San Antonio Breast Cancer Symposium: 2015 Dec 8-12; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2016;76(4 Suppl):Abstract nr P2-13-08.

Abstract P2-12-11: Does postmastectomy radiotherapy improve survival in patients with 1-3 positive axillary lymph nodes? A systematic review and meta-analysis of the current literature

In breast cancer with more than four positive axillary lymph nodes, it is common practice to deliver radiotherapy to the affected site following a mastectomy. However, less is known about the benefit s this might offer in women with 1-3 positive lymph nodes. In order to assess whether postmastectomy radiotherapy has any benefit in these women, a meta-analysis was performed to assess whether postmastectomy radiotherapy improved overall survival or reduced locoregional recurrence in this group of women. It was found that postmastectomy radiotherapy significantly reduced the risk of locoregional recurrence, with a relative risk ratio of 0.3 (95% confidence interval 0.23-0.38), and resulted in a small benefit in overall survival, with a relative risk ratio of 1.03 (95% confidence interval 1.00-1.07). Therefore, in women with 1-3 positive lymph nodes, postmastectomy radiotherapy reduces the risk of locoregional recurrence and is associated with a small benefit in overall survival, so should be recommended within this group after careful multidisciplinary discussion.

Citation Format: Kasem A, Headon H, Mokbel K. Does postmastectomy radiotherapy improve survival in patients with 1-3 positive axillary lymph nodes? A systematic review and meta-analysis of the current literature. [abstract]. In: Proceedings of the Thirty-Eighth Annual CTRC-AACR San Antonio Breast Cancer Symposium: 2015 Dec 8-12; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2016;76(4 Suppl):Abstract nr P2-12-11.

Abstract P2-13-04: Clinical outcome and patient satisfaction with the use of bovine-derived acellular dermal matrix (SurgiMendTM) in implant-based immediate reconstruction following skin sparing mastectomy: A prospective observational study

The advent of acellular dermal matrix devices (ADMs) has facilitated immediate breast reconstruction (IBR) with mammary implants following skin sparing mastectomy (SSM) for breast cancer treatment or risk reduction.

This is a prospective observational single institution study of 118 consecutive patients undergoing a total of 164 SSM and IBR procedures using an implant and bovine-derived ADM (SurgiMend) for breast cancer or risk reduction purposes during 2012-2014. The primary endpoint was the explantation rate and secondary endpoints included patient quality of life, patient satisfaction, objective assessment of aesthetic outcome, surgical complications, recurrence and mortality.

The mean age of the patients was 50.1 years (median age of 48, range of 27-78). Median follow up time was 21 months (mean of 21.4 months, range of 2-40 months). 46 patients had a bilateral SSM and IBR, 5 of whom had bilateral breast cancer and 3 for risk reduction due to a significant genetic mutation. The remaining 37 patients had unilateral breast cancer and a contralateral risk reducing mastectomy. 27 (37.5%) of the 72 patients who had unilateral SSM underwent contralateral adjustment procedures to optimise symmetry, including 9 augmentation mammoplasty, 12 mastopexy and 4 reduction mammaplasty procedures and 2 combined augmentation-mastopexies. 61 patients (51.7%) received chemotherapy, 5 of whom had primary systemic therapy prior to surgery. 32 (27.1%) patients received radiotherapy (10 patients had prior radiotherapy and 22 patients had post mastectomy radiation: PMR). Those with ER positive disease received hormonal therapy. Those with Her2 positivity received Herceptin +/- Pertuzumab.

Over the study period, 2 implants had to be removed resulting in an explantation rate of 1.2%. Overall, wound complications were observed in 6 (3.7%) cases. There were 2 cases of local recurrence (1.7%), one distant recurrence (0.8%) and one patient died of metastatic breast cancer (0.8%). Overall survival was 99.2% and locoregional disease free survival (LRFS) was 98.3%. One patient (0.8%) developed a mild inflammatory reaction secondary to the underlying mesh. Wound complications were observed in 3 other patients (2 haematomas and wound dehiscence/persistent seroma requiring implant replacement).

Patient satisfaction with the procedure was very high. The mean Breast Q Score was 85 and mean overall patient satisfaction was 9 out of a possible 10. The mean objective assessment score was 8.9 out of a possible 10 and the mean subjective capsular contracture severity score was 2.9 out of 10.

In patients undergoing reoperations, the incorporation rate of the mesh was found to be very high almost approaching 95%.

SurgiMendTM is an effective adjunct to IBR using implants following SSM for breast cancer or risk reduction, with a very low rate of implant loss and a high level of patient satisfaction. Furthermore, this ADM seems to incorporate readily and is associated with a very low incidence of inflammatory reactions. Neither prior radiotherapy nor PMR radiation represents a contraindication to its use.

Citation Format: Wazir U, Kasem A, Headon H, Choy C, Manson A, Heeney J, Mead O, Mokbel K. Clinical outcome and patient satisfaction with the use of bovine-derived acellular dermal matrix (SurgiMendTM) in implant-based immediate reconstruction following skin sparing mastectomy: A prospective observational study. [abstract]. In: Proceedings of the Thirty-Eighth Annual CTRC-AACR San Antonio Breast Cancer Symposium: 2015 Dec 8-12; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2016;76(4 Suppl):Abstract nr P2-13-04.