Limited Reporting of Histopathologic Details in a Multi-Institutional Academic Cohort of Phyllodes Tumors: Time for Standardization

BACKGROUND

Phyllodes tumors are rare fibroepithelial neoplasms that are classified by tiered histopathologic features. While there are protocols for the reporting of cancer specimens, no standardized reporting protocol exists for phyllodes.

METHODS

We performed an 11-institution contemporary review of phyllodes tumors. Granular histopathologic details were recorded, including the features specifically considered for phyllodes grade classification.

RESULTS

Of 550 patients, median tumor size was 3.0 cm, 68.9% (n = 379) of tumors were benign, 19.6% (n = 108) were borderline, and 10.5% (n = 58) were malignant. All cases reported the final tumor size and grade classification. Complete pathologic reporting of all histopathologic features was present in 15.3% (n = 84) of cases, while an additional 35.6% (n = 196) were missing only one or two features in the report. Individual details regarding the degree of stromal cellularity was not reported in 53.5% (n = 294) of cases, degree of stromal atypia in 58.0% (n = 319) of cases, presence of stromal overgrowth in 56.2% (n = 309) of cases, stromal cell mitoses in 37.5% (n = 206) of cases, and tumor border in 54.2% (n = 298) of cases. The final margin status (negative vs. positive) was omitted in only 0.9% of cases, and the final negative margin width was specifically reported in 73.8% of cases. Reporting of details was similar across all sites.

CONCLUSION

In this academic cohort of phyllodes tumors, one or more histopathologic features were frequently omitted from the pathology report. While all features were considered by the pathologist for grading, this limited reporting reflects a lack of reporting consensus. We recommend that standardized reporting in the form of a synoptic-style cancer protocol be implemented for phyllodes tumors, similar to other rare tumors.

Behavioral Implications of the Complete Absence of Guests on a Zoo-Housed Gorilla Troop

Research conducted on the effects that zoo visitors have on primate behavior has yielded inconsistent patterns. This study aims to contribute to the growing body of literature regarding visitor effects on zoo-housed primate's activity budgets, with the purpose of quantifying the behavioral variability under two conditions: guest presence and guest absence. Due to the COVID-19 pandemic, many zoos were closed to the public for varying lengths of time. The Buffalo Zoo was closed to guests for an 18-week period including the summer of 2020, which allowed us to effectively control for zoo guest presence. This case report compares data on the zoo's gorilla troop from the same time period in 2019. We found inconsistent results, similar to prior studies conducted with zoo-housed gorilla troops. Most gorillas were observed foraging less and exhibiting more inactivity in 2020, whereas the adult male silverback showed the opposite pattern. Abnormal or undesirable behaviors were performed less frequently when guests were absent however, these differences were not significant. We encourage others to compare behavior patterns during the pandemic shutdown to add to our knowledge base of visitor effects. We suggest that researchers do not try and generalize their individual and troop results to the entire population of gorillas in managed care, as both intrinsic and extrinsic factors contribute to individual differences in behavioral response.

Minimally Invasive Mastectomy Could Achieve Non-inferior Oncological Outcome in Appropriately Selected Patients: Propensity Matched Analysis of the National Cancer Database

BACKGROUND

Minimally invasive mastectomy (MIM) was emerged as an approach to decrease morbidity and increase patient satisfaction through improved cosmetic results; however, there is a paucity of data regarding the long-term oncologic outcomes of these minimally invasive approaches.

METHODS

Patients who underwent mastectomy procedures were identified in the National Cancer Database (2010-2016). Patients were categorized as MIM or open mastectomy. A 1:1 propensity match was performed to balance the bias on reconstruction, nipple sparing, lymph node procedures, and other confounding factors between the cohorts. Short- and long-term outcomes were compared.

RESULTS

A total of 328 811 patients met the criteria: 327 643 (99.6%) received open mastectomy and 1168 (.4%) received MIM. Propensity match identified 384 "pairs" of MIM and open mastectomy patients. Among them, MIM was associated with shorter length of stay (LOS) (mean 1.3 vs. 1.06 days, P = .003). No differences were observed in the rates of positive margins, unplanned readmissions, or 90-day mortality between the 2 operative approaches. Overall survival (OS) was equivalent between MIM and open mastectomy patients. Cox proportional hazard regression showed no effect of the procedure performed on OS.

DISCUSSION

MIM is associated with shorter LOS, and it is non-inferior to open mastectomy in terms of other short-term outcomes and long-term oncologic survival outcomes. These data suggest that MIM may be considered in appropriately selected breast cancer patients as an additional approach to the community.

Despite Equivalent Outcomes, Men Receive Neoadjuvant Chemotherapy Less Often Than Women for Lymph Node-Positive Breast Cancer

BACKGROUND

Neoadjuvant chemotherapy (NAC) downstages breast cancer and provides prognostic information. Males with breast cancer are known to receive less treatment overall and have poorer outcomes relative to females. We hypothesized that males would be less likely to receive NAC.

PATIENTS AND METHODS

Patients with a primary diagnosis of cN1-3 breast cancer were identified in the National Cancer Database (2004-2016). Multivariable logistic regression determined the association between NAC utilization and sex, and the relationship between sex and NAC response, controlling for demographic and tumor factors. Overall survival was analyzed using a multivariable Cox model.

RESULTS

In total, 196,027 patients (194,010 females, 2017 males) met inclusion criteria. A significantly greater proportion of males underwent mastectomy (80% vs. 60%, P < 0.001), and axillary lymph node dissection (76% vs. 74%, P = 0.022). Overall fewer men received chemotherapy than women (73% vs. 84%, P < 0.001); men also received NAC at a significantly lower rate (26% men vs. 45% women, P < 0.001). After accounting for demographic and oncologic factors including hormone receptor (HR) subtype, females remained more likely to undergo NAC (OR 1.84, P < 0.001). On multivariable analysis, sex was not associated with pathologic response or overall survival after NAC.

CONCLUSIONS

Although oncologic outcomes after NAC were similar, males with node-positive breast cancer received less NAC and more aggressive surgery than females. These data suggest men achieve outcomes comparable to women with cN1-3 disease, and NAC should be used in appropriate male patients to downstage the breast and axilla.

Abstract PS14-12: Trends in breast and axillary surgery for T1-T2 male breast cancer: A study from the national cancer database

Introduction: Due to the low incidence of male breast cancer, large scale prospective trials to guide therapy are lacking. Historically males with breast cancer present at more advanced stages than females and have been surgically treated with modified radical mastectomy. Recent studies suggest that breast-conserving therapy for early-stage male breast cancer yields similar outcomes as for female patients, and that sentinel lymph node biopsy (SLNB) can be used in place of axillary lymph node dissection (ALND) for appropriate clinically node-negative patients. Our study investigates trends in breast and axillary surgery for male breast cancer patients, focusing specifically on the treatment of early-stage disease. Methods: The National Cancer Database (NCDB) was utilized to identify male and female patients diagnosed with clinical T1-2 breast cancer from 2004-2016. Patient, tumor, facility, and surgical treatment factors were examined. Patients were stratified by surgery type: partial, unilateral, and bilateral mastectomy; simple versus modified radical mastectomy; SLNB (removal of ≤ 5 lymph nodes) and ALND (&gt;5 lymph nodes). Trends in surgery type were compared between male and female patients and over the study period for each gender. Results: 9,782 males and 1,078,105 females with T1-2 breast cancer were identified. Men were significantly older at diagnosis than women (31.4% vs. 23.6% age &gt;70, p&lt;0.0001), were more often insured by Medicare (44.5% vs. 35.3%, p&lt;0.0001), and had greater co-morbidity (21.9% vs. 15.6% Charlson Deyo Score &gt;0). ER/PR+ disease (94.2% vs. 84.1%, p&lt;.0001), moderate/high grade histology (85.4% vs. 77.8%, p&lt;.0001) and lymphovascular invasion (24% vs. 15.3%, p&lt;.0001) were also more common in males vs. females. The majority of all patients were clinically node negative (80.4% of males, 85% of females) and had AJCC clinical stage I or II disease (92.3% men, 95.2% women). Unilateral mastectomy was performed most commonly for men (67.1% men vs. 24.1% women, p&lt;0.001), while women more frequently underwent partial mastectomy (64.7% women vs. 26.4% men, p&lt;0.001). The rates of each surgery type remained disparate by gender and stable over the study period: male unilateral mastectomy rate 59.8% in 2004 and 66.1% in 2016; female partial mastectomy rate 65.9% in 2004, 68.4% in 2016. Modified radical mastectomy rates decreased in favor of simple mastectomy for both genders, 61.8% to 24.1% in males and 58.7% to 20.2% in females, 2004 to 2016. There was a similar overall increase in SLNB vs. ALND for all patients, though SLNB was not adopted as the more common procedure in male patients until 2009. In 2016, 78.2% of females and 65.3% of males underwent SLNB vs. 51.1% and 39.8% in 2004, respectively. Conclusions: Although breast-conserving therapy is the treatment of choice for female patients with early-stage breast cancer and could be similarly used to treat men with T1-T2 disease, the majority of male breast cancer patients continue to undergo unilateral mastectomy for early-stage disease. In more recent years, SLNB has surpassed ALND for men, mirroring the trend for women, though in a more delayed and gradual fashion. Partial mastectomy and SLNB warrant consideration for men with T1 and T2 breast cancer, in particular since male breast cancer patients present at older ages and with more co-morbidity than their female counterparts, and may benefit from de-escalation of surgical treatment.

Citation Format: Rashi Singh, Lifen Cao, Anuja L Sarode, Michael Kharouta, Robert Shenk, Megan E Miller. Trends in breast and axillary surgery for T1-T2 male breast cancer: A study from the national cancer database [abstract]. In: Proceedings of the 2020 San Antonio Breast Cancer Virtual Symposium; 2020 Dec 8-11; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2021;81(4 Suppl):Abstract nr PS14-12.

Abstract PS14-10: Trends in incidence and stage of male breast cancer, 2004-2016: An analysis from the national cancer database

Background: Male breast cancer has been less well studied due to the rarity of this condition compared with female breast cancer. Men have traditionally presented at later stages than women, leading to disparities in outcomes. Our aim was to identify the incidence of male breast cancer in recent years and determine trends in clinical and pathologic stage that could be utilized to improve breast cancer care. Methods: Patients diagnosed with primary breast cancer between 2004 and 2016 were identified using the National Cancer Database (NCDB), which collects hospital registry data from over 1,500 Commission on Cancer (CoC)-accredited facilities and represents more than 70% of newly diagnosed cancer cases in the United States. Patient, tumor, treatment, and facility data was compared between male and female patients. Incidence of male and female breast cancer was stratified by both AJCC clinical stage and pathologic stage (I-IV) and evaluated over the study period. Results: 17,814 male breast cancer patients and 2,001,551 female patients with breast cancer were identified. The incidence of male breast cancer increased by 1.5-fold from 1044 cases per year in 2004 to 1565 cases per year in 2016. The number of female breast cancer cases was 123,799 in 2004 and reached the highest annual volume of 184,718 in 2015. In 2010 incident male breast cancer cases rose by nearly 100% compared with the prior year, the majority of which represented early stage disease. In that year alone, for males there was a 99.6% increase (276 vs. 556 cases) in pathologic stage I disease, 89% increase (200 vs. 378 cases) in pathologic stage II disease and 94.7% increase (68 vs. 132 cases) in patients diagnosed with in situ disease. After 2010, incidence patterns for male breast cancer stabilized with ratio changes for Stage I or II at the level of only 1% to 7.3% per year. Interestingly, the proportion of male to female breast cancer incident cases remained constant over the study period, with males representing 0.8-0.9% of the total cases. Overall, a minority of patients presented with Stage III (6.6%) and Stage IV (4.6%) disease, though a greater proportion of males than females had advanced stage disease at diagnosis (16.88% of males vs. 11.14% females, p&lt; 0.001). The incidence of clinical Stage I and II disease increased over time for both genders, though a greater proportion of female breast cancer was Stage I (43.2% female vs. 35.93% male, p&lt;0.001), and Stage II disease was more common in men (33.83% male vs 24.22% female, p&lt;0.001). When pathologic stage was considered, Stage I and II represented the majority of male breast cancer cases, 74.7% to 80% per year, and was slightly higher than the combination of Stage I and II at clinical diagnosis, 65.7% to 78.7% per year. Conclusions: Over past 15 years, the incidence of male breast cancer has increased substantially, yet remains a stable proportion of total breast cancer cases. The greater frequency of Stage II, III and IV disease in men likely reflects the difference in diagnosis by clinical exam or symptoms in men vs. screening programs in women. Education to increase awareness of male breast cancer, promote symptom recognition, and encourage appropriate use of genetic testing should be emphasized to improve early diagnosis of breast cancer in men.

Citation Format: Lifen Cao, Rashi Singh, Anuja L Sarode, Michael Kharouta, Robert Shenk, Megan E Miller. Trends in incidence and stage of male breast cancer, 2004-2016: An analysis from the national cancer database [abstract]. In: Proceedings of the 2020 San Antonio Breast Cancer Virtual Symposium; 2020 Dec 8-11; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2021;81(4 Suppl):Abstract nr PS14-10.

Contemporary Multi-Institutional Cohort of 550 Cases of Phyllodes Tumors (2007-2017) Demonstrates a Need for More Individualized Margin Guidelines

PURPOSE

Phyllodes tumors (PTs) are rare breast neoplasms, which have little granular data on margins. Current guidelines recommend ≥ 1 cm margins; however, recent data suggest narrower margins are sufficient, and for benign PT, a negative margin may not be necessary.

METHODS

We performed an 11-institution contemporary (2007-2017) review of PT practices. Demographics, surgical, and histopathologic data were captured. Logistic regression was used to estimate the association of select covariates with local recurrence (LR).

RESULTS

Of 550 PT patients, the majority underwent excisional biopsy (55.3%, n = 302/546) or lumpectomy (wide excision) (38.5%, n = 210/546). Median tumor size was 30 mm, 68.9% (n = 379) were benign, 19.6% (n = 108) borderline, and 10.5% (n = 58) malignant. Surgical margins were positive in 42% (n = 231) and negative in 57.3% (n = 311). A second operation was performed in 38.0% (n = 209) of the total cohort, including 51 patients with an initial negative margin (82.4% with < 2 mm), and 157 with an initial positive margin, with residual disease only found in six (2.9%). Notably, 32.0% (n = 74) of those with an initial positive margin did not undergo a second operation, among whom only 2.7% (n = 2) recurred. Recurrence occurred in 3.3% (n = 18) of the total cohort (n = 15 LR, n = 3 distant), at median follow-up of 36.7 months. LR (all PT grades) was not reduced with wider negative margin width (≥ 2 mm v < 2 mm: odds ratio [OR] = 0.39; 95% CI, 0.07 to 2.10; P = .27) or final margin status (positive v negative: OR = 0.96; 95% CI, 0.26 to 3.52; P = .96).

CONCLUSION

In current practice, many patients are managed outside of current guidelines. For the entire cohort, a wider margin width was not associated with a reduced risk of LR. We do not recommend re-excision of a negative margin for benign PT, regardless of margin width, as a progressively wider surgical margin is unlikely to reduce LR.

Hospital System Adoption of Magnetic Seeds for Wireless Breast and Lymph Node Localization

BACKGROUND

As an alternative to traditional wire localization, an inducible magnetic seed system can be used to identify and remove nonpalpable breast lesions and axillary lymph nodes intraoperatively. We report the largest single-institution experience of magnetic seed placement for operative localization to date, including feasibility and short-term outcomes.

METHODS

Patients who underwent placement of a magnetic seed in the breast or lymph node were identified from July 2017 to March 2019. Imaging findings, core needle biopsy, surgical pathology results, and type of surgery were collected. Outcomes included procedural complications, magnetic seed and biopsy clip retrieval rates, and need for additional surgery.

RESULTS

A total of 842 magnetic seeds were placed by nine radiologists in 673 patients and retrieved by six surgeons at six operative locations. The majority of breast lesions were malignant (395/659, 59.9%); 136 seeds were placed for lymph node localization. The overall magnetic seed retrieval rate was 98.6%, whereas the biopsy clip retrieval rate was 90.9%. Only six patients (0.7%) experienced a complication from magnetic seed placement. Reexcision was performed in 15.2% of patients with breast cancer; 9.6% of benign/high risk lesions were upgraded to malignancy at surgical excision.

CONCLUSIONS

The magnetic seed technique is safe, effective, and accurate for localization of breast lesions and lymph nodes, and importantly uncouples surgery from the localization procedure. The high magnetic seed retrieval rate and low reexcision rate may reflect the accuracy of magnetic marker placement as a "second chance" localization procedure, especially in cases with biopsy clip migration.

Germline Genetic Mutations in a Multi-center Contemporary Cohort of 550 Phyllodes Tumors: An Opportunity for Expanded Multi-gene Panel Testing

BACKGROUND

A paucity of data exists regarding inherited mutations associated with phyllodes tumors (PT); however, some are reported (TP53, BRCA1, and RB1). A PT diagnosis does not meet NCCN criteria for testing, including within Li-Fraumeni Syndrome (TP53). We sought to determine the prevalence of mutations associated with PT.

METHODS

We performed an 11-institution review of contemporary (2007-2017) PT practice. We recorded multigenerational family history and personal history of genetic testing. We identified patients meeting NCCN criteria for genetic evaluation. Logistic regression estimated the association of select covariates with likelihood of undergoing genetic testing.

RESULTS

Of 550 PT patients, 59.8% (n = 329) had a close family history of cancer, and 34.0% (n = 112) had ≥ 3 family members affected. Only 6.2% (n = 34) underwent genetic testing, 38.2% (n = 13) of whom had only BRCA1/BRCA2 tested. Of 34 patients tested, 8.8% had a deleterious mutation (1 BRCA1, 2 TP53), and 5.9% had a BRCA2 VUS. Of women who had TP53 testing (N = 21), 9.5% had a mutation. Selection for testing was not associated with age (odds ratio [OR] 1.01, p = 0.55) or PT size (p = 0.12) but was associated with grade (malignant vs. benign: OR 9.17, 95% CI 3.97-21.18) and meeting NCCN criteria (OR 3.43, 95% confidence interval 1.70-6.94). Notably, an additional 86 (15.6%) patients met NCCN criteria but had no genetic testing.

CONCLUSIONS

Very few women with PT undergo germline testing; however, in those selected for testing, a deleterious mutation was identified in ~ 10%. Multigene testing of a PT cohort would present an opportunity to discover the true incidence of germline mutations in PT patients.

Thyroid cytology smear slides: An untapped resource for ThyroSeq testing

BACKGROUND

Molecular testing of thyroid nodules with indeterminate fine-needle aspiration (FNA) cytology is commonly used to guide patient management and is typically performed on freshly collected FNA samples. In this study, the authors evaluated the performance of the ThyroSeq test in cytology smear slides.

METHODS

Air-dried Diff-Quik (DQ)-stained and alcohol-fixed Papanicolaou (Pap)-stained smears were used to determine required cellularity and sensitivity of mutation detection and to compare ThyroSeq v3 Genomic Classifier (GC) results obtained in cytology smears and fresh FNA samples from the same nodules.

RESULTS

ThyroSeq testing of 31 cytology smears revealed that 25 smears (81%) were adequate for ThyroSeq analysis, including 14 Pap-stained smears (100%) and 11 DQ-stained smears (65%), whereas 6 DQ-stained smears (35%) failed RNA sequencing. The overall accuracy for detecting molecular alterations was 98%, with 100% concordance for mutations and gene expression alterations, 96% concordance for fusions, and 94% concordance for copy number alterations. Cytology smears were adequate for ThyroSeq analysis when at least 200 to 300 cells were present in 1 to 3 slides. ThyroSeq detected all studied mutations down to 5% allele frequency and BRAF mutations down to 1% allele frequency. Testing of smears yielded a positive ThyroSeq GC result in all nodules originally classified as positive.

CONCLUSIONS

Thyroid FNA cytology smear slides with adequate cellularity can be successfully used for ThyroSeq GC testing in approximately 80% of cases, with an even higher success rate in Pap-stained smears. Compared with FNA samples collected into preservative solution, 94% to 100% of different genetic alterations could be accurately detected in smears, validating cytology smears as an alternative for ThyroSeq testing in patients with indeterminate thyroid cytology.

Risk of Contralateral Breast Cancer in Women with Ductal Carcinoma In Situ Associated with Synchronous Ipsilateral Lobular Carcinoma In Situ

BACKGROUND

Lobular carcinoma in situ (LCIS) is a risk factor for breast cancer, but the effect of LCIS found in association with ductal carcinoma in situ (DCIS) is unknown. In this study, we compared contralateral breast cancer (CBC) and ipsilateral breast tumor recurrence (IBTR) rates among women with DCIS with or without synchronous ipsilateral LCIS treated with breast-conserving surgery (BCS).

METHODS

DCIS patients undergoing BCS from 2000 to 2011 with a contralateral breast at risk were stratified by the presence or absence of synchronous ipsilateral LCIS with the index DCIS (DCIS + LCIS vs. DCIS). Those with contralateral, bilateral, or prior ipsilateral LCIS were excluded. Associations of patient, tumor, and treatment factors with CBC and IBTR were evaluated.

RESULTS

Of 1888 patients identified, 1475 (78%) had DCIS and 413 (22%) had DCIS + LCIS. At median follow-up of 7.2 (range 0-17) years, 307 patients had a subsequent first breast event; 207 IBTR and 100 CBC. The 10-year cumulative incidence of IBTR was similar in both groups: 15.0% vs. 14.2% (log-rank, p = 0.8) for DCIS + LCIS vs. DCIS, respectively. The 10-year cumulative incidence of CBC was greater in the DCIS + LCIS group: 10.9% vs. 6.1% for DCIS (log-rank, p < 0.001). After adjustment for other factors, CBC risk remained higher in DCIS + LCIS compared with DCIS (hazard ratio 2.06, 95% confidence interval 1.36-3.11, p = 0.001); there was no significant difference in IBTR risk.

CONCLUSIONS

Compared with DCIS alone, DCIS + LCIS is associated with similar IBTR risk but double the risk of CBC. This finding should inform treatment decisions, in particular regarding endocrine therapy for risk reduction.

Abstract P5-18-01: Risk of contralateral breast cancer (CBC) in women with ductal carcinoma in situ (DCIS) with and without and synchronous lobular carcinoma in situ (LCIS)

Background: LCIS is considered a risk factor for bilateral breast cancer, but the effect of LCIS diagnosed concurrently with DCIS is not known. We sought to compare CBC and ipsilateral breast tumor recurrence (IBTR) rates in women with DCIS with and without synchronous LCIS treated with breast conserving surgery (BCS).

Methods: A prospectively maintained database of DCIS patients undergoing BCS from 2000-2011 was used to identify women with a contralateral breast at risk. Patients with synchronous ipsilateral LCIS found at core needle biopsy or surgical excision were included in the “DCIS + LCIS” group; those with contralateral or bilateral LCIS were excluded. Associations of patient, tumor, and treatment factors with CBC and IBTR were evaluated using logistic regression.

Results: Of the 1888 patients identified, 1475 (78%) had DCIS only and 413 (22%) had DCIS with synchronous LCIS. Median follow-up was 7.5 years (range 0-17 years). 305 patients had a subsequent breast event; 216 IBTR and 89 CBC.

The 5 and 10-year cumulative incidence of IBTR was similar in both groups: 6.3% and 14.4% for DCIS only, compared with 5.9% and 14.0% for DCIS + LCIS (p = 0.94), respectively. The 5 and 10-year cumulative incidence of CBC was significantly greater in the DCIS + LCIS group: 5.7% and 10.0%, compared with 2.4% and 5.0% for DCIS only (p &lt; 0.001).

Table 1 summarizes uni-and multi-variable analyses of risk factors associated with CBC and IBTR among women with DCIS treated with BCS. After adjustment for other factors, CBC risk was more than 2-fold higher in the DCIS + LCIS group compared with the DCIS only group (HR 2.37, 95% CI 1.54-3.65, p &lt; 0.001). There was no difference in IBTR risk based on presence of synchronous LCIS. Younger age and receipt of endocrine therapy were significantly associated with decreased risk of CBC.

Table 1:Risk factors associated with CBC and IBTR in patients with DCIS treated with BCS  Univariate Analysis Multivariate Analysis  Hazard Ratio (95% CI) Hazard Ratio (95% CI)  CBC IBTR CBC IBTRAge (continuous)1.02 (1.01-1.04) *0.99 (0.98-1.0)1.02 (1.0-1.04) *0.99 (0.97-1.0) *Presentation    Radiologic1111Clinical0.36 (0.11-1.14)1.56 (1.05-2.3) *0.41 (0.13-1.31)1.67 (1.12-2.47) *Family history    Yes1.32 (0.87-2.01)1.0 (0.76-1.32)1.33 (0.87-2.03)1.03 (0.78-1.35)Grade    Low1111Intermediate/high1.83 (1.0-3.37)1.32 (0.93-1.88)1.74 (0.92-3.29)1.62 (1.11-2.35) *Radiation    Yes1.16 (0.75-1.8)0.7 (0.54-0.92) *1.14 (0.71-1.82)0.64 (0.48-0.86) *Endocrine Therapy    Yes0.43 (0.23-0.81) *0.51 (0.35-0.74) *0.42 (0.22-0.8) *0.53 (0.36-0.77) *DCIS group    DCIS only1111DCIS + LCIS2.28 (1.49-3.5) *0.99 (0.71-1.36)2.37 (1.54-3.65) *0.99 (0.71-1.37)* p &lt; 0.05

Conclusions: LCIS diagnosed concurrently with DCIS is not associated with IBTR, but increases the risk of CBC two-fold. Endocrine therapy should be considered both for the index DCIS and for prevention of subsequent CBC.

Citation Format: Miller ME, Muhsen S, Zabor EC, Flynn J, Olcese C, Giri D, Van Zee KJ, Pilewskie M. Risk of contralateral breast cancer (CBC) in women with ductal carcinoma in situ (DCIS) with and without and synchronous lobular carcinoma in situ (LCIS) [abstract]. In: Proceedings of the 2018 San Antonio Breast Cancer Symposium; 2018 Dec 4-8; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2019;79(4 Suppl):Abstract nr P5-18-01.

Bridging the Gap: Interdepartmental Quality Improvement and Patient Safety Curriculum Created by Hospital Leaders, Faculty, and Trainees

BACKGROUND

The Accreditation Council for Graduate Medical Education Clinical Learning Environment Review recommends that quality improvement/patient safety (QI/PS) experts, program faculty, and trainees collectively develop QI/PS education.

OBJECTIVE

Faculty, hospital leaders, and resident and fellow champions at the University of Chicago designed an interdepartmental curriculum to train postgraduate year 1 (PGY-1) residents on core QI/PS principles, measuring outcomes of knowledge, attitudes, and event reporting.

METHODS

The curriculum consisted of 3 sessions: PS, quality assessment, and QI. Faculty and resident and fellow leaders taught foundational knowledge, and hospital leaders discussed institutional priorities. PGY-1 residents attended during protected conference times, and they completed in-class activities. Knowledge and attitudes were assessed using pretests and posttests; graduating residents (PGY-3-PGY-8) were controls. Event reporting was compared to a concurrent control group of nonparticipating PGY-1 residents.

RESULTS

From 2015 to 2017, 140 interns in internal medicine (49%), pediatrics (33%), and surgery (13%) enrolled, with 112 (80%) participating and completing pretests and posttests. Overall, knowledge scores improved (44% versus 57%, P < .001), and 72% of residents demonstrated increased knowledge. Confidence comprehending quality dashboards increased (13% versus 49%, P < .001). PGY-1 posttest responses were similar to those of 252 graduate controls for accessibility of hospital leaders, filing event reports, and quality dashboards. PGY-1 residents in the QI/PS curriculum reported more patient safety events than PGY-1 residents not exposed to the curriculum (0.39 events per trainee versus 0.10, P < .001).

CONCLUSIONS

An interdepartmental curriculum was acceptable to residents and feasible across 3 specialties, and it was associated with increased event reporting by participating PGY-1 residents.

Thermal sensitivity of Calonectria henricotiae and Calonectria pseudonaviculata conidia and microsclerotia

Knowledge of the thermal sensitivity of conidia and microsclerotia is useful for developing plant disease management approaches that deploy heat to inactivate infectious vegetative propagules of fungal pathogens. For boxwood blight disease, heat treatment of cuttings that harbor conidia and microsclerotia would provide a useful management tool for suppressing the pathogenic activity of Calonectria pseudonaviculata (present in the United States) and C. henricotiae (a quarantine pathogen not present in the United States). In this study, we investigated the thermal sensitivity of conidia and microsclerotia of the boxwood blight pathogens C. henricotiae and C. pseudonaviculata treated in water at 45, 47.5, 50, 52.5, and 55 C. For conidia, as time of exposure increased at each temperature, the proportion of germinated conidia decreased. The predicted time required to inactivate 90% of C. pseudonaviculata conidia (LD₉₀) decreased as water temperature increased from 45 to 55 C and ranged from 35.4 to 5.6 min, respectively. Inactivation of conidia was dependent on isolate, species of Calonectria, and length of exposure at each temperature tested. Microsclerotia of C. henricotiae and C. pseudonaviculata displayed reduced germination with increasing exposure and higher temperatures of hot water. Microsclerotia of C. henricotiae were significantly more resistant to heat treatment than C. pseudonaviculata at 47.5 and 50 C, whereas microsclerotia of both species were rapidly killed at 55 C.

De novo metastasis in breast cancer: occurrence and overall survival stratified by molecular subtype

Breast cancer molecular subtypes, categorized jointly by hormone receptors (HR) and human epidermal growth factor-2 (HER2), are utilized to guide systemic therapy. We hypothesized distinct patterns of de novo metastasis and overall survival by molecular subtype using a retrospective cohort of 399,772 women in the National Cancer Database diagnosed with first primary invasive breast cancer between 2010 and 2014, of whom 13,924 were diagnosed with de novo metastasis from 2010 to 2013 and had follow up data. The relationship of molecular subtype with patient and tumor characteristics, including site of de novo metastasis, were examined using Chi-squared tests. Kaplan-Meier and Cox proportional hazards analyses were used to examine overall survival by molecular subtype. Bone was the most frequent de novo metastatic site for all molecular subtypes. Compared to HR+/HER2-, patients with HR-/HER2+ experienced 4.5, 3.0, and 6.0 times the de novo brain, lung, and liver metastasis respectively. In survival analyses of women diagnosed with de novo metastasis, the mortality risk relative to HR+/HER2- was twice as high for triple-negative (hazard ratio = 2.02, 95% CI 1.89-2.16) and modestly lower for HR+/HER2+ (hazard ratio = 0.83, 95% CI 0.78-0.88). The median survival difference between metastatic patients with and without chemotherapy was 28.6 months in HR+/HER2+ and 28.2 months in HR-/HER2+, but only 10.9 months in triple-negative and 5.2 months in HR+/HER2-. In conclusion, despite unfavorable patterns of de novo metastasis, HER2+ breast cancers had relatively better survival in recent years, probably due to treatment differences. Utilizing molecular subtype and site of de novo metastasis may predict prognosis and guide treatment.

Cognitive Performance Does not Limit Physical Activity Participation in the Lifestyle Interventions and Independence for Elders Pilot Study (LIFE-P)

OBJECTIVES

We examined whether multiple domains of baseline cognitive performance were associated with prospective physical activity (PA) adherence in the Lifestyle Interventions and Independence for Elders Pilot study (LIFE-P).

DESIGN, SETTING, PARTICIPANTS

The LIFE-P study was a single-blind, multicenter, randomized controlled trial of a PA intervention compared to a successful aging educational intervention in sedentary, mobility-limited older adults.

INTERVENTION

A 12-month structured, moderate-intensity, multi-modal PA program that included walking, resistance training, and flexibility exercises. For the first 2 months (adoption), 3 center-based exercise sessions (40-60 min) / week were conducted. During the next 4 months (transition), center-based sessions were conducted 2 times / week. The subsequent maintenance phase consisted of optional once-to-twice-per-week center-based sessions and home-based PA.

MEASUREMENTS

Tests of executive and global cognitive functioning, working memory and psychomotor speed were administered at baseline. Median test scores were used to dichotomize participants into low or high cognitive performance groups.

RESULTS

52 mobility-limited older adults (age: 76.9 ±5 yrs) were randomized to the PA arm of LIFE-P. Compared to participants with high cognitive performance, participants with low performance had similar PA adherence rates (all P ≥ 0.34). Furthermore, weak and non-significant univariate relationships were elicited between all measures of cognition and overall PA adherence levels (r values ranged: -0.20 to 0.12, P ≥ 0.12).

CONCLUSION

These data suggest that cognitive performance does not limit long-term PA adherence in mobility-limited older adults. Additional studies in larger cohorts are warranted to verify these findings.

Contralateral Breast Cancer Risk in Women with Ductal Carcinoma In Situ: Is it High Enough to Justify Bilateral Mastectomy?

BACKGROUND

Women with ductal carcinoma in situ (DCIS) are increasingly choosing bilateral mastectomy. We sought to quantify rates of contralateral breast cancer (CBC) and ipsilateral breast tumor recurrence (IBTR) after breast-conserving surgery (BCS) for DCIS, and to compare risk factors for CBC and IBTR.

METHODS

From 1978 to 2011, DCIS patients undergoing BCS with a contralateral breast at risk were identified from a prospectively maintained database. The association of clinicopathologic and treatment factors with CBC and IBTR were evaluated using Kaplan-Meier analysis, multivariable Cox regression, and competing risk regression (CRR).

RESULTS

Of 2759 patients identified, 151 developed CBC and 344 developed IBTR. Five- and 10-year Kaplan-Meier CBC rates were 3.2 and 6.4%. Overall, 10-year IBTR rates were 2.5-fold higher than CBC rates, and, without radiation, 4-fold higher. On CRR, 5- and 10-year rates were 2.9 and 5.8% for CBC, and 7.8 and 14.5% for IBTR. CBC risk and invasive CBC risk were not significantly associated with age, family history, presentation, nuclear grade, year of surgery, or radiation. By multivariable Cox regression, endocrine therapy was associated with lower CBC risk (hazard ratio 0.57, p = 0.03). Ten-year risk of subsequent CBC in the subset of patients who developed IBTR was similar to the cohort as a whole (8.1 vs. 6.4%).

CONCLUSIONS

CBC rates were low across all groups, including those who experienced IBTR. CBC was not associated with factors that increase IBTR risk. While factors associated with IBTR risk are important in decision making regarding management of the index DCIS, they are not an indication for contralateral prophylactic mastectomy.