Ice Reduces Needle-Stick Pain Associated With Local Anesthetic Injection

BACKGROUND

Local anesthetic injections are widely used in the emergency department for different purposes. Pain management for such injections is of great importance to both patients and the healthcare system.

OBJECTIVES

Our study aimed to determine the effectiveness and safety of cryotherapy in patients receiving local anesthetic injections.

METHODS

Subjects who presented with superficial lacerations were randomly assigned to 2 groups, the first group received ice packing prior to injection and the second did not. The pain severity, length and depth of the laceration, and the other necessary information before and after the pain-reducing intervention were measured, documented, and compared at the end of the study. Pain scores were measured using a numerical rating scale before and after the procedure, and the differences were compared using a t-test.

RESULTS

Ninety subjects were enrolled in the study, 45 in each group. There were no statistical differences between the 2 groups in terms of baseline preoperative and operative characteristics (P > 0.05). The pain scores in the cryotherapy group were significantly lower before and after the procedure (P < 0.001). There was no statistically significant difference between the 2 groups for wound infection (P = 0.783).

CONCLUSIONS

Cooling the injection site prior to local anesthetic injection is an effective and inexpensive method to reduce the pain and discomfort caused by the injection.

Detection of circulating tumor cells using manually performed immunocytochemistry (MICC) does not correlate with outcome in patients with early breast cancer - Results of the German SUCCESS-A- trial

Background

Recently, the prognostic significance of circulating tumor cells (CTCs) in primary breast cancer as assessed using the Food-and-Drug-Administration-approved CellSearch® system has been demonstrated. Here, we evaluated the prognostic relevance of CTCs, as determined using manually performed immunocytochemistry (MICC) in peripheral blood at primary diagnosis, in patients from the prospectively randomized multicenter SUCCESS-A trial (EudraCT2005000490-21).

Methods

We analyzed 23 ml of blood from 1221 patients with node-positive or high risk node-negative breast cancer before adjuvant taxane-based chemotherapy. Cells were separated using a density gradient followed by epithelial cell labeling with the anti-cytokeratin-antibody A45-B/B3, immunohistochemical staining with new fuchsin, and cytospin preparation. All cytospins were screened for CTCs, and the cutoff for positivity was at least one CTC. The prognostic value of CTCs with regard to disease-free survival (DFS), distant disease-free survival (DDFS), breast-cancer-specific survival (BCSS), and overall survival (OS) was assessed using both univariate analyses applying the Kaplan–Meier method and log-rank tests, and using multivariate Cox regressions adjusted for other predictive factors.

Results

In 20.6 % of all patients (n = 251) a median of 1 (range, 1–256) CTC was detected, while 79.4 % of the patients (n = 970) were negative for CTCs before adjuvant chemotherapy. A pT1 tumor was present in 40.0 % of patients, 4.8 % had G1 grading and 34.6 % were node-negative. There was no association between CTC positivity and tumor stage, nodal status, grading, histological type, hormone receptor status, Her2 status, menopausal status or treatment. Univariate survival analyses based on a median follow-up of 64 months revealed no significant differences between CTC-positive and CTC-negative patients with regard to DFS, DDFS, BCSS, or OS. This was confirmed by fully adjusted multivariate Cox regressions, showing that the presence of CTCs (yes/no) as assessed by MICC did not predict DFS, DDFS, BCSS or OS.

Conclusions

We could not demonstrate prognostic relevance regarding CTCs that were quantified using the MICC method at the time of primary diagnosis in our cohort of early breast cancer patients. Further studies are necessary to evaluate if the presence of CTCs assessed using MICC has prognostic relevance, or can be used for risk stratification and treatment monitoring in adjuvant breast cancer.

Trial registration

The ClinicalTrial.gov registration ID of this prospectively randomized trial is NCT02181101; the (retrospective) registration date was June 2014 (study start date September 2005).

Neoadjuvant, anthracycline-free chemotherapy with carboplatin and docetaxel in triple-negative, early-stage breast cancer: a multicentric analysis of rates of pathologic complete response and survival

INTRODUCTION

Triple-negative breast cancer (TNBC) has the highest mortality rates of all subtypes. Anthracycline and taxane regimens yield unsatisfactorily low rates of pathologic complete response (pCR) and are often not feasible in cardiac comorbidity. This study seeks to increase pCR and survival by introducing platin agents.

PATIENTS AND METHODS

In this multicentric, open-label study with six cycles of docetaxel (75 mg/m(2)) and carboplatin AUC 6 q3w, patients were unwilling or unsuitable for anthracycline-based regimens. Primary endpoint was pCR (ypT0/ypTis ypN0) and survival.

RESULTS

pCR rate was 50%. After 2 and 5 years, overall survival (OS) was 96.7 and 89.7%, disease-free-survival (DFS) 96.7 and 85.7%, DDFS 96.7 and 89.6%. Grade 3/4 toxicities were rare. Ninety-three per cent of patients completed six cycles. No toxicity-related treatment discontinuation or febrile neutropaenia was recorded.

CONCLUSION

This regimen is highly effective and feasible in TNBC and may be combined with anthracyclines.

Toxicity Assessment of a Phase III Study Evaluating FEC-Doc and FEC-Doc Combined with Gemcitabine as an Adjuvant Treatment for High-Risk Early Breast Cancer: the SUCCESS-A Trial

Introduction: This paper aims to evaluate the toxicity profile of additive gemcitabine to adjuvant taxane-based chemotherapy in breast cancer patients. Methods: Patients enrolled in this open-label randomized controlled Phase III study were treated with 3 cycles of epirubicin-fluorouracil-cyclophosphamide (FEC) chemotherapy followed by 3 cycles of docetaxel with those receiving 3 cycles of FEC followed by 3 cycles of gemcitabine-docetaxel (FEC-DG). 3690 patients were evaluated according to National Cancer Institute (NCI) toxicity criteria (CTCAE). The study medications were assessed by the occurrence of grade 3-4 adverse events, dose reductions, postponements of treatment cycles and granulocyte colony-stimulating factor (G-CSF) support. Results: No differences in neutropenia or febrile neutropenia were demonstrated. However, thrombocytopenia was significantly increased with FEC-DG treatment (2.0 vs. 0.5 %, p < 0.001), as was leukopenia (64.1 vs. 58.5 %, p < 0.001). With FEC-DG significantly more G-CSF support in cycles 4 to 6 (FEC-DG: 57.8 %, FEC-D: 36.3 %, p < 0.001) was provided. Transaminase elevation was significantly more common with FEC-DG (SGPT: 6.3 %, SGOT: 2 %), whereas neuropathy (1.2 %), arthralgia (1.6 %) and bone pain (2.6 %) were more common using FEC-D. Dose reductions > 20 % (4 vs. 2.4 %) and postponement of treatment cycles (0.9 vs. 0.4 %) were significantly more frequent in the FEC-DG arm. Eight deaths occurred during treatment in the FEC-DG arm and four in the FEC-D arm. Conclusion: The addition of gemcitabine increased hematological toxicity and was associated with more dose reductions and postponements of treatment cycles.

Risk-reducing, conservative mastectomy-analysis of surgical outcome and quality of life in 272 implant-based reconstructions using TiLoop(®) Bra versus autologous corial flaps

BACKGROUND

Different approaches have evolved for conservative mastectomies, mostly according to surgeon's preference. Patients' perspective was not always in the primary focus. BRCA status has drawn much attention and therapeutic as well as prophylactic mastectomies are rising. However, knowledge on quality of life (QoL) thereafter is limited. We investigated the surgical and patient reported outcome of conservative mastectomies with implants and TiLoop(®) Bra vs. corial flaps.

METHODS

Conservative mastectomies were analyzed from a prospectively maintained database in a unicentric study of consecutive 272 reconstructions from 2000-2014. We used four validated QoL questionnaires: FACT-G, EORTC C-30, EORTC B-23 and Breast Cancer Treatment Outcome Scale (BCTOS). The use of TiLoop(®) Bra, a titanized polypropylene mesh, for lower breast pole coverage was compared to autologous corial flaps.

RESULTS

A total of 217 patients with 272 conservative mastectomies (55 bilateral) were included. Median follow-up was 3.5 years (range, 0-14 years). Skin-sparing mastectomy (SSM) was performed in 131 patients and subcutaneous mastectomy (SCM) in 86 patients. Invasive breast-cancer was the indication for surgery in 106 patients, non-invasive breast cancer (DCIS) in 80 patients, prophylactic indication (BRCA1/2-mutation) in 30 patients and contralateral alignment in 1 patient. TiLoop(®) Bra was used in 78 and corial flap in 79 patients. Response to questionnaires was 70%. TiLoop(®) Bra improved aesthetic results (P=0.049) and prevented implant dislocation (P=0.009). All patients expressed their adherence to the decision for surgery. Patients with SCM expressed their satisfaction even to a higher extent than those with SSM, particulary with regard to symmetry (P=0.018) and scars (P=0.037).

CONCLUSIONS

QoL after conservative mastectomies is demonstrated as excellent in several validated QoL-instruments. Double-plane technique for coverage of the implant yields good results with autologous corial flaps and Tiloop(®) Bra, favouring the latter in terms of aesthetics and prevention of implant dislocation.

Favorable results after conservative management of 316 valproate intoxicated patients

Background:

Valproic acid (VPA) is an effective antiepileptic drug widely used worldwide. Despite several studies indicating the usefulness of intravenous L-carnitine in the treatment of VPA poisoning, this drug is not readily available in Iran. The aim of this study was to determine whether supportive care without antidote would result in acceptable outcomes in VPA poisoned patients.

Materials and Methods:

In an observational, retrospective, single-center case series, all patients >12-year-old with VPA overdose who had referred to a tertiary center between 2009 and 2013 were consecutively enrolled. Patients’ demographic and presenting features, physical examinations, clinical management, laboratory data, and outcomes were recorded.

Results:

A total of 316 patients were enrolled with pure VPA toxicity. The most common presenting signs/symptoms were drowsiness, nausea and vomiting, vertigo, and headache. In the course of the disease, 14 patients (4.4%) were intubated and three (0.9%) required hemodialysis with mean dialysis sessions of two. Fourteen patients were admitted to Intensive Care Unit, and seizures occurred in five. The initial level of consciousness was lower in patients with poor outcome. The median ingested dose of VPA in patients who required dialysis was significantly higher (20 vs. 6 g; P = 0.006). Multivariate analyses revealed that coma on presentation was associated with a worse outcome (P = 0.001; odds ratio = 61.5, 95% CI = 5.8-646.7).

Conclusion:

Prognosis of VPA poisoned patients appears to be good even with supportive care. According to our study, older age, ingestion of higher amounts of VPA and lower PCO₂, HCO₃, base excess, and CPK levels prone the patients to more severe toxicities in univariate analysis, but the main poor prognostic factor is coma on presentation in multivariate analysis.

Breast conservative surgery and local recurrence

INTRODUCTION

Breast conservation is a legacy of Umberto Veronesi who laid the groundwork for the preservation of the body image of women affected by breast cancer (BC) with the Milan I study in the late 70ies of the last millennium. Breast conservative surgery (BCS) has two aspects: oncological safety of tumour resection with free margins and aesthetic preservation of the breast. Determinants of local control used to be T-size, nodal status and receptor status until biologically driven concepts defined risk of recurrence on the basis of molecular portraits. We explored whether these concepts of intrinsic subtypes prove at a large scale in the context of BCS and which surgical techniques procure best oncological and aesthetic outcomes, avoiding re-excision and necessity of conversion to mastectomy.

PATIENTS AND METHODS

We analyzed 1035 BCS patients with primary unilateral breast cancer (2004-2009) with regards to the local recurrence as a function of tumour location, surgical technique, resection volume, T-size, nodal status, grading, histopathological and intrinsic subtype and margins.

RESULTS

Five surgical techniques were applied to 944 eligible patients at a median follow-up of 5.2 years with the following frequency: Glandular rotation mammoplasty (63.8%), tumour-adapted rotation mammoplasty (20.9%), dermoglandular rotation mammoplasty (6.7%), 4.4% (lateral thoracic wall advancement), 0.7% latissimus dorsi flap (0.7%) and others (13.5%). Tumour-free margins were achieved in 88.6% of all patients at first surgery. Recurrence was independent of the surgical technique used, resection volume, T-size (in a T1/T2-cohort), nodal status (in low N-stages: NO/N1) and histopathology (inv.-ductal vs. lobular), however non-invasive subtype (DCIS), high grading (G3 vs. G1), non-luminal Her2 positive BC and triple-negative breast cancer (TNBC) were significantly associated with local recurrence.

CONCLUSIONS

Five defined oncoplastic principles presented in our nomogramme (targeted breast surgery) allow the reconstruction of major segmental resection defects during breast-conserving therapy with high clinical applicability and result in favorable oncological and aesthetic outcome. Recurrence was not a function of traditional prognostic factors like T-size or nodal status (in a T1/T2, N0/N1 cohort), but of grading, intrinsic subtypes and non-invasive breast cancer components. Lobular histology, multi-centricity and DCIS were predictive for breast preservation failure and conversion to mastectomy.

Prognostic Impact of Residual Disease After Neoadjuvant Chemotherapy in 648 Patients with Triple-negative Breast Cancer

AIM

In order to establish a new risk categorization system for triple-negative breast cancer (TNBC) after neoadjuvant chemotherapy, we analyzed a large database including more than 50% of all breast cancer cases nationwide.

PATIENTS AND METHODS

From a database of 39,570 primary breast cancer cases, 648 patients with TNBC were treated with neoadjuvant chemotherapy (2009-2011). The primary study end-point was the impact of residual tumor burden on survival.

RESULTS

Pathological complete response (pCR) was achieved in 199 patients; 449 patients had a non-pCR (pCR rate=30.8%). Stage ypT1 did not differ prognostically from ypT2, and likewise ypT3 not from ypT4 (in patients with N0 and N1-3 disease). Combined analysis of ypT1/2 and ypT3/4 yielded highly significant differences (p=0.000145).

CONCLUSION

A partial response still conveys a substantial survival benefit. There is no linear deterioration of prognosis according to residual tumor size. Post-neoadjuvant TNM stages ypT1 and ypT2, and ypT3 and ypT4 pairwise build uniform prognostic groups in TNBC, when there is no or low axillary lymph-node involvement.

Genetic variants in VEGF pathway genes in neoadjuvant breast cancer patients receiving bevacizumab: Results from the randomized phase III GeparQuinto study

Studies assessing the effect of bevacizumab (BEV) on breast cancer (BC) outcome have shown different effects on progression-free and overall survival, suggesting that a subgroup of patients may benefit from this treatment. Unfortunately, no biomarkers exist to identify these patients. Here, we investigate whether single nucleotide polymorphisms (SNPs) in VEGF pathway genes correlate with pathological complete response (pCR) in the neoadjuvant GeparQuinto trial. HER2-negative patients were randomized into treatment arms receiving either BEV combined with standard chemotherapy or chemotherapy alone. In a pre-planned biomarker study, DNA was collected from 729 and 724 patients, respectively from both treatment arms, and genotyped for 125 SNPs. Logistic regression assessed interaction between individual SNPs and both treatment arms to predict pCR. Five SNPs may be associated with a better response to BEV, but none of them remained significant after correction for multiple testing. The two SNPs most strongly associated, rs833058 and rs699947, were located upstream of the VEGF-A promoter. Odds ratios for the homozygous common, heterozygous and homozygous rare rs833058 genotypes were 2.36 (95% CI, 1.49-3.75), 1.20 (95% CI, 0.88-1.64) and 0.61 (95% CI, 0.34-1.12). Notably, some SNPs in VEGF-A exhibited a more pronounced effect in the triple-negative subgroup. Several SNPs in VEGF-A may be associated with improved pCR when receiving BEV in the neoadjuvant setting. Although none of the observed effects survived correction for multiple testing, our observations are consistent with previous studies on BEV efficacy in BC. Further research is warranted to clarify the predictive value of these markers.

Impact of Age, Obesity and Smoking on Patient Satisfaction with Breast Implant Surgery - A Unicentric Analysis of 318 Implant Reconstructions after Mastectomy

Aim: Breast reconstruction has become increasingly important for the body image of women with breast cancer. We conducted a study to investigate how patient characteristics correlate with surgical outcome after breast reconstruction with implant after mastectomy and to identify risk factors which could facilitate patient selection for reconstruction. Patients and Methods: For this case cohort analysis (n = 257 patients with 318 heterologous reconstructions), we analyzed BMI, smoking, pre-existing disease, chemotherapy and radiotherapy, one-stage/two-stage reconstruction, immediate/delayed reconstruction, antibiotic therapy and complications, partner interaction and adherence to the decision for reconstruction using a customized questionnaire. Results: 257 patients with 318 implant reconstructions (196 unilateral, 61 bilateral) were eligible for inclusion in the study. Median follow-up time was 3.1 years (range: 1 month to 10 years). Response rate to the questionnaire was 71.8 %. Median age was 49 years (range 24-79 years), median BMI was 22.44 (range 16.33-40.09). A BMI > 30 was inversely correlated with positive self-image (p = 0.004), and implant loss/rotation was more frequent in this group (p < 0.05). Smoking > 10 cigarettes/day had a negative impact on surgical outcome. A positive self-image had a positive impact on partner interaction (p < 0.001) and was correlated with a lower perception of pain. Aesthetic results did not vary with age (p = 0.054). Titanized polypropylene meshes were used to protect against implant rotation (p = 0.034). Rates of capsular fibrosis were low in our cohort (< 10 %), and implant loss rate was less than 2 %. Conclusions: This study offers a differentiated approach for the pre-surgical counselling of patients and shows that patients up to 80 years of age are highly satisfied with implant reconstruction. A high BMI and smoking > 10 cigarettes/day are unfavorable preconditions for implant reconstruction. The use of prophylactic antibiotics was confirmed as beneficial for surgical outcome. A positive self-image after reconstruction strongly influences partner interaction.

Translating the concept of intrinsic subtypes into an oncoplastic cohort of more than 1000 patients - predictors of recurrence and survival

INTRODUCTION

A paradigm shift in breast cancer was introduced by Sørlie's concept of intrinsic subtypes [1]. We validated this concept - which was originally based on 84 individuals - in a large cohort study of 1035 patients with oncoplastic surgery and analyzed if early and late recurrences are linked to a specific intrinsic tumor subtype or resection margins.

MATERIALS AND METHODS

1035 patients with oncoplastic surgery (2004-2009) were analyzed with regard to treatment characteristics and patterns of early (<5 years) and late recurrence (>5 years) and survival related to the intrinsic subtypes. Data was retrieved from patient's charts, customized patients questionnaires and cancer registries.

RESULTS

944 patients with primary, unilateral breast cancer, median age 58 years, were eligible for analysis. At a median FU of 5.2 years, LRR was 4.0%, 5-year-OS 94.5% and DFS 90.9%. Intrinsic subtypes, but not T-size, nodal-status, resections margins nor histopathology, governed local control and survival. There was no signal for prevelance of unclear margins in any of intrinsic subgroups and no preference of any oncoplastic technique attributed to them. TNBC and Her2 non-luminal breast cancer had highest recurrence and lowest survival rates. Although sentinel involvement (SLN+) was prevailing in the Luminal-B-Her 2 negative subtype at 34.3%, this did not translate into a higher axillary dissection rate.

CONCLUSION

This study confirmed the intrinsic subtype concept on a large clinical basis and describes the patterns of early and late recurrence in oncoplastic surgery, concluding that bigger risk may not be overcome by bigger surgery.

Abstract P2-13-01: Stage-related risk categorization and influence of free margins on survival in triple negative early breast cancer - a population-based study of 2037 TNBC patients with adjuvant chemotherapy

Introduction: Triple negative breast cancer (TNBC) represents 10-20% of all breast cancer entities [1][2] and has a known aggressive behavior and poor outcome. Patients treated in the setting of randomized clinical trials often do not represent actual treatment characteristics in real-life scenarios. To determine the stage-related survival and effect of surgical performance in TNBC with current multimodal treatment, we set out to analyze data of a large population-based registry of primary breast cancers which covering &gt;50% of all breast cancer cases in Germany.

Patients and methods: We analyzed data from a prospectively collected cancer registry of &gt;200 certified breast units of the West-German Breast Center (WBC) in Germany from 2009-2011. From a cohort of 39570 primary breast cancer patients treated in this period, 12759 underwent adjuvant systemic therapy, out of which 2037 were TNBC cases with adjuvant chemotherapy. Inclusion criteria were triple negative breast cancers (Her2-new1+/2+ (Fish negative) and estrogen receptor (ER) and progesterone receptor (PR) &lt;10%) and adjuvant chemotherapy, unilateral and non-metastasized breast cancer. Only those patients were included who have been followed-up within the first 3 years. Exclusion criteria were neoadjuvant chemotherapy, bilateral breast cancer and metastatic disease.

The use of first, second and third generation chemotherapy was analyzed as well as the effect of clear/unclear resection margins and its impact on survival data.

Results:

2037 patients were eligible for this study. Overall survival rates were as follows: T1 a and T1b 100 %, T1c 90,7 %, T2 90,9 %, T3 68,1 % and T4 64,3 %. No statistical differences were detected in between stages T1 and T2, and also not in between T3 and T4. Combining T1/T2 and T3/T4 and performing group-wise comparisons, differences for combined stages were highly statistically significant (3,9 x E-09). Inflammatory TNBC was prognostically worst with a survival-rate of 33,3 % at 24-months. (p&lt;0,001)

Unclear resection-margins versus clear margins in TNBC exerted a negative impact on DFS (87 vs. 73 %; p=0,00002) and DDFS (p=0,0004). Age was an independent risk factor for survival with a cut-off at 35 years.(p=0,044)

Third-generation chemotherapies (anthracycline+taxanes) were associated with a significant improved overall-survival at 24-months compared to first generation chemotherapies (non-anthracycline, non-taxane) (95 % vs. 87 %; p=0,0029)

Conclusion: Standard 3rd generation (anthracycline- and taxane-containing) chemotherapy and optimal surgical performance with clear margins is vital for patients with early, triple-negative breast cancer (TNBC). Within T1 and T2 stages, no stage-related deterioration of prognosis was detected, however these stages were markedly different from stages T3/T4, declining from 90-100% to 64-68 %.

This analysis of a large database of a population-based study demonstrates that tumor size, margins and guideline-adapted chemotherapy matter in triple-negative, early breast cancer.

[1] Schwentner et al. 2013

[2] Elsawaf et al. 2013.

Citation Format: Peter Kern, Gunter von Minckwitz, Carolin Pütter, Annika Flach, Sofia Pavlidou, Rainer Kimmig, Mahdi Rezai. Stage-related risk categorization and influence of free margins on survival in triple negative early breast cancer - a population-based study of 2037 TNBC patients with adjuvant chemotherapy [abstract]. In: Proceedings of the Thirty-Seventh Annual CTRC-AACR San Antonio Breast Cancer Symposium: 2014 Dec 9-13; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2015;75(9 Suppl):Abstract nr P2-13-01.

Abstract OT3-2-04: ADAPT - Adjuvant Dynamic marker-Adjusted Personalized Therapy trial optimizing risk assessment and therapy response prediction in early breast cancer

Background: Early therapy response is currently not regarded for further treatment decisions as standard of care in the treatment of breast cancer (BC). Predictive markers for the success of a certain therapy could support the physician’s choice of adequate and beneficial therapies by simultaneous reduction of unnecessary toxicity. Proliferation makers as Ki-67 seem to be a suitable tool, as dynamic changes of proliferation (as result of induction therapy) have been shown to be most important for outcome of neoadjuvant chemotherapy prediction in patients with pCR in distinct BC subtypes (luminal B, TNBC, HER2+).

Methods: Trial design: ADAPT combines early assessment of prognosis by conventional markers (e.g. molecular classification, nodal status) with dynamic measurement of proliferation changes during a 3-week induction therapy, using baseline diagnostic core biopsy and a second biopsy after induction therapy. ADAPT consists of an umbrella trial and five different sub-trials (HR+/HER2-, HR+/HER2+, HR-/HER2+, HR-/HER2-, Elderly) and is set up as prospective, multi-center, controlled, non-blinded, randomized phase II/III trial.

Subtype-specific treatment across the sub-trials is highly innovative and involves the following treatment strategies:

• HR+/HER2-: endocrine therapy (ET) vs. chemotherapy (4xPac q2w – 4xEC q2w vs. 8xNab-Pac q1w – 4xEC q2w) + ET, depending on risk classification/early response.

• HER2+/HR+: T-DM1 vs. T-DM1 + ET vs. trastuzumab + ET.

• HER2+/HR-: Trastuzumab + Pertzumab ± Paclitaxel q1w.

• TN: Nab-Paclitaxel + Gemcitabine vs. nab-Pac + Carboplatin.

• Elderly: 2xMyocet + Cyclophosphamide q3w, depending on cPR/cCR or NC/toxicity the treatment will be continued for two more cycles or changed to 6xPac q1w.

Adaptation/change in therapy regimens can be made by interim analysis after n=130 in each sub-trial.

Eligibility criteria: Histologically confirmed unilateral primary invasive BC with known HR-/HER2-status (central pathology) for allocation to the respective sub-trial. Pts requiring chemo- or targeted (anti-HER2) therapy must have adequate laboratory values and organ function and must have no contraindications for the planned treatment.

Primary endpoints: Evaluation of dynamic test for outcome prediction/prospective comparison of 5yr EFS in responders (intermediate risk (RS 12-25) / good response to short-term ET in HR+/HER2- or pts with pCR in HER2+/TN BC) compared to low risk HR+/HER2- (RS≤11, N0-1) pts (control group).

Statistical methods: Assumption across sub-protocols: adjuvant CTx can be spared in HR+/HER2- or pCR be achieved in HER2+/TN in expected 1120 (HR+/HER2-) or 170 (HER2+/TN) pts, respectively. Outcome will be compared to the control group (expected n=640 HR+/HER2- pts: low risk (by RS), i.e. no CTx). Assuming 94% 5yr survival in control group, one-sided test of non-inferiority at 95% CI will have 80% power for survival non-inferiority margin of 3.2% (i.e. 90.8% survival).

Present and target accrual: By June 2014, 73 active sites have recruited 1820 pts for ADAPT HR+/HER2-. Target accrual is 4000 pts. 190 of 380 pts were successfully randomized for ADAPT HER2+/HR+. ADAPT HER2+/HR- has included 17 of 220 pts and ADAPT Triple Negative has recruited 150 of 336 pts.

Citation Format: Ulrike Nitz, Oleg Gluz, Raquel von Schumann, Daniel Hofmann, Ronald E Kates, Sherko Kuemmel, Michael Braun, Claudia Schumacher, Benno Nuding, Bahriye Aktas, Helmut Forstbauer, Nicolai Maass, Mahdi Rezai, Stefan Kraemer, Mathias Warm, Rachel Wuerstlein, Nadia Harbeck. ADAPT - Adjuvant Dynamic marker-Adjusted Personalized Therapy trial optimizing risk assessment and therapy response prediction in early breast cancer [abstract]. In: Proceedings of the Thirty-Seventh Annual CTRC-AACR San Antonio Breast Cancer Symposium: 2014 Dec 9-13; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2015;75(9 Suppl):Abstract nr OT3-2-04.

Abstract P1-16-07: Translating the concept of intrinsic subtypes into an oncoplastic cohort of more than 1000 patients-predictors of recurrence and survival

Introduction:

The concept of breast cancer experienced a paradigm shift by Sørlie T. et al. with intrinsic subtypes as prognostic classification of breast cancer [1]. We validated this concept in a large cohort study of oncoplastic surgery.

Patients and methods:

We analysed 1035 patients with oncoplastic surgery (2004-2009) and survival parameters related to histopathological approximated intrinsic subtypes.

Data were retrieved from customized questionnaires and patients charts. Survival data were determined from cancer registries.

Results:

A total of 944 patients with primary unilateral breast cancer, median age 58 years, were eligible for analysis. At a median follow-up of 5.3 years, LRR was 4.1%, with 5-year-OS of 94.5% and DFS of 90.9%. Stage distribution was as follows: T1a 3%, T1b 12 %, T1c 44,2 % and T2 was 22,1%. 70,4 % of patients were nodal-negative and nodal involvement was predominantly low.

Intrinsic subtypes, not T-size, nodal-status, resection margin width nor histopathology, governed the prognosis of this cohort. Triple-negative and Her2 non luminal breast cancer had the highest recurrence and the lowest survival rates compared to Luminal A: Recurrence TNBC 11,3 %, Her2pos non luminal 9,3 %, Luminal A 2,5 %; Overall survival: TNBC 91,3 %, Her2 non luminal 93,7 %; Luminal A: 96,3 %. Our data confirmed the intrinsic subtype concept on a large basis in oncoplastic surgery.

(1) Sørlie T, Perou CM, Tibshirani R, Aas T, Geisler S, Johnsen H, Hastie T, Eisen MB, van de Rijn M, Jeffrey SS, Thorsen T, Quist H, Matese JC, Brown PO, Botstein D, Lønning PE, Børresen-Dale AL: Gene expression patterns of breast carcinomas distinguish tumor subclasses with clinical implications. Proc Natl Acad Sci USA 2001; 98: 10869–10874.

Citation Format: Mahdi Rezai, Stephanie Kellersmann, Sarah Knispel, Rainer Kimmig, Peter Kern. Translating the concept of intrinsic subtypes into an oncoplastic cohort of more than 1000 patients-predictors of recurrence and survival [abstract]. In: Proceedings of the Thirty-Seventh Annual CTRC-AACR San Antonio Breast Cancer Symposium: 2014 Dec 9-13; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2015;75(9 Suppl):Abstract nr P1-16-07.

Abstract P4-01-03: Prognostic relevance of circulating tumor cells across different molecular subgroups in the adjuvant SUCCESS-A study

Aim: The prognostic value of circulating tumor cells (CTCs) in the adjuvant setting has recently been demonstrated in the SUCCESS A Study (Rack et al. JNCI 2014). As breast carcinomas depend on partly different pathways for progression, the relevance of CTCs could differ between molecular intrinsic subtypes of breast cancer. Aim of this study was therefore to analyze the prognostic impact of CTCs in molecular subtypes of a large patient cohort.

Methods: Within the adjuvant SUCCESS A Study, patients were treated either with 5-Flourouracil, Epirubicin and Cyclophosphamid (FEC) followed by Docetaxel (D) or with FEC followed by D and Gemcitabine (DG). There was no restriction with regard to molecular subtype, however a high recurrence risk was required for study entry. In addition patients were assessed prospectively for the presence of CTCs before chemotherapy. Molecular subtypes were defined as: triple negative (TN), hormone receptor positive and grading 1/2 (LUM A like), hormone receptor positive and grading 3 (LUM B like), HER2 positive (HER2 like). We studied whether the addition of CTC status (0 CTC vs &gt; 0 CTCs) to well-known predictors such as age, BMI, tumor size, lymph node status improved the prediction of overall survival (OS) and disease free survival (DFS) across all patients and especially within molecular subtypes using likelihood ratio tests, which compared multivariable Cox regression models with and without CTC and the interaction between CTC and molecular subtype.

Results: Information about molecular subtype and CTCs was available in a total of 1994 patients. At least one CTC was seen in 422 (21.2%) of patients. 383 (19.2%) were TN, 798 were LUM A like (40.0%), 328 (16.4%) were LUM B like (16.4%) and 485 (24.3%) were HER2 like. The effect of CTC on overall survival had a HR of 2.50 (95%: 1.75 to 3.58) for the entire cohort. However as the effect was different across subtypes (p=0.04, likelihood ratio test), subtype specific HR were calculated. The effects on OS were most prominent in LUM B like patients (HR=3.96; 95%CI: 1.93 to 8.14) and LUM A like patients (HR=3.57; 95%CI: 1.81 to 7.03), less strong in HER2 like (HR=2.35; 95%CI: 1.04 to 5.32) and not present in TN patients (HR=1.18; 95%CI: 0.62 to 2.24). CTC status had a clear effect on DFS as well (HR=1.93, 95%CI: 1.48 to 2.52). It could not be shown that this effect was different across subtypes (p=0.07, likelihood ratio test). However, the effect size was similarly distributed like the ones for OS.

Conclusion: With regard to OS the prognostic effect of CTCs in this study cohort seems most prominent in patients with hormone receptor positive disease. It is still significant in HER2 positive, but not in TN breast cancer patients. Results with regard to DFS trended into the same direction, differences within subgroups could however not be shown, possibly due to power reasons.

Citation Format: Wolfgang Janni, Andreas Schneeweiss, Lothar Häberle, Peter A Fasching, Lukas Schwentner, Mahdi Rezai, Jörn Hilfrich, Hans Tesch, Georg Heinrich, Helmut Forstbauer, Thomas Friedl, Fabienne Schochter, Susanne Albrecht, Bernadette Jäger, Julia Jückstöck, Tanja Fehm, Volkmar Müller, Klaus Friese, Werner Lichtenegger, Matthias B Beckmann, Brigitte Rack. Prognostic relevance of circulating tumor cells across different molecular subgroups in the adjuvant SUCCESS-A study [abstract]. In: Proceedings of the Thirty-Seventh Annual CTRC-AACR San Antonio Breast Cancer Symposium: 2014 Dec 9-13; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2015;75(9 Suppl):Abstract nr P4-01-03.

Abstract P3-11-01: Neoadjuvant chemotherapy with or without bevacizumab or everolimus: Survival analysis of The HER2-negative cohort of the GEPARQUINTO study (GBG 44)

BACKGROUND: The GeparQuinto study showed that adding bevacizumab to 24 weeks of anthracycline-taxane-based neoadjuvant chemotherapy increases pathological complete response (pCR) rates from 14.9% to 18.4% (P=0.04) overall; specifically in patients with TNBC (27.9% to 39.3% (P=0.003) (von Minckwitz et al, NEJM 2012). No difference in pCR rate was observed for adding everolimus to paclitaxel patients who had no early response to neoadjuvant chemotherapy (Huober et al, Eur J Cancer 2013). Here, we present disease-free (DFS) and overall survival (OS) analyses.

PATIENTS AND METHODS: Patients (n = 1948) with HER2-negative tumors of a median tumor size of 4 cm were randomly assigned to neoadjuvant treatment with 4xEC à 4x docetaxel with or without bevacizumab, 15 mg/Kg q3w before surgery. 408 patients not clinically responding to EC ± Bev were randomized to 12x weekly paclitaxel with or without everolimus 5mg/day. Patients with HR-positive tumors received endocrine treatment after surgery. 379 events are required to show a HR of 0.75 (α=0.05, ß=0.8) between the bevacizumab arms. 397 relapses and 234 deaths were observed after a median follow up of 3.8 years overall, of those 115 relapses and 75 deaths occurred in the non-responding cohort.

RESULTS: Overall, 3-year DFS was 80.8% and 3-year OS was 89.7%. Outcome was not different for patients receiving bevacizumab (HR 1.03; P = 0.780 for DFS and HR 0.974; P = 0.842 for OS) compared to patients receiving chemotherapy alone. Patients with TNBC showed no improvement in DFS (HR 0.991; P = 0.948) and OS (HR 1.02; P = 0.891) when treated with bevacizumab. No other predefined subgroup (HR+/HER2-; locally advanced (cT4 or cN3) or not; cT1-3, cT4a-c, cT4d; pCR or not, CR, PR, NC after first 4 cycles chemotherapy) showed a benefit from bevacizumab. No difference in DFS (HR 0.997; P=0.987) and OS (HR 1.11; P=0.658) was observed for patients who had no early response to neoadjuvant chemotherapy receiving paclitaxel with or without everolimus overall as well as in subgroups.

CONCLUSIONS: Long-term results finally do not support the neoadjuvant use of bevacizumab in addition to an anthracycline-taxane-based chemotherapy or everolimus in addition to paclitaxel for patients who had no early response to neoadjuvant chemotherapy.

Citation Format: Bernd Gerber, Sibylle Loibl, Michael Untch, Holger Eidtmann, Mahdi Rezai, Peter A Fasching, Hans Tesch, Holm Eggemann, Iris Schrader, Kornelia Kittel, Claus Hanusch, Jens Huober, Christine Solbach, Christian Jackisch, Georg Kunz, Jens-Uwe Blohmer, Maik Hauschild, Tanja Fehm, Valentina Nekljudova, Gunter von Minckwitz. Neoadjuvant chemotherapy with or without bevacizumab or everolimus: Survival analysis of The HER2-negative cohort of the GEPARQUINTO study (GBG 44) [abstract]. In: Proceedings of the Thirty-Seventh Annual CTRC-AACR San Antonio Breast Cancer Symposium: 2014 Dec 9-13; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2015;75(9 Suppl):Abstract nr P3-11-01.

Systematization of Oncoplastic Surgery: Selection of Surgical Techniques and Patient-Reported Outcome in a Cohort of 1,035 Patients

Introduction

Functional and aesthetic outcome after breast-conserving surgery are vital endpoints for patients with primary breast cancer. A large variety of oncoplastic techniques exist; however, it remains unclear which techniques yield the highest rates of local control at first surgery, omission of reexcision or subsequent mastectomy, and merits the highest degree of patient satisfaction.

Methods

In this retrospective case cohort trial with a customized investigational questionnaire for assessment of patient satisfaction with the surgical result, we analyzed 1,035 patients with primary, unilateral breast cancer and oncoplastic surgery from 2004 to 2009.

Results

Analysis of patient reported outcome (PRO) revealed that 88 % of the cohort was satisfied with their aesthetic result using oncoplastic techniques following the concept presented. These results also were achieved in difficult tumor localizations, such as upper inner and lower inner quadrant. Conversion rate from breast-conserving therapy to secondary mastectomy was low at 7.2 % (n = 68/944 patients). The systematization of oncoplastic techniques presented—embedded in a multimodal concept of breast cancer therapy—facilitates tumor control with a few number of uncomplicated techniques adapted to tumor site and size with a median resection of 32 (range 11–793) g. Five-year recurrence rate in our cohort was 4.0 %.

Conclusions

Patient´s satisfaction was independent from age, body mass index, resection volume, tumor localization, and type of oncoplastic surgery (p > 0.05). We identified postoperative pain as an important negative impact factor on patient´s satisfaction with the aesthetic result (p = 0.0001).

Electronic supplementary material

The online version of this article (doi:10.1245/s10434-015-4396-4) contains supplementary material, which is available to authorized users.

Evaluation of Therapy Management and Patient Compliance in Postmenopausal Patients with Hormone Receptor-positive Breast Cancer Receiving Letrozole Treatment: The EvaluateTM Study

Introduction: The EvaluateTM study (Evaluation of therapy management and patient compliance in postmenopausal hormone receptor-positive breast cancer patients receiving letrozole treatment) is a prospective, non-interventional study for the assessment of therapy management and compliance in the routine care of postmenopausal women with invasive hormone receptor-positive breast cancer receiving letrozole. The parameters for inclusion in the study are presented and discussed here. Material and Methods: Between January 2008 and December 2009 a total of 5045 patients in 310 study centers were recruited to the EvaluateTM study. Inclusion criteria were hormone receptor-positive breast cancer and adjuvant treatment or metastasis. 373 patients were excluded from the analysis for various reasons. Results: A total of 4420 patients receiving adjuvant treatment and 252 patients with metastasis receiving palliative treatment were included in the study. For 4181 patients receiving adjuvant treatment, treatment with the aromatase inhibitor letrozole commenced immediately after surgery (upfront). Two hundred patients had initially received tamoxifen and started aromatase inhibitor treatment with letrozole at 1-5 years after diagnosis (switch), und 39 patients only commenced letrozole treatment 5-10 years after diagnosis (extended endocrine therapy). Patient and tumor characteristics were within expected ranges, as were comorbidities and concurrent medication. Conclusion: The data from the EvaluateTM study will offer a good overview of therapy management in the routine care of postmenopausal women with hormone receptor-positive breast cancer. Planned analyses will look at therapy compliance and patient satisfaction with how information is conveyed and the contents of the conveyed information.

Role of plasma ammonia level in detecting intra-abdominal hemorrhage following blunt abdominal trauma

BACKGROUND

Blunt abdominal injury is a leading cause of death in trauma patients. A reliable test predicting intra-abdominal hemorrhage would be a novel method. The study objective was to assess the diagnostic accuracy of plasma ammonia in detection of intra-abdominal bleeding in patients with blunt abdominal trauma (BAT).

MATERIALS AND METHODS

In this observational study, all patients suffering from BAT, referred to our university teaching hospital included. The levels of ammonia were measured at the time of emergency department admission and 1 h after initial treatment. Demographic data, vital signs, and venous blood gas reports were recorded. Findings of contrast-enhanced abdominopelvic computed tomography scan and laparotomy were assumed as a gold standard for abdominal injuries.

RESULTS

A total of 104 patients was enrolled in the study. 15 patients (14.4%) had intra-abdominal hemorrhage and the mean plasma ammonia level in this group was significantly higher than the other patients on admission time (101.73 ± 5.41 μg/dL vs. 47.36 ± 26.31 μg/dL, P < 0.001). On receiver-operator characteristic curve analysis, in cutoff point of 89 μg/dL, the sensitivity, specificity, positive and negative likelihood ratios were 100% (95% confidence interval [CI], 79.6-100), 93.26% (95% CI, 86-96.8), 14.83 (95% CI, 6.84-32.12), and 0, respectively.

CONCLUSION

The study findings suggest the measurement of ammonia level at the time of admission in the patients with BAT would be a useful test predicting intra-abdominal hemorrhage. Furthermore, decrease in the ammonia level could be a useful marker for monitoring response to treatment in these patients.

Impact of multifocal or multicentric disease on surgery and locoregional, distant and overall survival of 6,134 breast cancer patients treated with neoadjuvant chemotherapy

BACKGROUND

The impact of tumor focality on type of surgery, local recurrence rate, and survival after neoadjuvant chemotherapy (NACT) for breast cancer is not fully understood. This study aimed to compare local recurrence-free survival (LRFS), disease-free survival (DFS), and overall survival (OS) according to focality stratified by type of surgery and pathologic complete response (pCR), with a focus on breast conservation.

METHODS

Participants (n = 6,134) in the GeparTrio, GeparQuattro, and GeparQuinto trials with operable or locally advanced tumors receiving NACT were classified as having unifocal (1 lesion), multifocal (≥ 2 lesions in 1 quadrant), or multicentric (≥ 1 lesion in ≥ 2 quadrants) disease. The study investigated LRFS, DFS, and OS according to focality stratified by type of surgery and pathologic complete response.

RESULTS

The patients were classified as having unifocal (n = 4,733, 77.1 %), multifocal (n = 820, 13.4 %), or multicentric (n = 581, 9.5 %) tumors. The respective pCR rates were 19.4, 16.5, and 14.4 %. Breast conservation was performed for 71.6, 58.5, and 30 % of these patients, respectively (P < 0.001). The LRFS rate was 92.9 % for the unifocal, 95.1 % for the multifocal, and 90.4 % for the multicentric tumors (P = 0.002). The patients with multicentric tumors but not the patients with multifocal tumors had worse DFS (P < 0.001) and OS (P = 0.009) than the patients with unifocal tumors. However, LRFS, DFS, and OS were not inferior for the patients with multicentric or multifocal tumors if pCR was achieved or breast conservation was performed after NACT.

CONCLUSION

Breast conservation is feasible for clinically multifocal or multicentric breast cancer patients who undergo NACT without worsening LRFS if tumor-free margins can be attained or if patients achieve a pCR.

Survival after neoadjuvant chemotherapy with or without bevacizumab or everolimus for HER2-negative primary breast cancer (GBG 44-GeparQuinto)†

BACKGROUND

The GeparQuinto study showed that adding bevacizumab to 24 weeks of anthracycline-taxane-based neoadjuvant chemotherapy increases pathological complete response (pCR) rates overall and specifically in patients with triple-negative breast cancer (TNBC). No difference in pCR rate was observed for adding everolimus to paclitaxel in nonearly responding patients. Here, we present disease-free (DFS) and overall survival (OS) analyses.

PATIENTS AND METHODS

Patients (n = 1948) with HER2-negative tumors of a median tumor size of 4 cm were randomly assigned to neoadjuvant treatment with epirubicin/cyclophosphamide followed by docetaxel (EC-T) with or without eight infusions of bevacizumab every 3 weeks before surgery. Patients without clinical response to EC ± Bevacizumab were randomized to 12 weekly cycles paclitaxel with or without everolimus 5 mg/day. To detect a hazard ratio (HR) of 0.75 (α = 0.05, β = 0.8) 379 events had to be observed in the bevacizumab arms.

RESULTS

With a median follow-up of 3.8 years, 3-year DFS was 80.8% and 3-year OS was 89.7%. Outcome was not different for patients receiving bevacizumab (HR 1.03; P = 0.784 for DFS and HR 0.974; P = 0.842 for OS) compared with patients receiving chemotherapy alone. Patients with TNBC similarly showed no improvement in DFS (HR = 0.99; P = 0.941) and OS (HR = 1.02; P = 0.891) when treated with bevacizumab. No other predefined subgroup (HR+/HER2-; locally advanced (cT4 or cN3) or not; cT1-3 or cT4; pCR or not) showed a significant benefit. No difference in DFS (HR 0.997; P = 0.987) and OS (HR 1.11; P = 0.658) was observed for nonearly responding patients receiving paclitaxel with or without everolimus overall as well as in subgroups.

CONCLUSIONS

Long-term results, in opposite to the results of pCR, do not support the neoadjuvant use of bevacizumab in addition to an anthracycline-taxane-based chemotherapy or everolimus in addition to paclitaxel for nonearly responding patients.

CLINICAL TRIAL NUMBER

NCT 00567554, www.clinicaltrials.gov.