Abstract P1-01-25: Sentinella® an Alternative for Conventional Scintigram and a Modality To Improve Intra-Operative Localisation of Sentinel Nodes in Breast Cancer

Sentinel Lymph Node (SLN) biopsy is now a standard practice for staging of the axilla in early breast cancer. Access to nuclear medicine department and sentinel node imaging reamins an issue in number of hospitals in the UK and many parts of the word Sentinella® is a new portable imaging camera used intraoperatively to produce real time visual localisation of Sentinel nodes. Sentinella® was tested in a controlled laboratory environment at our centre and we report the first use of this novel technique in Breast cancer patients from UK.

Methods: Sensitvity and spatial resolution of Sentinella® mobile gamma camera was compared with a CGC (conventional single headed gamma camera) normally used for sentinel node imaging. Spatial resolution was measured by calculating the full width half maximum (FWHM) of a line profile measured perpendicular to the image of a capillary tube filled with high activity concentration technetium-99m pertechnetate. Next a special simulator mimicking the axilla was planted with seeds containing radiocolloid Tc, mimicking lymph nodes. Seeds were placed at varying depths in the axilla. For each combination of depths and radioactivity images with Sentinella® and CGC were obtained. Sentinella® scans of the axilla was also obtained in 50 patients undergoing SLNB to correlate with the preoperative scintigrams and determine presence of any residual hot nodes after use of the standard hand held gamma probe.If hot areas suggesting residual lymph nodes were detected, further exploration was carried out until no further residual activity was noted. Results

Sentinella® resolution is comparable with the CGC for objects close to the camera i.e. ∼ 5 cm, but reduces rapidly as you move away from the camera. For distances up to about 7 cm the Sentinella® with the blue collimator is more sensitive than the CGC.

68 Sentinella® images and 34 CGC images obtained from the simulated axilla. Sentinella detects high radioactivity (500 kBq) faster than CGC (1 vs 2.5min). In cases of low radioactivity (10kBq) Sentinella® was equally accurate and faster than cGC, when placed close to the skin. Identification of different number of beads with varying radioactivity was similar in Sentinella and CGC.

Sentinella® scans correlated with all the lymphoscintigrams in demonstrating hot lymph nodes in all the 50 cases. Sentinella® scans demonstrated a serial decay in activity with removal of every hot node and its LED guided localisation helped in detecting residual nodes. Sentinella® picked up extra nodes in 5/50 cases (10%) after the axilla was found silent using hand held gamma probe.In 2/50 (4%) cases extra nodes found using Sentinella® had presence of cancer that led to a complete Axillary clearance

Conclusion: The initial patient and laboratory data confirms the excellent sensitivity and specificity of the machine in localisation of radioactive nodes. This new imaging technique will increase our pick up of sentinel lymph nodes intraoperatively that are missed due to inadequate visualisation and provide an alternative to static scintigram imaging. This would be particularly useful in centres that do not have nuclear medicine facilities on site.

Citation Information: Cancer Res 2010;70(24 Suppl):Abstract nr P1-01-25.

Factors affecting rise in the incidence of infiltrating lobular carcinoma of the breast

BACKGROUND

Infiltrating ductal carcinoma and infiltrating lobular carcinoma account for more than 90% of all invrasive breast cancer histological types. The rate of lLC is reported to be increasing steadily in the United States and Europe.

OBJECTIVES

To describe the trend in the incidence of ILC in a large cohort of patients who underwent surgery in a single institution over an 18 year period. METHODS Our comprehensive database of 2175 consecutive patients with invasive breast cancer diagnosed during the period 1992-2009 served for the analysis. Several potential factors associated with lobular carcinoma as compared with ductal carcinoma were evaluated.

RESULTS

During this period, a 2.4-fold increase in the incidence of pure ILC was noted, from 4.6% in theyears 1992-1994 to 10.9% in 2004-2006, followed by a modest decrease to 8.7% in 2007-2009. A significant association of lobular malignancies with external hormonal use was noted, including hormone replacement therapy exposure in patients diagnosed at age 50-64, and ovarian overstimulation during in vitro fertilization in those diagnosed at age 50 or less

CONCLUSIONS

Better diagnostic tools - such as the liberal use of ultrasound and magnetic resonance imaging- and more accurate pathological definition for ILC type appear to influence the changes in the incidence of ILC in the subgroups of invasive breast cancer.

Anticancer activity of botanical compounds in ancient fermented beverages (review)

Humans around the globe probably discovered natural remedies against disease and cancer by trial and error over the millennia. Biomolecular archaeological analyses of ancient organics, especially plants dissolved or decocted as fermented beverages, have begun to reveal the preliterate histories of traditional pharmacopeias, which often date back thousands of years earlier than ancient textual, ethnohistorical, and ethnological evidence. In this new approach to drug discovery, two case studies from ancient Egypt and China illustrate how ancient medicines can be reconstructed from chemical and archaeological data and their active compounds delimited for testing their anticancer and other medicinal effects. Specifically, isoscopoletin from Artemisia argyi, artemisinin from Artemisia annua, and the latter's more easily assimilated semi-synthetic derivative, artesunate, showed the greatest activity in vitro against lung and colon cancers. In vivo tests of these compounds previously unscreened against lung and pancreatic cancers are planned for the future.

Current status and advances in management of early breast cancer

Breast cancer is the most common female cancer. Worldwide, more than a million women are diagnosed every year. However despite this increase, the mortality rate is declining. This is due to combination of factors including early diagnosis and effective treatment. This manuscript which is presented in two sections outlines the current status in management of early breast cancer. Section 1 focuses on the advances in diagnosis and surgical treatment of breast cancer and give an overview of the histopathological aspects. The focus of section 2 is on advances on adjuvant treatment of breast cancer including radiotherapy, chemotherapy and endocrine treatment.

A Novel Evidence-Adaptive Computerised Decision Support System for Breast Cancer Multidisciplinary Meetings: Results of an Evaluation Study

Background: Multidisciplinary meetings (MDM) also known as multidisciplinary cancer conferences are a forum for providing evidence-based care and are widely accepted as a part of standard cancer care worldwide. In United Kingdom, it is a mandatory requirement that the care of all breast cancer patients is managed through breast MDMs. However the lack of required support for conducting MDM is documented in many recent reviews. Advanced Computerised Decision Support (CDS) technology can play an important role in supporting MDMs and improving its functioning. We present a novel breast MDM support tool which integrates a CDS system into an electronic patient record to assist breast Multi Disciplinary Team (MDT) in making an evidence based, transparent treatment decisions during MDM. To the best of our knowledge there are no published studies of implementing computerised decision support systems for breast MDM.Methods: The Multi-disciplinary meeting Assistant and Treatment sElector (MATE) is a tool designed to assist breast clinicians in making management decisions for their patients in MDM. MATE is developed using a PROforma CDS technology which is funded by the Cancer Research UK. The tool is implemented in the breast unit of Royal Free hospital, London for its pilot testing. MATE evaluates patient's clinical facts and suggests optimal management options according to incorporated national and international clinical guidelines. The evidence base used in MATE can be updated as and when new evidence is published. MATE recommendations are not binding and the final decision is taken by breast MDT. MATE facilitates the flexible conduct of MDM. Additionally, it highlights if the patient is eligible to take part in any local, national or international clinical trials. In the evaluation study, the data of 300 consecutive breast patients presented at the Royal Free breast MDM along with their documented MDM recommendations are entered in MATE. MDM recommendations and MATE suggestions are analysed.Results: MATE system is able to suggest the treatment recommendations in concordance with breast MDT in most of the cases (91 %). MATE suggested more management options per patient than the documented MDT recommendations (3.4% vs. 1.2 %). MATE also identified 65% more patients suitable for ongoing clinical trials. Deviations that occur specially in unaided MDMs can be minimised using electronic data capture and decision support system like MATE.Conclusion: This evaluation study has shown the feasibility of implementing MATE into MDM and its potential to improve certain aspects of MDM by helping overburdened clinicians. The evidence adaptive decision support component of MATE can improve the guideline-compliance and transparency in the decision-making and also identify more patients to be considered for recruitment in clinical trials. Another important benefit could be completeness of documentation. Further evaluations of MATE in a randomised controlled trial are under way. If found beneficial, the system could easily be adapted for other cancers.

Citation Information: Cancer Res 2009;69(24 Suppl):Abstract nr 5118.

Hairy cell leukemia presenting as multiple discrete hepatic lesions

The involvement of hairy cell leukemia in the liver is in the form of portal and sinusoidal cellular infiltration. Here we describe the first case of hepatic hairy cell leukemia presenting as multiple discrete lesions, which was treated successfully. We suggest that in the investigation of discrete hepatic lesions in cases of cancer of unknown primary, hairy cell leukemia should be considered. The excellent response of hairy cell leukemia to therapy highlights the need for such a consideration.

18F- FDG-PET/CT for the diagnosis of tumor thrombosis

BACKGROUND

Venous thromboembolism is a well-recognized and relatively frequent complication of malignancy, whereas tumor thrombosis is a rare complication of solid cancers. The correct diagnosis of tumor thrombosis and its differentiation from VTE can alter patient management and prevent unnecessary long-term anticoagulation treatment.

OBJECTIVES

To evaluate the contribution of 18F-fluorodeoxyglucose positron emission tomography/computed tomography to the diagnosis of tumor thrombosis and its differentiation from VTE.

METHODS

PET/CT scans from 11 patients with suspected tumor thrombosis were retrospectively evaluated. Suspicion arose from positive PET/CT in eight cases, or from findings on contrast-enhanced CT in three patients. Criteria for positivity of PET/CT included increased focal or linear uptake of 18F-FDG in the involved vessel. Findings were categorized as PET/CT positive, or PET/CT negative and compared to contrast-enhanced or ultrasound Doppler, pathology where available, and clinical follow-up.

RESULTS

Eight occult tumor thromboses were identified by PET/CT-positive scans. Underlying pathologies included pancreatic, colorectal, renal cell, and head-neck squamous cell carcinoma, as well as lymphoma (4 patients). Three thrombotic lesions on contrast-enhanced CT were PET/ CT negative, due to VTE (2 patients) and leiomyomatosis. Accuracy of PET/CT to differentiate between tumor thrombosis and benign VTE was 100% in this small study.

CONCLUSIONS

Contrast-enhanced CT defines the extent of thrombotic lesions, while the functional information from PET/CT characterizes the lesions. It appears that PET/CT may be helpful in the diagnosis of occult tumor thrombosis and its differentiation from VTE.

Is the incidence of breast cancer among Asian women living in the UK, higher at a younger age than that of the Caucasian women?

Abstract #5011

Introduction: The South Asian population comprises 3% of total UK population. An observational study showed that the Asian women living in the London boroughs of Redbridge and Camden present at a younger age with breast cancer than their Caucasian counterpart. This raises the question as to whether or not an earlier intervention with breast screening would be beneficial for this group.
 Methods: To verify our study, we audited two centres in these London boroughs. The patients with breast cancer from areas with a higher concentration of women of South Asian ethnic origin have been audited from January 2000 to December 2007 (Total 9 years). The borough of Redbridge has an Asian population of 25% from a total of 240,000 residents and Camden has an Asian population of 10.4% from a total of 198,000 residents. Data was collected from the breast units and from patient databases of King George Hospital and Royal Free hospital, London, UK.
 Results: A total of 1314(513+801) patients presented with breast cancer from January 2000 to December 2004 at King George Hospital and from January 2002 to December 2007 at Royal Free Hospital. 147(11.18%) of these patients were of South Asian origin (Indian, Pakistani, Bangladeshi, Sri Lankan) and 1149 (87.44%) were Caucasian. The age at which breast cancer was presented for the Caucasian population ranges from 25 to 99 years with a mean of 65.16 in contrast to the age for the Asian population which ranges from 31 to 78 years with a mean of 54.04.
 Conclusions: The finding of a lower mean age of incidence of breast cancer amongst South Asian women in Redbridge and Camden raises the increased possibility of breast cancer occurring among younger women of the South Asian population in general, compared to Caucasian women living in the United Kingdom. The evidence of a generally younger age of presentation of breast cancer in Asian women living in the UK suggests that more awareness of this condition is needed amongst this group. Therefore, an earlier breast screening programme will possibly increase the chances of early detection of breast cancer among this group of patients.

Citation Information: Cancer Res 2009;69(2 Suppl):Abstract nr 5011.

Combined increased and decreased skeletal uptake of F-18 FDG

Increased uptake of F-18 FDG is the general mainstay of diagnosis, because it indicates hypermetabolic foci of pathology. This case, describing a patient with relapsing lymphoma, represents the diagnostic dilemmas of both locally decreased and diffusely increased uptake in the skeleton.

PET/CT detects abdominal wall and port site metastases of colorectal carcinoma

Abdominal wall metastases from colorectal cancer (CRC) may be resected with curative results. Such lesions, often indicators of additional intra-abdominal lesions, may appear in surgical scars, stomas and port site metastases after laparoscope-assisted surgery (LAS). Post-operative changes, primarily surgical scars, alter local physical findings making early detection of small lesions challenging. The purpose of this study was to retrospectively evaluate the contribution of PET/CT to the diagnosis of recurrent colorectal cancer in the post-operative abdominal wall. 120 patients were referred for PET/CT with suspected recurrent CRC based on clinical, radiological or laboratory findings. All underwent whole body PET/CT imaging. 12 of these 120 (10%), were found to have abdominal wall lesions. A total of 16 abdominal wall lesions were detected, located to surgical scars, stomas, drain and laparoscope ports. Additional findings on PET/CT in this group included liver metastases, intra-abdominal lesions and retroperitoneal lymph node involvement. In general, the patients in this small group were young with high grade tumours presenting in advanced stages. In conclusion, PET/CT appears to be a sensitive tool for the diagnosis of abdominal wall recurrence of CRC. The accuracy of localization afforded by the fused functional and anatomic images makes PET/CT a likely tool for diagnosing abdominal wall lesions, including port site metastases of other aetiologies.

PET/CT in the evaluation of patients with squamous cell cancer of the head and neck

The purpose of this study was to compare the findings of positron emission tomography (PET) with fused PET and computed tomography (CT) in patients with suspected locoregional and distant head and neck cancer and to evaluate the impact of those findings on clinical management. Studies of 25 patients were retrospectively evaluated. PET findings were classified as malignant, benign or equivocal. PET/CT findings were then similarly classified and the PET-only results were amended accordingly. Comparison of findings was done on lesion and patient levels. A total of 45 foci of increased 18F-fluorodeoxyglucose (FDG) uptake were noted in 18 patients. PET/CT imaging defined anatomic localization of 41/45 lesions and clarified 6/10 equivocal PET findings. Additional information was provided by PET/CT regarding 9/45 (20%) of the lesions. PET/CT significantly affected patient management in 3/25 patients (12%) by limiting the extent of disease in one and excluding viable disease in two others. The accuracy of PET/CT was 88%, the sensitivity 100% and the specificity was 77%. The negative predictive value was 100% in this combined group of patients with locoregional and distant head and neck cancer. PET/CT is highly contributory for initial staging and in the evaluation of patients with suspected recurrent SCC of the head and neck, in whom anatomic imaging is inconclusive due to the locoregional distortions rendered by surgery and radiotherapy.