Effect of postoperative radiotherapy on autologous deep inferior epigastric perforator flap volume after immediate breast reconstruction

Background

The effect of postoperative radiotherapy following autologous flap breast reconstruction is controversial. The aim of this study was to measure whether adjuvant radiotherapy following immediate deep inferior epigastric perforator (DIEP) free flap breast reconstruction affected flap volume.

Methods

Sixty-eight women underwent immediate autologous DIEP flap reconstruction following mastectomy for breast cancer. Twenty-two of the 68 received postoperative radiotherapy (45Gy in 20 fractions over 4 weeks). Intraoperative flap volume data were collected prospectively. Volumetric assessment was carried out a minimum of 1 year after surgery. Patients who had volume adjustment surgery after initial reconstruction were analysed separately.

Results

The mean age of the women was 52 (range 37–69) years and median follow-up was 3·5 (range 1–10) years. There was no statistically significant difference in volume change between patients who had and those who did not have postreconstruction radiotherapy for the whole cohort (median reduction 65 versus 0 ml) or when women who had undergone further volume adjustment surgery were excluded.

Conclusion

In this study postoperative radiotherapy did not significantly affect breast volume after DIEP flap reconstruction. The potential need for postoperative radiotherapy should not deter women from undergoing immediate DIEP flap breast reconstruction.

αB-crystallin, vimentin and increased p53 expression levels in breast cancer is associated with poor prognosis

Abstract #5070

Background: Previous studies have identified αB-crystallin as a marker of poor prognosis for breast cancer and have suggested that it is an excellent marker for tumours of basal origin. Increased expression of αB-crystallin has been associated with anchorage-independent growth and metastasis leading to the suggestion that αB-crystallin is an oncoprotein. We have considered whether the αB-crystallin binding proteins, vimentin and HSP27 also show a similar association with poor prognosis. We also investigated whether either HSP27 phosphorylation HSP27 or p53 expression could be associated with αB-crystallin expression.
 Methods: Tissue Micro Arrays of 0.6x0.6mm cores of 205 breast cancers were stained with antibodies to αB-crystallin, vimentin, p53 (antibodies DO1, FP3), HSP27 (antibody ERD5) and HSP27 82P. The levels of protein expressions were then compared with clinical and pathological parameters.
 Results: The expression of αB-crystallin was positively associated with vimentin (P<0.001 Fisher's exact test (FET)). We have confirmed that αB-crystallin expression is linked to a low expression of the estrogen receptor and reduced survival (P<0.001 (FET), P=0.002 Kaplan Meier Log Rank (KM) respectively). Vimentin expression was similarly associated with estrogen receptor (ER) negative cancers and poor survival (P <0.001 (FET), P= 0.002 (KM Log Rank) respectively). Low expression of HSP27 resulted in poor three-year survival (P=0.007 (KM Log Rank)), but longer-term survival was unaffected (P=0.09 (KM Log Rank)). In contrast to αB-crystallin, low expression of HSP27 was associated with ER and progesterone receptor (PGR) negativity (P<0.001 (FET), P=0.001 (FET)). HSP27 82P similarly resulted in poor three-year survival (P=0.01 (KM Log Rank)) compared with longer-term survival (P=0.05 (KM Log Rank)). In samples positive for either αB-crystallin or vimentin, a strong association with increased p53 expression (p53 antibodies: DO1(P<0.001 (FET)) and FP3(P<0.001 (FET))) was found.
 Conclusions: The increased expression of the protein chaperone, αB-crystallin was linked with reduced survival as well as it's binding partner, vimentin. We found that within this patient subgroup, there was an increased level of p53. The potential functional significance of this interaction for metastasis will be discussed in the context of other predictive markers for breast cancer. A similar association was not found for HSP27 expression.

Citation Information: Cancer Res 2009;69(2 Suppl):Abstract nr 5070.

Cohort study examining tamoxifen adherence and its relationship to mortality in women with breast cancer

Increasing duration of tamoxifen therapy improves survival in women with breast cancer but the impact of adherence to tamoxifen on mortality is unclear. This study investigated whether women prescribed tamoxifen after surgery for breast cancer adhered to their prescription and whether adherence influenced survival. A retrospective cohort study of all women with incident breast cancer in the Tayside region of Scotland between 1993 and 2002 was linked to encashed prescription records to calculate adherence to tamoxifen. Survival analysis was used to determine the effect of adherence on all-cause mortality. In all 2080 patients formed the study cohort with 1633 (79%) prescribed tamoxifen. The median duration of use was 2.42 years (IQR=1.04–4.89 years). Longer duration was associated with better survival but this varied over time. The hazard ratio for mortality in relation to duration at 2.4 years was 0.85, 95% CI=0.83–0.87. Median adherence to tamoxifen was 93% (interquartile range=84–100%). Adherence <80% was associated with poorer survival, hazard ratio 1.10, 95% CI=1.001–1.21. Persistence with tamoxifen was modest with only 49% continuing therapy for 5 years of those followed up for 5 years or more. Increased duration of tamoxifen reduces the risk of death, although one in two women do not complete the recommended 5-year course of treatment. A significant proportion of women have low adherence to tamoxifen and are at increased risk of death.

Meta-analysis of sentinel node biopsy in ductal carcinoma in situ of the breast

BACKGROUND

The need for sentinel lymph node (SLN) biopsy in patients with a preoperative diagnosis of ductal carcinoma in situ (DCIS) is debated. Advocates recommend such biopsy based on a high incidence of SLN involvement in some series. Opponents discourage SLN biopsy based on a perceived low incidence of nodal involvement in this setting. These contradictory arguments are generally based on small studies. The present study is a meta-analysis of the reported data on the incidence of SLN metastasis in patients with DCIS.

METHODS

A search of electronic databases identified studies reporting the frequency of SLN metastases in DCIS. The random-effects method was used to combine data.

RESULTS

Twenty-two published series were included in the meta-analysis. The estimate for the incidence of SLN metastases in patients with a preoperative diagnosis of DCIS was 7.4 (95 per cent confidence interval (c.i.) 6.2 to 8.9) per cent compared with 3.7 (95 per cent c.i. 2.8 to 4.8) per cent in patients with a definitive (postoperative) diagnosis of DCIS alone. This was a significant difference with an odds ratio of 2.11 (95 per cent c.i. 1.15 to 2.93).

CONCLUSION

Patients with a preoperative diagnosis of DCIS should be considered for SLN biopsy.

Streptococcus gordonii's sequenced strain CH1 glucosyltransferase determines persistent but not initial colonization of teeth of rats

OBJECTIVE

Extracellular glucan synthesis from sucrose by Streptococcus gordonii, a major dental plaque biofilm bacterium, is assumed important for colonization of teeth; but this hypothesis is un-tested in vivo.

METHODS

To do so, we studied an isogenic glucosyltransferase (Gtf)-negative mutant (strain AMS12, gtfG(-)) of S. gordonii sequenced wild type (WT, strain Challis CH1, gtfG(+)), comparing their in vitro abilities to grow in the presence of glucose and sucrose and, in vivo, to colonize and persist on teeth and induce caries in rats. Weanling rats of two breeding colonies, TAN:SPFOM(OM)BR and TAN:SPFOM(OMASF)BR, eating high sucrose diet, were inoculated with either the WT (gtfG(+)), its isogenic gtfG(-) mutant, or reference strains of Streptococcus mutans. Control animals were not inoculated.

RESULTS

In vitro, the gtfG(-) strain grew at least as rapidly in the presence of sucrose as its WT gtfG(+) progenitor, but formed soft colonies on sucrose agar, consistent with its lack of insoluble glucan synthesis. It also had a higher growth yield due apparently to its inability to channel carbon flow into extracellular glucan. In vivo, the gtfG(-) mutant initially colonized as did the WT but, unlike the WT, failed to persist on the teeth as shown over time. By comparison to three S. mutans strains, S. gordonii WT, despite its comparable ecological success on the teeth, was associated with only modest caries induction. Failure of the gtfG(-) mutant to persistently colonize was associated with slight diminution of caries scores by comparison with its gtfG(+) WT.

CONCLUSIONS

Initial S. gordonii colonization does not depend on Gtf-G synthesis; rather, Gtf-G production determines S. gordonii's ability to persist on the teeth of sucrose-fed rats. S. gordonii appears weakly cariogenic by comparison with S. mutans reference strains.

Hospital volume does not influence long-term survival of patients undergoing surgery for oesophageal or gastric cancer

BACKGROUND

Guidelines suggest that surgery for oesophageal and gastric cancer should be conducted in large cancer centres. This national study examined the relationship between hospital volume and outcome in Scotland.

METHODS

This was a prospective, population-based study of 3293 consecutive patients with oesophageal or gastric cancer diagnosed between 1997 and 1999. Some 1302 patients underwent surgery and were followed for 5 years after operation.

RESULTS

The 5-year adjusted overall survival rate for the 3293 patients was 18.7 (95 per cent confidence interval (c.i.) 17.2 to 20.2) per cent and that after surgical resection was 39.6 (95 per cent c.i. 36.3 to 43.0) per cent. Death within 1 year after surgical resection was associated with a postoperative complication (odds ratio (OR) 2.5 (95 per cent c.i. 1.6 to 3.8); P < 0.001) or resection margin involvement by tumour (OR 7.2 (95 per cent c.i. 1.1 to 47.5); P = 0.042) after adjustment for age, sex and tumour location. There was no relationship between hospital volume and postoperative morbidity or mortality, nor between survival and volume of patients either for hospital of diagnosis or hospital of surgery.

CONCLUSION

This population-based study of oesophageal and gastric cancer suggests that the link between hospital volume and long-term survival for patients undergoing surgery requires re-evaluation.

The role of ambulatory blood pressure monitoring in chronic and end-stage renal disease

In the past 30 years or so, the introduction of 24-h ambulatory blood pressure monitoring (ABPM) has enabled a more comprehensive estimate of a patient's true blood pressure (BP) and its changes. Although this tool has been used in the general population for the diagnosis of white coat hypertension, its role in the clinical management of patients with chronic and end-stage kidney disease is less well defined. In patients with kidney disease, routine clinic and dialysis center BP measurements may be poor indicators of BP control. Loss of the normal nocturnal decline in BP is also common. Moreover, there is increasing evidence that this loss, which ABPM alone can detect, is associated with poor renal and cardiovascular outcomes. To slow the progression of renal disease and lessen cardiovascular morbidity and mortality in patients with kidney disease, tight BP control is needed. However, the traditional methods of measuring BP intermittently in the medical setting may fail to provide an accurate picture of BP load. Ambulatory or some form of home BP monitoring should be more widely adopted in patients with chronic and end-stage renal disease.

Age threshold for endoscopy and risk of missing upper gastrointestinal malignancy--data from the Scottish audit of gastric and oesophageal cancer

BACKGROUND

Urgent endoscopy is indicated for suspected upper gastrointestinal malignancy. However, there is limited evidence on the age threshold for performing urgent endoscopy in uncomplicated dyspepsia (that is, without alarm features).

AIM

To quantify the risk of missing upper gastrointestinal malignancy within Scotland, if the age threshold for urgent endoscopy in uncomplicated dyspepsia was increased from 45 to 55 years.

METHODS

Analysis of data collected prospectively by the Scottish Audit of Gastric and Oesophageal Cancer. 'Alarm' features at presentation were defined as dysphagia, weight loss, gastrointestinal bleeding, anaemia, vomiting, history of gastric surgery and history of peptic ulcer disease.

RESULTS

Of the 3293 patients diagnosed with upper gastrointestinal malignancy, 290 (8.8%) patients were <55 years of age. Twenty-one of the patients aged <55 years had no alarm features (0.64% of all patients); 12 were aged 45-55 years and nine were aged <45 years. Only two patients (one aged <45 years) underwent potentially curative surgery.

CONCLUSION

Upper gastrointestinal malignancy is uncommon under 55 years of age and most of the patients present with alarm features. Raising the age threshold for endoscopy for new-onset uncomplicated dyspepsia from 45 to 55 years would not impact adversely on the diagnosis or outcome of upper gastrointestinal malignancy.