Abstract P2-10-05: PowerPIINC trial: Changes in tumor proliferation index and quality of life with 7 days of preoperative tamoxifen

BACKGROUND: A decrease in Ki67 has been shown to be a predictor of response to tamoxifen. Previous trials have shown a decreased Ki67 proliferation index in breast tumors with as little as 2 weeks of preoperative tamoxifen. However, shortening the preoperative treatment time in window of opportunity studies increases patient acceptance for trial participation. The POWERPIINC trial examined the effect of 7 days of preoperative tamoxifen on breast tumor proliferation and patient symptoms.

METHODS: Adult women with untreated stage I or II invasive breast cancer that was ER positive (>1%) planning on breast surgery with no contraindications to tamoxifen were enrolled. Women received 20mg of tamoxifen for 7 days up to the day of surgery and for 14 days afterwards. Proliferation was assessed by Ki67 immunohistochemistry before and after 7 days of tamoxifen. The proliferation genes from the PAM50 were also assessed by RT-PCR. Symptoms and QOL were assessed by the FACT-ES, MENQoL, and BMQ.

RESULTS: 52 women were enrolled, and 44 were evaluable for Ki67. The median age was 58.5 years, and the median tumor diameter was 1.2cm. Most women (73%) were post-menopausal. Most tumors were PR positive (88%). Only 8% of tumors were HER2-positive. The Ki67 decreased by a geometric mean of 40% (95% CI 29%-63%), and 73% (95% CI 57%-85%) of women had tumors with decreased proliferation after 7 days of tamoxifen (p=0.0001 by paired t-test). No correlation was seen between the change in Ki-67 and change in FACT-ES or MENQoL scores. Women reported minimal to no bother from psychosocial or physical symptoms at baseline or on the day of surgery. Expression level of individual proliferation genes did not change after 7 days of tamoxifen.

CONCLUSION: Seven days of tamoxifen showed a similar relative decrease in the Ki67 proliferation index as that reported for longer courses. Therefore, short window of opportunity trials can be informative.

Citation Format: Cohen AL, Factor RE, Mooney K, Wade M, Serpico V, Salama M, Nelson E, Porretta J, Matsen C, Ostrander E, Bernard P, Boucher K, Neumayer L. PowerPIINC trial: Changes in tumor proliferation index and quality of life with 7 days of preoperative tamoxifen [abstract]. In: Proceedings of the 2016 San Antonio Breast Cancer Symposium; 2016 Dec 6-10; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2017;77(4 Suppl):Abstract nr P2-10-05.

In vivo evaluation of a breast-specific magnetic resonance guided focused ultrasound system in a goat udder model

PURPOSE

This work further evaluates the functionality, efficacy, and safety of a new breast-specific magnetic resonance guided high intensity focused ultrasound (MRgFUS) system in an in vivo goat udder model.

METHODS

Eight female goats underwent an MRgFUS ablation procedure using the breast-specific MRgFUS system. Tissue classification was achieved through the 3D magnetic resonance imaging (MRI) acquisition of several contrasts (T1w, T2w, PDw, 3-point Dixon). The MRgFUS treatment was performed with a grid trajectory executed in one or two planes within the glandular tissue of the goat udder. Temperature was monitored using a 3D proton resonance frequency (PRF) MRI technique. Delayed contrast enhanced-MR images were acquired immediately and 14 days post MRgFUS treatment. A localized tissue excision was performed in one animal and histological analysis was performed. Animals were available for adoption at the conclusion of the study.

RESULTS

The breast-specific MRgFUS system was able to ablate regions ranging in size from 0.4 to 3.6 cm(3) in the goat udder model. Tissue damage was confirmed through the correlation of thermal dose measurements obtained with realtime 3D MR thermometry to delayed contrast enhanced-MR images immediately after the treatment and 14 days postablation. In general, lesions were longer in the ultrasound propagation direction, which is consistent with the dimensions of the ultrasound focal spot. Thermal dose volumes had better agreement with nonenhancing areas of the DCE-MRI images obtained 14 days after the MRgFUS treatment.

CONCLUSIONS

The system was able to successfully ablate lesions up to 3.6 cm(3). The thermal dose volume was found to correlate better with the 14-day postablation nonenhancing delayed contrast enhanced-MR image volumes. While the goat udder is not an ideal model for the human breast, this study has proven the feasibility of using this system on a wide variety of udder shapes and sizes, demonstrating the flexibility that would be required in order to treat human subjects.

Abstract OT3-2-02: PreOperative window of endocrine therapy provides information to increase compliance: POWER PIINC: A feasibility study

Background: The addition of systemic therapy to the surgical treatment of breast cancer has improved survival of patients. A mainstay of systemic therapy in the setting of hormone receptor positive breast cancer is endocrine therapy. Despite the known advantages, the compliance with short and long term systemic endocrine therapy is less than ideal. Several studies report significant rates of non-compliance with endocrine therapy, either in patients never starting the medication or not completing the recommended multi-year course. It is estimated that as many as 10% of patients per year discontinue their therapy. We wondered why women would forgo such an important part of their treatment and how we might intervene to improve compliance. Using information gleaned from POWER PIINC, we hope to design a behavioral intervention study to see if the patient knowing her tumor's preoperative response to endocrine therapy will improve long term compliance. In order to do such a study we would need to define the minimal length of preoperative endocrine therapy needed to detect measurable changes in the tumor.

After 14 days of endocrine therapy, significant decreases in Ki67 can be seen in most hormone sensitive breast cancers. In fact two current studies are using this information (POETIC and ADAPT trials). Both of these trials are being conducted outside of the U.S. where operative therapy does not typically occur within a week or two of seeing the surgeon. POWER PIINC is a feasibility study to determine if we can detect changes in Ki67 with only 7 days of therapy. The results of POWER PIINC will inform the behavioral intervention trial.

Trial Design: This is a prospective, single-arm feasibility study. Participants take tamoxifen for 7 days prior to surgery. Ki67 is measured pre (core biopsy) and post (surgical specimen) tamoxifen.

Eligibility critieria: Non-pregnant women age 18 or older with a hormone positive (>1% ER or PR) clinical Stage 1 or 2 breast cancer who are candidates for surgical therapy of their breast cancer. No concurrent CYP2D6 inhibitors or other contraindications to tamoxifen.

Specific Aims:

Primary Objective:

Demonstrate a significant reduction in Ki67 expression in tumors with 7 days of pre-surgical tamoxifen.

Secondary Objectives:

- Evaluate symptom patterns from baseline through 18 months of follow-up (presence, severity, and bother)

-Evaluate 18-month endocrine therapy adherence

-Evaluate change in attitude regarding endocrine therapy

-Evaluate correlation between changes in Ki67 expression and symptom scores

-Evaluate additional changes in proliferative markers (subset of PAM 50)

Statistical Methods: A one-sample t-test will be applied to the log-ratio of Ki67 at resection to pre therapy. If this ratio is not normally distributed we will use a non-parametric Wilcoxon test. Secondary objectives will be analyzed using a variety of appropriate statistical tests.

Accrual: Target accrual is 52 patients over 18 months. We opened this study in August of 2012. To date (9 months) we have accrued 23 patients.

Citation Information: Cancer Res 2013;73(24 Suppl): Abstract nr OT3-2-02.

Design and characterization of a laterally mounted phased-array transducer breast-specific MRgHIFU device with integrated 11-channel receiver array

PURPOSE

This work presents the design and preliminary evaluation of a new laterally mounted phased-array MRI-guided high-intensity focused ultrasound (MRgHIFU) system with an integrated 11-channel phased-array radio frequency (RF) coil intended for breast cancer treatment. The design goals for the system included the ability to treat the majority of tumor locations, to increase the MR image's signal-to-noise ratio (SNR) throughout the treatment volume and to provide adequate comfort for the patient.

METHODS

In order to treat the majority of the breast volume, the device was designed such that the treated breast is suspended in a 17-cm diameter treatment cylinder. A laterally shooting 1-MHz, 256-element phased-array ultrasound transducer with flexible positioning is mounted outside the treatment cylinder. This configuration achieves a reduced water volume to minimize RF coil loading effects, to position the coils closer to the breast for increased signal sensitivity, and to reduce the MR image noise associated with using water as the coupling fluid. This design uses an 11-channel phased-array RF coil that is placed on the outer surface of the cylinder surrounding the breast. Mechanical positioning of the transducer and electronic steering of the focal spot enable placement of the ultrasound focus at arbitrary locations throughout the suspended breast. The treatment platform allows the patient to lie prone in a face-down position. The system was tested for comfort with 18 normal volunteers and SNR capabilities in one normal volunteer and for heating accuracy and stability in homogeneous phantom and inhomogeneous ex vivo porcine tissue.

RESULTS

There was a 61% increase in mean relative SNR achieved in a homogeneous phantom using the 11-channel RF coil when compared to using only a single-loop coil around the chest wall. The repeatability of the system's energy delivery in a single location was excellent, with less than 3% variability between repeated temperature measurements at the same location. The execution of a continuously sonicated, predefined 48-point, 8-min trajectory path resulted in an ablation volume of 8.17 cm(3), with one standard deviation of 0.35 cm(3) between inhomogeneous ex vivo tissue samples. Comfort testing resulted in negligible side effects for all volunteers.

CONCLUSIONS

The initial results suggest that this new device will potentially be suitable for MRgHIFU treatment in a wide range of breast sizes and tumor locations.

P2-16-03: Outcomes of Nipple-Sparing Mastectomy (NSM) and Immediate Reconstruction

Background

Nipple-sparing mastectomy (NSM) is the surgical removal of breast tissue that preserves the entire skin envelope including the nipple areola skin (NAS). We report our experience performing NSMs and immediate breast reconstruction for both high-risk breast cancer treatment and prophylaxis over a six-year period at The University of Utah and Huntsman Cancer Hospital.

Methods: A retrospective chart review was performed on patients undergoing NSM from April 2005 - April 2011. Data collection included: patient demographics, oncologic details, surgical information (including reconstruction timing and type), and complications (infection, hematoma, seroma, skin necrosis, NAS complication, skin flap loss, premature expander exchange/removal, and capsular contracture).

Results: 130 patients underwent 205 NSMs. Of these, 106 (81.5%) patients received mastectomy treatment for cancer while 24 (18.5%) patients were prophylactically treated. 102 NSMs (49.8%) were on breasts with biopsy-proven cancer, while 103 (50.2%) NSMs were on breasts for prophylaxis. All patients were female with a mean age of 44.7 years (range, 16–82 years). 119 (92.2%) patients were Caucasian, 3 (2.3%) were Asian, and 1 (0.8%) was Hispanic. The mean weight was 65.2 kg (range, 42.8 - 98.8 kg) and BMI (n=106) was 23.7 kg/m2 (SE±0.4). 14 (10.9%) and 12 (9.3%) of the patients were known to have a BRCA1 and BRCA2 mutation, respectively. Two (1.6%) patients had a p53 mutation. 172 (83.5%) of the nipples were spared via an 8 cm incision lateral to the midpoint of the areola, while 5 (2.4%) of the incisions were made along the IMF. The remaining 28 (13.7%) incisions were made by other techniques. 201 (98.0%) breasts were immediately reconstructed with tissue expanders (193 went on to implant reconstruction and 8 underwent autologous tissue reconstruction). 4 (2.0%) breasts received delayed reconstruction. Positive margins were found in 15 (7.3%) of 205 breasts. 60 (58.8%) of 102 cancerous breasts that underwent NSM were Stage 0-I, 35 (34.3%) were Stage II and the remaining 8 (7.8%) were Stage III - IV. Complications by case (Table 1) and by breast (Table 2) are shown below.

Comparison of surgical outcomes between teaching and nonteaching hospitals in the Department of Veterans Affairs

OBJECTIVE

To determine whether the investment in postgraduate education and training places patients at risk for worse outcomes and higher costs than if medical and surgical care was delivered in nonteaching settings.

SUMMARY BACKGROUND DATA

The Veterans Health Administration (VA) plays a major role in the training of medical students, residents, and fellows.

METHODS

The database of the VA National Surgical Quality Improvement Program was analyzed for all major noncardiac operations performed during fiscal years 1997, 1998, and 1999. Teaching status of a hospital was determined on the basis of a background and structure questionnaire that was independently verified by a research fellow. Stepwise logistic regression was used to construct separate models predictive of 30-day mortality and morbidity for each of seven surgical specialties and eight operations. Based on these models, a severity index for each patient was calculated. Hierarchical logistic regression models were then created to examine the relationship between teaching versus nonteaching hospitals and 30-day postoperative mortality and morbidity, after adjusting for patient severity.

RESULTS

Teaching hospitals performed 81% of the total surgical workload and 90% of the major surgery workload. In most specialties in teaching hospitals, the residents were the primary surgeons in more than 90% of the operations. Compared with nonteaching hospitals, the patient populations in teaching hospitals had a higher prevalence of risk factors, underwent more complex operations, and had longer operation times. Risk-adjusted mortality rates were not different between the teaching and nonteaching hospitals in the specialties and operations studied. The unadjusted complication rate was higher in teaching hospitals in six of seven specialties and four of eight operations. Risk adjustment did not eliminate completely these differences, probably reflecting the relatively poor predictive validity of some of the risk adjustment models for morbidity. Length of stay after major operations was not consistently different between teaching and nonteaching hospitals.

CONCLUSION

Compared with nonteaching hospitals, teaching hospitals in the VA perform the majority of complex and high-risk major procedures, with comparable risk-adjusted 30-day mortality rates. Risk-adjusted 30-day morbidity rates in teaching hospitals are higher in some specialties and operations than in nonteaching hospitals. Although this may reflect the weak predictive validity of some of the risk adjustment models for morbidity, it may also represent suboptimal processes and structures of care that are unique to teaching hospitals. Despite good quality of care in teaching hospitals, as evidenced by the 30-day mortality data, efforts should be made to examine further the structures and processes of surgical care prevailing in these hospitals.

Using the Veterans Administration National Surgical Quality Improvement Program to improve patient outcomes

BACKGROUND

The primary goal of collecting quality assurance data is to ultimately improve patient care. The VA National Surgical Quality Improvement Program (NSQIP) provides each station with risk-adjusted morbidity and mortality data on a regular basis. This report of one medical center's use of the risk-adjusted data shows how it can be used to improve patient care.

MATERIALS AND METHODS

Risk-adjusted surgical outcome data for Fiscal Year 1996 (FY96) was received from the NSQIP coordinating center. The Salt Lake City VA medical center was identified as a high outlier for morbidity in general surgery. Patient charts were reviewed and data analyzed to determine practice patterns and to determine if there were any provider issues. Data analysis revealed a large number of wound complications and uncovered a practice pattern of closure of contaminated wounds. Using these data and data from the literature, wound infection and disruption prevention protocols were instituted in the fall of 1997. Wound complications from January to December 1996 (preprotocol) and January to December 1998 (postprotocol) were compared using Student's t test.

RESULTS

The total number of operations in 1998 was 719 compared with 634 in 1996. Superficial wound infections dropped from 3.6 to 1.7%, while overall wound complications dropped from 5.5 to 2.9%. None of these changes were statistically significant.

CONCLUSIONS

Although introduction of wound infection and disruption prevention protocols did not result in a statistically significant decrease in wound complication, it did result in a clinically significant improvement in patient care.

Characteristics of women surgeons in the United States

BACKGROUND

Women surgeons are becoming increasingly prevalent. Despite this, there have been few studies of personal or professional characteristics of US surgeons of either gender.

METHODS

Data were taken from the Women Physicians' Health Study, a nationally representative random sample (n = 4,501 respondents) of US women physicians, and data were analyzed in SUDAAN.

RESULTS

Surgeons were younger, and more likely to be US born, white, unmarried, and childless than were other women physicians; their personal health behaviors were similar to those of others. They worked significantly more clinical hours and call nights, but were not more likely to report feeling that they worked too much, had too much work stress, or had less control of their work environment. Their career satisfaction was similar to that of other women physicians, and satisfaction with their specialty was greater. They were less avid preventionists than were primary care practitioners, and somewhat less avid than other specialists.

CONCLUSIONS

Women surgeons differ in interesting and important ways from other women physicians.

Does volume of patients seen in an outpatient setting impact test scores?

BACKGROUND

Methods of teaching surgery in the outpatient setting and means to measure the effectiveness of these methods have not been defined. This study was designed to evaluate the impact of number of outpatient encounters on test scores for third-year medical students.

METHODS

Students rotating on the required third-year surgery clerkship between July 1994 and June 1996 kept a log of their activities including number of patients seen in clinic, number of cases scrubbed, and pages read. At the end of the rotation the students were given an essay examination and a multiple-choice examination. The data were analyzed looking for correlation between examination scores and volume of patients seen. United States Medical Licensing Examination (USMLE) Step 1 scores were used as a baseline measure to compare the rotation groups.

RESULTS

USMLE scores did not differ between groups. Mean essay examination scores varied significantly between some rotation groups, but did not follow a pattern. There was no correlation between the number of patients seen in clinic and essay examination scores. There was a significant correlation between essay score and USMLE Step 1 score (Pearson's r = 0.398) and between essay and multiple-choice examination scores (Pearson's r = 0.313). There was a significant negative correlation between number of patients seen in clinic and number of cases scrubbed (Pearson's r = -0.347).

CONCLUSIONS

Participation in outpatient surgery clinics did not result in improved performance on written examinations in this surgery clerkship. To achieve the most benefit from the outpatient clinic, objectives of the experience need to be determined and appropriate tools used to measure their successful achievement.

Female surgeons in the 1990s. Academic role models

As part of a larger survey of the membership of the Association of Women Surgeons, data were collected to characterize the participation of women in academic surgery and surgical education. Of the 1500 members, 676 (45%) responded, and 318 of these respondents held a faculty appointment. Two hundred thirty-nine of the respondents' practices were based in a university or university-affiliated hospital. This sample was biased toward more academically motivated, upwardly mobile surgeons. Two hundred thirty-six of the respondents believed policies relating to tenure are unfair to women. Four hundred fifty-three respondents reported having role models at some point in their career, half of whom were men. However, only 204 still had access to role models or mentors at the time of the survey. Six hundred thirty respondents believed that female medical students need successful female surgeons as role models.

Influence of spousal opinions on residency selection

Fourth-year medical students face the difficult task of choosing a residency consistent with their career goals. Our study investigates the input of the spouse on the residency selection. From July 1, 1988, to July 1, 1990, questionnaires were sent to all 69 spouses of fourth-year medical students at the University of Arizona Medical Center. Fifty-six were returned for a response rate of 81%. Of the 16 women and 40 men who responded (mean age: 27 years), 55 (98%) spouse stated that there had been family discussions on the choice of a residency program, and 41 (73%) respondents thought that they had significant input. When asked to rank the items that most influenced their support for a particular training program, career goals of the medical student (68%) and lifestyle (21%) were most important, whereas prestige, earning capacity, and program length were ranked lowest. Specific concerns expressed by spouses on the selection of a surgical residency included time commitment as the most commonly cited (79%), followed by fatigue (48%). A statistically significant correlation existed between those spouses actively discouraging the choice of general surgery and those objecting to the time commitment during residency (p less than 0.05). We conclude that spouses have significant preferences regarding the choice of a training program following medical school. Career goals and lifestyle appear to be the most important factors; however, despite concern about the time commitment, the majority of spouses are supportive of the selection of a surgical residency.

Immunophenotyping in the management of gastric lymphoma

Primary gastric lymphoma is a rare tumor in which surgical resection plays a major role in improving the response rate and reducing the incidence of bleeding and perforation after chemotherapy. In 17 consecutive patients, the diagnosis of gastric lymphoma was made by immunophenotyping snap-frozen endoscopic biopsy specimens. All neoplasms were B-cell lymphomas. Pan B surface marker antigens were present in all patients. Levels of Ki-67, a nuclear marker of tumor proliferation, were greater than 45% in two of the four patients who died after progression of their lymphoma. All patients alive had Ki-67 levels of less than 30%. A lower proliferation index, as measured by Ki-67, appears to be associated with better prognosis. Ten of 11 patients treated by resection prior to chemotherapy had no complications. Immunophenotyping is the key in the differential diagnosis when considering malignant lymphoma with gastric carcinoma and benign conditions such as pseudolymphoma.

Clinical restoration of voice function after loss of the vagus nerve

One hundred eleven patients with unilateral vocal cord paralysis underwent Teflon injection for the rehabilitation of laryngeal function. The most common etiology was vocal cord paralysis after surgical treatment of thoracic abdominal aortic aneurysms, which accounted for 36.9% of patients. Of the 111 patients, 85% had improved voice function after Teflon injection. Two patients developed airway obstruction secondary to edema and required temporary tracheostomy. Twenty-four patients with paralysis after aneurysm surgery were injected acutely with no morbidity and immediate restoration of voice function. We now advocate Teflon injection in patients with vocal cord paralysis after thoracic aneurysm surgery in the immediate convalescent period to restore voice function and lessen pulmonary complications.