'PartBreCon' study. A UK multicentre retrospective cohort study to assess outcomes following PARTial BREast reCONstruction with chest wall perforator flaps

BACKGROUND

Partial breast reconstruction with a pedicled chest wall perforator flap (CWPF) enables breast conservation in a higher tumour: breast volume ratio scenario. Since there is limited evidence, this retrospective cohort study aimed to ascertain immediate (30-days) and medium-term (follow-up duration) surgical outcomes.

METHODS

STROBE-compliant protocol ascertained CWPF outcomes between March 2011-March 2021. UK centres known to perform CWPF were invited to participate if they performed at least 10 cases. Data were retrospectively collected, including patient demographics, tumour and treatment characteristics, and surgical and oncological outcomes. Statistical analysis (R™) included multivariable logistic regression and sensitivity analysis.

RESULTS

Across 15 centres, 507 patients with median age (54 years, IQR; 48-62), body mass index (25.4 kg/m2, IQR; 22.5-29), tumour size (26 mm, IQR; 18-35), and specimen weight (62 g, IQR; 40-92) had following flap types: LiCAP (54.1%, n = 273), MiCAP/AiCAP (19.6%, n = 99), LiCAP + LTAP (19.8%, n = 100) and TDAP (2.2%, n = 11). 30-days complication rates were in 12%: haematoma (4.3%, n = 22), wound infection (4.3%, n = 22), delayed wound healing (2.8%, n = 14) and flap loss (0.6%, n = 3; 1 full) leading to readmissions (2.6%, n = 13) and re-operations (2.6%, n = 13). Positive margins (n = 88, 17.7%) led to 15.9% (n = 79) re-excisions, including 7.5% (n = 37) at the planned 2nd of 2-stage surgery and 1.8% (n = 9) mastectomy. At median 23 months (IQR; 11-39) follow-up, there were 1.2% (n = 6) symmetrisations; recurrences: local (1%), regional/nodal (0.6%) and distant (3.2%).

CONCLUSIONS

This large multicentre cohort study demonstrates acceptable complication and margin re-excision rates. CWPF extends the range of breast conservation techniques. Further studies are required for long-term oncological outcomes.

Routine four-quadrant cavity shaving at the time of wide local excision for breast cancer reduces re-excision rate

INTRODUCTION

Breast conservation therapy (BCT) has been shown to have comparable long-term survival outcomes when compared with mastectomy. Clearance of excision margin is one of the mainstays of the surgical treatment, which if not achieved at the first operation of BCT results in the need for subsequent surgery.

METHODS

This study evaluated the impact of routinely taken cavity shavings on re-excision rates. This retrospective two-centre study describes the use of routine four-quadrant cavity shaving in 449 patients with consecutively treated with wide local excision for invasive cancer or ductal carcinoma in situ.

RESULTS

The overall incomplete excision rate was 10.6%. Routine cavity shaving prevented the need for re-excision in 84 patients (18.7%) and identified the need for further re-excision in 33 patients (7.3%). Median time from surgery to radiotherapy was 50 days (range 13-209) for non-re-excised patients versus 78 days (range 47-260) for re-excised patients (p<0.001). Median time to chemotherapy (n=75) was 44 days (range 14-106) for non-re-excised patients versus 56 days (range 35-116) for re-excised patients (p=0.017).

CONCLUSIONS

This study demonstrates that routine cavity shaving decreases re-excision rate in patients treated with wide local excision and prevents delays to adjuvant treatment due to incomplete excision.

A systematic review of oncoplastic volume replacement breast surgery: oncological safety and cosmetic outcome

INTRODUCTION

Oncoplastic breast conserving surgery allows higher volume excision to achieve oncological safety with minimal aesthetic compromise. The primary outcome of this study was to assess the oncological safety in the setting of volume replacement oncoplastic breast conserving surgery. The secondary objective was to assess cosmetic outcome.

METHODS

A systematic literature review was conducted using the Preferred Reporting Items for Systematic Reviews and Meta-analyses guidelines to explore the oncological safety of oncoplastic breast conserving surgery, with particular focus on volume replacement. Resection margin rates, re-excision rates, conversion to mastectomy rates, local and distant disease recurrence, volume replacement techniques, cosmetic outcomes and patient-reported outcome measures were assessed.

FINDINGS

The search criteria identified 155 articles, of which 40 met the inclusion criteria. These studies included 2,497 patients with a mean age of 47.8 years (range 38.4-59.6 years), a body mass index of 24.3kg/m² (22.1-28.0kg/m²), with a mean follow-up of 37.1 months (6-125 months). A variety of volume replacement techniques were used, most commonly latissimus dorsi and chest wall perforator flaps. Whole mean pathological tumour size was 29.7mm (17-65mm) and mean specimen weight was 123.6g (46.5-220g). Mean re-excision rate was 7.2% and completion mastectomy rate was 2.3%. Locoregional and distant recurrence rate was 2.5% (0-8.1%) and 3.1% (0-14.6%), respectively. There were a variety of patient-reported outcome measures employed, with overall good to excellent outcomes.

CONCLUSIONS

This review demonstrates that volume replacement oncoplastic breast conserving surgery is a safe option in terms of re-excision, completion mastectomy rates, and local and distant recurrence. Available patient-related outcome measures and cosmetic assessment tend towards better outcomes compared with wide local excision and mastectomy. However, data are significantly limited, with a paucity of high-level evidence, and it is therefore necessary to be cautious regarding the strength and interpretation of data in this review. Further prospective studies are required on this subject.

Innovations for the future of breast surgery

BACKGROUND

Future innovations in science and technology with an impact on multimodal breast cancer management from a surgical perspective are discussed in this narrative review. The work was undertaken in response to the Commission on the Future of Surgery project initiated by the Royal College of Surgeons of England.

METHODS

Expert opinion was sought around themes of surgical de-escalation, reduction in treatment morbidities, and improving the accuracy of breast-conserving surgery in terms of margin status. There was emphasis on how the primacy of surgical excision in an era of oncoplastic and reconstructive surgery is increasingly being challenged, with more effective systemic therapies that target residual disease burden, and permit response-adapted approaches to both breast and axillary surgery.

RESULTS

Technologies for intraoperative margin assessment can potentially half re-excision rates after breast-conserving surgery, and sentinel lymph node biopsy will become a therapeutic procedure for many patients with node-positive disease treated either with surgery or chemotherapy as the primary modality. Genomic profiling of tumours can aid in the selection of patients for neoadjuvant and adjuvant therapies as well as prevention strategies. Molecular subtypes are predictive of response to induction therapies and reductive approaches to surgery in the breast or axilla.

CONCLUSION

Treatments are increasingly being tailored and based on improved understanding of tumour biology and relevant biomarkers to determine absolute benefit and permit delivery of cost-effective healthcare. Patient involvement is crucial for breast cancer studies to ensure relevance and outcome measures that are objective, meaningful, and patient-centred.

Systematic review of partial breast reconstruction with pedicled perforator artery flaps: Clinical, oncological and cosmetic outcomes

The use of chest wall perforator flaps (CWPFs) following breast conservation surgery for breast cancer has become a useful tool in the armamentarium of the oncoplastic breast surgeon, however robust evidence for the technique is lacking. The aim of this study was to conduct a systematic review appraising the current evidence for the use of CWPFs, evaluating clinical, oncological and cosmetic outcomes. A PRISMA-compliant systematic review, with PROSPERO published protocol a priori and search of all relevant database and trial registries between 1990 to July 2020. Eleven studies amounting to 432 cases were reviewed and considered to be at high risk of bias due to small sample size, selective outcome reporting and selection bias. Heterogeneity due to lack of consensus of outcome measures prevented meaningful analysis. Fifty-two (12.3%) clinical complications were recorded: seroma (n = 9; 2.1%), fat necrosis (n = 9; 2.4%), haematoma (n = 8; 1.9%), infection (n = 9; 2.1%), and flap necrosis (n = 9; 2.1%). Thirty-four (10.8%) patients had an involved positive margin, 29 patients underwent re-excision (9.3%) and four underwent completion mastectomy (1.3%). One local recurrence and six distant recurrences were observed during a mean follow up of 21 months (1-49). A pooled patient cosmetic satisfaction descriptor of good or excellent was described in 93% of cases. CWPFs are a safe method of partial breast reconstruction following BCS. They are associated with a low complication rate, acceptable short-term oncological outcomes and satisfactory cosmetic outcome. There is a relative paucity in quality of data in this field and larger prospective studies are needed to investigate outcomes further.

The effect of postoperative complications on survival and recurrence after surgery for breast cancer: A systematic review and meta-analysis

BACKGROUND

This systematic review investigated the impact of complications on long term outcomes for patients with primary invasive operable breast cancer.

METHODS

A systematic review was performed using appropriate keywords, and meta-analysis using a random effects model completed.

RESULTS

Ten retrospective cohort studies, including 37,657 patients were included. Five studies identified a relationship between wound complications, infection and pyrexia and recurrence or recurrence-free survival. Risk of recurrence, 1-year and 5-year recurrence-free survival and overall survival were related to complications, particularly for patients with poor Nottingham Prognostic Index. Five studies failed to demonstrate a relationship between complications and prognosis. Complication was found to significantly affect 5-year recurrence-free survival (HR 1.48 95 % CI 1.02-2.14, p = 0.04) but not recurrence (HR 2.39, 95 %CI 0.94-6.07, p = 0.07), with a high degree of heterogeneity amongst analysed studies (I2 = 95 %).

DISCUSSION

Further research is needed to quantify the effects of postoperative complication on prognosis following surgery for breast cancer.

Multifocal and multicentric breast cancer, is it time to think again?

Multifocal multicentric breast cancer has traditionally been considered a contraindication to breast conserving surgery because of concerns regarding locoregional control and risk of disease recurrence. However, the evidence supporting this practice is limited. Increasingly, many breast surgeons are advocating breast conservation in selected cases. This short narrative review summarises current evidence on the role of surgery in multifocal multicentric breast cancer and shows that when technically feasible the option of breast conservation is oncologically safe.

The presentation, management and outcome of inflammatory breast cancer cases in the UK: Data from a multi-centre retrospective review

OBJECTIVES

Inflammatory Breast cancer (IBC) is a rare but aggressive form of breast cancer. Its incidence and behaviour in the UK is poorly characterised. We collected retrospective data from hospitals in the UK and Ireland to describe the presentation, pathology, treatment and clinical course of IBC in the UK.

MATERIALS AND METHODS

Patients with IBC diagnosed between 1997-2014 at fourteen UK and Irish hospitals were identified from local breast unit databases. Patient characteristics, tumour pathology and stage, and details of surgical, systemic and radiotherapy treatment and follow-up data were collected from electronic patient records and medical notes.

RESULT

This retrospective review identified 445 patients with IBC accounting for 0.4-1.8% of invasive breast cancer cases. Median follow-up was 4.2 years. 53.2% of tumours were grade 3, 56.2% were oestrogen receptor positive, 31.3% were HER2 positive and 25.1% were triple negative. 20.7% of patients had distant metastases at presentation. Despite trimodality treatment in 86.4%, 40.1% of stage III patients developed distant metastases. Five-year overall survival (OS) was 61.0% for stage III and 21.4% for stage IV patients.

CONCLUSIONS

This is the largest series of UK IBC patients reported to date. It indicates a lower incidence than in American series, but confirms that IBC has a high risk of recurrence with poor survival despite contemporary multi-modality therapy. A national strategy is required to facilitate translational research into this aggressive disease.

Population-based study of the sensitivity of axillary ultrasound imaging in the preoperative staging of node-positive invasive lobular carcinoma of the breast

BACKGROUND

Preoperative staging of the axilla is important to allow decisions regarding neoadjuvant treatment and the management of the axilla. Invasive lobular carcinoma metastases are difficult to detect because of the infiltrative pattern of the nodal spread. In this study the sensitivity of preoperative axillary staging between invasive lobular (ILC) and ductal (IDC) carcinoma was compared.

METHODS

All women diagnosed with pure ILC or IDC in the West of Scotland in 2012-2014 were identified from a database maintained prospectively within the Managed Clinical Network. Pretreatment axillary ultrasound imaging (AUS), core biopsy and fine-needle aspiration cytology (FNAC) results were compared between ILC and IDC.

RESULTS

Some 602 women with ILC and 4199 with IDC had undergone axillary surgery, of whom 209 and 1402 respectively had nodal metastases. Pretreatment AUS sensitivity was significantly lower in ILC than in IDC (32·1 versus 50·1 per cent respectively, P < 0·001; OR 0·47, 95 per cent c.i. 0·34 to 0·64). Core biopsy had equally high sensitivity of 86 per cent in both subtypes; however, FNAC was significantly less sensitive in both ILC (55 per cent; P = 0·003) and IDC (75·6 per cent; P = 0·006). Multivariable analysis revealed that cT3-4 status and symptomatic presentation were both significant in predicting nodal metastasis in patients with ILC and false-negative AUS findings (OR 3·77, 95 per cent c.i. 1·69 to 8·42, P = 0·001; and OR 1·92, 1·24 to 2·98, P = 0·003, respectively).

CONCLUSION

AUS is inferior in detecting axillary node metastasis in ILC compared with IDC. Women with cT3-4 lobular carcinoma may benefit from ultrasound-guided axillary biopsy regardless of the ultrasonographic appearance of the nodes.

Abstract P4-13-09: Immediate breast reconstruction versus delayed breast reconstruction: An analysis of oncological outcomes

Introduction

Breast reconstruction is an important option for patients who undergo mastectomy for breast cancer. Several studies have investigated outcomes for patients who undergo either immediate or delayed reconstruction versus mastectomy alone but few have evaluated the relationship of the timing of reconstruction to oncological outcome.

Aim

To determine if there is a difference in oncological outcomes for patients who undergo delayed versus immediate breast reconstruction following mastectomy for breast cancer.

Methods

Patients who underwent immediate or delayed breast reconstruction between 2005 and 2006 were identified from a database maintained prospectively at the regional plastic surgery unit. Tumour pathology details were obtained retrospectively from the electronic patient record and from local electronic laboratory systems. Details of treatment, and recurrence and mortality data were obtained by review of each patient's electronic record. In the delayed reconstruction cohort, patients who underwent reconstruction 6-60 months after initial cancer surgery were included. In the immediate reconstruction group, patients who had recurrence or died within the first 6 months after surgery were excluded. Logistic regression survival analysis was carried out for the two cohorts and compared using Chi square test.

Results

193 patients who underwent immediate reconstruction and 116 patients who underwent delayed reconstruction were identified. Patients who had immediate reconstruction were more likely to have DCIS only, compared to those who had delayed reconstruction, but otherwise there was no significant difference between the two groups in terms of pathological characteristics or type of reconstruction performed (autologous or implant-based). Of those who had delayed reconstruction, median time from initial cancer surgery to reconstructive surgery was 27 months (6-58 months). There were 49 breast cancer deaths, 13 deaths from other causes and 65 recurrences. Median follow up time from reconstruction, of those who survived, was 111 months (29-134 months). Median follow up from initial cancer surgery was 116 months (46-185 months). There was no difference in breast cancer specific survival between the two groups when measured from time of cancer surgery (delayed reconstruction HR 1.05, 95% CI 0.59-1.89, p=0.861) or from time of reconstruction (delayed reconstruction HR 1.33, 95% CI 0.75-2.40, p=0.334). There was no difference in recurrence rates between the two groups when measured from time of cancer surgery (delayed reconstruction HR 0.94, 95% CI 0.56-1.60, p=0.822) or from time of reconstruction (delayed reconstruction HR 1.23, 95% CI 0.73-2.07, p=0.433).

Conclusion

Our data has demonstrated no difference in cancer specific survival or recurrence rates in patients who underwent mastectomy with immediate breast reconstruction compared to patients who had delayed reconstruction.

Citation Format: Morrow ES, Dolan RD, Blackhall V, Romics L. Immediate breast reconstruction versus delayed breast reconstruction: An analysis of oncological outcomes [abstract]. In: Proceedings of the 2017 San Antonio Breast Cancer Symposium; 2017 Dec 5-9; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2018;78(4 Suppl):Abstract nr P4-13-09.

Abstract P4-13-01: Oncoplastic breast conservations – The Scottish Audit: Surgical techniques, oncological outcomes, complication rates and variations in practice across the country based on the analysis of 589 patients

Introduction: current evidence for oncoplastic breast conservation (OBC) is based on single institutional series. We studied the outcomes of OBC practice in Scotland and compare individual breast units.

Methods: a predefined database of patients treated with OBC was completed retrospectively in 11 breast units in Scotland. Patients were treated with OBC from 2005 onwards were included. For statistical calculations Chi-test, ANOVA and Pearson correlation analysis were used.

Results: Altogether 589 patients were included. Median age was 56 years [21-86]. Patients were diagnosed between September 2005 and March 2017. Number of patients treated with OBC per unit ranged between 4 and 145. High volume units were doing a mean of 19.3 OBCs per year [17.3 – 26.5] vs. low volume units doing 11.1 OBCs per year [7 .7– 14.4] (p=0.012).

23 different oncoplastic surgical techniques were applied. Range of oncoplastic techniques used was associated with case-loads: high volume units used a wider range (8 – 14 different techniques) compared to low volume units (3 – 6) (p=0.004). Volume displacement was done in 515 patients (91.3%), volume replacement in 49 patients (8.7%). OBC was carried out as a joint operation between a breast and a plastic surgeon in 66.3% (389 patients). Immediate contralateral symmetrisation rate was significantly higher when the procedure was carried out as a joint operation (70.7% vs. not joint operations: 29.8%; p&lt;0.001).

Incomplete excision rate was 10.4% (60 of 578). Incomplete excision was significantly higher after invasive lobular carcinoma (18.9%; 10 of 43; p=0.0292). After neoadjuvant chemotherapy incomplete excision rate was significantly lower (3%; 2 of 66 vs. no neoadjuvant chemotherapy: 11%; 35 of 319; p=0.031).

Neodjuvant systemic treatment rate was 28.6% (142 of 496 patients). Of those 68 patients received neoadjuvant chemotherapy (13.7%) and 74 patients had neoadjuvant hormonal treatment (14.9%). Neoadjuvant systemic treatment rate varied amongst the units from 9.7% to 57.2% for patients with invasive carcinoma.

259 patients diagnosed with (non)invasive carcinoma had a median follow-up time of 5 years [35-124]. Of these 7 patients (2.7%) developed isolated local recurrence. 5-year local recurrence rate after DCIS was higher than after pure invasive ductal carcinoma (DCIS: 8.3%; 3 of 36 vs. ductal: 1.6%; 3 of 181; p=0.02567). 5-year disease-free survival of these patients was 91.7%, overall survival was 93.8%, and cancer-specific survival was 96.1%.

145 of 510 patients developed complications, which is 28.4% overall complication rate. 71 patients had major complications (13.9%) and 74 patients had minor complications (14.5%). Overall complication rate was significantly lower after neoadjuvant chemotherapy (15.9%; 11 of 69) compared to patients who did not receive neoadjuvant chemotherapy (27.9%; 127 of 455 patients) (p=0.035).

Conclusion: this national audit demonstrated similar outcomes overall compared to relevant published data. Units should be urged to build stronger collaboration in order to reduce variability in OBC practices.

None of the authors have conflict of interest to declare.

Citation Format: Romics L, Macaskill J, Fernandez T, Morrow E, Simpson L, Pitsinis V, Barber M, Tovey S, Masannat Y, Young O, Mansell J, Stallard S, Doughty J, Dixon M. Oncoplastic breast conservations – The Scottish Audit: Surgical techniques, oncological outcomes, complication rates and variations in practice across the country based on the analysis of 589 patients [abstract]. In: Proceedings of the 2017 San Antonio Breast Cancer Symposium; 2017 Dec 5-9; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2018;78(4 Suppl):Abstract nr P4-13-01.

Oncoplastic breast conservation surgery is oncologically safe when compared to wide local excision and mastectomy

BACKGROUND

Support for the oncological safety of oncoplastic breast conservation surgery (OBCS) is mostly based on evidence comparing recurrence rates after OBCS to wide local excision (WLE). However, OBCS is often indicated for larger cancers and oncological results should also be compared to patients treated with mastectomy. In this study we compared recurrence and survival following OBCS, mastectomy and WLE.

METHODS

Patients treated with OBCS between 2009 and 2012 were identified from a prospectively maintained database. For comparison, consecutive patients treated with WLE or mastectomy with or without immediate reconstruction (Ms ± IR) over the same time period were identified. Histological variables of patients were compared using Fisher Exact or Chi squared tests, and recurrence and survival were compared using Kaplan-Meier and Cox regression survival analysis.

RESULTS

980 patients' data were analysed (OBCS: n = 104; WLE: n = 558; Ms ± IR: n = 318). Tumour size, grade, nodal status, ER, and PR expression of patients treated with OBCS were all significantly more adverse compared with patients treated with WLE (p < 0.001). These histological variables were similar in patients treated with Ms ± IR and OBCS. 5-year local recurrence rates were similar in all three groups (WLE: 3.4 per cent, OBCS: 2 per cent, Ms ± IR: 2.6 per cent; log rank = 0.973), while distant recurrence rates were higher after Ms ± IR and OBCS (Ms ± IR:13.1 per cent, OBCS:7.5 per cent, WLE:3.3 per cent; log rank: p < 0.001).

CONCLUSION

OBCS is oncologically safe in patients even when histological results are similar to patients treated with Ms ± IR.

Abstract P2-12-14: Therapeutic mammoplasty reduces high incomplete excision rate in lobular cancer

Introduction: Incomplete excision rate for lobular cancer is much higher compared to other types of breast cancer, since lobular cancer is frequently occult on imaging. This, and the inability to downstage lobular cancer with neoadjuvant therapy lead to the highest mastectomy rate of all subtypes. Here, we investigated the association between histopathological characteristics and incomplete excision as well as mastectomy rates.

Further, we investigated whether the application of level 2 therapeutic mammoplasty (TM) would extend the indication for conservation with lobular cancers.

Methods: Data of 1389 consecutive patients underwent surgery for (non)invasive breast cancer between January 2008 and June 2012 was analysed. Pathological and preoperative radiological results were analysed in the context of final surgery and tumour excision margins. Statistical significance was calculated using Chi-square, Mann-Whitney and Z-tests with a significance&lt;0.05.

Results: Overall incomplete excision rate was 13.74% (131/953), and mastectomy rate was 35.35% (491/1389). Higher incomplete excision and mastectomy rates were strongly associated with lobular subtype (IE: 26.03% (19/73)); M: 51.22% (63/123); p&lt;0.01 vs. other subtypes), node positivity (IE: 25% (36/144) vs. 10.43% (68/652); p=0 and M: 60.69% (193/318) vs. 25.65% (216/842); p=0) and tumour size (IE:T3 80% (4/5) vs. T2 22.51% (43/191) vs. T1 9.23% (55/596); all p&lt;0.01; and M: T3 95.35% (41/43) vs. 59.46% (242/407) vs. 16.16% (112/693); all p=0). Incomplete excision rates were independent of hormonal and HER-2 expressions (ER+: 12.55% (89/709) vs. ER-: 16.67% (15/90); p=0.27 and HER2 neg.: 12.67% (91/718) vs. HER2 pos.: 16.67% (13/78); p=0.32) and it was just higher in grade 2 and 3 cancers (14.6% (60/411); p=0.037 and 16.22% (36/222); p=0.021 vs. G1:6.86% (7/102). However, hormonal and HER-2 expressions as well as tumour grade were in strong association with mastectomy rate (ER pos.: 33.28% (335/1007) vs. ER neg.: 48.75% (78/160); p&lt;0.01; HER2 neg.: 33.43% (341/1020) vs. HER2 pos.: 49.65% (71/143); p&lt;0.01; G3: 50.49% (205/406) vs. G2: 30.77%(172/559) vs. G1: 14.28% (17/119); all p=0).

135 patients underwent surgery for lobular cancer (simple wide excision: 66; TM:19; mastectomy: 50). TM was offered for significantly larger tumours than lumpectomy (28.29mm (10-62) vs. 19.96mm(5-57);p&lt;0.01; vs. mastectomy: 37.56 mm(5-110);p=0.096). Incomplete margins were found with significantly smaller tumours when lumpectomy was applied compared to TM(25.94 mm(6-56) vs. 38.6 mm(30-45);p=0.031). Conservation was achieved with significantly bigger tumours when TM was used (25.46mm (10-62) vs. 17.66mm (5-57); p=0.032). Multifocality, however, significantly increased the chance for incomplete excision even after TM (4/7; p=0.019).

Conclusion: Higher incomplete excision rate is strongly associated with lobular subtype, node positivity and tumour size, but independent of hormonal end HER-2 expression, while tumour grade is not a strong predictor. All histopathological characteristics are strong predictors of final mastectomy rate. Using TM, breast conservation can be achieved for significantly larger lobular cancers, and incomplete excision rate decreased in smaller cancers, which are routinely treated with wide excision.

Citation Format: Romics L, Kabir SA, Mansell J, Mallon EA, Stallard S, Doughty JC. Therapeutic mammoplasty reduces high incomplete excision rate in lobular cancer. [abstract]. In: Proceedings of the Thirty-Eighth Annual CTRC-AACR San Antonio Breast Cancer Symposium: 2015 Dec 8-12; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2016;76(4 Suppl):Abstract nr P2-12-14.

An International Multicenter Review of the Malignancy Rate of Excised Papillomatous Breast Lesions

BACKGROUND

Papillary lesions of the breast are a relatively rare, but heterogeneous group ranging from benign to atypical and malignant. Debate exists regarding the optimal management of these lesions. In the absence of more accurate risk-stratification models, traditional management guidelines recommend surgical excision, despite the majority of lesions proving benign. This study sought to determine the rate of malignancy in excised breast papillomas and to elucidate whether there exists a population in which surgical excision may be unnecessary.

METHODS

A multicenter international retrospective review of core biopsy diagnosed breast papillomas and papillary lesions was performed between 2009 and 2013, following institutional ethical approval. Patient demographics, histopathological, and radiological findings were recorded. All data was tabulated, and statistical analysis performed using Stata.

RESULTS

A total of 238 patients were included in the final analysis. The age profile of those with benign pathology was significantly younger than those with malignant pathology (p < 0.001). Atypia on core needle biopsy was significantly associated with a final pathological diagnosis of malignancy (OR = 2.73). The upgrade rate from benign core needle biopsy to malignancy on the final pathological sample was 14.4 %; however, only 3.7 % had invasive cancer.

CONCLUSIONS

This international dataset is one of the largest in the published literature relating to breast papillomas. The overall risk of malignancy is significantly associated with older age and the presence of atypia on core needle biopsy. It may be possible to stratify higher-risk patients according to age and core needle biopsy findings, thereby avoiding surgery on low-risk patients.

How to compare the oncological safety of oncoplastic breast conservation surgery - To wide local excision or mastectomy?

BACKGROUND

Comparative studies suggest that patients treated with oncoplastic breast conservation surgery (OBCS) have similar pathology to patients treated with wide local excision (WLE). However, patients treated with OBCS have never been compared to patients treated with mastectomy. The aim of this study was to identify which control group was comparable to patients undergoing OBCS.

METHODS

Commonly reported histopathological variables of patients treated with OBCS, WLE or mastectomy ± immediate reconstruction (Ms ± IR) were compared using Fisher Exact or Chi squared tests.

RESULTS

1000 patients' data were analysed (OBCS: n = 119; WLE: n = 600; Ms ± IR: n = 281). Tumour size was significantly bigger after OBCS than WLE (p < 0.001), but similar to Ms ± IR (p = 0.138). Tumour grade was higher after OBCS than WLE (p < 0.001), but similar to Ms ± IR (p = 0.497). More axillary nodes were involved in patients with OBCS than WLE (p < 0.001), but comparable to Ms ± IR (p = 0.175). ER and PR expressions were lower after OBCS compared to WLE (p = 0.007, p = 0.009), but identical to Ms ± IR (p = 1, p = 0.904 respectively). Differences in application of systemic (neo)adjuvant therapy followed the above trend.

CONCLUSION

Striking similarities found between OBCS and mastectomy patients' histopathological results are in sharp contrast with previously published data. This study suggests that oncological outcomes following OBCS should be compared to mastectomy besides WLE.

Abstract P5-15-07: Therapeutic mammaplasty - Radical breast conservation or conservative mastectomy? A comperative analysis of 1000 patients’ pathology results

Background: oncological principles of therapeutic mammaplasty (TM) is based on evidence arising from studies on the oncological safety of traditional breast conservation, i.e. wide local excision (WLE). Hence, oncological safety of TM is benchmarked to patients treated with WLE. However, TM can also be defined as a conversion of mastectomy (Ms) to breast conservation surgery applying plastic surgical techniques in patients conventionally requiring mastectomy. The aim of this study was to decide if TM was similar to WLE or Mx in terms of pathological characteristics.

Methods: 1006 consequtive patients were involved in the analysis, who were treated with TM, WLE or Ms in two Glasgow breast units between 2008 and 2011. Histopathological characteristics of patients treated with TM were compared to those treated with WLE or Ms. Statistical calculations were carried out with Chi-square test. The difference was considered statistically significant if p&gt;0.05.

Results: 121 patients were treated with TM, while 600 patients were treated with WLE and 285 with Ms. Tumour size of TM was significantly different from WLE as well as Ms, although the difference between TM and WLE was more significant than between TM and Ms (TM/Ms/WLE: T1: 43.8%, 34%, 78%; T2: 52.1%, 54.7%, 21%; T3: 4.1%, 11.2%, 1%; TM vs. WLE: p&lt;0.001; vs. Ms: p = 0.03). Tumour grade of TM was significantly higher than grade of WLE, but there was no significant difference between the grades of TM and Ms (TM/Ms/WLE: G1: 6.4%, 4.5%, 19.3%; G2: 37.6%, 41.8%, 54.8%; G3: 56%, 53.7%, 26%; TM vs. SZE: p&lt;0.001; vs. Ms: p = 0.625). Similarly, significantly more axillary nodes were involved in patients treated with TM compared to patients with WLE, while the same was comparable in patients with TM and Ms (TM/Ms/WLE: 0: 73.5%, 70.4%, 87.7%; 1-3: 24.5%, 25.6%, 12.2%; &gt;3: 2%, 4%, 0.2%; TM vs. WLE: p&lt;0.001; vs. Ms: p = 0.601). In terms of histological subtypes, again, there was a significant difference between TM and WLE, but we found no difference when TM was compared to Ms (TM vs. WLE: p = 0.027; vs. Ms: p = 0.582). There was statistically significantly more ER and/or PR positive patients in the group treated with WLE compared to TM (ER/PR TM vs. WLE p = 0.012 / = 0.014), but ER/PR expression was similar in TM and Ms patients (ER/PR TM vs. Ms p = 0.890 / = 0.635). While the trend above was similar in HER-2 expression pattern, there was no statistically significant difference could be demonstrated in between the groups (table).

Discussion: pathological characteristics of patients treated with therapeutic mammaplasty is similar to patients treated with mastectomy, but significantly different from patients who were treated with WLE. Pathology after WLE is significantly more favourable compared to TM. Hence, studies investigating oncological safety of TM comparing to patients treated with WLE only may not be adequate, and Ms patients should be included in the analyses.

Citation Information: Cancer Res 2013;73(24 Suppl): Abstract nr P5-15-07.

Oncoplastic breast conservation does not lead to a delay in the commencement of adjuvant chemotherapy in breast cancer patients

INTRODUCTION

There is hardly any evidence that oncoplastic breast conservation surgery (OBCS) does not lead to a delay in the commencement of adjuvant chemotherapy. Although this is an integral part of overall oncological safety, no controlled studies have been published so far. Therefore, our aim was to determine whether OBCS led to a delay when compared to simple wide local excision (WLE), mastectomy (Ms) or mastectomy with immediate reconstruction (MsIR).

METHODS

Breast cancer patients who required adjuvant chemotherapy after OBCS, WLE, Ms and MsIR were identified from prospectively maintained institutional databases. Time between multidisciplinary team decision to offer chemotherapy and delivery of first cycle of chemotherapy was measured and compared among the four groups of patients.

RESULTS

time to chemotherapy of breast cancer patients (n = 169) treated with OBCS (n = 31) were 29 [16-58] days, while it was 29.5 [15-105] days after WLE (n = 66), 29 [15-57] days after Ms (n = 56) and 31 [15-58] days after MsIR (n = 16). A combined analysis involving all four groups demonstrated no statistically significant difference (p = 0.524). Similarly, inter-group analysis revealed no significant differences in between patients treated with OBCS compared to any of the three control groups (OBCS to WLE: p = 0.433; OBCS to Ms: p = 0.800; OBCS to MsIR: p = 0.405).

CONCLUSION

OBCS seems as safe as WLE, Ms or MsIR in terms of delivery of adjuvant chemotherapy, and, therefore, should not adversely affect breast cancer outcome in this respect.

Abstract P4-14-13: Therapeutic mammaplasty does not cause a delay in the delivery of chemotherapy in high risk breast cancer patients

Introduction: oncosurgical safety of therapeutic mammaplasty (TM) is widely investigated. The interval between surgery and delivery of adjuvant chemotherapy is an integral part of overall oncological safety. Therefore, we examined the time between TM and AC, and compared it to wide local excision (WLE) and mastectomy (Mx) with or without immediate breast reconstruction (IBR), respectively.

Methods: data of 174 patients who underwent TM, WLE and Mx±IBR was analyzed retrospectively. All patients were operated within three breast units of Glasgow during a period of 48 months. Time between decision to offer adjuvant chemotherpay and delivery of the first cycle of chemotherapy was analyzed. Significance was calculated with Mann-Whitney and Kruskal-Wallis tests (two and four groups compared, respectively).

Results: median time to adjuvant chemotherapy after TM (n = 36) was 29 [16–58] days, WLE (n = 66) was 29.5 [15–105], Mx only (n = 56) was 29 [15–57], and Mx and IBR (n = 16) was 31 [15–58] days. No significant difference was found in terms of time to adjuvant chemotherpay in patients treated with TM compared to WLE (p = 0.384), Mx only (p = 0.828) or Mx and IBR (p = 0.366). Further, there was no significant difference when a cumulative comparison of the four groups was carried out (p = 0.507).

Conclusions: our data indicate that oncosurgical safety of TM in terms of time to chemotherapy is similar to other high risk breast cancer patients treated WLE and Mx with or without IBR. This also suggests that there is no significant difference in postoperative complication rates after these four ways of surgical treatment of breast cancer, which would possibly be the primary cause for a delay in delivering adjuvant chemotherapy.

Citation Information: Cancer Res 2012;72(24 Suppl):Abstract nr P4-14-13.

Ten-year follow-up of skin-sparing mastectomy followed by immediate breast reconstruction

BACKGROUND

The oncological safety of skin-sparing mastectomy (SSM) followed by immediate breast reconstruction (IBR) is debated owing to a presumed compromise in the completeness of mastectomy. Current evidence is poor as it is based mostly on short-term follow-up data from highly selected patients.

METHODS

A prospectively maintained institutional database was searched to identify patients who underwent SSM and IBR between 1995 and 2000. A retrospective review of medical records was carried out, including only patients with ductal carcinoma in situ and invasive breast cancer. During this time all patients treated with mastectomy were offered IBR regardless of tumour stage.

RESULTS

Follow-up data from 253 consecutive patients with IBR were reviewed. Patients with incomplete follow-up data and those undergoing SSM for recurrent disease following previous lumpectomy were disregarded, leaving 207 for analysis. Offering IBR to all women requiring mastectomy resulted in a large proportion of patients with advanced disease. During a median follow-up of 119 months, 17 (8·2 per cent) locoregional, six (2·9 per cent) local and 22 (10·6 per cent) distant recurrences were detected; the overall recurrence rate was 39 (18·8 per cent). Overall recurrence rate was associated with axillary lymph node metastasis (P = 0·009), higher stage (P < 0·001) and higher tumour grade (P = 0·031). The breast cancer-specific survival rate was 90·8 per cent (19 of 207 women died from recurrence).

CONCLUSION

Based on these long-term follow-up data, SSM combined with IBR is an oncologically safe treatment option regardless of tumour stage.

P2-16-11: Role of Proper Patient Counselling in Combination with Effect of Socioeconomic Deprivation on the Rate of Immediate Breast Reconstruction after Mastectomy

Introduction: current guidelines in the United Kingdom suggest that the possibility of breast reconstruction should be discussed with all patients prior to mastectomy. However, the majority of patients are still treated with mastectomy alone and no reconstruction is carried out. It has also been suggested that women from more deprived areas are less likely to undergo immediate breast reconstruction (IBR). We investigated potential pitfalls in patient counselling and consequent decision making contributing to present IBR rate in combination with the effect of socioeconomic deprivation.

Methods: data from 89 consecutive mastectomy patients was prospectively collected in a single centre in Glasgow between August 2010 and March 2011. Each patient was scored for deprivation based on The Scottish Index of Multiple Deprivation. The patients were then divided into two groups: high and low deprivation levels. Consultations about IR and patients’ acceptance of counselling were analysed. For statistical calculations Fischer's exact test was applied. Results: IBR was offered to 41 (46%) patients, but it was not to 42 (47%) (6 were excluded due to incomplete data). 25 patients accepted IBR, and of those 24 (27%) underwent IBR. 16 of 41 patients refused to undergo IBR due to lack of interest (10), not feeling ready for it (2), preference of delayed procedure (2) and fear of delaying adjuvant therapy (2). Of 42 patients whom IBR was not offered, only 10 were documented in the notes, while there was no reference for discussing reconstruction in 32 (36%) cases. Reasons for not even discussing reconstruction were the following: age (15), co-morbidities (18), locally advanced cancer (2), co-morbidities with age (5), and locally advanced cancer with age (2). As regards to socioeconomic deprivation; 44 (49%) patients were from deprived areas and 39 (44%) from affluent areas. 41 patients were offered IBR and of these 23 (26%) were from affluent areas compared to 18 (20%). Of the 42 patients who were not offered IR, 26 (29%) were from deprived while 16 (18%) from affluent areas (p&lt;0.05). Of the 44 deprived patients, 18 were offered IBR but 26 were not. 15 of 25 patients, who accepted IBR, were from affluent areas. The 16 patients who refused IBR had equal distribution of deprivation.

Conclusions: while none of the reasons for not offering IBR represent absolute contraindication to IBR, decisions about refusal are based mostly on patients’ subjective intuitions. Further, a greater proportion of the patients who were not offered IBR were from more deprived areas, and it seems that patients from affluent areas are more likely to be offered IBR compared to ones from deprived areas. However, confounding factors such as co-morbidities may contribute to the above. We believe, therefore, that detailed counselling about reconstruction of each patient requiring mastectomy is necessary, which is likely to further increase IBR rate.

The effect of azathioprine, cyclosporine A and insulin on the in vitro lymphocyte-mediated cytotoxicity in type I diabetic patients

Previously both specific and nonspecific immune reactions have been reported in patients with type I diabetes mellitus. In this study the effect of various immunosuppressive drugs and insulin was studied on in vitro lymphocyte-mediated cytotoxicity in 20 type I diabetic patients. Twenty sex- and age-matched healthy subjects served as controls. Human pancreas-extract (300 micrograms/ml protein)-coated, 51-Chromium labeled chicken erythrocytes were used as target cells and separated T-lymphocytes as effector cells with and without azathioprine 50 micrograms/50 microliters (Wellcome), Cyclosporine A 5 ng/50 microliters (Sandoz) and MC Actrapid insulin 0.1 IU/50 microliters (Novo). The degree of cytotoxicity was expressed with cytotoxic capacity: the number of maximal killed target cells. Simultaneously islet cell antibodies (ICA) in sera and the number of activated T-lymphocytes were assessed. Significant lymphocyte-mediated cytotoxicity was observed in the majority of type I diabetic patients (18/20), while no cytotoxicity was found in the control cases. The cytotoxicity decreased in all 16 patients using azathioprine or insulin, independently of ICA and HLA-DR positivity. The number of killed target cells was lowered considerably by Cyclosporine A in all 18 patients having cytotoxicity against pancreas-extract. Our observations reveal that Cyclosporine A proved to be the most effective immunosuppressive agent in vitro. It decreases not only the leucocyte migration inhibition as previously observed, but also the lymphocyte-mediated cytotoxicity, which represents the late stage of cellular immune reactions against pancreatic tissue.

Randomized clinical trial of techniques for closure of the pancreatic remnant following distal pancreatectomy

BACKGROUND

Pancreatic fistula and intra-abdominal fluid collection are the commonest complications after distal pancreatectomy. Several techniques have been described to achieve perfect closure of the stump.

METHODS

In this randomized clinical trial the stapler technique was compared with stapling combined with a seromuscular patch. Seventy patients who underwent distal pancreatectomy were randomized between January 2002 and December 2006 to either closure of the pancreatic stump by stapler (35 patients) or closure by stapler and covering with a seromuscular patch of jejunum (35). The primary endpoint was the rate of postoperative fistula and/or intra-abdominal fluid collections.

RESULTS

The overall rate of these pancreas-related complications was higher in the stapling-alone group. However, rates of clinically relevant postoperative complications (grade B or C fistula and/or fluid collection requiring treatment) were comparable. The reintervention rate and median hospital stay were similar in both groups.

CONCLUSION

Covering the stapled pancreatic remnants with a seromuscular patch is a simple method that decreased overall pancreas-related complications such as fistula. This technique did not affect clinically relevant outcomes as severe complications requiring treatment were similar with both techniques.

Preventive strategies for septic complications of acute pancreatitis

The diagram of the mortality of acute pancreatitis is characterized by two distinct peaks, in a similar manner to other generalized acute inflammatory responses. In the first phase, which is characterized by "hyper-inflammatory" mechanisms, death occurs due to overwhelming SIRS and subsequent multi-organ failure. The second peak of death is usually detected much later, at least two weeks after the onset of acute pancreatitis. Infection in necrotising pancreatitis is frequently observed in this so-called "compensatory antiinflammatory" phase. Since there has been no effective therapy evolved to prevent the activation of inflammatory and proteolytic cascades, the treatment of acute pancreatitis is merely symptomatic. Adequate fluid resuscitation and analgesia are the mainstays of treatment. In case of development of multi-organ failure, extensive medical and ventilatory supportive therapy is usually necessary. However, recent studies suggested certain methods might decrease the incidence of infection in pancreatic necrosis, which is usually due to bacterial translocation from the gut. Numerous attempts have been published in the literature to decrease the frequency of septic complications. Furthermore, the outcome of studies favouring antibiotic prophylaxis in acute pancreatitis were debatable. The development of multi-resistant strains of Gram-positive bacteria and Candida, due to long-term antibiotic use, is a strong argument against the indication of prophylactic antibiotic use. Recently, various clinical studies aimed to decrease bacterial translocation, including probiotic use and enteral feeding as part of the treatment. This paper provides a systematic review on data available in the evidence based literature on the use of antibiotics and the role of alternative and supportive therapy in the treatment of severe acute pancreatitis.

Rapid Intraoperative Parathyroid Hormone Assay—More than Just a Comfort Measure

BACKGROUND

Minimally invasive radio-guided parathyroidectomy (MIRP) has been embraced as an acceptable therapeutic approach to primary hyperparathyroidism. Preoperative sestamibi scanning has facilitated this technique. Here we evaluate the addition of a rapid intraoperative parathyroid hormone (iPTH) assay for patients undergoing MIRP.

METHODS

A series of 51 patients underwent sestamibi localization of parathyroid glands followed by MIRP for primary hyperparathyroidism. Using peripheral venous samples, iPTH levels were measured prior to gland excision, as well as post-excision at 5, 10, and 15 minutes, taking a 50% reduction in iPTH level as indicative of complete excision. Next, changes in serum iPTH were compared with preoperative and postoperative changes in serum calcium, as well as levels of intraoperative ex-vivo radiation counts taken by hand-held gamma probe.

RESULTS

In this series, a drop of greater than 50% in iPTH levels was observed in 94% of patients (n=48). Moreover, a significant drop in iPTH occurred within 10 minutes of excision in the majority (n=42) of cases (P<0.004). Changes in iPTH were comparable with the therapeutic reduction in calcium levels, as well as with the change in intraoperative ex-vivo gamma counts.

CONCLUSIONS

This study demonstrates that the addition of an iPTH assay to MIRP provides a quick and reliable intraoperative diagnostic modality in confirming correct adenoma removal. Moreover, it precludes the requirement of frozen section.

Massive retroperitoneal ganglioneuroma presenting with small bowel obstruction 18 years following initial diagnosis

BACKGROUND

Ganglioneuroma is a rare tumour of neural crest origin, which arises from maturation of a neuroblastoma. While previously considered to be non-functioning, they are now known to be frequently endocrinologically active.

AIMS AND METHODS

We report a case of a massive retroperitoneal ganglioneuroma presenting with small bowel obstruction in an adult, 18 years after initial diagnosis. Urinary dopamine levels were elevated, but other catecholamines were within normal limits. This is the first report in the English-language literature of a retroperitoneal ganglioneuroma presenting with or causing intestinal obstruction. We also review the metabolic, radiological, and histological features of these tumours. Relevant publications were identified from a Medline search using the MeSH headings 'ganglioneuroma', 'retroperitoneal neoplasms' and 'intestinal obstruction', and also from the reference lists of retrieved articles.

CONCLUSIONS

Ganglioneuroma can grow to a massive size and present in a varied manner. It should be included in the differential diagnosis of any large retroperitoneal or mediastinal mass, including those causing bowel obstruction.

Low levels of antibodies against E. coli and mycobacterial 65kDa heat shock proteins in patients with inflammatory bowel disease

OBJECTIVE AND DESIGN

The aim of the present study was to support and extend our initial observation, where we found low levels of antibodies against mycobacterial 65kD heat shock proteins in patients with inflammatory bowel disease (IBD). For this purpose we tested a new group of 124 patients with IBD, and beside measuring antibodies to Mycobacterium bovis 65kD heat shock protein (Hsp65) and human 60kD heat shock protein (Hsp60) as described previously, we also determined IgG antibody levels to Hsp65 from E. coli, called GroEL.

PATIENTS AND CONTROL SUBJECTS

seventy-four patients with Crohn's disease (CD) (30 males, 44 females, 33 (27-45) years old, median (interquartile range)) and 50 patients with ulcerative colitis (UC) (22 males, 28 females, 38 (30-50) years old) were involved in the study. 110 healthy subjects (34 males, 76 females, 47 (37-53) years old) served as controls. Study subjects were consecutive patients referred to an IBD center for complex treatment of the disease. Methods and statistical analysis: The amounts of IgG-type antibodies reacting with proteins of the chaperonin 60 family were assessed by ELISA. Since the antibody levels to heat-shock proteins as variables were not normally distributed, non-parametric Mann-Whitney test and Dunn post hoc test were used for group comparisons.

RESULTS

Median levels of anti-GroEL (7,5 (3,5-18,3)) and anti-Hsp65 (4,8 (2,1-7,85)) were significantly (GroEL p = 0,008; and Hsp65 p < 0,001) lower in the IBD patients than in the healthy subjects (GroEL: 10,0 (5,4-31,0); Hsp65: 7,04 (4,66-12,77)). However this difference was found to be restricted to the CD patients (GroEL: 7,5 (3,7-14,2); p < 0,05; Hsp65: 4,35 (1,90-6,94); p < 0,001). We did not find difference in the concentration of anti-human Hsp60 IgG levels between patients (Hsp60: 45,5 (24,9-69,0)) and healthy controls (38,4 (21,6-69,4). Regarding the serum concentrations of each antibody tested there was no significant difference between the active and inactive stage of disease.

CONCLUSION

Our present findings support conclusion of our previous work, antibody levels not only for Mycobacterium bovis hsp65 but for E. coli GroEl were found to be decreased as well. In contrast no changes in the concentrations of human anti-hsp60 antibodies were observed. These findings indicate that production of antibodies to 65 kDa bacterial heat shock proteins is selectively impaired in IBD.

High levels of C-reactive protein with low total cholesterol concentrations additively predict all-cause mortality in patients with coronary artery disease

BACKGROUND

This study aimed to investigate independent and additive predictive effects of raised C-reactive protein (CRP) levels and decreased total cholesterol levels on mortality in patients with chronic coronary artery disease (CAD). Low total cholesterol (TC) levels are associated with worsened survival in chronic and acute diseases. Elevated CRP level is an important predictor of vascular events and mortality in patients with CAD. Potential inhibition of immune activation by circulating lipoproteins could be a link between cholesterol and inflammatory markers.

MATERIALS AND METHODS

A group of 387 patients (median age 59 years) with CAD and with or without severe heart failure (HF) were followed for a median of 5.06 years. Serum total cholesterol and CRP concentrations were measured at enrollment.

RESULTS

The relationship between lipoproteins, CRP and survival was explored. High CRP concentrations were in significant association with severity of HF and predicted worsened survival in patients with CAD (hazard ratio 5.214, 95% CI 1.762-15.427). The association between CRP levels and mortality was independent of potential confounding factors such as age, body-mass index, severity of HF, smoking habits, hypertension and TC levels. The prediction of mortality by low TC levels was significant (hazard ratio 2.932, 95% CI 1.021-8.422). Furthermore, patients with increased CRP and decreased TC (additive predictive effect) phenotype had 11.714-times higher risk (95% CI 2.619-52.385) of being nonsurvivors than patients with low CRP/high TC.

CONCLUSIONS

High CRP levels and low TC concentrations are independent and additive predictors of mortality in patients with CAD. Our data indicate that joint analysis of circulating lipoproteins and inflammatory biomarkers may improve prediction of survival in patients with CAD.

Marked decrease in the levels of two inflammatory markers, hs-C-reactive protein and fibrinogen in patients with severe carotid atherosclerosis after eversion carotid endarterectomy

OBJECTIVE AND DESIGN

To study changes in the levels of two acute phase proteins, plasma fibrinogen and serum C-reactive protein (hs-CRP) in patients with severe carotid stenosis after eversion endarterectomy.

MATERIAL AND SUBJECTS

A total of 117 consecutive patients who underwent eversion endarterectomy were included in the study. Blood samples for acute phase protein measurement were taken before operation as well as 5.7 weeks and 13.8 months (median) post-surgery. Plasma fibrinogen and serum hs-CRP concentrations were promptly determined.

RESULTS

During the follow-up period sharp, highly significant (p < 0.0001) drop occurred in the serum concentrations of both acute phase proteins. The drop in the hs-CRP levels during the follow up period was mainly due to decrease in patients with highest baseline CRP levels.

CONCLUSIONS

Our present findings indicate that removal of atherosclerotic plaques from the carotid arteries markedly decreases the production of two acute phase proteins due to the decrease of the inflammatory burden or the removal of the advanced plaques able to produce these proteins.

Complement activating antibodies against the human 60 kDa heat shock protein as a new independent family risk factor of coronary heart disease

BACKGROUND

Several groups have reported high levels of antibodies against 60 kDa heat shock proteins (hsp) associated with coronary heart disease.

METHODS AND RESULTS

Complement activating (CA) antihsp60 autoantibodies were measured by the AtheroRisk kit (CardioPath Ltd, Alloa, UK), in parallel with IgG antibodies to human hsp60 and mycobacterial hsp65 by ELISA in 32 healthy children (18 boys, 14 girls, 11.8 +/- 4.0 years). At least one of the parents of these children had a history of myocardial infarction before 55 years of age (high family risk (HFR) group). The control group consisted of 63 healthy children (31 boys, 32 girls, 9.0 +/- 3.6 years) without known family history of coronary heart disease (CHD), hypertension, and diabetes mellitus. Concentrations of CA antihsp60 antibodies were significantly (P = 0.021) higher in the HFR group than in the control group. Also in the HFR group, significantly (P = 0.004) lower high-density lipoprotein cholesterol (HDL-C)-cholesterol (measured enzymatically) and significantly (P = 0.020) higher low-density lipoprotein cholesterol (LDL-C)-cholesterol levels (calculated by the Friedewald formula) were observed when compared with the controls. The difference in the CA antihsp60 antibody levels between the HFR and control groups remained significant even after adjustments for age, smoking, HDL-cholesterol, LDL-cholesterol levels, and white blood cell count. Children with high (in the highest quartile) CA antihsp60 antibody levels compared with those with normal levels of these antibodies also had adjusted odds ratios (OR) of 9.80 (2.15-44.58, P = 0.003), indicating high family risk. No significant difference in the IgG antihsp antibody levels was observed.

CONCLUSIONS

These findings indicate that high levels of CA autoantibodies against hsp60 can be considered to be a novel family risk factor of CHD, independent of HDL- and LDL-cholesterol levels.

Increased frequency of the C3*F allele and the Leiden mutation of coagulation factor V in patients with severe coronary heart disease who survived myocardial infarction

The aim of the present study was to compare the frequencies of the F allele of C3 complement component and the Leiden mutation of coagulation factor V in patients with severe coronary heart disease (CHD) who survived myocardial infarction (MI; group A), and those who had no MI in their case history (group B). We have determined the C3 allele frequencies by electrophoresis, and Leiden mutation by PCR in 338 patients with severe CHD and in 490 and 523 healthy controls, respectively. The C3*F allele frequency was significantly (p = 0.006) higher in group A (0.213) that in group B (0.132). A significant (p = 0.045) difference was found between < or = 60-year group A (0.077) and group B (0.029) patients in the frequency of Leiden mutation. These findings indicate that the C3*F allele and the Leiden mutation may be associated with an increased risk of developing myocardial infarction in CHD patients.

Antibodies against different epitopes of heat-shock protein 60 in children with type 1 diabetes mellitus

The aim of this study was to investigate the amounts and epitope specificity of antibodies against heat shock protein 60 (hsp60) in the sera of type 1 diabetic and healthy children. Antibodies specific for peptide p277 of human hsp60 and of M. bovis as well as for human hsp60, M. bovis hsp65 proteins were measured by ELISA. Other autoantibodies (islet cell antibodies, glutamate decarboxylase antibodies and IA-2 antibodies) were also determined. A total number of 83 serum samples from children with type 1 diabetes mellitus and 81 samples of control children were investigated. Epitope scanning of the hsp60 for linear antibody epitopes was carried out using synthetic peptides attached to pins. The antibody levels specific for peptide p277 of human- and of M. bovis origin were significantly (human: P=0.0002, M. bovis: P=0.0044) higher in the diabetic children group than in the healthy children. We could not find significant difference in the antibody levels to whole, recombinant hsp proteins among the examined groups of children. Antibodies to two epitope regions on hsp60 (AA394-413 and AA435-454) were detected in high titres in sera of children with diabetes mellitus. The first region similar to the sequence found in glutamate decarboxylase, whereas the second one overlaps with p277 epitope to a large extent. Presence of antibodies to certain epitopes of hsp60 (AA394-413-glutamic acid decarboxylase-like epitope; AA435-454-p277-like epitope) in diabetic children may reflect their possible role in the autoimmune diabetogenic process of the early diabetes.

[Latent autoimmune diabetes in adults(LADA): part of the clinical spectrum of type-1 diabetes mellitus of autoimmune origin]

According to the most recent classification of diabetes mellitus the latent autoimmune diabetes in adults belongs to the group of type 1 autoimmune diabetes mellitus, as a slowly progressive form. It is not clear whether LADA is a distinct clinical entity or it is a part of the clinical spectrum of type 1 diabetes mellitus. The authors compare the antropologic (body mass index, waist to hip ratio), immunologic (occurrence of islet cell cytoplasmic autoantibodies and autoantibodies against glutamic acid decarboxylase and tyrosin phosphatase), genetic (HLA DR and DQ alleles known to be associated to type 1 diabetes mellitus) characteristics and occurrence of the features of the metabolic syndrome in the groups of type 1 and type 2 diabetes and LADA. 81 type 1 and 190 type 2 diabetics and 38 LADA patients were involved into the study. Freshly diagnosed type 1 diabetics served for controls of the autoantibody study: 48 patients manifested < or = 16 years of age and 89 type 1 diabetics manifested above 16 years of age. The three main diabetic groups differed in age: the average age in the type 1, type 2 and LADA groups were 37, 63 and 58 years respectively. There was no difference among the three groups in gender. The duration of the disease differed significantly between the type 2 and LADA groups (4.0 and 8.0 years respectively). In spite of the shorter duration of the disease in the LADA group, compared to the type 2 diabetics the frequency of insulin dependency was significantly higher in the LADA (81.6%) than in the type 2 group (46.7%). The BMI and WHR were comparable between the type 1 and LADA patients (average values were 23 and 0.83 in type 1 patients and 23.25 and 0.89 in LADA). The type 2 group differed significantly from type 1 and LADA (average values were 29.1 and 0.5). The concentration of glycated hemoglobin was comparable in the three groups. But there was a significant difference in HbA1c concentration between the freshly diagnosed subgroups of type 1 and LADA patients: 10.85% and 8% respectively. The fasting C-peptid levels were significantly higher in the sera of type 2 diabetics (0.75 pmol/l) compared to type 1 (0.2 pmol/l) and LADA patients (0.29 pmol/l). There was a significant difference in C-peptid concentrations between the type 1 and LADA groups, too. The insulin deficiency in LADA seemed to be not as severe as in type 1 diabetes. The serum total cholesterol and triglyceride levels were significantly higher and the HDL cholesterol concentration significantly lower in type 2 diabetics comparing to type 1 and LADA patients and there was no significant difference in this respect between the type 1 and LADA groups. The frequency of occurrence of hypertension differed no significantly between type 2 and LADA, but that of in type 1 diabetes was significantly lower than both type 2 and LADA. The occurrence of multiple autoantibodies (ICA + GADA + anti-IA2) was much more frequent in type 1 diabetes compared to LADA. In the sera of LADA patients the occurrence of ICA and GADA alone or ICA + GADA was characteristic (31.5% - 21.1% - 15.8% respectively). There was no difference between type 1 diabetes and LADA in the occurrence of the alleles of the MHC kown to be associated with type 1 diabetes. The occurrence of the haplotypes HLA DQ2/DR3 and/or DQ8/DR4 was observed in two thirds of type 1 diabetic and LADA patients. Chronic diabetic complications were observed in all of the groups and there was only a secondary connection of the complications with the type of the diabetes. Based on the results the authors suggest that LADA is a part of the clinical spectrum of type 1 diabetes of autoimmune origin.

High levels of antibodies against Clq are associated with disease activity and nephritis but not with other organ manifestations in SLE patients

OBJECTIVE

Serum concentration of antibodies to C1q (C1qAb) has been reported to be elevated in a high percentage of patients with systemic lupus erythematosus (SLE). The associations of high C1qAb levels with different clinical manifestations and the activity of the disease, however, are not definitely understood.

METHODS

We measured the levels of IgG type C1qAb in the sera of 137 patients with SLE using an ELISA method.

RESULTS

Serum concentrations of C1qAb were found to be higher (p < 0.0001) in SLE patients than in healthy controls. High titer (> 66 AU/ml) C1qAb was found in 40/137 (29.2%) SLE patients, and 4/192 (2.1%) healthy controls (p < 0.0001). A strong negative correlation (R = -0.4, p < 0.0001) between the age of the patients and the C1qAb titers could be detected. C1qAb levels in clinically active SLE patients significantly (p < 0.0001) exceeded those measured in the sera of patients in the inactive stage of the disease. A significant positive correlation was detected between C1qAb levels and the laboratory activity markers (anti-DNA, low C3 level) of the disease. We found a significant negative correlation between levels of C1qAb and a negative acute phase protein, alpha2-HS-glycoprotein. Renal involvement was present in 11/40 (27.5%) and 11/97 (11%) of the patients with high and low titers of C1qAb, respectively (p = 0.038). The prevalence of other organ manifestations was, however, the same in the patients with or without high titer C1qAb.

CONCLUSION

These findings indicate that C1qAb measurement is a useful method for detecting the activity of SLE and predicting renal manifestations, but not other organ involvement in the disease.

High level of anticholesterol antibodies (ACHA) in HIV patients. Normalization of serum ACHA concentration after introduction of HAART

Anticholesterol antibodies (ACHA) are natural antibodies against the 3beta-OH group of cholesterol. Since lipid disorders are common in HIV infection and HAART may further enhance dislipidaemia, we determined by using an ELISA method serum ACHA concentrations in HIV patients and healthy HIV-seronegative controls. ACHA levels were almost 4 times higher in the sera of 46 patients than in 110 controls. No difference in the specificity of ACHA was found between HIV-seropositive and HIV-seronegative sera. Binding of ACHA to cholesterol-coated plates from a HIV-seropositive serum was dose-dependently inhibited by preincubation with HIV-1(BA-L) preparation. Serum concentration of ACHA was significantly higher in the patients with low serum cholesterol levels than in those with normal cholesterol levels. HAART induced a marked drop of ACHA concentration. We found a significant negative correlation between the length of HAART and the ACHA levels. By contrast, HAART did not significantly influence total IgG concentration and titers of antibodies against 60 kD heat shock protein. Our findings indicate that high levels of ACHA in HIV-infection may contribute to the development of hypocholesterolaemia frequently observed in this disease.

Anti-cholesterol antibodies (ACHA) in patients with different atherosclerotic vascular diseases and healthy individuals. Characterization of human ACHA

In animal experiments the protective role of anti-cholesterol antibodies (ACHA) in the development of atherosclerosis has been demonstrated. Despite the fact that ACHA are present in the serum of healthy humans, no data on the occurrence of these antibodies in human diseases are available. We determined serum concentrations of IgG type ACHA by an enzyme immunosorbent assay in 600 patients with atherosclerotic vascular diseases (86 patients with peripheral occlusive atherosclerosis, 146 patients with cerebrovascular diseases, 341 patients with severe coronary heart disease (CHD) who received aorto-coronary by-pass, 27 patients with myocardial infarction who did not undergo by-pass operation), in 57 patient controls (complaints of CHD, without coronarographic alterations) and in 218 healthy individuals. ACHA were present in the sera of all persons tested. No serum cofactor is needed for the binding of human ACHA to solid phase cholesterol, binding can be inhibited dose-dependently by LDL and even more strongly with LDL/VLDL preparations purified from human serum. ACHA levels were found to be considerably lower in patients with peripheral occlusive atherosclerosis and cerebrovascular diseases compared with the levels in healthy individuals. By contrast, the ACHA levels of patients with CHD were considerably higher. No differences in the IgG subclass distribution and binding efficiency of ACHA in the sera of CHD patients and controls were found. Thus, our present findings indicate that both low and high ACHA production may be associated with different atherosclerotic vascular diseases.