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Turza L, Mohamed Ali AM, Mylander WC, Cattaneo I, Pack D, Rosman M, Tafra L, Jackson RS. Can Axillary Ultrasound Identify Node Positive Patients Who can Avoid an Axillary Dissection After Neoadjuvant Chemotherapy? J Surg Res 2024; 293:625-631. [PMID: 37837818 DOI: 10.1016/j.jss.2023.09.028] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2023] [Revised: 09/07/2023] [Accepted: 09/09/2023] [Indexed: 10/16/2023]
Abstract
INTRODUCTION Axillary lymph node dissection (ALND) is recommended for patients with invasive breast cancer with axillary metastasis treated with neoadjuvant chemotherapy (NAC) who do not have a nodal pathologic complete response (n-pCR). We hypothesized that patients with a single, ultrasound-suspicious, nonpalpable lymph node (LN) at diagnosis, who do not achieve an n-pCR, will have ypN1 disease on surgical pathology. METHODS This retrospective study identified breast cancer patients in our institution from 2012 to 2020 with axillary metastasis treated with NAC who did not achieve an n-pCR and had an ALND. Patient's tumor characteristics, axillary ultrasound, and lymph node disease burden at the time of surgery were reviewed. RESULTS Fifty five patients met the criteria and 36% had one suspicious LN on ultrasound, 25% had 2, and 38% had >3. After chemotherapy, 64% had ypN1 disease, 29% had ypN2 disease, and 7% had ypN3 disease. Of the 20 patients with one abnormal LN on initial ultrasound, 17 (85%, 95% CI 61-96%) had ypN1 disease. Eleven patients with one abnormal LN on initial ultrasound also had no suspicious LNs on prechemotherapy physical exam; among these patients, 100% had ypN1 disease. CONCLUSIONS For breast cancer patients who do not achieve an n-pCR after NAC, pretreatment normal clinical axillary exam and prechemotherapy ultrasound showing only one abnormal LN is associated with ypN1 disease. It may be reasonable to consider omitting completion ALND in this subset of patients while awaiting the results of the Alliance A011202 trial.
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Affiliation(s)
- Lauren Turza
- Breast Surgery Division, Department of Surgery, INOVA Schar Cancer Institute, Fairfax, Virginia
| | | | - W Charles Mylander
- Luminis Health Anne Arundel Medical Center, Rebecca Fortney Breast Center, Annapolis, Maryland
| | - Isabella Cattaneo
- Luminis Health Anne Arundel Medical Center, Rebecca Fortney Breast Center, Annapolis, Maryland
| | - Daina Pack
- Luminis Health Anne Arundel Medical Center, Rebecca Fortney Breast Center, Annapolis, Maryland
| | - Martin Rosman
- Luminis Health Anne Arundel Medical Center, Rebecca Fortney Breast Center, Annapolis, Maryland
| | - Lorraine Tafra
- Luminis Health Anne Arundel Medical Center, Rebecca Fortney Breast Center, Annapolis, Maryland
| | - Rubie Sue Jackson
- Luminis Health Anne Arundel Medical Center, Rebecca Fortney Breast Center, Annapolis, Maryland.
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Sibia US, Mylander C, Martin T, Rosman M, Sanders TJ, Lee Y, Tafra L, Jackson RS. OncotypeDX Testing Does Not Benefit Patients with Estrogen and Progesterone Receptor Positive Grade 1 Breast Cancers: A TAILORx Validated Study. Hematol Oncol Stem Cell Ther 2023; 16:412-419. [PMID: 37363979 DOI: 10.56875/2589-0646.1089] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/25/2022] [Accepted: 01/30/2023] [Indexed: 06/28/2023] Open
Abstract
BACKGROUND & OBJECTIVES We previously described a predictive AAMC model that identifies patients (grade 1, hormonepositive) who would not benefit from OncotypeDX testing. The purpose of this study was to validate the AAMC model by assessing distant recurrence-free interval (DRFI) and invasive disease-free survival (IDFS) using TAILORx clinical trial data. MATERIALS & METHODS We retrospectively analyzed TAILORx trial data and categorized patients based on the AAMC model. AAMC low-risk patients are those with grade 1 and hormone-positive tumors. Kaplan-Meier curves examined DRFI and IDFS. RESULTS Of the 9195 cases, 2246 (24.4%) were identified by AAMC as low-risk. Among these AAMC low-risk patients, 55.2% had Recurrence Score (RS) 0-15, 42.3% had RS 15-25, and 2.4% had RS > 25. The 10-year DRFI did not differ for those who received adjuvant chemotherapy versus those who did not (98% vs. 96%, log-rank p = 0.46). Similarly, IDFS was comparable between those who received adjuvant chemotherapy and those that did not (86% vs. 86%, log-rank p = 0.66). Only 2.4% of AAMC low-risk patients were categorized as high-risk (RS > 25). A sensitivity analysis of this discordant group, wherein those with RS > 25 were re-classified into the no-chemotherapy group and assumed to have experienced recurrences at the rate expected without chemotherapy, did not find any difference in DRFI between those who received adjuvant chemotherapy and those who did not (log-rank p = 0.16). CONCLUSION OncotypeDX testing does not benefit AAMC low-risk patients with hormone-positive grade 1 tumors. Based on these data, 1 in 4 TAILORx participants would not need OncotypeDX testing.
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Affiliation(s)
- Udai S Sibia
- The Rebecca Fortney Breast Center, Anne Arundel Medical Center, 2000 Medical Parkway, Annapolis, MD, 21401, USA
| | - Charles Mylander
- The Rebecca Fortney Breast Center, Anne Arundel Medical Center, 2000 Medical Parkway, Annapolis, MD, 21401, USA
| | - Tasha Martin
- The Rebecca Fortney Breast Center, Anne Arundel Medical Center, 2000 Medical Parkway, Annapolis, MD, 21401, USA
| | - Martin Rosman
- The Rebecca Fortney Breast Center, Anne Arundel Medical Center, 2000 Medical Parkway, Annapolis, MD, 21401, USA
| | - Thomas J Sanders
- The Rebecca Fortney Breast Center, Anne Arundel Medical Center, 2000 Medical Parkway, Annapolis, MD, 21401, USA
| | - Young Lee
- The Rebecca Fortney Breast Center, Anne Arundel Medical Center, 2000 Medical Parkway, Annapolis, MD, 21401, USA
| | - Lorraine Tafra
- The Rebecca Fortney Breast Center, Anne Arundel Medical Center, 2000 Medical Parkway, Annapolis, MD, 21401, USA
| | - Rubie S Jackson
- The Rebecca Fortney Breast Center, Anne Arundel Medical Center, 2000 Medical Parkway, Annapolis, MD, 21401, USA
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Lee Y, Mylander WC, Martin T, Rosman M, Sanders TJ, Sibia US, Tafra L, Jackson RS. Abstract P4-06-01: OncotypeDX testing does not appear to benefit patients with grade 1, progesterone receptor positive breast cancers: A TAILORx validated study. Cancer Res 2022. [DOI: 10.1158/1538-7445.sabcs21-p4-06-01] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Abstract
Background: We previously described a validated (AAMC) risk prediction model, based on pathology, which may eliminate the need for OncotypeDX testing in AAMC low-risk (grade 1, progesterone (PR) positive) tumors. Our previous study used the SEER database and examined breast cancer specific survival (BCSS) and overall survival (OS), but was limited by our inability to assess distant recurrence-free interval (DRFI) and invasive disease-free survival (IDFS) with the available data. The purpose of this study was to validate the AAMC model using the TAILORx database, specifically with regard to DRFI and IDFS. Methods: We retrospectively analyzed TAILORx trial data and categorized patients into groups based on the AAMC model (Table). AAMC low-risk were defined as tumors that were both grade 1 and PR positive, while high-risk tumors were grade 3 or estrogen (ER) negative/PR positive. Intermediate-risk were those not categorized as low- or high-risk. The AAMC model recommends against OncotypeDX testing in low-risk tumors, but recommends testing in intermediate- or high-risk tumors. Kaplan-Meier curves were used to examine DRFI and IDFS. Results: A total of 9143 patients with grade and ER/PR information were categorized into AAMC low-risk (24.6%), intermediate-risk (57.9%), and high-risk (17.5%) groups. In the AAMC low-risk cohort, 22.3% had Recurrence Score (RS) 0-10 and did not receive chemotherapy per the TAILORx protocol, while 75.3% had RS 11-25 and were randomized to chemotherapy versus no-chemotherapy, and 2.4% had RS > 25 and received adjuvant chemotherapy. In these AAMC low-risk patients, DRFI did not differ for patients who received adjuvant chemotherapy versus those that did not (log-rank p=.96). Similarly, IDFS was comparable between the chemotherapy and no-chemotherapy groups (log-rank p=.66). Only 2.4% of AAMC low-risk patients were categorized as high-risk per OncotypeDX testing (RS > 25). To account for the fact that all patients in this small group received chemotherapy per protocol, a sensitivity analysis was performed in which AAMC low-risk patients with RS > 25 were re-classified into the no-chemotherapy group and assumed to have experienced recurrences at rates expected without chemotherapy. Under these assumptions, there still was no difference in DRFI (log-rank p=.16) between chemotherapy and no-chemotherapy groups. Conclusion: This study validates our previous recommendations that OncotypeDX testing may be omitted in early-stage breast cancers with grade 1 and PR positive tumors (AAMC low-risk), as adjuvant chemotherapy does not improve distant recurrence-free interval in this group of patients. Based on our recommendations, 1 in 4 TAILORx participants would not need OncotypeDX testing. This would result in substantial cost savings to the healthcare system.
Percent of TAILORx trial participants and treatment recommendations based on OncotypeDX testing versus AAMC model.ModelAAMC ModelLow-risk (n=2246, 24.6%)Intermediate-risk (n=5298, 57.9%)High-risk (n=1599, 17.5%)Treatment recommendation*No chemotherapy/No OncotypeDX testingProceed with OncotypeDX testProceed with OncotypeDX testOncotypeDX testing*RS 0 to 15No chemotherapy1240 (55.2%)2224 (42.0%)306 (19.1%)RS 16 to 20, age ≤50Chemotherapy and/or OFS/AI258 (11.5%)492 (9.3%)108 (6.8%)RS 21 to 25, age ≤50Chemotherapy and/or OFS/AI93 (4.1%)274 (5.2%)101 (6.3%)RS 16 to 25, age >50No chemotherapy600 (26.7%)1719 (32.4%)450 (288.1%)RS >25Chemotherapy55 (2.4%)589 (11.1%)634 (39.6%)Ovarian function suppression (OFS); Aromatase inhibitor (AI)*Based on TAILORx results
Citation Format: Young Lee, W. Charles Mylander, Tasha Martin, Martin Rosman, Thomas J Sanders, Udai S Sibia, Lorraine Tafra, Rubie S Jackson. OncotypeDX testing does not appear to benefit patients with grade 1, progesterone receptor positive breast cancers: A TAILORx validated study [abstract]. In: Proceedings of the 2021 San Antonio Breast Cancer Symposium; 2021 Dec 7-10; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2022;82(4 Suppl):Abstract nr P4-06-01.
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Affiliation(s)
- Young Lee
- Luminis Health Anne Arundel Medical Center, Annapolis, MD
| | | | - Tasha Martin
- Luminis Health Anne Arundel Medical Center, Annapolis, MD
| | - Martin Rosman
- Luminis Health Anne Arundel Medical Center, Annapolis, MD
| | | | - Udai S Sibia
- Luminis Health Anne Arundel Medical Center, Annapolis, MD
| | - Lorraine Tafra
- Luminis Health Anne Arundel Medical Center, Annapolis, MD
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Sibia US, Sanders TJ, Mylander C, Rosman M, Tweed C, Tafra L, Jackson RS. Recurrence score testing does not appear to benefit patients with Grade 1, progesterone receptor-positive breast cancers: An opportunity to eliminate overtreatment and decrease testing costs. Hematol Oncol Stem Cell Ther 2021; 15:44-51. [PMID: 34174200 DOI: 10.1016/j.hemonc.2021.05.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/03/2021] [Accepted: 05/30/2021] [Indexed: 10/21/2022] Open
Abstract
BACKGROUND We previously described a risk prediction model (Anne Arundel Medical Center [AAMC] model) based on pathology which may eliminate the need for recurrence score (RS) testing in select early-stage breast cancers. There is a concern that patients in discordant risk prediction groups (AAMC vs. RS) may be overtreated or undertreated if RS testing were omitted. METHODS We queried the Surveillance, Epidemiology, and End Results (SEER) database for all breast cancer patients between 2004 and 2015. AAMC low-risk was defined as Grade 1 and progesterone receptor-positive (PR + ) tumors, while AAMC high-risk was defined as Grade 3 or estrogen-negative tumors. RS low-risk group was defined as RS < 16 and age ≤ 50 years, or RS ≤ 25 and age > 50 years. RS high-risk group was defined as RS > 25. RESULTS A total of 71,212 cases were analyzed. Of these, 590 were AAMC low-risk/RS high-risk discordant, while 5,596 were AAMC high-risk/RS low-risk discordant. For AAMC low-risk/RS high-risk discordant, 10-year breast cancer-specific survival (BCSS) did not differ for patients who received adjuvant chemotherapy versus those who did not (93% chemotherapy vs. 99% unknown/no chemotherapy, p = .12). Overall survival (OS) was also comparable (92% chemotherapy vs. 91% unknown/no chemotherapy, p = .42). In the AAMC high-risk/RS low-risk discordant group, 10-year BCSS (92% chemotherapy vs. 96% unknown/no chemotherapy, p = .06) and OS (87% chemotherapy vs. 90% unknown/no chemotherapy, p = .52) did not differ between adjuvant chemotherapy and unknown/no chemotherapy groups. CONCLUSIONS Adjuvant chemotherapy in the AAMC low-risk/RS high-risk and AAMC high-risk/RS low-risk discordant groups did not improve survival. This supports consideration of omission of RS testing in Grade 1, PR + tumors. Patients with Grade 3 tumors do benefit from RS testing.
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Affiliation(s)
- Udai S Sibia
- The Rebecca Fortney Breast Center, Anne Arundel Medical Center, Annapolis, MD, USA
| | - Thomas J Sanders
- The Rebecca Fortney Breast Center, Anne Arundel Medical Center, Annapolis, MD, USA
| | - Charles Mylander
- The Rebecca Fortney Breast Center, Anne Arundel Medical Center, Annapolis, MD, USA
| | - Martin Rosman
- The Rebecca Fortney Breast Center, Anne Arundel Medical Center, Annapolis, MD, USA
| | - Carol Tweed
- The Geaton and JoAnn DeCesaris Cancer Institute, Anne Arundel Medical Center, Annapolis, MD, USA
| | - Lorraine Tafra
- The Rebecca Fortney Breast Center, Anne Arundel Medical Center, Annapolis, MD, USA
| | - Rubie S Jackson
- The Rebecca Fortney Breast Center, Anne Arundel Medical Center, Annapolis, MD, USA.
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Martin TA, Choudhry S, Holton LH, Tafra L, Jackson RS. Is Sentinel Lymph Node Biopsy Reliable After Recent Oncoplastic Breast Reduction? Am Surg 2021:31348211023408. [PMID: 34053241 DOI: 10.1177/00031348211023408] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
An oncoplastic breast reduction may disrupt normal lymphatic drainage and make subsequent identification of the sentinel lymph nodes (SLNs) unreliable. There are little data on the success rate of sentinel lymph node biopsy (SLNB) after recent oncoplastic breast reduction, and there is no agreement on whether SLNB should be done at the time of the partial mastectomy and reduction for ductal carcinoma in situ (DCIS). The primary goals of this study were to evaluate the identification rate of SLNB after recent oncoplastic or functional breast reduction and to examine recurrence rates in this setting. Results reveal SLNB is feasible in this setting. At least one SLN was found in all patients, and there were no recurrences with an average follow-up of 34 months.
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Affiliation(s)
- Tasha A Martin
- Rebecca Fortney Breast Center, 20615Anne Arundel Medical Center, Annapolis, MD, USA
| | - Salman Choudhry
- Department of General Surgery, 20615Anne Arundel Medical Center, Annapolis, MD, USA
| | - Luther H Holton
- Division of Plastic Surgery, 20615Anne Arundel Medical Center, Annapolis, MD, USA
| | - Lorraine Tafra
- Rebecca Fortney Breast Center, 20615Anne Arundel Medical Center, Annapolis, MD, USA
| | - Rubie Sue Jackson
- Rebecca Fortney Breast Center, 20615Anne Arundel Medical Center, Annapolis, MD, USA
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Boehmer L, Shivakumar L, Weldon CB, Trosman JR, Cohen SA, Nixon D, Ali-Khan Catts Z, Miesfeldt S, Wiryaman S, Tafra L, Muto L, Fadrowski N, Hulvat MC, Pallister T, Gaines C, Shelton CH. Genetic counseling and testing rates among community cancer programs for patients with breast cancer following site-directed quality improvement. J Clin Oncol 2021. [DOI: 10.1200/jco.2021.39.15_suppl.10529] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
10529 Background: National Comprehensive Cancer Network (NCCN) guidelines recommend testing for highly penetrant breast/ovarian cancer genes in several scenarios, including women with early-onset (≤ 45 years) or metastatic HER-2 negative breast cancer regardless of family history. A 2018 Association of Community Cancer Centers (ACCC) survey (N = 95) showed that > 80% of respondents reported ≤ 50% testing rate of patients with breast cancer who met guidelines. To improve rates of genetic counseling(GC)/testing, ACCC partnered with 15 community cancer programs to support site-directed quality improvement (QI) interventions. Methods: Pre- and post-intervention data from 9/15 partner programs for genetically at-risk women with early-onset or HER-2 negative metastatic breast cancer (MBC) were analyzed. Pre-intervention data were collected between 01/01/2017 and 06/30/2019 while post-intervention data were collected as early as 07/01/2019 and as late as 10/01/2020. QI project scope ranged from creation of testing eligibility education to implementation of a virtual GC clinic. De-identified data collected included: family history documentation; GC appointment; test results; and timing of results relative to surgical date. Results: The pre-intervention cohort included 2691 women and the post- cohort included 3104 women who were eligible for GC. Early-onset patients in the post-intervention group attended a GC appointment 83% (331/401) of the time and 74% (296/401) had genetic test results, with 92% (271/296) receiving results before surgery. Sixty-one percent (1387/2267) of women with HER-2 negative MBC in the post-intervention group received GC, compared to 36% (658/1845) in the pre-intervention group. There was an overall increase in the number of MBC patients with documented test results following GC in the post-intervention cohort (55% (1243/2267) versus 15% (273/1845); p < 0.0001). Rates of GC appointments improved overall, regardless of family history documentation. Rates among those with a documented high-risk family history improved from 57% (729/1284) to 85% (1485/1741) following QI interventions (p < 0.0001). There was also a significantly higher rate of GC provided in the post-intervention group among women with negative family histories (40% (462/1155) versus 23% (181/778); p < 0.0001). GC also increased from 6% (35/629) to 45% (94/208) of women in the post-intervention cohort with no documentation of family history (p < 0.0001). Conclusions: Genetic testing is underutilized in women with breast cancer. Significant improvement was achieved with QI initiatives specifically designed to target easily identified populations meeting guidelines for GC/testing. This project demonstrates the importance of attention to practice-directed strategies aimed at improving identification of risk as well as follow through to GC/testing.
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Affiliation(s)
- Leigh Boehmer
- Association of Community Cancer Centers, Rockville, MD
| | | | | | | | | | | | | | | | | | | | - Lisa Muto
- Cabell Huntington Hospital, Huntington, WV
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Lee E, Tweed C, Mylander C, Martino L, Rosman M, Huerta N, Waite K, Tafra L, Jackson RS. The Impact of Genomic Profiling on Adjuvant Therapy Recommendation in Postmenopausal Women with ER-Positive, T1-2 Breast Cancer: Can Genomic Profiling Eliminate the Need for Sentinel Lymph Node Biopsy? Clin Breast Cancer 2021; 21:e731-e737. [PMID: 34006481 DOI: 10.1016/j.clbc.2021.02.011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/06/2020] [Revised: 02/14/2021] [Accepted: 02/27/2021] [Indexed: 11/19/2022]
Abstract
INTRODUCTION With the advent of genomic assays, sentinel lymph node biopsy (SLNB) may be less impactful in determining adjuvant breast cancer therapy. We evaluated the influence of SLNB on adjuvant therapy recommendation when the Oncotype DX recurrence score (RS) is known. METHODS We reviewed postmenopausal women with ER-positive/HER2-negative, pT1-2 breast cancers with non-suspicious axillary ultrasound treated with SLNB at the time of cancer resection, from 2011 to 2015. For each case, the recommended adjuvant therapy based on the actual SLNB was compared with recommendations if SLNB had been omitted (presumed negative). RESULTS Surgical nodal status was N0 in 184 patients (84.8%), Nmi-N1 in 29 patients (13.4%), and N2-3 in 4 patients (1.8%). SLNB resulted in a recommendation for axillary lymph node dissection in 4.1% (n = 9). Axillary surgery resulted in a change in radiation recommendation (nodal radiation considered or recommended) in 15.2% (n = 33). Of the 147 patients with known RS, 95 patients had RS > 18, 29 had RS 18-25, and 23 had RS < 25. When chemotherapy was only recommended for RS > 25, or N2-3 disease, SLNB changed the recommendation to have chemotherapy in one patient (0.7%), and the recommendation of which chemotherapy regimen (second- vs. third-generation) in an additional 5 patients. CONCLUSION SLNB changed the recommendation for/against chemotherapy, or the chemotherapy regiment recommended, in 4.8% of postmenopausal women with early-stage, ER-positive/HER2-negative breast cancer, and sonographically negative axilla when using RS > 25 or N2-3 disease as an indication for chemotherapy. Preoperative genomic profiling can guide de-escalation of axillary surgery.
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Affiliation(s)
- Elaine Lee
- Rebecca Fortney Breast Center, Anne Arundel Medical Center, Annapolis, MD
| | - Carol Tweed
- Maryland Oncology Hematology, Annapolis Division, Annapolis, MD
| | - Charles Mylander
- Rebecca Fortney Breast Center, Anne Arundel Medical Center, Annapolis, MD
| | - Laura Martino
- Rebecca Fortney Breast Center, Anne Arundel Medical Center, Annapolis, MD
| | - Martin Rosman
- Rebecca Fortney Breast Center, Anne Arundel Medical Center, Annapolis, MD
| | - Nicholas Huerta
- Rebecca Fortney Breast Center, Anne Arundel Medical Center, Annapolis, MD
| | - Kip Waite
- Rebecca Fortney Breast Center, Anne Arundel Medical Center, Annapolis, MD
| | - Lorraine Tafra
- Rebecca Fortney Breast Center, Anne Arundel Medical Center, Annapolis, MD
| | - Rubie Sue Jackson
- Rebecca Fortney Breast Center, Anne Arundel Medical Center, Annapolis, MD.
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Jackson RS, Lee E, Tweed C, Mylander C, Martino L, Rosman M, Waite K, Huerta N, Tafra L. Abstract PD4-03: Can genomic profiling eliminate the need for SLNB in ER positive, T1-2 breast cancer? Cancer Res 2021. [DOI: 10.1158/1538-7445.sabcs20-pd4-03] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Abstract
Background: As tumor biology has taken precedence over anatomic staging, NCCN guidelines now allow for genomic profiling to make adjuvant treatment recommendations for Nmi-N1 breast cancer (BC). This makes nodal status, determined by sentinel lymph node biopsy (SLNB), less influential. Although generally safe, SLNB adds an incision, operative time, monetary costs, and carries risks of chronic paresthesia (9%) or lymphedema (2-6%). We hypothesized that, if ultrasound (US) excludes occult nodal metastasis and genomic profiling is used in making chemotherapy recommendations for N0-N1 disease, SLNB will be the sole indicator of a need for chemotherapy in <5% of patients.
Methods: This was a retrospective data and tissue analysis of patients treated at our breast center (11/2011 – 12/2015). Postmenopausal women with ER positive, HER2 negative, pT1-2 BC with non-suspicious axillary US who underwent SLNB without preoperative chemotherapy were included. For each patient, we compared recommended adjuvant therapy (per NCCN guidelines) based on SLNB results, versus the recommendation had SLNB been negative. For N0-N1 cases, we used Oncotype DX Breast Recurrence Score® test to determine chemotherapy. For Nmi-N1 cases, chemotherapy was considered for Recurrence Score® (RS) 18-25 and recommended for RS > 25. When not in the electronic medical record (EMR), RS result was obtained from stored specimens, with patient consent. Patients without a RS result were excluded from the chemotherapy outcomes analysis.
Results: Of 217 included patients, nodal status was as follows: N0, n=184 (85%); Nmi-N1, n=29 (13%); N2-3, n=4 (2%). Therefore, in 85% of patients SLNB did not influence any adjuvant treatment recommendation. In 4.1% of patients, SLNB resulted in a recommendation for axillary lymph node dissection (Table). In 15.2% of patients (n=33), SLNB resulted in a consideration (13.4%) or recommendation for (1.8%) nodal irradiation. RS result was available in 147 patients (68% of cohort). However, only 8 of those with unknown RS result (4% of cohort) were node-positive; for node-negative patients, RS would not affect any study outcome (change in treatment based on SLNB). Among patients with RS result, based on actual SLNB result, chemotherapy was recommended or considered in 30 patients. In 23 of these, chemotherapy would have been recommended regardless of SLNB result based on RS > 25. Therefore, SLNB made a difference in whether to recommend or consider chemotherapy in 4.7% of patients (7/147).
Conclusions: SLNB changed the recommendation whether to receive chemotherapy (no to yes, or no to consider) in only 4.7% of patients. More often, SLNB influenced the chemotherapy regimen recommended (2nd vs. 3rd generation), or local therapy recommendations. With increasing role for genomic profiling, the role of SLNB in determining adjuvant therapy is diminishing. When chemotherapy would not be considered, omission of SLNB may be considered in postmenopausal patients with ER positive, T1-2 BC and negative axillary US. If genomic profiling were performed prior to surgery, the results could change surgical management. In women with RS 0-11, SLNB is highly unlikely to alter the recommendation against chemotherapy. In women with RS > 25, chemotherapy is recommended regardless of SLN status, but a positive SLN would affect the regimen recommended. SLNB is most influential in patients with RS 18-25. Use of genomic profiling preoperatively to tailor whether SLNB is performed should be prospectively validated.
Table. Comparison of adjuvant treatment recommendations based on SLNB result vs. presumed negative SLNBBased on presumed negative SLNBBased on actual SLNB result% for whom SLNB would change treatment recommendation8Axillary lymph node dissection recommended1094.1% (9/217)Nodal irradiation recommended2041.8% (4/217)Nodal irradiation considered302913.4% (29/217)Chemotherapy recommended423240.6% (1/147)Chemotherapy considered5064.1% (6/147)Third-generation chemotherapy recommended6064.1% (6/147)Third-generation chemotherapy considered7064.1% (6/147)1)For >2 positive SLN, or gross extranodal extension (ENE). Since surgeon determination of gross ENE was not consistently available, > 2 mm of ENE on pathology was used to defined “gross” extension. 2)For N2-3 disease 3)For Nmi-N1 disease 4)For RS > 25, or N2-3 5)For Nmi-N1 disease, with RS 18-25 6)For Nmi-N1 disease with RS > 25; or N2-3; this group is a subset of those for whom chemotherapy would be recommended 7)For Nmi-N1 disease with RS 18-25; this group is a subset of those for whom chemotherapy would be recommended 8)Patients without Recurrence Score result were excluded from analysis of chemotherapy outcomes; fractions are included to show the denominator used for each calculation.
Citation Format: Rubie Sue Jackson, Elaine Lee, Carol Tweed, Charles Mylander, Laura Martino, Martin Rosman, Kip Waite, Nicholas Huerta, Lorraine Tafra. Can genomic profiling eliminate the need for SLNB in ER positive, T1-2 breast cancer? [abstract]. In: Proceedings of the 2020 San Antonio Breast Cancer Virtual Symposium; 2020 Dec 8-11; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2021;81(4 Suppl):Abstract nr PD4-03.
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Affiliation(s)
| | - Elaine Lee
- Anne Arundel Medical Center, Annapolis, MD
| | | | | | | | | | - Kip Waite
- Anne Arundel Medical Center, Annapolis, MD
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Kaufman CS, Cross MJ, Barone JL, Dekhne NS, Devisetty K, Dilworth JT, Edmonson DA, Eladoumikdachi FG, Gass JS, Hall WH, Hong RL, Kuske RR, Patton BJ, Perelson C, Phillips RF, Smith AB, Smith LA, Tafra L, Lebovic GS. A Three-Dimensional Bioabsorbable Tissue Marker for Volume Replacement and Radiation Planning: A Multicenter Study of Surgical and Patient-Reported Outcomes for 818 Patients with Breast Cancer. Ann Surg Oncol 2020; 28:2529-2542. [PMID: 33221977 PMCID: PMC8043870 DOI: 10.1245/s10434-020-09271-2] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/24/2020] [Accepted: 10/05/2020] [Indexed: 12/14/2022]
Abstract
Background Accurate identification of the tumor bed after breast-conserving surgery (BCS) ensures appropriate radiation to the tumor bed while minimizing normal tissue exposure. The BioZorb® three-dimensional (3D) bioabsorbable tissue marker provides a reliable target for radiation therapy (RT) planning and follow-up evaluation while serving as a scaffold to maintain breast contour. Methods After informed consent, 818 patients (826 breasts) implanted with the BioZorb® at 14 U.S. sites were enrolled in a national registry. All the patients were prospectively followed with the BioZorb® implant after BCS. The data collected at 3, 6, 12, and 24 months included all demographics, treatment parameters, and provider/patient-assessed cosmesis. Results The median follow-up period was 18.2 months (range, 0.2–53.4 months). The 30-day breast infection rate was 0.5 % of the patients (n = 4), and re-excision was performed for 8.1 % of the patients (n = 66), whereas 2.6 % of the patients (n = 21) underwent mastectomy. Two patients (0.2 %) had local recurrence. The patient-reported cosmetic outcomes at 6, 12, and 24 months were rated as good-to-excellent by 92.4 %, 90.6 %, and 87.3 % of the patients, respectively and similarly by the surgeons. The radiation oncologists reported planning of target volume (PTV) reduction for 46.2 % of the patients receiving radiation boost, with PTV reduction most commonly estimated at 30 %. Conclusions This report describes the first large multicenter study of 818 patients implanted with the BioZorb® tissue marker during BCS. Radiation oncologists found that the device yielded reduced PTVs and that both the patients and the surgeons reported good-to-excellent long-term cosmetic outcomes, with low adverse effects. The BioZorb® 3D tissue marker is a safe adjunct to BCS and may add benefits for both surgeons and radiation oncologists. Electronic supplementary material The online version of this article (10.1245/s10434-020-09271-2) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Cary S Kaufman
- Department of Surgery, University of Washington, Seattle, WA, USA. .,Bellingham Regional Breast Center, 2075 Barkley Blvd. Suite 250, Bellingham, WA, USA.
| | | | | | | | | | | | - David A Edmonson
- Womens Oncology, Women and Infants Hospital, Providence, RI, USA
| | | | - Jennifer S Gass
- Women and Infants Hospital, Breast Health Center, Providence, RI, USA
| | - William H Hall
- Radiation Oncology, PeaceHealth St. Joseph Medical Center, Bellingham, WA, USA
| | - Robert L Hong
- Virginia Hospital Center, Arlington Health System, Arlington, VA, USA
| | | | | | | | | | | | | | - Lorraine Tafra
- Anne Arundel Medical Center, The Breast Center, Annapolis, MD, USA
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Boehmer L, Shivakumar L, Weldon CB, Trosman JR, Cohen SA, Nixon D, Ali-Khan Catts Z, Miesfeldt S, Wiryaman S, Tafra L, Muto L, Fadrowski N, Hulvat M, Pallister T, Shelton CH. BRCA testing concordance with national guidelines for patients with breast cancer in community cancer programs. J Clin Oncol 2020. [DOI: 10.1200/jco.2020.38.15_suppl.1526] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
1526 Background: Current National Comprehensive Cancer Network guidelines for genetic/familial high-risk assessment state that testing for highly penetrant breast/ovarian cancer genes is clinically indicated for women with early onset (≤ 45 years) or metastatic HER-2 negative breast cancer. A recent Association of Community Cancer Centers (ACCC) survey (N = 95) showed that > 80% of respondents reported ≤ 50% testing rate of patients with breast cancer who met guidelines. Given this disconnect, ACCC partnered with 15 community cancer programs to assess practice gaps and support interventions to improve access to genetic counseling (GC)/testing. Methods: Pre-intervention data from 9/15 partner programs for women diagnosed with stages 0-III breast cancer between 01/01/2017 and 06/30/2019 was collected. De-identified variables included: family history documentation, GC appointment/test results, and timing of results relative to treatment decisions. Results: There were 2691 women with stages 0-III breast cancer. Forty-eight percent (1284/2691) had a documented high-risk family history, 57% (729/1284) of whom had a GC appointment. This was a significantly higher rate of GC compared to the 23% (181/778) of women with no family history and 6% (35/629) of women with no documentation of family history (p < 0.0001). Patients ≤ 45 years old attended a GC appointment 72% (199/278) of the time and 49% (135/278) had genetic test results, with 84% (113/135) receiving results before surgery. For women with test results available before surgery, 37% (119/322) had breast conserving surgery, compared to 60% (144/240) with test results disclosed post-operatively (p < 0.0001). Conclusions: Genetic testing is underutilized in a community cohort of women with breast cancer. Further analysis is needed to understand the impact genetic test results have on surgical decisions. Opportunities exist to improve current rates of appropriate GC/testing. ACCC will share results of quality improvement projects to illuminate which strategies hold promise in reducing the hereditary breast cancer GC/testing practice gap.
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Affiliation(s)
- Leigh Boehmer
- Association of Community Cancer Centers, Rockville, MD
| | | | | | | | | | | | | | | | | | | | - Lisa Muto
- Cabell Huntington Hospital, Huntington, WV
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Le Du F, Takeo F, Park M, Hess K, Liu D, Jackson R, Mylander C, Rosman M, Raghavendra A, Tafra L, Ueno N. 10P Prediction of the 21-gene recurrence score by a non-genomic approach in stage I estrogen receptor-positive, HER2-negative breast cancer. Ann Oncol 2020. [DOI: 10.1016/j.annonc.2020.03.146] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022] Open
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12
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Tran HT, Pack D, Mylander C, Martino L, Rosman M, Tafra L, Jackson RS. Ultrasound-Based Nomogram Identifies Breast Cancer Patients Unlikely to Harbor Axillary Metastasis: Towards Selective Omission of Sentinel Lymph Node Biopsy. Ann Surg Oncol 2020; 27:2679-2686. [PMID: 32026063 DOI: 10.1245/s10434-019-08164-3] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/22/2019] [Indexed: 11/18/2022]
Abstract
BACKGROUND As tumor biology takes precedence over anatomic staging to determine breast cancer (BC) prognosis, there is growing interest in limiting axillary surgery. There is a need for tools to identify patients at the lowest risk of harboring axillary lymph node (ALN) disease, to determine when omission of sentinel lymph node biopsy (SLNB) may be appropriate. We examined whether a nomogram using preoperative axillary ultrasound (axUS) findings, clinical tumor size, receptor status, and grade to calculate the probability of nodal metastasis (PNM) has value in surgical decision making. METHODS This was a retrospective analysis of female patients (February 2011-October 2014) with invasive BC who underwent preoperative axUS and axillary surgery. Cases with locally advanced BC, neoadjuvant treatment, or bilateral BC were excluded. PNM was calculated for each case. Using various PNM thresholds, the proportion of cases with ALN metastasis on pathology was examined to determine an optimal PNM cut-point to predict ALN negativity. RESULTS Of 357 included patients, 72% were node-negative on surgical staging, and 69 (19.6%) had a PNM < 9.3%. Of these 69 patients, 6 had ALN metastasis on surgical pathology, yielding a false negative rate (FNR) of 8.7% for predicting negative ALN when a PNM threshold of < 9.3% was used. CONCLUSION A nomogram incorporating axUS findings and tumor characteristics identified a sizeable subgroup (19.6%) in whom ALN was predicted to be negative, with an 8.7% FNR. Surgeons can use this nomogram to quantify the probability of ALN metastasis and select patients who may benefit from omitting SLNB.
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Affiliation(s)
- Hanh-Tam Tran
- The Rebecca Fortney Breast Center, Anne Arundel Medical Center, Annapolis, MD, USA
| | - Daina Pack
- The Rebecca Fortney Breast Center, Anne Arundel Medical Center, Annapolis, MD, USA
| | - Charles Mylander
- The Rebecca Fortney Breast Center, Anne Arundel Medical Center, Annapolis, MD, USA
| | - Laura Martino
- The Rebecca Fortney Breast Center, Anne Arundel Medical Center, Annapolis, MD, USA
| | - Martin Rosman
- The Rebecca Fortney Breast Center, Anne Arundel Medical Center, Annapolis, MD, USA
| | - Lorraine Tafra
- The Rebecca Fortney Breast Center, Anne Arundel Medical Center, Annapolis, MD, USA
| | - Rubie Sue Jackson
- The Rebecca Fortney Breast Center, Anne Arundel Medical Center, Annapolis, MD, USA.
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Gage MM, Mylander WC, Rosman M, Fujii T, Le Du F, Raghavendra A, Sinha AK, Espinosa Fernandez JR, James A, Ueno NT, Tafra L, Jackson RS. Combined pathologic-genomic algorithm for early-stage breast cancer improves cost-effective use of the 21-gene recurrence score assay. Ann Oncol 2019; 29:1280-1285. [PMID: 29788166 DOI: 10.1093/annonc/mdy074] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022] Open
Abstract
Background The 21-gene recurrence score (RS) (Oncotype DX®; Genomic Health, Redwood City, CA) partitions hormone receptor positive, node negative breast cancers into three risk groups for recurrence. The Anne Arundel Medical Center (AAMC) model has previously been shown to accurately predict RS risk categories using standard pathology data. A pathologic-genomic (P-G) algorithm then is presented using the AAMC model and reserving the RS assay only for AAMC intermediate-risk patients. Patients and methods A survival analysis was done using a prospectively collected institutional database of newly diagnosed invasive breast cancers that underwent RS assay testing from February 2005 to May 2015. Patients were assigned to risk categories based on the AAMC model. Using Kaplan-Meier methods, 5-year distant recurrence rates (DRR) were evaluated within each risk group and compared between AAMC and RS-defined risk groups. Five-year DRR were calculated for the P-G algorithm and compared with DRR for RS risk groups and the AAMC model's risk groups. Results A total of 1268 cases were included. Five-year DRR were similar between the AAMC low-risk group (2.7%, n = 322) and the RS < 18 low-risk group (3.4%, n = 703), as well as between the AAMC high-risk group (22.8%, n = 230) and the RS > 30 high-risk group (23.0%, n = 141). Using the P-G algorithm, more patients were categorized as either low or high risk and the distant metastasis rate was 3.3% for the low-risk group (n = 739) and 24.2% for the high-risk group (n = 272). Using the P-G algorithm, 44% (552/1268) of patients would have avoided RS testing. Conclusions AAMC model is capable of predicting 5-year recurrences in high- and low-risk groups similar to RS. Further, using the P-G algorithm, reserving RS for AAMC intermediate cases, results in larger low- and high-risk groups with similar prognostic accuracy. Thus, the P-G algorithm reliably identifies a significant portion of patients unlikely to benefit from RS assay and with improved ability to categorize risk.
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Affiliation(s)
- M M Gage
- Department of Surgery, Johns Hopkins Hospital, Baltimore
| | - W C Mylander
- The Rebecca Fortney Breast Center, Anne Arundel Medical Center, Annapolis
| | - M Rosman
- The Rebecca Fortney Breast Center, Anne Arundel Medical Center, Annapolis
| | - T Fujii
- Department of Breast Medical Oncology, The University of Texas MD Anderson Cancer Center, Houston, USA
| | - F Le Du
- Department of Breast Medical Oncology, The University of Texas MD Anderson Cancer Center, Houston, USA
| | - A Raghavendra
- Department of Breast Medical Oncology, The University of Texas MD Anderson Cancer Center, Houston, USA
| | - A K Sinha
- Department of Breast Medical Oncology, The University of Texas MD Anderson Cancer Center, Houston, USA
| | - J R Espinosa Fernandez
- Department of Breast Medical Oncology, The University of Texas MD Anderson Cancer Center, Houston, USA
| | - A James
- Department of Breast Medical Oncology, The University of Texas MD Anderson Cancer Center, Houston, USA
| | - N T Ueno
- Department of Breast Medical Oncology, The University of Texas MD Anderson Cancer Center, Houston, USA.
| | - L Tafra
- The Rebecca Fortney Breast Center, Anne Arundel Medical Center, Annapolis
| | - R S Jackson
- The Rebecca Fortney Breast Center, Anne Arundel Medical Center, Annapolis.
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14
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Bleicher RJ, Chang C, Wang CE, Goldstein LJ, Kaufmann CS, Moran MS, Pollitt KA, Suss NR, Winchester DP, Tafra L, Yao K. Treatment delays from transfers of care and their impact on breast cancer quality measures. Breast Cancer Res Treat 2018; 173:603-617. [DOI: 10.1007/s10549-018-5046-x] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/01/2018] [Accepted: 11/08/2018] [Indexed: 11/25/2022]
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15
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Abstract
INTRODUCTION Controversy over the need for sentinel node biopsy (SNB) continues to exist for the optimal treatment of breast cancer in patients ≥ 70 years of age, especially in those with lower-risk disease. Clinicians must balance competing risks to give the best individualized care. METHODS The American Society of Breast Surgeons (ASBrS) conducted a debate discussing the pros and cons of routinely performing SNB in this age group. Small, randomized studies have been conducted that show no overall survival benefit to axillary intervention (either axillary dissection or SNB) in patients with clinically T1N0 estrogen receptor (ER)- and progesterone receptor (PR)-positive, HER2/neu-negative tumors. There may be a small local recurrence benefit to axillary staging in patients who do not undergo radiation. Alternatively, axillary ultrasound, which carries a low false-negative rate for heavy disease burden, can be used to select patients who can avoid SNB. CONCLUSION Surgeons must continue to individualize care of breast cancer patients over 70 years of age in whom competing comorbidities may dictate care. No randomized clinical trials (RCTs) have found a survival benefit to axillary staging in this low-risk population. However, in healthy patients, axillary staging may improve local control, provide prognostic information, and help guide decisions regarding adjuvant therapy such as chemotherapy and radiation. Ongoing RCTs are evaluating the benefit of SNB in patients with a negative axillary ultrasound. Until those results are available, clinicians and patients must balance the risk and benefits to determine if SNB adds significant value to their overall care.
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Affiliation(s)
- Sarah L Blair
- University of California San Diego, La Jolla, CA, USA.
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16
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Wellington J, Sanders T, Mylander C, Alden A, Harris C, Buras R, Tafra L, Liang W, Stelle L, Rosman M, Jackson RS. Routine Axillary Ultrasound for Patients with T1–T2 Breast Cancer Does Not Increase the Rate of Axillary Lymph Node Dissection Based on Predictive Modeling. Ann Surg Oncol 2018; 25:2271-2278. [DOI: 10.1245/s10434-018-6545-z] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/21/2018] [Indexed: 11/18/2022]
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17
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Stelle L, Wellington J, Liang W, Buras R, Tafra L. Local-Regional Evaluation and Therapy: Maximizing Margin-Negative Breast Cancer Resection Rates on the First Try. Curr Breast Cancer Rep 2018. [DOI: 10.1007/s12609-018-0273-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/17/2022]
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18
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Kaufmann C, Barone J, Cross M, Dekhne N, Devisetty K, Dilworth J, Edmonson D, Eladoumikdachi F, Gass J, Hong R, Kuske R, Lebovic G, Patton B, Phillips R, Tafra L, Smith A, Smith L. Use of a 3-D bioabsorbable marker for planning and targeting radiation to the lumpectomy cavity: 3 year results from a registry study. Eur J Cancer 2018. [DOI: 10.1016/s0959-8049(18)30454-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/17/2022]
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Mylander C, Rosman M, Gage M, Fujii T, Le Du F, Raghavendra A, Sinha A, Espinosa Fernandez JR, James A, Ueno N, Tafra L, Jackson R. Abstract P3-09-05: Getting the most out of the 21-gene recurrence score assay: Increasing actionable results with a combined pathologic-genomic model. Cancer Res 2018. [DOI: 10.1158/1538-7445.sabcs17-p3-09-05] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Abstract
Introduction: The 21-gene recurrence score (RS) assay categorizes hormone receptor positive, node negative breast cancers (BC) into 3 risk groups for recurrence. We previously showed that the AAMC Model, using only standard pathology data, accurately does the same. This study compares the recurrence rate of the AAMC Model's risk groups to RS-based risk groups. A 2-step approach then is used, in which the AAMC model is applied first, and the RS assay is used only for AAMC intermediate risk cases. AAMC intermediate cases were reclassified by RS into low or high risk groups.
Methods: From a prospective registry of newly diagnosed BC, we selected invasive, hormone receptor positive, HER2 negative, lymph node negative cases from 2005 to 2015 tested with RS assay. Five-year Kaplan-Meier distant recurrence rates were calculated for each risk category.
Results: 1268 cases were included. Five-year recurrence rates were similar between the AAMC Model's low risk group and RS<18 low risk group, as well as between the AAMC Model's high risk group and the RS>30 high risk group. Applying the RS assay to the 715 cases in the AAMC Model's intermediate group resulted in re-classifying 417 (58%) as low risk and 41 (6%) as high risk. Using RS alone, 33% of cases were intermediate risk (n=424), whereas in the 2-step approach 20% were intermediate risk (n=257). For the 2-step approach, the 5-year distant recurrence rate was 3.3% for the low risk group (n=740) and 24.4% for the high risk group (n=271).
Conclusions: Five-year recurrence rates in the AAMC Model's low and high risk groups were similar to those in RS-based risk groups. The 2-step approach, with RS used only for AAMC intermediate cases, resulted in larger low and high risk groups with equivalent prognostic accuracy, compared to use of the RS assay alone. The 2-step approach reliably identifies a large number of patients unlikely to benefit from 21 gene assay and provides substantial cost savings.
Kaplan-Meier Calculated 5-year Distant Recurrences Rates for 4 Models: 1268 Patients Oncotype DXTAILORxAAMC Model2 Step Model with OncotypeDX for AAMC IntermediatesLow RiskRS < 18 (n=703)RS < 11 (n=250)Grade 1 and PR ≥ 1% (n=323)AAMC Low or AAMC intermediate/RS <18 (n=740) 3.4% (95% CI 1.6 – 5.1%, nf=17)4.0% (95% CI 0.8 – 7.2%, nf=8)2.7% (95% CI 0.0 – 5.4%, nf=5)3.3% (95% CI 1.4 – 5.2%, nf=16)Intermediate RiskRS 18 - 30 (n=424)RS 11 - 25 (n=787)Not meeting AAMC definition for low or high risk (n=715)AAMC Intermediate and RS 18-30 (n=257) 15.2% (95% CI 10.3 – 20.1%, nf=38)7.3% (95% CI 4.7 – 9.9%, nf=35)8.4% (95% CI 5.4 – 11.3%, nf=36)12.0% (95% CI 5.8 – 18.1%, nf=15)High RiskRS > 30 (n=141)RS > 25 (n=231)Grade 3 or ER < 20% (n=230)AAMC High or AAMC intermediate/RS > 30 (n=271) 23.0% (95% CI 14.7 – 31.3%, nf=27)22.9% (95% CI 15.9 – 29.9%, nf=39)22.8% (95% CI 16.1 – 29.5%, nf=41)24.4% (95% CI 18.0 – 30.7%, nf=51)RS= Recurrence Score, nf=number of recurrences, CI = confidence interval.
Citation Format: Mylander C, Rosman M, Gage M, Fujii T, Le Du F, Raghavendra A, Sinha A, Espinosa Fernandez JR, James A, Ueno N, Tafra L, Jackson R. Getting the most out of the 21-gene recurrence score assay: Increasing actionable results with a combined pathologic-genomic model [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 P3-09-05.
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Affiliation(s)
- C Mylander
- Anne Arundel Medical Center, Annapolis, MD; Walter Reed National Military Medical Center, Bethesda, MD; MD Anderson Cancer Center, Houston, TX
| | - M Rosman
- Anne Arundel Medical Center, Annapolis, MD; Walter Reed National Military Medical Center, Bethesda, MD; MD Anderson Cancer Center, Houston, TX
| | - M Gage
- Anne Arundel Medical Center, Annapolis, MD; Walter Reed National Military Medical Center, Bethesda, MD; MD Anderson Cancer Center, Houston, TX
| | - T Fujii
- Anne Arundel Medical Center, Annapolis, MD; Walter Reed National Military Medical Center, Bethesda, MD; MD Anderson Cancer Center, Houston, TX
| | - F Le Du
- Anne Arundel Medical Center, Annapolis, MD; Walter Reed National Military Medical Center, Bethesda, MD; MD Anderson Cancer Center, Houston, TX
| | - A Raghavendra
- Anne Arundel Medical Center, Annapolis, MD; Walter Reed National Military Medical Center, Bethesda, MD; MD Anderson Cancer Center, Houston, TX
| | - A Sinha
- Anne Arundel Medical Center, Annapolis, MD; Walter Reed National Military Medical Center, Bethesda, MD; MD Anderson Cancer Center, Houston, TX
| | - JR Espinosa Fernandez
- Anne Arundel Medical Center, Annapolis, MD; Walter Reed National Military Medical Center, Bethesda, MD; MD Anderson Cancer Center, Houston, TX
| | - A James
- Anne Arundel Medical Center, Annapolis, MD; Walter Reed National Military Medical Center, Bethesda, MD; MD Anderson Cancer Center, Houston, TX
| | - N Ueno
- Anne Arundel Medical Center, Annapolis, MD; Walter Reed National Military Medical Center, Bethesda, MD; MD Anderson Cancer Center, Houston, TX
| | - L Tafra
- Anne Arundel Medical Center, Annapolis, MD; Walter Reed National Military Medical Center, Bethesda, MD; MD Anderson Cancer Center, Houston, TX
| | - R Jackson
- Anne Arundel Medical Center, Annapolis, MD; Walter Reed National Military Medical Center, Bethesda, MD; MD Anderson Cancer Center, Houston, TX
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Jackson RS, Sanders T, Park A, Buras R, Liang W, Harris C, Mylander C, Rosman M, Holton L, Singh D, Martino L, Tafra L. Prospective Study Comparing Surgeons’ Pain and Fatigue Associated with Nipple-Sparing versus Skin-Sparing Mastectomy. Ann Surg Oncol 2017; 24:3024-3031. [DOI: 10.1245/s10434-017-5929-9] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/17/2017] [Indexed: 11/18/2022]
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21
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Harris CK, Tran HT, Lee K, Mylander C, Pack D, Rosman M, Tafra L, Umbricht CB, Andrade R, Liang W, Jackson RS. Positive Ultrasound-guided Lymph Node Needle Biopsy in Breast Cancer may not Mandate Axillary Lymph Node Dissection. Ann Surg Oncol 2017; 24:3004-3010. [PMID: 28766210 DOI: 10.1245/s10434-017-5935-y] [Citation(s) in RCA: 31] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/16/2017] [Indexed: 11/18/2022]
Abstract
BACKGROUND The ACOSOG Z0011 (Z11) trial demonstrated that in patients with nonpalpable axillary lymph nodes (LN) and one to two positive sentinel LN (SLN), axillary LN dissection (ALND) is unnecessary.JAMA 305:569-575, [2011], Ann Surg 264:413-42, [2016] The Z11 trial did not require preoperative axillary ultrasound (axUS). In many centers, preoperative axUS is part of the standard workup of a newly diagnosed breast cancer patient, but in light of the Z11 results, its role is now questioned. METHODS We retrospectively analyzed newly diagnosed breast cancer patients at two institutions. Inclusion criteria were patients with (1) no palpable lymphadenopathy, (2) abnormal axUS, (3) axillary LN metastasis confirmed preoperatively by axUS-lymph node needle biopsy, (4) no neoadjuvant therapy, and (5) ALND. LN disease burden was dichotomized as N1 versus N2-3. We examined relationships between clinicopathologic factors, including axUS characteristics, and LN disease burden. RESULTS Of 129 included cases, 67 had N1 disease (51.9%) and 62 had N2-3 disease (48.1%). Factors significantly associated with N1 disease were tumor size ≤2 cm (p = 0.012), nonlobular histology (p = 0.013), and one suspicious LN on axUS (p = 0.008). For patients with both tumor size on imaging ≤2 cm and one abnormal LN on axUS, only 27% had N2-3 disease (p = 0.007). CONCLUSIONS More than half of patients without palpable adenopathy but with preoperative US-guided biopsy proven axillary LN metastases had N1 disease. For patients with both tumor size ≤2 cm and only 1 abnormal LN on axUS, 73% had N1 disease. This suggests that such patients, if they are otherwise analogous to Z11 patients, may undergo attempt at SLNB.
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Affiliation(s)
- Christine K Harris
- Rebecca Fortney Breast Center, Anne Arundel Medical Center, Annapolis, USA.
| | - Hanh Tam Tran
- Department of General Surgery, Union Memorial Hospital, Baltimore, USA
| | - Katherine Lee
- Rebecca Fortney Breast Center, Anne Arundel Medical Center, Annapolis, USA
| | - Charles Mylander
- Anne Arundel Medical Center, Annapolis, USA.,Division of Mathematics, US Naval Academy, Annapolis, USA
| | - Daina Pack
- Rebecca Fortney Breast Center, Anne Arundel Medical Center, Annapolis, USA
| | | | - Lorraine Tafra
- Rebecca Fortney Breast Center, Anne Arundel Medical Center, Annapolis, USA
| | - Christopher B Umbricht
- Division of Endocrine and Oncologic Surgery, Johns Hopkins Hospital and Health System, Baltimore, USA
| | - Reema Andrade
- Rebecca Fortney Breast Center, Anne Arundel Medical Center, Annapolis, USA
| | - Wen Liang
- Rebecca Fortney Breast Center, Anne Arundel Medical Center, Annapolis, USA
| | - Rubie Sue Jackson
- Rebecca Fortney Breast Center, Anne Arundel Medical Center, Annapolis, USA
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22
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Winner M, Rosman M, Mylander C, Jackson RS, Pozo ME, Wolff AC, Tafra L, Umbricht CB. Abstract P2-05-13: Negative progesterone receptor is associate early breast cancer relapse, even among good prognosis tumors. Cancer Res 2017. [DOI: 10.1158/1538-7445.sabcs16-p2-05-13] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Abstract
Background/objective: A minority of estrogen-receptor (ER) positive breast cancers lack progesterone receptor (PR) expression, but little is known of the clinical meaning of PR negativity (PR-). In the present study we sought to clarify the association between PR- and outcomes of ER+, human-epidermal growth factor (HER2)-negative breast cancers using a large, single institution database.
Methods: We retrospectively analyzed consecutive, non-metastatic, unilateral HER2- invasive breast cancers diagnosed between 2000 and 2011. Records were reviewed for age at diagnosis, disease stage, tumor features, and histologically confirmed recurrence. ER+ and PR+ status was defined as ≥1% immunoreactive cells. We used Kaplan-Meier curves to determine the association between PR- and early (≤5 years) and late (>5 years) disease recurrence, defined as locoregional or distant breast cancer relapse >6 months after diagnosis.
Results: We identified 1,933 patients with TN (n=337) or ER+/HER2- (n=1,596) breast cancer. Patients with ER+/PR- (n=107) vs. ER+/PR+ (n=1,489) tumors did not differ in age or disease stage at diagnosis; however, PR- tumors were more frequently high grade (37.9% vs. 17.8%, p<0.001), with higher median Ki67 indices (20.0% vs. 10.0%, p<0.001). Median ER expression was also lower in PR- as compared to PR+ tumors (80.0% vs. 90.0%, p<0.001).
Over a median follow-up of 84 months, there were 119 early and 54 late locoregional or distant breast cancer relapses. Negative PR was strongly associated with early relapse, with PR- tumors demonstrating a 2.1-fold higher hazard of relapse in the first 5 years as compared to PR+ tumors (95% CI 1.0-4.2)
Hazards of early (<5 years) breast cancer relapse by hormone status. Shown are univariable Cox proportional hazard ratios and 95% confidence intervals among all tumors, and in subsets defined by %ER, node status, Ki67, and grade. All tumors n=1,933High ER (80-100%) n=1,383TN3.9 (2.6-5.6)*--PR 0%2.1 (1.0-4.2)*1.7 (0.6-4.6)PR 1-100%ReferenceReference Node-negative n=1,299Node-positive n=634TN4.3 (2.5-7.5)*3.6 (2.1-6.0)*PR 0%2.7 (1.0-7.0)*1.6 (0.6-4.5)PR 1-100%ReferenceReference Ki67 <14% n=768Ki67 ≥14% n=997TN**2.4 (1.5-3.8)*PR 0%4.1 (1.2-14.1)*1.6 (0.7-3.8)PR 1-100%ReferenceReference Grade 1/2 n=1,337Grade 3 n=564TN3.4 (1.4-7.9)*1.9 (1.2-3.3)*PR 0%2.0 (0.7-5.7)1.2 (0.4-3.5)PR 1-100%ReferenceReference*p<0.05; **too few subjects/events for analysis.
Negative PR remained significantly associated with a higher hazard of early relapse even in node-negative (HR 2.7, 95%CI 1.0-7.0) and low-proliferating tumors (Ki67<14%, HR 4.1, 95%CI 1.2-14.1). There was no significant association between PR- and late breast cancer relapse (HR 0.7, 95%CI 0.2-2.9).
Conclusions: Compared to ER+/PR+ breast cancers, ER+/PR- breast cancers have a significantly greater risk of early recurrence, similar to triple-negative cancers. These results suggest that negative PR expression is importantly and independently associated with early breast cancer prognosis, and may be an indicator of unique tumor biology.
Citation Format: Winner M, Rosman M, Mylander C, Jackson RS, Pozo ME, Wolff AC, Tafra L, Umbricht CB. Negative progesterone receptor is associate early breast cancer relapse, even among good prognosis tumors [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 P2-05-13.
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Affiliation(s)
- M Winner
- Johns Hopkins University School of Medicine, Baltimore, MD; The Breast Center, Anne Arundel Medical Center, Annapolis, MD
| | - M Rosman
- Johns Hopkins University School of Medicine, Baltimore, MD; The Breast Center, Anne Arundel Medical Center, Annapolis, MD
| | - C Mylander
- Johns Hopkins University School of Medicine, Baltimore, MD; The Breast Center, Anne Arundel Medical Center, Annapolis, MD
| | - RS Jackson
- Johns Hopkins University School of Medicine, Baltimore, MD; The Breast Center, Anne Arundel Medical Center, Annapolis, MD
| | - ME Pozo
- Johns Hopkins University School of Medicine, Baltimore, MD; The Breast Center, Anne Arundel Medical Center, Annapolis, MD
| | - AC Wolff
- Johns Hopkins University School of Medicine, Baltimore, MD; The Breast Center, Anne Arundel Medical Center, Annapolis, MD
| | - L Tafra
- Johns Hopkins University School of Medicine, Baltimore, MD; The Breast Center, Anne Arundel Medical Center, Annapolis, MD
| | - CB Umbricht
- Johns Hopkins University School of Medicine, Baltimore, MD; The Breast Center, Anne Arundel Medical Center, Annapolis, MD
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Mylander C, Jackson RS, Rosman M, Fujii T, Le Du F, Raghavendra A, Sinha A, Ueno NT, Tafra L. Abstract PD7-03: A model using grade and hormone receptor staining defines groups at low vs. high risk for distant metastasis: Comparison to the 21-gene recurrence score. Cancer Res 2017. [DOI: 10.1158/1538-7445.sabcs16-pd7-03] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Abstract
Background: The 21-gene recurrence score (RS) combines breast cancer (BC) expression of multiple genes into a single number which is prognostic for BC recurrence. We previously showed that a model using standard pathology data (AAMC Risk Groups) has substantial overlap with RS Risk Groups. The present study compared the recurrence rate of AAMC Risk Groups to that of RS-based Risk Groups as defined by the TAILORx trial and OncotypeDX (ODX) assay.
Methods: From a prospective registry of BC treated at MD Anderson Cancer Center (2/2005 – 5/2015), we selected cases tested with ODX. Cases were excluded for: other cancer in the past 5 years, T4 stage, node positivity, missing grade, missing ER%, ER&PR<1% or HER2 positivity. Three methods were used to categorize distant metastatic risk: ODX and TAILORx Risk Groups were defined using RS, and AAMC Risk Groups were defined using grade and ER/PR level (Tables). For each method, the proportion of patients experiencing metastasis was calculated within Risk Groups.
Results: 1296 cases were included, with a mean follow-up of 3.5 years (25% had ≥ 4.9 years of follow-up). 82 cases (6.3%, 95% CI 5.1 – 7.8%) experienced distant metastasis, with a mean time-to-metastasis of 2.7 years. The proportion of patients experiencing distant metastasis was similar between the AAMC Low Risk Group (1.5%) and the TAILORx (3.2%) and ODX (2.4%) Low Risk Groups. The AAMC Low Risk Group was less than half the size of the ODX Low Risk Group. Of the 5 recurrences in the AAMC Low Risk Group, 1 was ODX Low Risk and 4 were ODX Intermediate Risk; 2 had 1% PR staining. Of the 17 recurrences in the ODX Low Risk Group, 1 was AAMC Low Risk and 5 (all grade 3) were AAMC High Risk; 3 had PR staining < 10%. The proportion of patients experiencing distant metastasis was similar between the AAMC High Risk Group (17.4%) and the TAILORx (16.4%) and ODX (18.2%) High Risk Groups. The number of patients in the AAMC High Risk Group was greater than the ODX High Risk Group.
Table 1: Distant Metastasis in Low Risk GroupsAAMC Definition (n=329)TAILORx Definition (n=250)OncotypeDX Definition (n=704)Low Risk DefinitionGrade 1 & PR ≥1%RS < 11RS <18% with Distant Metastasis1.5% (95% CI 0.6–3.7%; n=5)3.2% (95% CI 1.5-6.4%, n=8)2.4% (95% CI 1.5-3.9%, n=17)% in Common with AAMC Low Risk Group100% (329/329)31.7% (80/250)33.3% (235/704)
Table 2: Distant Metastasis in High Risk GroupsAAMC Definition (n=235)TAILORx Definition (n=238)OncotypeDX Definition (n=148)High Risk DefinitionGrade 3 or ER <20%RS > 25RS > 30% with Distant Metastasis17.4% (95% CI 12.9-23.0%, n=41)16.4% (95% CI 12.0-21.8%, n=39)18.2% (95% CI 12.6– 25.6%, n=27)% in Common with AAMC High Risk Group100% (235/235)56.7% (135/238)70.3% (104/148)
Conclusions: AAMC Low and High Risk Groups were prognostic of the likelihood of distant metastasis, and performed similarly to TAILORx and ODX Low and High Risk Groups. If RS were omitted for AAMC Low and High Risk cases, 44% [(329+235)/1296] of cases in the present cohort could have been spared ODX testing. The AAMC Risk Groups, using standard pathology data, can reliably identify a large number of patients unlikely to benefit from ODX testing and thus provide substantial cost savings.
Citation Format: Mylander C, Jackson RS, Rosman M, Fujii T, Le Du F, Raghavendra A, Sinha A, Ueno NT, Tafra L. A model using grade and hormone receptor staining defines groups at low vs. high risk for distant metastasis: Comparison to the 21-gene recurrence score [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 PD7-03.
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Affiliation(s)
- C Mylander
- The Rebecca Fortney Breast Center; Anne Arundel Medical Center, Annapolis, MD; MD Anderson Cancer Center, Houston, TX; Département d'Oncologie Médicale Centre Eugène Marquis, Rennes, France
| | - RS Jackson
- The Rebecca Fortney Breast Center; Anne Arundel Medical Center, Annapolis, MD; MD Anderson Cancer Center, Houston, TX; Département d'Oncologie Médicale Centre Eugène Marquis, Rennes, France
| | - M Rosman
- The Rebecca Fortney Breast Center; Anne Arundel Medical Center, Annapolis, MD; MD Anderson Cancer Center, Houston, TX; Département d'Oncologie Médicale Centre Eugène Marquis, Rennes, France
| | - T Fujii
- The Rebecca Fortney Breast Center; Anne Arundel Medical Center, Annapolis, MD; MD Anderson Cancer Center, Houston, TX; Département d'Oncologie Médicale Centre Eugène Marquis, Rennes, France
| | - F Le Du
- The Rebecca Fortney Breast Center; Anne Arundel Medical Center, Annapolis, MD; MD Anderson Cancer Center, Houston, TX; Département d'Oncologie Médicale Centre Eugène Marquis, Rennes, France
| | - A Raghavendra
- The Rebecca Fortney Breast Center; Anne Arundel Medical Center, Annapolis, MD; MD Anderson Cancer Center, Houston, TX; Département d'Oncologie Médicale Centre Eugène Marquis, Rennes, France
| | - A Sinha
- The Rebecca Fortney Breast Center; Anne Arundel Medical Center, Annapolis, MD; MD Anderson Cancer Center, Houston, TX; Département d'Oncologie Médicale Centre Eugène Marquis, Rennes, France
| | - NT Ueno
- The Rebecca Fortney Breast Center; Anne Arundel Medical Center, Annapolis, MD; MD Anderson Cancer Center, Houston, TX; Département d'Oncologie Médicale Centre Eugène Marquis, Rennes, France
| | - L Tafra
- The Rebecca Fortney Breast Center; Anne Arundel Medical Center, Annapolis, MD; MD Anderson Cancer Center, Houston, TX; Département d'Oncologie Médicale Centre Eugène Marquis, Rennes, France
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Kim HS, Umbricht CB, Illei PB, Cimino-Mathews A, Cho S, Chowdhury N, Figueroa-Magalhaes MC, Pesce C, Jeter SC, Mylander C, Rosman M, Tafra L, Turner BM, Hicks DG, Jensen TA, Miller DV, Armstrong DK, Connolly RM, Fetting JH, Miller RS, Park BH, Stearns V, Visvanathan K, Wolff AC, Cope L. Optimizing the Use of Gene Expression Profiling in Early-Stage Breast Cancer. J Clin Oncol 2016; 34:4390-4397. [PMID: 27998227 DOI: 10.1200/jco.2016.67.7195] [Citation(s) in RCA: 43] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/03/2023] Open
Abstract
Purpose Gene expression profiling assays are frequently used to guide adjuvant chemotherapy decisions in hormone receptor-positive, lymph node-negative breast cancer. We hypothesized that the clinical value of these new tools would be more fully realized when appropriately integrated with high-quality clinicopathologic data. Hence, we developed a model that uses routine pathologic parameters to estimate Oncotype DX recurrence score (ODX RS) and independently tested its ability to predict ODX RS in clinical samples. Patients and Methods We retrospectively reviewed ordered ODX RS and pathology reports from five institutions (n = 1,113) between 2006 and 2013. We used locally performed histopathologic markers (estrogen receptor, progesterone receptor, Ki-67, human epidermal growth factor receptor 2, and Elston grade) to develop models that predict RS-based risk categories. Ordering patterns at one site were evaluated under an integrated decision-making model incorporating clinical treatment guidelines, immunohistochemistry markers, and ODX. Final locked models were independently tested (n = 472). Results Distribution of RS was similar across sites and to reported clinical practice experience and stable over time. Histopathologic markers alone determined risk category with > 95% confidence in > 55% (616 of 1,113) of cases. Application of the integrated decision model to one site indicated that the frequency of testing would not have changed overall, although ordering patterns would have changed substantially with less testing of estimated clinical risk-high or clinical risk-low cases and more testing of clinical risk-intermediate cases. In the validation set, the model correctly predicted risk category in 52.5% (248 of 472). Conclusion The proposed model accurately predicts high- and low-risk RS categories (> 25 or ≤ 25) in a majority of cases. Integrating histopathologic and molecular information into the decision-making process allows refocusing the use of new molecular tools to cases with uncertain risk.
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Affiliation(s)
- Hyun-Seok Kim
- Hyun-seok Kim, Christopher B. Umbricht, Peter B. Illei, Ashley Cimino-Mathews, Soonweng Cho, Nivedita Chowdhury, Maria Cristina Figueroa-Magalhaes, Catherine Pesce, Stacie C. Jeter, Deborah K. Armstrong, Roisin M. Connolly, John H. Fetting, Ben Ho Park, Vered Stearns, Antonio C. Wolff, and Leslie Cope, The Johns Hopkins University School of Medicine; Kala Visvanathan, The Johns Hopkins University Bloomberg School of Public Health, Baltimore; Charles Mylander, Martin Rosman, and Lorraine Tafra, Anne Arundel Medical Center, Annapolis, MD; Bradley M. Turner, David G. Hicks, University of Rochester Medical Center, Rochester, NY; Robert S. Miller, American Society of Clinical Oncology, Alexandria, VA; and Tyler A. Jensen and Dylan V. Miller, Intermountain Healthcare, Salt Lake City, UT
| | - Christopher B Umbricht
- Hyun-seok Kim, Christopher B. Umbricht, Peter B. Illei, Ashley Cimino-Mathews, Soonweng Cho, Nivedita Chowdhury, Maria Cristina Figueroa-Magalhaes, Catherine Pesce, Stacie C. Jeter, Deborah K. Armstrong, Roisin M. Connolly, John H. Fetting, Ben Ho Park, Vered Stearns, Antonio C. Wolff, and Leslie Cope, The Johns Hopkins University School of Medicine; Kala Visvanathan, The Johns Hopkins University Bloomberg School of Public Health, Baltimore; Charles Mylander, Martin Rosman, and Lorraine Tafra, Anne Arundel Medical Center, Annapolis, MD; Bradley M. Turner, David G. Hicks, University of Rochester Medical Center, Rochester, NY; Robert S. Miller, American Society of Clinical Oncology, Alexandria, VA; and Tyler A. Jensen and Dylan V. Miller, Intermountain Healthcare, Salt Lake City, UT
| | - Peter B Illei
- Hyun-seok Kim, Christopher B. Umbricht, Peter B. Illei, Ashley Cimino-Mathews, Soonweng Cho, Nivedita Chowdhury, Maria Cristina Figueroa-Magalhaes, Catherine Pesce, Stacie C. Jeter, Deborah K. Armstrong, Roisin M. Connolly, John H. Fetting, Ben Ho Park, Vered Stearns, Antonio C. Wolff, and Leslie Cope, The Johns Hopkins University School of Medicine; Kala Visvanathan, The Johns Hopkins University Bloomberg School of Public Health, Baltimore; Charles Mylander, Martin Rosman, and Lorraine Tafra, Anne Arundel Medical Center, Annapolis, MD; Bradley M. Turner, David G. Hicks, University of Rochester Medical Center, Rochester, NY; Robert S. Miller, American Society of Clinical Oncology, Alexandria, VA; and Tyler A. Jensen and Dylan V. Miller, Intermountain Healthcare, Salt Lake City, UT
| | - Ashley Cimino-Mathews
- Hyun-seok Kim, Christopher B. Umbricht, Peter B. Illei, Ashley Cimino-Mathews, Soonweng Cho, Nivedita Chowdhury, Maria Cristina Figueroa-Magalhaes, Catherine Pesce, Stacie C. Jeter, Deborah K. Armstrong, Roisin M. Connolly, John H. Fetting, Ben Ho Park, Vered Stearns, Antonio C. Wolff, and Leslie Cope, The Johns Hopkins University School of Medicine; Kala Visvanathan, The Johns Hopkins University Bloomberg School of Public Health, Baltimore; Charles Mylander, Martin Rosman, and Lorraine Tafra, Anne Arundel Medical Center, Annapolis, MD; Bradley M. Turner, David G. Hicks, University of Rochester Medical Center, Rochester, NY; Robert S. Miller, American Society of Clinical Oncology, Alexandria, VA; and Tyler A. Jensen and Dylan V. Miller, Intermountain Healthcare, Salt Lake City, UT
| | - Soonweng Cho
- Hyun-seok Kim, Christopher B. Umbricht, Peter B. Illei, Ashley Cimino-Mathews, Soonweng Cho, Nivedita Chowdhury, Maria Cristina Figueroa-Magalhaes, Catherine Pesce, Stacie C. Jeter, Deborah K. Armstrong, Roisin M. Connolly, John H. Fetting, Ben Ho Park, Vered Stearns, Antonio C. Wolff, and Leslie Cope, The Johns Hopkins University School of Medicine; Kala Visvanathan, The Johns Hopkins University Bloomberg School of Public Health, Baltimore; Charles Mylander, Martin Rosman, and Lorraine Tafra, Anne Arundel Medical Center, Annapolis, MD; Bradley M. Turner, David G. Hicks, University of Rochester Medical Center, Rochester, NY; Robert S. Miller, American Society of Clinical Oncology, Alexandria, VA; and Tyler A. Jensen and Dylan V. Miller, Intermountain Healthcare, Salt Lake City, UT
| | - Nivedita Chowdhury
- Hyun-seok Kim, Christopher B. Umbricht, Peter B. Illei, Ashley Cimino-Mathews, Soonweng Cho, Nivedita Chowdhury, Maria Cristina Figueroa-Magalhaes, Catherine Pesce, Stacie C. Jeter, Deborah K. Armstrong, Roisin M. Connolly, John H. Fetting, Ben Ho Park, Vered Stearns, Antonio C. Wolff, and Leslie Cope, The Johns Hopkins University School of Medicine; Kala Visvanathan, The Johns Hopkins University Bloomberg School of Public Health, Baltimore; Charles Mylander, Martin Rosman, and Lorraine Tafra, Anne Arundel Medical Center, Annapolis, MD; Bradley M. Turner, David G. Hicks, University of Rochester Medical Center, Rochester, NY; Robert S. Miller, American Society of Clinical Oncology, Alexandria, VA; and Tyler A. Jensen and Dylan V. Miller, Intermountain Healthcare, Salt Lake City, UT
| | - Maria Cristina Figueroa-Magalhaes
- Hyun-seok Kim, Christopher B. Umbricht, Peter B. Illei, Ashley Cimino-Mathews, Soonweng Cho, Nivedita Chowdhury, Maria Cristina Figueroa-Magalhaes, Catherine Pesce, Stacie C. Jeter, Deborah K. Armstrong, Roisin M. Connolly, John H. Fetting, Ben Ho Park, Vered Stearns, Antonio C. Wolff, and Leslie Cope, The Johns Hopkins University School of Medicine; Kala Visvanathan, The Johns Hopkins University Bloomberg School of Public Health, Baltimore; Charles Mylander, Martin Rosman, and Lorraine Tafra, Anne Arundel Medical Center, Annapolis, MD; Bradley M. Turner, David G. Hicks, University of Rochester Medical Center, Rochester, NY; Robert S. Miller, American Society of Clinical Oncology, Alexandria, VA; and Tyler A. Jensen and Dylan V. Miller, Intermountain Healthcare, Salt Lake City, UT
| | - Catherine Pesce
- Hyun-seok Kim, Christopher B. Umbricht, Peter B. Illei, Ashley Cimino-Mathews, Soonweng Cho, Nivedita Chowdhury, Maria Cristina Figueroa-Magalhaes, Catherine Pesce, Stacie C. Jeter, Deborah K. Armstrong, Roisin M. Connolly, John H. Fetting, Ben Ho Park, Vered Stearns, Antonio C. Wolff, and Leslie Cope, The Johns Hopkins University School of Medicine; Kala Visvanathan, The Johns Hopkins University Bloomberg School of Public Health, Baltimore; Charles Mylander, Martin Rosman, and Lorraine Tafra, Anne Arundel Medical Center, Annapolis, MD; Bradley M. Turner, David G. Hicks, University of Rochester Medical Center, Rochester, NY; Robert S. Miller, American Society of Clinical Oncology, Alexandria, VA; and Tyler A. Jensen and Dylan V. Miller, Intermountain Healthcare, Salt Lake City, UT
| | - Stacie C Jeter
- Hyun-seok Kim, Christopher B. Umbricht, Peter B. Illei, Ashley Cimino-Mathews, Soonweng Cho, Nivedita Chowdhury, Maria Cristina Figueroa-Magalhaes, Catherine Pesce, Stacie C. Jeter, Deborah K. Armstrong, Roisin M. Connolly, John H. Fetting, Ben Ho Park, Vered Stearns, Antonio C. Wolff, and Leslie Cope, The Johns Hopkins University School of Medicine; Kala Visvanathan, The Johns Hopkins University Bloomberg School of Public Health, Baltimore; Charles Mylander, Martin Rosman, and Lorraine Tafra, Anne Arundel Medical Center, Annapolis, MD; Bradley M. Turner, David G. Hicks, University of Rochester Medical Center, Rochester, NY; Robert S. Miller, American Society of Clinical Oncology, Alexandria, VA; and Tyler A. Jensen and Dylan V. Miller, Intermountain Healthcare, Salt Lake City, UT
| | - Charles Mylander
- Hyun-seok Kim, Christopher B. Umbricht, Peter B. Illei, Ashley Cimino-Mathews, Soonweng Cho, Nivedita Chowdhury, Maria Cristina Figueroa-Magalhaes, Catherine Pesce, Stacie C. Jeter, Deborah K. Armstrong, Roisin M. Connolly, John H. Fetting, Ben Ho Park, Vered Stearns, Antonio C. Wolff, and Leslie Cope, The Johns Hopkins University School of Medicine; Kala Visvanathan, The Johns Hopkins University Bloomberg School of Public Health, Baltimore; Charles Mylander, Martin Rosman, and Lorraine Tafra, Anne Arundel Medical Center, Annapolis, MD; Bradley M. Turner, David G. Hicks, University of Rochester Medical Center, Rochester, NY; Robert S. Miller, American Society of Clinical Oncology, Alexandria, VA; and Tyler A. Jensen and Dylan V. Miller, Intermountain Healthcare, Salt Lake City, UT
| | - Martin Rosman
- Hyun-seok Kim, Christopher B. Umbricht, Peter B. Illei, Ashley Cimino-Mathews, Soonweng Cho, Nivedita Chowdhury, Maria Cristina Figueroa-Magalhaes, Catherine Pesce, Stacie C. Jeter, Deborah K. Armstrong, Roisin M. Connolly, John H. Fetting, Ben Ho Park, Vered Stearns, Antonio C. Wolff, and Leslie Cope, The Johns Hopkins University School of Medicine; Kala Visvanathan, The Johns Hopkins University Bloomberg School of Public Health, Baltimore; Charles Mylander, Martin Rosman, and Lorraine Tafra, Anne Arundel Medical Center, Annapolis, MD; Bradley M. Turner, David G. Hicks, University of Rochester Medical Center, Rochester, NY; Robert S. Miller, American Society of Clinical Oncology, Alexandria, VA; and Tyler A. Jensen and Dylan V. Miller, Intermountain Healthcare, Salt Lake City, UT
| | - Lorraine Tafra
- Hyun-seok Kim, Christopher B. Umbricht, Peter B. Illei, Ashley Cimino-Mathews, Soonweng Cho, Nivedita Chowdhury, Maria Cristina Figueroa-Magalhaes, Catherine Pesce, Stacie C. Jeter, Deborah K. Armstrong, Roisin M. Connolly, John H. Fetting, Ben Ho Park, Vered Stearns, Antonio C. Wolff, and Leslie Cope, The Johns Hopkins University School of Medicine; Kala Visvanathan, The Johns Hopkins University Bloomberg School of Public Health, Baltimore; Charles Mylander, Martin Rosman, and Lorraine Tafra, Anne Arundel Medical Center, Annapolis, MD; Bradley M. Turner, David G. Hicks, University of Rochester Medical Center, Rochester, NY; Robert S. Miller, American Society of Clinical Oncology, Alexandria, VA; and Tyler A. Jensen and Dylan V. Miller, Intermountain Healthcare, Salt Lake City, UT
| | - Bradley M Turner
- Hyun-seok Kim, Christopher B. Umbricht, Peter B. Illei, Ashley Cimino-Mathews, Soonweng Cho, Nivedita Chowdhury, Maria Cristina Figueroa-Magalhaes, Catherine Pesce, Stacie C. Jeter, Deborah K. Armstrong, Roisin M. Connolly, John H. Fetting, Ben Ho Park, Vered Stearns, Antonio C. Wolff, and Leslie Cope, The Johns Hopkins University School of Medicine; Kala Visvanathan, The Johns Hopkins University Bloomberg School of Public Health, Baltimore; Charles Mylander, Martin Rosman, and Lorraine Tafra, Anne Arundel Medical Center, Annapolis, MD; Bradley M. Turner, David G. Hicks, University of Rochester Medical Center, Rochester, NY; Robert S. Miller, American Society of Clinical Oncology, Alexandria, VA; and Tyler A. Jensen and Dylan V. Miller, Intermountain Healthcare, Salt Lake City, UT
| | - David G Hicks
- Hyun-seok Kim, Christopher B. Umbricht, Peter B. Illei, Ashley Cimino-Mathews, Soonweng Cho, Nivedita Chowdhury, Maria Cristina Figueroa-Magalhaes, Catherine Pesce, Stacie C. Jeter, Deborah K. Armstrong, Roisin M. Connolly, John H. Fetting, Ben Ho Park, Vered Stearns, Antonio C. Wolff, and Leslie Cope, The Johns Hopkins University School of Medicine; Kala Visvanathan, The Johns Hopkins University Bloomberg School of Public Health, Baltimore; Charles Mylander, Martin Rosman, and Lorraine Tafra, Anne Arundel Medical Center, Annapolis, MD; Bradley M. Turner, David G. Hicks, University of Rochester Medical Center, Rochester, NY; Robert S. Miller, American Society of Clinical Oncology, Alexandria, VA; and Tyler A. Jensen and Dylan V. Miller, Intermountain Healthcare, Salt Lake City, UT
| | - Tyler A Jensen
- Hyun-seok Kim, Christopher B. Umbricht, Peter B. Illei, Ashley Cimino-Mathews, Soonweng Cho, Nivedita Chowdhury, Maria Cristina Figueroa-Magalhaes, Catherine Pesce, Stacie C. Jeter, Deborah K. Armstrong, Roisin M. Connolly, John H. Fetting, Ben Ho Park, Vered Stearns, Antonio C. Wolff, and Leslie Cope, The Johns Hopkins University School of Medicine; Kala Visvanathan, The Johns Hopkins University Bloomberg School of Public Health, Baltimore; Charles Mylander, Martin Rosman, and Lorraine Tafra, Anne Arundel Medical Center, Annapolis, MD; Bradley M. Turner, David G. Hicks, University of Rochester Medical Center, Rochester, NY; Robert S. Miller, American Society of Clinical Oncology, Alexandria, VA; and Tyler A. Jensen and Dylan V. Miller, Intermountain Healthcare, Salt Lake City, UT
| | - Dylan V Miller
- Hyun-seok Kim, Christopher B. Umbricht, Peter B. Illei, Ashley Cimino-Mathews, Soonweng Cho, Nivedita Chowdhury, Maria Cristina Figueroa-Magalhaes, Catherine Pesce, Stacie C. Jeter, Deborah K. Armstrong, Roisin M. Connolly, John H. Fetting, Ben Ho Park, Vered Stearns, Antonio C. Wolff, and Leslie Cope, The Johns Hopkins University School of Medicine; Kala Visvanathan, The Johns Hopkins University Bloomberg School of Public Health, Baltimore; Charles Mylander, Martin Rosman, and Lorraine Tafra, Anne Arundel Medical Center, Annapolis, MD; Bradley M. Turner, David G. Hicks, University of Rochester Medical Center, Rochester, NY; Robert S. Miller, American Society of Clinical Oncology, Alexandria, VA; and Tyler A. Jensen and Dylan V. Miller, Intermountain Healthcare, Salt Lake City, UT
| | - Deborah K Armstrong
- Hyun-seok Kim, Christopher B. Umbricht, Peter B. Illei, Ashley Cimino-Mathews, Soonweng Cho, Nivedita Chowdhury, Maria Cristina Figueroa-Magalhaes, Catherine Pesce, Stacie C. Jeter, Deborah K. Armstrong, Roisin M. Connolly, John H. Fetting, Ben Ho Park, Vered Stearns, Antonio C. Wolff, and Leslie Cope, The Johns Hopkins University School of Medicine; Kala Visvanathan, The Johns Hopkins University Bloomberg School of Public Health, Baltimore; Charles Mylander, Martin Rosman, and Lorraine Tafra, Anne Arundel Medical Center, Annapolis, MD; Bradley M. Turner, David G. Hicks, University of Rochester Medical Center, Rochester, NY; Robert S. Miller, American Society of Clinical Oncology, Alexandria, VA; and Tyler A. Jensen and Dylan V. Miller, Intermountain Healthcare, Salt Lake City, UT
| | - Roisin M Connolly
- Hyun-seok Kim, Christopher B. Umbricht, Peter B. Illei, Ashley Cimino-Mathews, Soonweng Cho, Nivedita Chowdhury, Maria Cristina Figueroa-Magalhaes, Catherine Pesce, Stacie C. Jeter, Deborah K. Armstrong, Roisin M. Connolly, John H. Fetting, Ben Ho Park, Vered Stearns, Antonio C. Wolff, and Leslie Cope, The Johns Hopkins University School of Medicine; Kala Visvanathan, The Johns Hopkins University Bloomberg School of Public Health, Baltimore; Charles Mylander, Martin Rosman, and Lorraine Tafra, Anne Arundel Medical Center, Annapolis, MD; Bradley M. Turner, David G. Hicks, University of Rochester Medical Center, Rochester, NY; Robert S. Miller, American Society of Clinical Oncology, Alexandria, VA; and Tyler A. Jensen and Dylan V. Miller, Intermountain Healthcare, Salt Lake City, UT
| | - John H Fetting
- Hyun-seok Kim, Christopher B. Umbricht, Peter B. Illei, Ashley Cimino-Mathews, Soonweng Cho, Nivedita Chowdhury, Maria Cristina Figueroa-Magalhaes, Catherine Pesce, Stacie C. Jeter, Deborah K. Armstrong, Roisin M. Connolly, John H. Fetting, Ben Ho Park, Vered Stearns, Antonio C. Wolff, and Leslie Cope, The Johns Hopkins University School of Medicine; Kala Visvanathan, The Johns Hopkins University Bloomberg School of Public Health, Baltimore; Charles Mylander, Martin Rosman, and Lorraine Tafra, Anne Arundel Medical Center, Annapolis, MD; Bradley M. Turner, David G. Hicks, University of Rochester Medical Center, Rochester, NY; Robert S. Miller, American Society of Clinical Oncology, Alexandria, VA; and Tyler A. Jensen and Dylan V. Miller, Intermountain Healthcare, Salt Lake City, UT
| | - Robert S Miller
- Hyun-seok Kim, Christopher B. Umbricht, Peter B. Illei, Ashley Cimino-Mathews, Soonweng Cho, Nivedita Chowdhury, Maria Cristina Figueroa-Magalhaes, Catherine Pesce, Stacie C. Jeter, Deborah K. Armstrong, Roisin M. Connolly, John H. Fetting, Ben Ho Park, Vered Stearns, Antonio C. Wolff, and Leslie Cope, The Johns Hopkins University School of Medicine; Kala Visvanathan, The Johns Hopkins University Bloomberg School of Public Health, Baltimore; Charles Mylander, Martin Rosman, and Lorraine Tafra, Anne Arundel Medical Center, Annapolis, MD; Bradley M. Turner, David G. Hicks, University of Rochester Medical Center, Rochester, NY; Robert S. Miller, American Society of Clinical Oncology, Alexandria, VA; and Tyler A. Jensen and Dylan V. Miller, Intermountain Healthcare, Salt Lake City, UT
| | - Ben Ho Park
- Hyun-seok Kim, Christopher B. Umbricht, Peter B. Illei, Ashley Cimino-Mathews, Soonweng Cho, Nivedita Chowdhury, Maria Cristina Figueroa-Magalhaes, Catherine Pesce, Stacie C. Jeter, Deborah K. Armstrong, Roisin M. Connolly, John H. Fetting, Ben Ho Park, Vered Stearns, Antonio C. Wolff, and Leslie Cope, The Johns Hopkins University School of Medicine; Kala Visvanathan, The Johns Hopkins University Bloomberg School of Public Health, Baltimore; Charles Mylander, Martin Rosman, and Lorraine Tafra, Anne Arundel Medical Center, Annapolis, MD; Bradley M. Turner, David G. Hicks, University of Rochester Medical Center, Rochester, NY; Robert S. Miller, American Society of Clinical Oncology, Alexandria, VA; and Tyler A. Jensen and Dylan V. Miller, Intermountain Healthcare, Salt Lake City, UT
| | - Vered Stearns
- Hyun-seok Kim, Christopher B. Umbricht, Peter B. Illei, Ashley Cimino-Mathews, Soonweng Cho, Nivedita Chowdhury, Maria Cristina Figueroa-Magalhaes, Catherine Pesce, Stacie C. Jeter, Deborah K. Armstrong, Roisin M. Connolly, John H. Fetting, Ben Ho Park, Vered Stearns, Antonio C. Wolff, and Leslie Cope, The Johns Hopkins University School of Medicine; Kala Visvanathan, The Johns Hopkins University Bloomberg School of Public Health, Baltimore; Charles Mylander, Martin Rosman, and Lorraine Tafra, Anne Arundel Medical Center, Annapolis, MD; Bradley M. Turner, David G. Hicks, University of Rochester Medical Center, Rochester, NY; Robert S. Miller, American Society of Clinical Oncology, Alexandria, VA; and Tyler A. Jensen and Dylan V. Miller, Intermountain Healthcare, Salt Lake City, UT
| | - Kala Visvanathan
- Hyun-seok Kim, Christopher B. Umbricht, Peter B. Illei, Ashley Cimino-Mathews, Soonweng Cho, Nivedita Chowdhury, Maria Cristina Figueroa-Magalhaes, Catherine Pesce, Stacie C. Jeter, Deborah K. Armstrong, Roisin M. Connolly, John H. Fetting, Ben Ho Park, Vered Stearns, Antonio C. Wolff, and Leslie Cope, The Johns Hopkins University School of Medicine; Kala Visvanathan, The Johns Hopkins University Bloomberg School of Public Health, Baltimore; Charles Mylander, Martin Rosman, and Lorraine Tafra, Anne Arundel Medical Center, Annapolis, MD; Bradley M. Turner, David G. Hicks, University of Rochester Medical Center, Rochester, NY; Robert S. Miller, American Society of Clinical Oncology, Alexandria, VA; and Tyler A. Jensen and Dylan V. Miller, Intermountain Healthcare, Salt Lake City, UT
| | - Antonio C Wolff
- Hyun-seok Kim, Christopher B. Umbricht, Peter B. Illei, Ashley Cimino-Mathews, Soonweng Cho, Nivedita Chowdhury, Maria Cristina Figueroa-Magalhaes, Catherine Pesce, Stacie C. Jeter, Deborah K. Armstrong, Roisin M. Connolly, John H. Fetting, Ben Ho Park, Vered Stearns, Antonio C. Wolff, and Leslie Cope, The Johns Hopkins University School of Medicine; Kala Visvanathan, The Johns Hopkins University Bloomberg School of Public Health, Baltimore; Charles Mylander, Martin Rosman, and Lorraine Tafra, Anne Arundel Medical Center, Annapolis, MD; Bradley M. Turner, David G. Hicks, University of Rochester Medical Center, Rochester, NY; Robert S. Miller, American Society of Clinical Oncology, Alexandria, VA; and Tyler A. Jensen and Dylan V. Miller, Intermountain Healthcare, Salt Lake City, UT
| | - Leslie Cope
- Hyun-seok Kim, Christopher B. Umbricht, Peter B. Illei, Ashley Cimino-Mathews, Soonweng Cho, Nivedita Chowdhury, Maria Cristina Figueroa-Magalhaes, Catherine Pesce, Stacie C. Jeter, Deborah K. Armstrong, Roisin M. Connolly, John H. Fetting, Ben Ho Park, Vered Stearns, Antonio C. Wolff, and Leslie Cope, The Johns Hopkins University School of Medicine; Kala Visvanathan, The Johns Hopkins University Bloomberg School of Public Health, Baltimore; Charles Mylander, Martin Rosman, and Lorraine Tafra, Anne Arundel Medical Center, Annapolis, MD; Bradley M. Turner, David G. Hicks, University of Rochester Medical Center, Rochester, NY; Robert S. Miller, American Society of Clinical Oncology, Alexandria, VA; and Tyler A. Jensen and Dylan V. Miller, Intermountain Healthcare, Salt Lake City, UT
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Zysk AM, Chen K, Gabrielson E, Tafra L, May Gonzalez EA, Canner JK, Schneider EB, Cittadine AJ, Carney PS, Boppart SA, Tsuchiya K, Sawyer K, Jacobs LK. Intraoperative Assessment of Final Margins with a Handheld Optical Imaging Probe During Breast-Conserving Surgery May Reduce the Reoperation Rate: Results of a Multicenter Study. Ann Surg Oncol 2015; 22. [PMID: 26202553 PMCID: PMC4839389 DOI: 10.1245/s10434-015-4665-2] [Citation(s) in RCA: 80] [Impact Index Per Article: 8.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
BACKGROUND A multicenter, prospective, blinded study was performed to test the feasibility of using a handheld optical imaging probe for the intraoperative assessment of final surgical margins during breast-conserving surgery (BCS) and to determine the potential impact on patient outcomes. METHODS Forty-six patients with early-stage breast cancer (one with bilateral disease) undergoing BCS at two study sites, the Johns Hopkins Hospital and Anne Arundel Medical Center, were enrolled in this study. During BCS, cavity-shaved margins were obtained and the final margins were examined ex vivo in the operating room with a probe incorporating optical coherence tomography (OCT) hardware and interferometric synthetic aperture microscopy (ISAM) image processing. Images were interpreted after BCS by three physicians blinded to final pathology-reported margin status. Individual and combined interpretations were assessed. Results were compared to conventional postoperative histopathology. RESULTS A total of 2,191 images were collected and interpreted from 229 shave margin specimens. Of the eight patients (17 %) with positive margins (0 mm), which included invasive and in situ diseases, the device identified all positive margins in five (63%) of them; reoperation could potentially have been avoided in these patients. Among patients with pathologically negative margins (>0 mm), an estimated mean additional tissue volume of 10.7 ml (approximately 1% of overall breast volume) would have been unnecessarily removed due to false positives. CONCLUSIONS Intraoperative optical imaging of specimen margins with a handheld probe potentially eliminates the majority of reoperations.
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Affiliation(s)
| | - Kai Chen
- The Johns Hopkins Hospital, Baltimore, MD
- Sun Yat-sen Memorial Hospital, Guangzhou, Guangdong, People’s Republic of China
| | | | | | | | | | | | | | | | - Stephen A. Boppart
- Diagnostic Photonics, Inc., Chicago, IL
- University of Illinois at Urbana-Champaign, Urbana, IL
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Jackson RS, Mylander C, Rosman M, Andrade R, Sawyer K, Sanders T, Tafra L. Normal Axillary Ultrasound Excludes Heavy Nodal Disease Burden in Patients with Breast Cancer. Ann Surg Oncol 2015. [DOI: 10.1245/s10434-015-4717-7] [Citation(s) in RCA: 29] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
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Gage MM, Rosman M, Mylander C, Tran C, Jackson RS, Tafra L. Abstract P1-07-10: Immunohistochemical (IHC) marker discordance between primary breast cancer biopsy and recurrent cancer: Would IHC testing of the surgical breast or lymph node have altered treatment? Cancer Res 2015. [DOI: 10.1158/1538-7445.sabcs14-p1-07-10] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Abstract
Objective: Based on emerging data on tumor heterogeneity and the evolutionary branching of tumor cells, tumor cells in the lymph node may represent more virulent clones with the inherent capability of metastasis. IHC discordance from original cancer diagnosis to recurrence is documented to occur in up to 20% of cases, raising the question if characterization of these likely more virulent cells would more accurately guide treatment and predict prognosis. Our pilot study sought to determine if crucial clinical information is gained by IHC testing of the surgical breast or lymph node specimens at the time of initial surgery.
Methods: Using the cancer registry and oncology records, all invasive breast cancers diagnosed after 2001 with subsequent recurrence were identified. Cases missing all IHC data were disqualified. We then evaluated ER and HER2 of the primary cancer biopsy and recurrence biopsy to identify discordances. Those with discordances who had surgical breast and lymph node specimens available were accessed, tested, and evaluated by our breast cancer pathologist.
Results: A total of 128 recurrence cases with partial or complete primary and recurrence IHC data were identified. Of the 95 initially ER positive cases with recurrence IHC available, 13/95 had discordant, or ER negative, recurrence. Additionally, 5/27 initially ER negative tumors, 3/14 initially HER2 positive tumors, and 6/69 initially HER2 negative tumors had discordant recurrence results. In 128 cases, 27 cases were identified to have ER or HER2 discordance from primary biopsy diagnosis to recurrence. Of all cases with original surgical breast or positive lymph node specimen available, 9 markers on 7 patients were performed for our pilot study. One of seven surgical breast specimens and one of two lymph node specimens were concordant with the recurrence, but not the initial biopsy. The tested surgical breast was ER positive, while the surgical lymph node was HER2 positive, concordant to their recurrences, but discordant with initial biopsy.
Breast BiopsyRecurrence ConcordantRecurrence DiscordantER Positive98/12782/9513/95 (14%)ER Negative29/12724/275/27 (19%) Total ER Discordance 18/122 (15%)HER2 Positive19/11911/143/14 (22%)HER2 Negative100/11963/696/69 (9%) Total HER2 Discordance 9/83 (11%)
Conclusion: Tumor discordance of the original cancer biopsy and recurrence is not uncommon. Our pilot study demonstrated that ER and HER2 discordance occurred in 15% and 11% of cases, respectively. Though our pilot study was limited by small sample size, we found that IHC testing of the surgical breast and lymph node specimen may provide additional clinical information and affect management. Of the two cases that had a positive lymph node available, one was HER2 positive and concordant with the recurrence. Of the seven breast specimens tested, one was ER positive and concordant with the recurrence. Had IHC testing been performed at that time of surgery, adjuvant treatment management would have been altered. Further testing of our IHC discordant recurrence patient population will be pursued to investigate the potential benefits of surgical breast and lymph node IHC testing.
Citation Format: Michele M Gage, Martin Rosman, Charles Mylander, Crystal Tran, Rubie S Jackson, Lorraine Tafra. Immunohistochemical (IHC) marker discordance between primary breast cancer biopsy and recurrent cancer: Would IHC testing of the surgical breast or lymph node have altered treatment? [abstract]. In: Proceedings of the Thirty-Seventh Annual CTRC-AACR San Antonio Breast Cancer Symposium: 2014 Dec 9-13; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2015;75(9 Suppl):Abstract nr P1-07-10.
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Gage MM, Rosman M, Mylander C, Giblin E, Kim HS, Cope L, Umbricht C, Wolff AC, Tafra L. A simple, validated model for identifying cases that are unlikely to benefit from the 21-gene recurrence score (RS) assay. J Clin Oncol 2014. [DOI: 10.1200/jco.2014.32.15_suppl.540] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Affiliation(s)
| | | | | | | | | | - Leslie Cope
- The Johns Hopkins University School of Medicine, Baltimore, MD
| | | | - Antonio C. Wolff
- The Johns Hopkins Hospital and The Sidney Kimmel Comprehensive Cancer Center at Johns Hopkins, Baltimore, MD
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Kim H, Umbricht C, Illei PB, Magalhaes MCF, Pesce C, Gage MM, Mylander C, Rosman M, Tafra L, Visvanathan K, Cope L, Wolff AC. An estimation model for Oncotype DX recurrence score using routine histopathologic variables. J Clin Oncol 2014. [DOI: 10.1200/jco.2014.32.15_suppl.559] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Affiliation(s)
- Hyunseok Kim
- The Johns Hopkins University School of Medicine, Baltimore, MD
| | | | - Peter B. Illei
- The Sidney Kimmel Comprehensive Cancer Center at Johns Hopkins, Baltimore, MD
| | | | | | | | | | | | | | - Kala Visvanathan
- The Sidney Kimmel Comprehensive Cancer Center at Johns Hopkins, Baltimore, MD
| | - Leslie Cope
- The Johns Hopkins University School of Medicine, Baltimore, MD
| | - Antonio C. Wolff
- The Sidney Kimmel Comprehensive Cancer Center at Johns Hopkins, Baltimore, MD
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Schnabel F, Boolbol SK, Gittleman M, Karni T, Tafra L, Feldman S, Police A, Friedman NB, Karlan S, Holmes D, Willey SC, Carmon M, Fernandez K, Akbari S, Harness J, Guerra L, Frazier T, Lane K, Simmons RM, Estabrook A, Allweis T. A randomized prospective study of lumpectomy margin assessment with use of MarginProbe in patients with nonpalpable breast malignancies. Ann Surg Oncol 2014; 21:1589-95. [PMID: 24595800 PMCID: PMC3975090 DOI: 10.1245/s10434-014-3602-0] [Citation(s) in RCA: 118] [Impact Index Per Article: 11.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/04/2013] [Indexed: 12/17/2022]
Abstract
Background The presence of tumor cells at the margins of breast lumpectomy specimens is associated with an increased risk of ipsilateral tumor recurrence. Twenty to 30 % of patients undergoing breast-conserving surgery require second procedures to achieve negative margins. This study evaluated the adjunctive use of the MarginProbe device (Dune Medical Devices Ltd, Caesarea, Israel) in providing real-time intraoperative assessment of lumpectomy margins. Methods This multicenter randomized trial enrolled patients with nonpalpable breast malignancies. The study evaluated MarginProbe use in addition to standard intraoperative methods for margin assessment. After specimen removal and inspection, patients were randomized to device or control arms. In the device arm, MarginProbe was used to examine the main lumpectomy specimens and direct additional excision of positive margins. Intraoperative imaging was used in both arms; no intraoperative pathology assessment was permitted. Results
In total, 596 patients were enrolled. False-negative rates were 24.8 and 66.1 % and false-positive rates were 53.6 and 16.6 % in the device and control arms, respectively. All positive margins on positive main specimens were resected in 62 % (101 of 163) of cases in the device arm, versus 22 % (33 of 147) in the control arm (p < 0.001). A total of 19.8 % (59 of 298) of patients in the device arm underwent a reexcision procedure compared with 25.8 % (77 of 298) in the control arm (6 % absolute, 23 % relative reduction). The difference in tissue volume removed was not significant. Conclusions Adjunctive use of the MarginProbe device during breast-conserving surgery improved surgeons’ ability to identify and resect positive lumpectomy margins in the absence of intraoperative pathology assessment, reducing the number of patients requiring reexcision. MarginProbe may aid performance of breast-conserving surgery by reducing the burden of reexcision procedures for patients and the health care system.
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Affiliation(s)
- Freya Schnabel
- Department of Surgery, NYU Langone Medical Center, NYU Clinical Cancer Center, New York, NY, USA,
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Greer LT, Rosman M, Charles Mylander W, Liang W, Buras RR, Chagpar AB, Edwards MJ, Tafra L. A prediction model for the presence of axillary lymph node involvement in women with invasive breast cancer: a focus on older women. Breast J 2014; 20:147-53. [PMID: 24475876 DOI: 10.1111/tbj.12233] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
Axillary lymph node (ALN) status at diagnosis is the most powerful prognostic indicator for patients with breast cancer. Our aim is to examine the contribution of variables that lead to ALN metastases in a large dataset with a high proportion of patients greater than 70 years old. Using the data from two multicenter prospective studies, a retrospective review was performed on 2,812 patients diagnosed with clinically node-negative invasive breast cancer from 1996 to 2005 and who underwent ALN sampling. Univariate and multivariate logistic regression were used to identify variables that were strongly associated with axillary metastases, and an equation was developed to estimate risk of ALN metastases. Of the 2,812 patients with invasive breast cancer, 18% had ALN metastases at diagnosis. Based on univariate analysis, tumor size, lymphovascular invasion (LVI), tumor grade, age at diagnosis, menopausal status, race, tumor location, tumor type, and estrogen and progesterone receptor status were statistically significant. The relationship between age and involvement of axillary metastases was nonlinear. In multivariate analysis, LVI, tumor size and menopausal status were the most significant factors associated with ALN metastases. Age, however, was not a significant contributing factor for axillary metastases. Tumor size, LVI, and menopausal status are strongly associated with ALN metastases. We believe that age may have been a strong factor in previous analyses because there was not an adequate representation of women in older age groups and because of the violation of the assumption of linearity in their multivariate analyses.
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Affiliation(s)
- Lauren T Greer
- General Surgery Service, Walter Reed National Military Medical Center, Bethesda, Maryland
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Kovatich AJ, Chen Y, Fantacone-Campbell JL, Wareham JA, Tafra L, Kvecher L, Hyslop T, Hooke JA, Rui H, Shriver CD, Mural RJ, Hu H. Abstract P4-06-03: Assays on core biopsies and surgically resected tumors may result in different subtyping of the invasive breast cancer from the same patient. Cancer Res 2013. [DOI: 10.1158/0008-5472.sabcs13-p4-06-03] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Abstract
Background Core biopsies (CBs) are often used for biomarker expression assays to determine the treatment regimen. However, a number of other clinically important analyses (e.g. OncoType Dx), are performed on surgically resected tumors (SRTs). A previous study has shown that biomarkers ER, PR, and Ki67 expressed higher in CBs than in SRTs. Here we analyze how this difference impacts the subtyping of ER+ breast tumors.
Methods Female patients enrolled in the Clinical Breast Care Project (CBCP) from a civilian site were selected for this study, where expression of ER, PR, HER2, and Ki67 were assayed by IHC in a reference lab on CBs; the same 4 assays were performed on SRTs by a CBCP central lab. Both labs are CLIA-certified. Patients treated with neoadjuvant chemotherapy and those with multiple tumors were excluded. 167 cases were identified for this study to compare assays performed on CBs and SRTs from the same patients. ER and PR were positive if >1% nuclear staining, HER2 was negative if IHC = 0 or 1+, positive if IHC = 3+, and for IHC = 2+ FISH was used for the final call. Ki67 was positive if > = 15% nuclear staining. LA was ER+/HER2-/Ki67-, LB1 was ER+/HER2-/Ki67+, and LB2 was ER+/HER2+. For histologic grades, only readings from the central lab on SRTs were used. Statistical analyses were performed using SAS.
Results This analysis confirmed that Ki67, ER, and PR showed higher percent nuclear staining in CBs than in SRTs from the same patients. The difference for Ki67 was more striking and unidirectional. ER and PR cases clustered at the upper percent levels. Histograms with a bin-width of 15% show a peak at 15% for Ki67 difference between CBs and SRTs, whereas the peaks for ER and PR differences were at 0%. McNemar's (or Exact McNemar’s) test showed significant differences between the binary status calls for Ki67 (p = 3.2E-15) and ER (p = 0.012), but not for PR (p = 0.65). Assays on CBs and SRTs resulted in different subtype calls for the cases (Table 1). Grade distributions were different between LA and LB (p<0.001 for both CB- and SRT-based subtypes, Chi-Square or Fisher's Exact test), but not so between LB1 and LB2 (p = 0.23 for CB, 0.31 for SRT). However, SRT-based LB1 cases concentrate more on higher grades compared to CB-based cases (p = 0.048).
Table 1. ER+ subtypes based on IHC assays (from CBs and SRTs) and corresponding grades (from SRTs) CBSRTSubtypeG1G2G3G1G2G3LA2126034518LB11435342820LB2036032
Discussion On IHC assays, Ki67 expression is strikingly higher in CBs than in SRTs, and ER expression is also higher in CBs than in SRTs. This directly resulted in more LB than LA subtypes based on CBs. SRT-based LB1 cases concentrate more on higher grades compared to CB-based cases, which is more consistent with the observation that LB subtypes have worse outcomes. A limitation of this study is that technical differences between the labs may contribute to the observed differences between CBs and SRTs. Further studies need to be performed to determine whether SRT should also be assayed in addition to CB for treatment regimen decision-making.
The views expressed in this abstract are those of the authors and do not reflect the official policy of the Department of Defense, or US Government.
Citation Information: Cancer Res 2013;73(24 Suppl): Abstract nr P4-06-03.
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Affiliation(s)
- AJ Kovatich
- Clinical Breast Care Project, Walter Reed National Military Medical Center, Bethesda, MD; Biomedical Informatics, Windber Research Institute, Windber, PA; Breast Center, Anne Arundel Medical Center, Annapolis, MD; Kimmel Cancer Center, Thomas Jefferson University, Philadelphia, PA
| | - Y Chen
- Clinical Breast Care Project, Walter Reed National Military Medical Center, Bethesda, MD; Biomedical Informatics, Windber Research Institute, Windber, PA; Breast Center, Anne Arundel Medical Center, Annapolis, MD; Kimmel Cancer Center, Thomas Jefferson University, Philadelphia, PA
| | - JL Fantacone-Campbell
- Clinical Breast Care Project, Walter Reed National Military Medical Center, Bethesda, MD; Biomedical Informatics, Windber Research Institute, Windber, PA; Breast Center, Anne Arundel Medical Center, Annapolis, MD; Kimmel Cancer Center, Thomas Jefferson University, Philadelphia, PA
| | - JA Wareham
- Clinical Breast Care Project, Walter Reed National Military Medical Center, Bethesda, MD; Biomedical Informatics, Windber Research Institute, Windber, PA; Breast Center, Anne Arundel Medical Center, Annapolis, MD; Kimmel Cancer Center, Thomas Jefferson University, Philadelphia, PA
| | - L Tafra
- Clinical Breast Care Project, Walter Reed National Military Medical Center, Bethesda, MD; Biomedical Informatics, Windber Research Institute, Windber, PA; Breast Center, Anne Arundel Medical Center, Annapolis, MD; Kimmel Cancer Center, Thomas Jefferson University, Philadelphia, PA
| | - L Kvecher
- Clinical Breast Care Project, Walter Reed National Military Medical Center, Bethesda, MD; Biomedical Informatics, Windber Research Institute, Windber, PA; Breast Center, Anne Arundel Medical Center, Annapolis, MD; Kimmel Cancer Center, Thomas Jefferson University, Philadelphia, PA
| | - T Hyslop
- Clinical Breast Care Project, Walter Reed National Military Medical Center, Bethesda, MD; Biomedical Informatics, Windber Research Institute, Windber, PA; Breast Center, Anne Arundel Medical Center, Annapolis, MD; Kimmel Cancer Center, Thomas Jefferson University, Philadelphia, PA
| | - JA Hooke
- Clinical Breast Care Project, Walter Reed National Military Medical Center, Bethesda, MD; Biomedical Informatics, Windber Research Institute, Windber, PA; Breast Center, Anne Arundel Medical Center, Annapolis, MD; Kimmel Cancer Center, Thomas Jefferson University, Philadelphia, PA
| | - H Rui
- Clinical Breast Care Project, Walter Reed National Military Medical Center, Bethesda, MD; Biomedical Informatics, Windber Research Institute, Windber, PA; Breast Center, Anne Arundel Medical Center, Annapolis, MD; Kimmel Cancer Center, Thomas Jefferson University, Philadelphia, PA
| | - CD Shriver
- Clinical Breast Care Project, Walter Reed National Military Medical Center, Bethesda, MD; Biomedical Informatics, Windber Research Institute, Windber, PA; Breast Center, Anne Arundel Medical Center, Annapolis, MD; Kimmel Cancer Center, Thomas Jefferson University, Philadelphia, PA
| | - RJ Mural
- Clinical Breast Care Project, Walter Reed National Military Medical Center, Bethesda, MD; Biomedical Informatics, Windber Research Institute, Windber, PA; Breast Center, Anne Arundel Medical Center, Annapolis, MD; Kimmel Cancer Center, Thomas Jefferson University, Philadelphia, PA
| | - H Hu
- Clinical Breast Care Project, Walter Reed National Military Medical Center, Bethesda, MD; Biomedical Informatics, Windber Research Institute, Windber, PA; Breast Center, Anne Arundel Medical Center, Annapolis, MD; Kimmel Cancer Center, Thomas Jefferson University, Philadelphia, PA
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Milburn M, Rosman M, Mylander C, Tafra L. Is oncotype DX recurrence score (RS) of prognostic value once HER2-positive and. low-ER expression patients are removed? Breast J 2013; 19:357-64. [PMID: 23701403 DOI: 10.1111/tbj.12126] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
Oncotype DX has been criticized for not providing significantly more prognostic information than histopathologic analysis. Oncotype DX was validated in cohorts that included poor prognostic factors (HER2-positive, low-estrogen receptor [ER] expression), raising the question: if patients with known high recurrence rates are excluded, is the Recurrence Score (RS) still valid? Our purpose was to determine if RS can be predicted with readily available measures. One hundred and twenty samples from August 2006 to November 2010 that underwent Oncotype DX testing were analyzed. Data included RS, ER, progesterone receptor (PR), HER2, and Ki67 status by immunohistochemistry (IHC). IHC data were used to create two linear regression models to predict RS. SAS's JMP-7 was used for statistical analysis. When comparing Oncotype DX- and IHC-derived ER and PR values, there were 21 discordant samples. The linear regression model PRS-F created with IHC data (ER, PR, HER2, Ki67) from all samples (n = 120) had an adjusted R(2) = 0.60 indicating a good model for predicting RS. The PRS-R model was built without low-ER and HER2-positive samples (n = 110). It had an adjusted R(2) = 0.38 indicating poor prediction of RS. Oncotype DX data showed good concordance with IHC for ER- and PR-expression in this cohort. Low-ER samples had high RS. After removing low-ER and HER2-positives, calculating RS with PRS-R from remaining data showed poor predictive power for RS (adjusted R(2) = 0.38). This result questions whether RS is prognostic in this subgroup (who would most benefit from further clarification of recurrence risk) and independent of pathology, or is simply producing random RS values. Data bases available to Genomic Health can resolve this issue.
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Affiliation(s)
- Meghan Milburn
- Surgery, Division of Surgical Oncology, University of Maryland School of Medicine, Baltimore, Maryland, USA
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Jacobs LK, Carney PS, Cittadine AJ, McCormick DT, Somera AL, Darga DA, Putney JL, Adie SG, Ray P, Cradock KA, Tafra L, Gabrielson EW, Boppart SA. Abstract OT2-1-04: Intraoperative assessment of tumor margins with a new optical imaging technology: A multi-center, randomized, blinded clinical trial. Cancer Res 2012. [DOI: 10.1158/0008-5472.sabcs12-ot2-1-04] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Abstract
Background: Partial mastectomy is the most commonly performed procedure for invasive breast cancer and is associated with a reexcision rate commonly ranging from 20% to 40% in the literature. This high rate of reexcision is associated with significant additional cost (estimated over $4,000 per reexcision) and lower quality outcomes.
Optical coherence tomography (OCT) is a high-resolution imaging technology that images tissue structure with micron-scale resolution – on the same scale as histopathology. It is similar to ultrasound except it uses near infra-red light waves instead of sound waves to create detailed images several millimeters deep into tissue. Although widely used in ophthalmology with growing use in cardiovascular imaging, high-resolution OCT imaging has a narrow depth of focus and requires instrumentation that is not well suited for intraoperative use. Drawing from OCT technology, interferometric synthetic aperture microscopy (ISAM) is a computational imaging technique that creates high-resolution, always in-focus images in software with basic optical instrumentation. A high-resolution ISAM probe and imaging system has been developed for intraoperative imaging of tissue structure and has the potential to broadly impact intraoperative assessment of tumor margins. Intraoperative ISAM imaging of the excised breast cancer specimen margins and in vivo imaging within the surgical cavity may reduce the high rate of reexcision associated with partial mastectomy.
Trial Design: The trial design is a prospective, multi-center, randomized, double arm study comparing the reexcision rate of standard of care partial mastectomy versus the reexcision rate of standard of care partial mastectomy plus intraoperative ISAM imaging.
Inclusion Criteria: Women histologically diagnosed with invasive carcinoma of the breast (invasive ductal or lobular)Undergoing partial mastectomy (lumpectomy) procedureAge 18 years or more
Exclusion Criteria Multicentric diseaseBilateral diseaseNeoadjuvant systemic therapyAll T4 tumorsPrevious radiation in the operated breastPrior surgical procedure in the same quadrantImplants in the operated breastPregnancyLactationParticipating in any other investigational study which can influence collection of valid data
Primary Endpoints Measure of surgical reexcision rateRate of tumor at final surgical marginsSecondary EndpointsVolume of tissue excisedClinical and economic measures of addressing asymmetry
Statistical Methods: The trial is designed to show superiority of the ISAM imaging arm to the standard of care. Statistical design is two group, continuity corrected chi-squared test of equal proportions with 90% power and alpha=0.05. The trial design assumes a baseline reoperation rate in the standard of care arm of 24% with at least a 50% reduction in the ISAM imaging arm.
Present Accrual and Target Accrual
Not yet recruiting. Target accrual is 230 patients in the partial mastectomy + imaging arm and 230 patients in the standard of care partial mastectomy arm.
Citation Information: Cancer Res 2012;72(24 Suppl):Abstract nr OT2-1-04.
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Affiliation(s)
- LK Jacobs
- The Johns Hopkins University School of Medicine, Baltimore, MD; University of Illinois, Urbana, IL; Diagnostic Photonics, Inc, Chicago, IL; Carle Foundation Hospital, Urbana, IL; AdvancedMEMS, San Francisco, CA; Anne Arundel Medical Center, Annapolis, MD
| | - PS Carney
- The Johns Hopkins University School of Medicine, Baltimore, MD; University of Illinois, Urbana, IL; Diagnostic Photonics, Inc, Chicago, IL; Carle Foundation Hospital, Urbana, IL; AdvancedMEMS, San Francisco, CA; Anne Arundel Medical Center, Annapolis, MD
| | - AJ Cittadine
- The Johns Hopkins University School of Medicine, Baltimore, MD; University of Illinois, Urbana, IL; Diagnostic Photonics, Inc, Chicago, IL; Carle Foundation Hospital, Urbana, IL; AdvancedMEMS, San Francisco, CA; Anne Arundel Medical Center, Annapolis, MD
| | - DT McCormick
- The Johns Hopkins University School of Medicine, Baltimore, MD; University of Illinois, Urbana, IL; Diagnostic Photonics, Inc, Chicago, IL; Carle Foundation Hospital, Urbana, IL; AdvancedMEMS, San Francisco, CA; Anne Arundel Medical Center, Annapolis, MD
| | - AL Somera
- The Johns Hopkins University School of Medicine, Baltimore, MD; University of Illinois, Urbana, IL; Diagnostic Photonics, Inc, Chicago, IL; Carle Foundation Hospital, Urbana, IL; AdvancedMEMS, San Francisco, CA; Anne Arundel Medical Center, Annapolis, MD
| | - DA Darga
- The Johns Hopkins University School of Medicine, Baltimore, MD; University of Illinois, Urbana, IL; Diagnostic Photonics, Inc, Chicago, IL; Carle Foundation Hospital, Urbana, IL; AdvancedMEMS, San Francisco, CA; Anne Arundel Medical Center, Annapolis, MD
| | - JL Putney
- The Johns Hopkins University School of Medicine, Baltimore, MD; University of Illinois, Urbana, IL; Diagnostic Photonics, Inc, Chicago, IL; Carle Foundation Hospital, Urbana, IL; AdvancedMEMS, San Francisco, CA; Anne Arundel Medical Center, Annapolis, MD
| | - SG Adie
- The Johns Hopkins University School of Medicine, Baltimore, MD; University of Illinois, Urbana, IL; Diagnostic Photonics, Inc, Chicago, IL; Carle Foundation Hospital, Urbana, IL; AdvancedMEMS, San Francisco, CA; Anne Arundel Medical Center, Annapolis, MD
| | - P Ray
- The Johns Hopkins University School of Medicine, Baltimore, MD; University of Illinois, Urbana, IL; Diagnostic Photonics, Inc, Chicago, IL; Carle Foundation Hospital, Urbana, IL; AdvancedMEMS, San Francisco, CA; Anne Arundel Medical Center, Annapolis, MD
| | - KA Cradock
- The Johns Hopkins University School of Medicine, Baltimore, MD; University of Illinois, Urbana, IL; Diagnostic Photonics, Inc, Chicago, IL; Carle Foundation Hospital, Urbana, IL; AdvancedMEMS, San Francisco, CA; Anne Arundel Medical Center, Annapolis, MD
| | - L Tafra
- The Johns Hopkins University School of Medicine, Baltimore, MD; University of Illinois, Urbana, IL; Diagnostic Photonics, Inc, Chicago, IL; Carle Foundation Hospital, Urbana, IL; AdvancedMEMS, San Francisco, CA; Anne Arundel Medical Center, Annapolis, MD
| | - EW Gabrielson
- The Johns Hopkins University School of Medicine, Baltimore, MD; University of Illinois, Urbana, IL; Diagnostic Photonics, Inc, Chicago, IL; Carle Foundation Hospital, Urbana, IL; AdvancedMEMS, San Francisco, CA; Anne Arundel Medical Center, Annapolis, MD
| | - SA Boppart
- The Johns Hopkins University School of Medicine, Baltimore, MD; University of Illinois, Urbana, IL; Diagnostic Photonics, Inc, Chicago, IL; Carle Foundation Hospital, Urbana, IL; AdvancedMEMS, San Francisco, CA; Anne Arundel Medical Center, Annapolis, MD
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Greer LT, Rosman M, Mylander WC, Hooke J, Kovatich A, Sawyer K, Buras RR, Shriver CD, Tafra L. Does breast tumor heterogeneity necessitate further immunohistochemical staining on surgical specimens? J Am Coll Surg 2012; 216:239-51. [PMID: 23141136 DOI: 10.1016/j.jamcollsurg.2012.09.007] [Citation(s) in RCA: 42] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/08/2012] [Revised: 09/11/2012] [Accepted: 09/12/2012] [Indexed: 01/24/2023]
Abstract
BACKGROUND Prognostic and predictive tumor markers in breast cancer are most commonly performed on core needle biopsies (CNB) of the primary tumor. Because treatment recommendations are influenced by these markers, it is imperative to verify strong concordance between tumor markers on CNB specimens and the corresponding surgical specimens (SS). STUDY DESIGN A prospective study was performed on 165 women (205 samples) with breast cancer diagnosed from January 2009 to July 2011. Tumor type, grade, estrogen receptor (ER), progesterone receptor (PR), human epidermal growth factor 2 (HER2), and Ki67 expression by immunohistochemical (IHC) testing were retrospectively analyzed in the CNB and SS. Contingency tables and agreement modeling were performed. RESULTS There was substantial agreement between the CNB and SS for PR% and HER2; moderate agreement for tumor type, grade, and ER%; and fair agreement for Ki67%. In 8% of patients (n = 13), tumor heterogeneity was seen. In heterogeneous tumors the overall concordance between the CNB and SS was worse, especially for HER2. Six of these patients had areas of tumor that were positive for HER2, which were not detected in their CNBs. Nine patients had multiple distinct molecular subtypes within their tumor(s). CONCLUSIONS The heterogeneous distribution of antigens in breast cancer tumors raises concern that the CNB may not adequately represent the true biologic profile in all patients. There is strong concordance for tumor type, ER, and PR between CNB and SS (although a quantitative decline was noted from CNB to SS); however, HER2 activity does not appear to be adequately detected on CNB in patients with heterogeneous tumors. These data suggest that IHC testing on the CNB alone may not be adequate to tailor targeted therapy in all patients.
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Affiliation(s)
- Lauren T Greer
- Clinical Breast Care Project, Walter Reed National Military Medical Center, Bethesda, MD 20889-5600, USA.
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Freedman BC, Boolbol SK, Cocilovo C, Tafra L. Reduced re-excisions while conserving tissue volume resected in DCIS patients. J Clin Oncol 2012. [DOI: 10.1200/jco.2012.30.27_suppl.144] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
144 Background: The ability to obtain negative margins with a single surgical procedure remains a challenge, particularly in patients with ductal carcinoma in situ (DCIS). Many techniques have been reported to lower the positive margin rate, at a cost of additional tissue resected. A novel device (MarginProbe, Dune Medical Devices, Inc.) is intended to provide surgeons with real time, intraoperative detection of cancerous tissues at the margins of excised specimens. An analysis was performed to determine the impact on tissue volume of the previously reported improvement in candidates for re-excision associated with device use for patients with a DCIS component. Methods: 596 patients undergoing breast conservation using wire localization were randomized in a prospective, international, multicenter (n=21) study. Randomization occurred in the operating room, following standard of care lumpectomy, including palpation and any indicated additional resections. Positive readings required additional resections of the cavity; device was used on main lumpectomy specimen only. Pathologists were blinded to study arm. Tissue volume of all specimens and resections was recorded. Since reducing candidates for re-excision requires removing additional tissue associated with cancer, we looked at total tissue volume removed across all surgeries, to assess the final impact to the patient. Results: Total tissue volumes removed during all surgeries (lumpectomy and re-excisions) for patients with DCIS alone was similar between the study group and control group, while the decrease in candidates for re-excision was significant (13% vs. 37%, p=0.004). For patients with DCIS and invasive carcinoma, the total volume excised was also similar, and the decrease in re-excision candidates was significant (13% vs. 33%, p<0.001). Conclusions: Unlike other techniques for reducing re-excisions, device use does not require an increase in tissue volume to achieve a significant reduction in the number of candidates for re-excision. [Table: see text]
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Affiliation(s)
| | - Susan K. Boolbol
- Beth Israel Medical Center, Continuum Cancer Centers of New York, New York, NY
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Greer LT, Rosman M, Mylander CW, Wareham JA, Campbell LJ, Hooke J, Kovatich AJ, Shriver CD, Tafra L. Should immunohistochemical (IHC) markers be performed on axillary lymph node metastases in view of the lack of concordance between the primary tumor and axillary lymph node metastases? J Am Coll Surg 2012. [DOI: 10.1016/j.jamcollsurg.2012.06.322] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/28/2022]
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Gittleman M, Tafra L. 418 Analysis of the Impact of Intraoperative Margin Assessment with Adjunctive Use of MARGINPROBE® Vs. Standard of Care on Margin Status with Different Definitions of Positive Margin Depth, Results From a Randomized Prospective Multi Center Study. Eur J Cancer 2012. [DOI: 10.1016/s0959-8049(12)70484-7] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
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Boolbol SK, Cocilovo C, Tafra L. P3-12-02: Intra-Operative Margin Assessment of Diffuse Disease with MarginProbe” as an Adjunct to Standard of Care, Results from a Randomized Prospective Multi Center Study. Cancer Res 2011. [DOI: 10.1158/0008-5472.sabcs11-p3-12-02] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Abstract
Background
The ability to obtain negative margins with a single surgical procedure remains a challenge, particularly in patients with diffuse disease such as DCIS and lobular pathology. A novel device (MarginProbe, Dune Medical Devices, Inc.) is intended to provide surgeons with real time, intraoperative detection of cancerous tissues at the margins of excised specimens. A study was performed to determine if there was a device-associated improvement in complete surgical resection (CSR) and therefore a decrease in the rate of patients requiring re-excision with these disease types. The current analysis stratified the data based on tumor type with a special focus on DCIS patients, patient with a DCIS component, and lobular patients.
Methods: All 596 patients underwent breast conservation, with image-guided localization, and were randomized in a prospective, international, multicenter (n=21) study. Randomization occurred in the operating room, following standard lumpectomy procedure, including palpation followed by additional cavity resections as indicated. In the device arm, MarginProbe was used on each specimen margin and device positive readings required additional resections of the cavity. Pathologists were blinded to study arm. Re-excision criteria were not dictated by the protocol.
A primary endpoint of this study was CSR, defined as the correct intraoperative identification and resection (if not skin or fascia) of all positive margins on the main lumpectomy specimen. Positive lumpectomy specimens were defined as those having at least one margin having cancer ≤1mm from the surface. Successful CSR results in reduced positive margin rate after lumpectomy.
Results: Results are presented in Table 1. The improvement in CSR was significant for all diagnosis types. The decrease in candidates for re-excision due to failed CSR was significant for all DCIS and mixed tumor types.
Conclusions: Use of the device resulted in significant improvement in CSR and therefore a significant decrease in the need for reexcisions. Further studies should be conducted to evaluate the use of the device for additional patient cohorts, such as patients receiving neoadjuvant treatment and patients who have undergone prior breast surgery.
Citation Information: Cancer Res 2011;71(24 Suppl):Abstract nr P3-12-02.
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Affiliation(s)
- SK Boolbol
- 1Beth Israel Medical Center, New York, NY; Inova, Alexandria, VA; Anne Arundel Health System, Annapolis, MD
| | - C Cocilovo
- 1Beth Israel Medical Center, New York, NY; Inova, Alexandria, VA; Anne Arundel Health System, Annapolis, MD
| | - L Tafra
- 1Beth Israel Medical Center, New York, NY; Inova, Alexandria, VA; Anne Arundel Health System, Annapolis, MD
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Boolbol SK, Cocilovo C, Tafra L. Use of a novel device to reduce positive margins for ductal carcinoma in situ. J Clin Oncol 2011. [DOI: 10.1200/jco.2011.29.27_suppl.87] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
87 Background: The ability to obtain negative margins with a single surgical procedure remains a challenge, particularly in patients with ductal carcinoma in situ (DCIS). A novel device (MarginProbe, Dune Medical Devices, Inc.) is intended to provide surgeons with real-time, intraoperative detection of cancerous tissues at the margins of excised specimens. A study was performed to determine if there was a device-associated improvement in complete surgical resection (CSR) and therefore a decreased re-excision rate in patients with a DCIS component. Methods: 596 patients who were undergoing breast conservation using needle localization were randomized in a prospective, international, multicenter (n=21) study. Randomization occurred in the operating room, following standard of care lumpectomy, including palpation followed by indicated additional cavity resections. Device positive readings required additional resections of the cavity. Pathologists were blinded to study arm. A primary endpoint of this study was CSR, defined as the correct intraoperative identification and resection (if not skin or fascia) of all positive margins on the main lumpectomy specimen. Positive lumpectomy specimens were those having at least one margin having cancer ≤1mm from the surface. Successful CSR results in reduced positive margin rate after lumpectomy. Results: The improvement in CSR was significant for each diagnosis (p<0.0001). The decrease in candidates for reexcision due to failed CSR was significant for all pathology involving DCIS (p<0.0001). Overall results are presented in the table. Conclusions: Device use delivered significant improvement in CSR and therefore a significant decrease in reexcision rates for patients with DCIS. Further studies need to be conducted evaluating the use of the device on additional margins that the surgeon may resect or in the actual cavity. [Table: see text]
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Affiliation(s)
- S. K. Boolbol
- Beth Israel Medical Center, New York, NY; Inova Breast Care Center, Fairfax, VA; Anne Arundel Medical Center, Annapolis, MD
| | - C. Cocilovo
- Beth Israel Medical Center, New York, NY; Inova Breast Care Center, Fairfax, VA; Anne Arundel Medical Center, Annapolis, MD
| | - L. Tafra
- Beth Israel Medical Center, New York, NY; Inova Breast Care Center, Fairfax, VA; Anne Arundel Medical Center, Annapolis, MD
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Ellsworth RE, Valente AL, Field LA, Kane JL, Love B, Tafra L, Shriver CD. Abstract P4-06-09: Genetic Signature Discriminating Metastatic from Non-Metastatic Small Tumors. Cancer Res 2010. [DOI: 10.1158/0008-5472.sabcs10-p4-06-09] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Abstract
Background: The widespread use of mammographic screening resulted in increased diagnosis of small (<2 cm; T1) tumors. Small tumors are associated with better prognosis, including a lower likelihood of developing metastasis, than larger tumors. Although this lower propensity to metastasize suggests that less aggressive treatments may be warranted in patients with T1 tumors, a subset of patients with small tumors (10-20%) will be diagnosed with lymph node metastasis.
Methods: Frozen breast specimens were collected from women with T1 tumors and either negative (n=29) or positive (n=15) lymph node status. RNA was isolated from pure tumor cell populations after laser microdissection. Gene expression data was generated using HG U133A 2.0 arrays (Affymetrix). Differential expression was determined using Mann-Whitney testing using a P-value < 0.001 to define significance. Results for ESR1 were validated by immunohistochemistry.
Results: Tumor characteristics did not differ significantly between groups in terms of age at diagnosis, grade, HER2 or PR status; however, tumors from patients with positive lymph nodes (47%) were significantly (P<0.05) more frequently ER negative compared to node negative (14%) patients. Gene expression analysis revealed 17 genes that were differentially expressed between node negative and node positive tumors: 6 with higher expression in node positive, including AURKA, and 11 with higher expression in node negative patients, including ESR1 and EPHX2. Of note, ESR1 was expressed at >4X higher levels in tumors without metastasis, in agreement with IHC findings.
Conclusions: Small metastatic tumors differ in gene expression from those without metastasis. EPHX2 has been implicated as a metastasis suppressor while AURKA has been implicated as a metastasis promoter. These results suggest that small tumors have different propensities to metastasize and the genetic signature may serve as a new molecular tool to discriminate metastatic and non-metastatic small tumors, allowing appropriate treatment and risk assessment to be performed.
Citation Information: Cancer Res 2010;70(24 Suppl):Abstract nr P4-06-09.
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Affiliation(s)
- RE Ellsworth
- Henry M. Jackson Foundation, Windber, PA; Windber Research Institute, Windber, PA; BioReka, Timonium, MD; Anne Arundel Medical Center, Annapolis, MD; Walter Reed Army Medical Center, Washington DC
| | - AL Valente
- Henry M. Jackson Foundation, Windber, PA; Windber Research Institute, Windber, PA; BioReka, Timonium, MD; Anne Arundel Medical Center, Annapolis, MD; Walter Reed Army Medical Center, Washington DC
| | - LA Field
- Henry M. Jackson Foundation, Windber, PA; Windber Research Institute, Windber, PA; BioReka, Timonium, MD; Anne Arundel Medical Center, Annapolis, MD; Walter Reed Army Medical Center, Washington DC
| | - JL Kane
- Henry M. Jackson Foundation, Windber, PA; Windber Research Institute, Windber, PA; BioReka, Timonium, MD; Anne Arundel Medical Center, Annapolis, MD; Walter Reed Army Medical Center, Washington DC
| | - B Love
- Henry M. Jackson Foundation, Windber, PA; Windber Research Institute, Windber, PA; BioReka, Timonium, MD; Anne Arundel Medical Center, Annapolis, MD; Walter Reed Army Medical Center, Washington DC
| | - L Tafra
- Henry M. Jackson Foundation, Windber, PA; Windber Research Institute, Windber, PA; BioReka, Timonium, MD; Anne Arundel Medical Center, Annapolis, MD; Walter Reed Army Medical Center, Washington DC
| | - CD. Shriver
- Henry M. Jackson Foundation, Windber, PA; Windber Research Institute, Windber, PA; BioReka, Timonium, MD; Anne Arundel Medical Center, Annapolis, MD; Walter Reed Army Medical Center, Washington DC
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Ellsworth RE, Deyarmin B, Patney HL, Shriver CD, Ellison K, Thornton JD, Dang H, Tafra L, Cheng Z, Rosman M. Abstract P6-04-10: Genetic Discrimination of Aggressive from Indolent DCIS. Cancer Res 2010. [DOI: 10.1158/0008-5472.sabcs10-p6-04-10] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Abstract
Background: Treatment options for DCIS vary from surgical excision with or without radiation and/or chemopreventive therapy, or mastectomy. Intuitively, more aggressive treatment options should lead to improved survival rates, however, studies have shown no difference in breast cancer mortality between women treated with wide excision only versus those with excision plus radiation and treatments can be costly, lengthy and associated with side effects. To avoid over-treating women with indolent disease, while intensively treating women with aggressive disease, new molecular tools must be developed to supplement pathological information to classify DCIS lesions and predict clinical outcome.
Methods: Formalin-fixed paraffin-embedded (FFPE) pure DCIS biopsy specimens were collected from the pathology archives of the Anne Arundel Medical Center. Samples included those with poor prognosis characterized by either recurrence of DCIS or progression to invasive cancer (n=7) and those good prognosis, having ≥5-year disease-free survival (n=10). RNA was isolated after laser-microdissection of pure tumor cells and hybridized to Breast Cancer DSA™ microarrays (Almac Diagnostics). S-way ANOVA was used to account for batch effects and then Support Vector Machine (SVM) was used to identify candidate genes effective at discriminating good from poor prognosis DCIS. Pathway analysis was performed using MetaCore (GeneGeo).
Results: 328 genes were found to be differentially expressed between good and poor prognosis specimens (P<0.01). Preliminary analysis with SVM found that a 70-gene candidate signature from these 328 genes wasoptimal under the tested conditions for discriminating favorable from poor prognosis DCIS. This candidate signature included genes such as MEF2C, PTK2 and ZBTB2. Pathway analysis revealed that genes involved in cytoskeleton modeling, apoptosis and survival, DNA damage repair and cell adhesion are expressed at lower levels in poor prognosis DCIS while those involved in cell cycle, immune response and cell proliferation are expressed at higher levels.
Conclusions: While studies have attempted to identify molecular profiles associated with aggressive DCIS by comparing DCIS co-occurring with invasive disease to pure DCIS, to our knowledge, this is the first study that identified a candidate molecular signature of prognosis in pure DCIS. Although many of the 70 genes found to differ between favorable and poor prognosis DCIS have not been previously associated with breast cancer or have unknown function, MEF2C and PTK2 have been implicated in invasion and migration, while ZBTB2 is a master regulator of p53 and stimulates cellular proliferation. These data demonstrate aggressive DCIS do differ from indolent DCIS at the genetic level and that these differences may be useful in developing molecular tools to classify DCIS lesions and guide appropriate treatment.
Citation Information: Cancer Res 2010;70(24 Suppl):Abstract nr P6-04-10.
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Affiliation(s)
- RE Ellsworth
- Henry M Jackson Foundation, Windber, PA; Windber Research Institute, Windber, PA; Walter Reed Army Medical Center, Washington DC; Almac Diagnostics, Durham, NC; Anne Arundel Medical Center, Annapolis, MD
| | - B Deyarmin
- Henry M Jackson Foundation, Windber, PA; Windber Research Institute, Windber, PA; Walter Reed Army Medical Center, Washington DC; Almac Diagnostics, Durham, NC; Anne Arundel Medical Center, Annapolis, MD
| | - HL Patney
- Henry M Jackson Foundation, Windber, PA; Windber Research Institute, Windber, PA; Walter Reed Army Medical Center, Washington DC; Almac Diagnostics, Durham, NC; Anne Arundel Medical Center, Annapolis, MD
| | - CD Shriver
- Henry M Jackson Foundation, Windber, PA; Windber Research Institute, Windber, PA; Walter Reed Army Medical Center, Washington DC; Almac Diagnostics, Durham, NC; Anne Arundel Medical Center, Annapolis, MD
| | - K Ellison
- Henry M Jackson Foundation, Windber, PA; Windber Research Institute, Windber, PA; Walter Reed Army Medical Center, Washington DC; Almac Diagnostics, Durham, NC; Anne Arundel Medical Center, Annapolis, MD
| | - JD Thornton
- Henry M Jackson Foundation, Windber, PA; Windber Research Institute, Windber, PA; Walter Reed Army Medical Center, Washington DC; Almac Diagnostics, Durham, NC; Anne Arundel Medical Center, Annapolis, MD
| | - H Dang
- Henry M Jackson Foundation, Windber, PA; Windber Research Institute, Windber, PA; Walter Reed Army Medical Center, Washington DC; Almac Diagnostics, Durham, NC; Anne Arundel Medical Center, Annapolis, MD
| | - L Tafra
- Henry M Jackson Foundation, Windber, PA; Windber Research Institute, Windber, PA; Walter Reed Army Medical Center, Washington DC; Almac Diagnostics, Durham, NC; Anne Arundel Medical Center, Annapolis, MD
| | - Z Cheng
- Henry M Jackson Foundation, Windber, PA; Windber Research Institute, Windber, PA; Walter Reed Army Medical Center, Washington DC; Almac Diagnostics, Durham, NC; Anne Arundel Medical Center, Annapolis, MD
| | - M. Rosman
- Henry M Jackson Foundation, Windber, PA; Windber Research Institute, Windber, PA; Walter Reed Army Medical Center, Washington DC; Almac Diagnostics, Durham, NC; Anne Arundel Medical Center, Annapolis, MD
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Verbanac KM, Min CJ, Mannie AE, Lu J, O'Brien KF, Rosman M, Tafra L. Long-term follow-up study of a prospective multicenter sentinel node trial: molecular detection of breast cancer sentinel node metastases. Ann Surg Oncol 2010; 17 Suppl 3:368-77. [PMID: 20853060 DOI: 10.1245/s10434-010-1262-2] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/30/2010] [Indexed: 11/18/2022]
Abstract
BACKGROUND This prospective multicenter sentinel lymph node (SLN) trial investigated whether molecular analysis would improve the detection of SLN metastases and their prognostic value. We report mammaglobin quantitative real-time polymerase chain reaction (qRT-PCR) results and clinical outcome for 547 patients (mean follow-up 7 years). METHODS Breast cancer patients (excluding stage IV disease or palpable nodes) were enrolled from 1996 to 2005 at 16 institutional review board-approved sites. Alternate 2-mm serial sections of each SLN were examined by hematoxylin and eosin staining with or without immunohistochemistry at multiple levels or blinded and assayed by Taqman qRT-PCR according to previously established thresholds. RESULTS Mammaglobin remains a highly specific (99%), sensitive (97% primary tumor; 82% N1 SLN) marker for breast cancer. Mammaglobin SLN expression was associated with other prognostic factors, was detected in most patients with distant recurrence (48 of 79; 61%), and was associated with decreased recurrence-free survival (log rank P < 0.0001). Molecular analysis upstaged 13% (52 of 394) node-negative (N0) patients who exhibited a significantly lower distant recurrence-free survival compared to node-negative, PCR-negative patients (80 vs. 91%; P < 0.04). N0 patients with PCR-positive SLN were 3.4 times more likely to experience relapse than PCR-negative patients (odds ratio 3.4; 95% confidence interval 1.6-7.1; P = 0.001). However, molecular staging failed to predict most of the N0 patient recurrences (25 of 34) and was not a statistically significant independent predictor of distant recurrence. CONCLUSIONS To our knowledge, these data are the first to prospectively compare PCR detection of SLN metastases with long-term outcome in breast cancer patients. Molecular staging of SLN detected clinically significant disease missed by standard pathology. Further refinement and optimization of molecular staging is indicated to improve clinical utility.
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Affiliation(s)
- Kathryn Mary Verbanac
- Department of Surgery, The Brody School of Medicine at East Carolina University, Greenville, NC, USA.
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Hollowell K, Olmsted CL, Richardson AS, Pittman HK, Bellin L, Tafra L, Verbanac KM. American Society of Clinical Oncology-recommended surveillance and physician specialty among long-term breast cancer survivors. Cancer 2010; 116:2090-8. [PMID: 20198707 DOI: 10.1002/cncr.25038] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
BACKGROUND It is unclear whether it is appropriate to transfer the follow-up care of breast cancer (BrCa) survivors from cancer specialists to primary care physicians (PCPs). This contemporary study compared physician specialty and documented the long-term surveillance of survivors who underwent surgery at an American academic center. METHODS Women in this institutional review board-approved study underwent breast surgery between 1996 and 2006. Data were collected for 270 patients with stage I to III BrCa (mean follow-up, 6 years). Charts were reviewed based on American Society of Clinical Oncology (ASCO) guidelines for recommended surveillance frequency and care. RESULTS The majority of patients (90%; n = 242) were followed by specialists with 10% (n = 28) followed by PCPs. Patients with advanced disease and a greater risk of disease recurrence more often received specialist care. Patients followed by specialists were more often seen at ASCO-recommended intervals (eg, 89% vs 69% of patients followed by a PCP at follow-up Year 6; P < .01); however, many patients were followed inconsistently. Breast disease was often not the focus of PCP visits or mentioned in clinic notes (18% patients). Women seen by specialists were more likely to have documented clinical examinations of the breast (93% vs 44% at Year 6), axilla (94% vs 52%), or annual mammograms (74% vs 48%; P = .001-.02). CONCLUSIONS Consistent compliance with surveillance guidelines and chart documentation needs improvement among all providers; however, specialists more consistently met ASCO guidelines. If transfer of care to a PCP occurs, it should be formalized and include follow-up recommendations and defined physician responsibilities. Providers and patients should be educated regarding surveillance care and current guidelines incorporated into standard clinical practice.
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Affiliation(s)
- Kerry Hollowell
- Department of Surgery, The Brody School of Medicine, East Carolina University, Greenville, North Carolina 27858, USA
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Reed J, Rosman M, Verbanac KM, Mannie A, Cheng Z, Tafra L. Prognostic implications of isolated tumor cells and micrometastases in sentinel nodes of patients with invasive breast cancer: 10-year analysis of patients enrolled in the prospective East Carolina University/Anne Arundel Medical Center Sentinel Node Multicenter Study. J Am Coll Surg 2008; 208:333-40. [PMID: 19317993 DOI: 10.1016/j.jamcollsurg.2008.10.036] [Citation(s) in RCA: 121] [Impact Index Per Article: 7.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/27/2008] [Revised: 10/16/2008] [Accepted: 10/27/2008] [Indexed: 11/30/2022]
Abstract
BACKGROUND Sentinel lymph node biopsy (SLNB) is a more sensitive and accurate nodal staging procedure than axillary lymph node dissection (ALND). Because of increased pathologic evaluation in the sentinel node era, more nodal micrometastases (MIC) (> 0.2 mm to 2 mm) and isolated tumor cells (ITC; < or = 0.2 mm) have been identified. We present the 10-year analysis of our prospective SLN study, focusing on regional axillary node status and distant metastases in patients with nodal ITC and MIC. STUDY DESIGN From 1996 to 2005, breast cancer patients were enrolled in an Institutional Review Board-approved, multicenter study. SLNs were examined at multiple levels by hematoxylin and eosin; most (85%) hematoxylin and eosin-negative SLNs were also examined by cytokeratin immunohistochemistry. Data from 1,259 patients with invasive breast cancer and in whom an SLN was found were reviewed for this analysis. RESULTS Of the 1,259 patients, 893 (71%) had negative SLNs, 25 (2%) had ITCs, 57 (5%) had MIC, and 284 (23%) had positive SLNs. None of the 13 patients with ITCs who underwent an ALND had additional positive nodes, compared with 27% (11 of 41) of patients with MIC. At a mean followup of 4.9 years, the distant recurrence rates for SLN-negative, ITC, MIC, and SLN-positive groups were 6%, 8%, 14%, and 21%, respectively. The presence of MIC in the SLN was associated with a significantly shorter disease-free interval than was SLN negativity (p < 0.02 by Cox regression model). CONCLUSIONS This prospective breast cancer study found that sentinel node MIC, but not ITCs, were associated with additional positive nodes and with distant recurrence. These data suggest that ALND may be unnecessary in patients with ITCs. But ALND and more aggressive adjuvant therapy should be considered in patients with SLN micrometastases.
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Affiliation(s)
- Jennifer Reed
- The Breast Center for Anne Arundel Medical Center, Annapolis, MD 21401, USA
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Affiliation(s)
- Lorraine Tafra
- The Breast Center, Anne Arundel Medical Center, 2002 Medical Parkway, Suite 120, Annapolis, MD 21401, USA.
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Tafra L, Fine R, Whitworth P, Berry M, Woods J, Ekbom G, Gass J, Beitsch P, Dodge D, Han L, Potruch T, Francescatti D, Oetting L, Smith JS, Snider H, Kleban D, Chagpar A, Akbari S. Prospective randomized study comparing cryo-assisted and needle-wire localization of ultrasound-visible breast tumors. Am J Surg 2006; 192:462-70. [PMID: 16978950 DOI: 10.1016/j.amjsurg.2006.06.012] [Citation(s) in RCA: 48] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/11/2006] [Revised: 06/15/2006] [Accepted: 06/15/2006] [Indexed: 10/24/2022]
Abstract
BACKGROUND This study compared the surgical results of 2 localization methods-cryo-assisted localization (CAL) and needle-wire localization (NWL)-in patients undergoing breast lumpectomy for breast cancer. METHODS A total of 310 patients were treated in an institutional review board-approved study with 18 surgeons at 17 sites. Patients were randomized 2:1 to undergo either intraoperative CAL or NWL. A cryoprobe was inserted under ultrasound guidance in the operating room and an ice ball created an 8- to 10-mm margin around the lesion. The palpable ice ball then was dissected. NWL was placed according to institutional practice and resection was performed in a standard fashion. Surgical margins, complications, re-excisions, tissue volume, procedure times, ease of localization, specimen quality, and patient satisfaction were evaluated. Positive margins were defined as any type of disease present 1 mm or less from any specimen edge. RESULTS Positive margin status did not differ between the 2 groups (28% vs. 31%). The volume of tissue removed was significantly less in the CAL group (49 vs. 66 mL, P = .002). Re-excisions were similar in both groups. CAL was superior in ease of lumpectomy, quality of specimen, acute surgical cosmesis, short-term cosmesis, patient satisfaction, and overall procedure time for the patient. CAL had a lower invasive positive margin rate (11% vs. 20%, P = .039) but a higher observed ductal carcinoma in situ-positive margin rate (30% vs. 18%, approaching statistical significance, P = .052). CONCLUSIONS CAL is a preferred alternative to standard wire localization because it provides a palpable template, removes less tissue and improves cosmesis, decreases overall procedure time, and is more convenient for the patient and surgeon.
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Affiliation(s)
- Lorraine Tafra
- Anne Arundel Medical Center, 2002 Medical Pkwy., Suite 120, Annapolis, MD 21401, USA.
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