Abstract P3-14-07: Neoadjuvant radiotherapy in mastectomy and immediate autologous free flap reconstruction. Findings from the primary radiotherapy and DIEP flap (PRADA) pilot study

Background:

The need for post mastectomy radiotherapy (PMRT), may preclude reconstructive surgeons from offering patients immediate, autologous reconstruction. This is due to historical evidence suggesting high rates of short- and long-term complications as well as poorer aesthetic outcomes. As the indications for PMRT broaden this practice denies an ever-increasing number of women the benefit of an immediate reconstruction.

Aim:

This pilot study evaluates the safety of offering radiotherapy prior to mastectomy and immediate DIEP flap reconstruction.

Methods:

Women planned for neoadjuvant chemotherapy (NAcT), mastectomy (following unsuccessful breast conservation surgery (BCS) or upfront selection) and PMRT were offered a change in sequencing of RT at two academic breast surgery units in London, UK. Data was prospectively captured on 19 women, including: patient demographics, treatment details, tumour characteristics, oncological and post-operative outcomes. Operative parameters included unplanned return to theatre [RTT] <30 days, mastectomy skin flap necrosis, and evidence of wound infection at 5 days, 4 and 12 weeks post-operatively. All mastectomies, were performed by one of 3 breast surgeons (DH, FAM, DRL) using a circumareolar incisions with one patient undergoing a vertical pattern incision for skin reduction.

Results:

The cohort demonstrated a broad range of age, body mass index (BMI) and mastectomy weight [mean (range): age=46 years (28-72); BMI = 28.4 kg/m2 (23-37.6) and specimen weight=678gm (257-1040)]. The mean time from completion of NAcT to neoadjuvant radiotherapy (NART) was 31.1 days (9-49 days), and time from completion of NART to mastectomy and DIEP was 17.8 days (13-24 days). There was one unplanned RTT at 72 hours for an evacuation of haematoma, 1 revision of micro-vascular anastomosis, 1 clinical fat necrosis requiring formal excision and 1 wound debridement and primary closure for poor wound healing (vertical pattern skin reduction). There were no flap failures and no mastectomy envelope necrosis. With a mean follow-up of 16.2 months, there were no loco-regional recurrences, 5 distant relapses with mean presentation at 13.7 months and 2 breast-cancer related deaths at 13.9 and 22.2months respectively.

Conclusion:

This pilot study suggests that mastectomy and DIEP reconstruction is surgically feasible within 4 weeks of completing NART. In this small cohort of oncologically high-risk women with altered sequencing of RT we did not observe flap failure or post-mastectomy skin flap necrosis. A larger multicentre study with aesthetic assessment, PROMS and translational aspects is planned.

Citation Format: Thiruchelvam P, Hadjiminas D, Cleator S, Wood S, Leff D, Jallali N, James S, MacNeill F. Neoadjuvant radiotherapy in mastectomy and immediate autologous free flap reconstruction. Findings from the primary radiotherapy and DIEP flap (PRADA) pilot study [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 P3-14-07.

Abstract P2-18-18: Improving training in breast surgical oncology: The development and preliminary validation of a simulator for wide local excision

Background

Simulation training has the potential to increase resident confidence in basic procedural tasks prior to operating room (OR) refinements, offsets a reduction in mentoring opportunities, avoids the use of patients for skills practice, and facilitates objective assessment of technical skills. Despite a multitude of benefits, adoption of simulation training and assessment in breast surgical oncology has not been forthcoming.

Aims

To develop and validate a high-fidelity surgical simulator for the practice, training and assessment of technical skills in wide local excision (WLE) of a palpable breast tumour.

Methods

Subjects (attendings and residents with an interest in breast surgery, and novice trainees) were invited to perform a WLE of 25mm palpable breast lesion located 30mm from the nipple areolar complex in the 3o clock position, on a synthetic breast simulator developed at Imperial College London as part of the London Deanery Skills Programme. Procedures were videotaped (blind) and were retrospectively reviewed and independently rated against procedure-specific ratings of performance (VAS 0-100) by two expert breast surgeons (>10 years experience). Specimen radiographs were performed (BioVision, Faxitron, USA) and margin of clearance (mm) were calculated from the edge of the “tumour” to the limits of surrounding breast tissue excised in 4 cardinal directions (i.e. N, S, E W). Specimen weights were recorded (g). Subjects completed a comprehensive questionnaire to determine simulator content and face validity.

Results

21 subjects participated (5 attendings, 13 registrars, and 3 junior trainees). Data was analysed according to experience (high = >100 independent wide local procedures; low = no independent wide local procedures). Statistically significant (p ≤ 0.05) differences in performance were observed between high and low experience surgeons [for each category data are VAS score medians±IQR; ‘exposure’: low = 70.0±50.0, high = 80.0±20.0; ‘skin flap development’: low = 70.0±50.0, high = 80.0±40.0; ‘resection skills’: low = 60.0±55.0, high = 80.0±45.0; ‘glandular remodelling’: low = 70.0±25.0; high = 80.0±50.0, ‘skin closure’: low = 70.0±25.0, high = 90.0±20.0]. Resection margin width and specimen weight (MWU = 52.5, p = 1.0) did not discriminate high-low experience surgeons. The majority of participants believed that training on the model simulated the same steps as a real WLE (94.7%) and was useful for real practice (84.2%).

Discussion

Preliminary data on a WLE simulator suggests that the model is face and construct valid, and may be useful to supplement early stage practice prior to skills development in the OR. Video performance ratings whilst time consuming appear to distinguish high-low experience surgeons better than do specimen weight or radiographic margin width.

Citation Information: Cancer Res 2013;73(24 Suppl): Abstract nr P2-18-18.

Invasive Lobular Carcinoma: Imaging Characteristics, Size at Presentation and Bilaterality

Aims: Invasive Lobular Carcinoma (ILC) is often described as elusive to standard imaging modalities and usually requiring mastectomy to obtain clear margins. Its reputation of being bilateral has been disputed by most recent studies. The aim of this study is to investigate whether the radiological diagnosis of ILC at first symptomatic presentation is more difficult than that of Invasive Ductal Carcinoma (IDC) in a modern breast clinic; also whether its size, surgical treatment at presentation and bilaterality is different from IDC and its subtypes.Materials & Methods: The radiological codes given to all new symptomatic patients with invasive breast cancer, presenting at the breast clinic of St Mary's Hospital and undergoing surgery as first treatment, (n=754), were collected prospectively between 1998 and 2005 and final mastectomy rates were also recorded. Histological reports of all synchronous and metachronous bilateral cancers presenting with at least one tumour between 1998 and 2007 were analyzed (n=65).Results: ILC was given suspicious radiological codes as often as IDC (90% vs 93%). On final histology, ILC measured on average 3.6cm compared to 2.5cm for IDC (p<0.05). There was a trend of ILC requiring mastectomy more often (51% vs 43%). 12.7% of patients with at least one ILC diagnosis have developed bilateral breast cancer compared to 4.5% of patients who have never had an ILC diagnosis (p<0.05).Results IDCILCMixedSpecialUnknownTotalNo of patients551 (73%)86 (11%)52 (7%)62 (8%)3 (0.4%)754Age (mean)5861596157.659Mastectomy191 (43%)36 (51%)23 (49%)13 (25%) 263Breast conservation257 (58%)36 (51%)24 (51%)41 (77%) 358Size cm (mean)2.53.62.52.0-2.7USS suspicious473 (93%)72 (90%)41 (90%)42 (76%)2 (100%)630MMG suspicious412 (81%)58 (73%)39 (80%)43 (80&)2 (100%)554 Conclusions: ILC is as easy to diagnose radiologically as IDC in symptomatic breast patients. However, ILC is larger at first presentation. In our database, ILC identified a subgroup of breast cancer patients who have a 3-fold higher risk of developing bilateral breast cancer of various histological types.

Citation Information: Cancer Res 2009;69(24 Suppl):Abstract nr 4015.

Optimising preoperative diagnosis in phyllodes tumour of the breast

The role of the pathologist in the preoperative diagnosis of phyllodes tumours of the breast is critical to appropriate surgical planning. However, reliable differentiation of phyllodes tumour from cellular fibroadenoma remains difficult. Preoperative diagnostic accuracy allows correct surgical treatment, avoiding the pitfalls of reoperation because of inadequate excision, or surgical overtreatment. Specific clinical indices may arouse diagnostic suspicion but are unreliable for confirmation, as with current imaging modes. Fine needle aspiration cytology has a high false negative rate. Few studies have evaluated the role of core needle biopsy, but it may prove a useful adjunct. Both diagnostic and prognostic information may in future be gained from application of immunohistochemical and other techniques assessing the expression of proliferative markers including p53, Ki-67, and others.

Endothelin-1 expression in the small intestine during chronic peritonitis

Endothelins (ET) have been demonstrated to mediate intestinal microvascular constriction during acute Escherichia coli bacteremia, however, their role during chronic infection is unknown. The purpose of this study was to determine whether ET-1 is synthesized in the small intestine in a more chronic peritonitis model. ET-1 mRNA levels of the terminal ileum in mice following cecal ligation and puncture (CLP) were compared to sham-operated animals and normal unoperated animals. ET gene expression was analyzed using differential reverse transcriptase chain reaction (RT-PCR) with co-amplification of beta-actin as an internal standard. To assess ET peptide expression, serum and intestinal tissue levels were measured using a specific enzyme immunoassay (ELISA). The pattern of ET-1 gene expression post-CLP with a single puncture of the cecum with a 23 ga. needle demonstrated a 3.6-fold increase at 8 h, and a return to sham levels by 24 h (374 +/- 64% at 8 h, p < .05, 128 +/- 13%). An increase of mRNA levels at 24 h post-CLP was observed with a double puncture with an 18 ga. needle (230 +/- 36%, p < .05) accompanied by an increase in serum ET levels (270 +/- 31%, p < .05) and higher tissue ET levels. These data indicate a time-dependent response of ET-1 gene expression in the terminal ileum post-CLP which is related to severity of infection.

Antibiotic overkill of trauma victims?

Antibiotic usage was assessed in a prospective, randomized trial of recombinant interferon-gamma (rIFN-gamma) versus placebo for 212 severely injured trauma patients in four university hospitals. All patients were observed until death or discharge from the hospital. We found the number of antibiotics used and their associated costs staggering and difficult to justify, although serious antibiotic-related complications were infrequent. Regular antibiotic administration following severe trauma should be re-evaluated since clinical evidence supports the use of shorter courses for these patients, with presumed similar outcomes and much-reduced expenses.