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

INTRODUCTION

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Abstract P2-08-23: A combined score of tumour budding and tumour necrosis has prognostic value for cancer specific survival in both ER positive and ER negative primary operable breast cancer

Background: As new systemic therapies emerge for the treatment of breast cancer, new prognostic markers are required to help stratify patients into higher and lower risk groups to aid treatment decision making. Features of the tumour microenvironment, such as tumour necrosis, tumour-stroma percentage (TSP), and tumour budding have been shown to have prognostic value in some cancers. However, their role in breast cancer is unclear.

Methods: Patients who underwent surgery for primary operable breast cancer in 2 centres between 1995-2007 and who had paraffin-embedded tissue blocks available were identified. Clinicopathological details and survival data were obtained from patient records. Haematoxylin & Eosin-stained slides were visually assessed within a set visual field for TSP (&lt;50% or &gt;50% tumour stroma), tumour necrosis (&lt;25% or &gt;25% necrosis) and tumour budding (&lt;20 buds or &gt;20 buds). A combined score of tumour necrosis and tumour budding was then created. A score of 0 was assigned to tumours where both components were low, 1 to those where only one component was high, and 2 to those where both were high. Multivariate cox regression analysis was carried out for cancer specific survival (CSS).

Results: A breast cancer cohort of 1301 patients was utilised, from which 1186 H&E slides were scored for necrosis, TSP and tumour budding. Median follow up was 158 months (26-183) and there were 234 breast cancer deaths. In the full cohort, necrosis (p&lt;0.0001), high TSP (p=0.010) and high budding (p&lt;0.0001) were associated with CSS and all 3 were independently prognostic on multivariate analysis (necrosis HR 1.54, 95%CI 1.15-2.07, p=0.004; high TSP HR 1.49, 95%CI 1.12-1.98; p=0.006; high budding HR 1.38, 95%CI 1.02-1.87, p=0.035). In ER positive disease (n=826), necrosis was associated with worse CSS (p&lt;0.0001) and was independently prognostic (HR 1.46, 95%CI 1.03-2.08, p=0.033). In ER negative disease (n=359), necrosis, high TSP and high budding were associated with worse CSS (p=0.001, p=0.002, p&lt;0.0001 respectively) and were independently prognostic (necrosis HR 2.44, 95%CI 1.34-4.43, p=0.003; high TSP HR 1.64, 95%CI 1.06-2.53, p=0.026; high budding HR 2.47, 95%CI 1.56-3.89, p&lt;0.0001) . To assess if combining these markers added additional prognostic power a combined budding/necrosis score was established. This was associated with worse CSS in ER positive disease (p&lt;0.0001) and a score of 2 was independently associated with worse CSS compared to a score of 0 (HR 1.96, 95%CI 1.19-3.23, p=0.008). This was potentiated in node-negative patients (HR 5.14, 95%CI 2.18-12.08, p&lt;0.0001). In ER negative disease, an increasing score was associated with worse CSS (p&lt;0.0001) and was independently prognostic (combined score 1 vs. 0: HR 2.37, 95%CI 1.13-5.00, p=0.023; score 2 vs. 0: HR 5.93, 95%CI 2.62-13.40, p&lt;0.0001).

Conclusions: A combined score of tumour necrosis and budding shows promise as a readily-available prognostic tool to aid treatment decision making in primary operable breast cancer, both by stratifying risk in ER negative disease, and by identifying a high-risk group in ER positive, node negative disease.

Citation Format: Morrow ES, Gujam F, Mohammed Z, McMillan DC, Horgan PG, Roseweir AK, Edwards J. A combined score of tumour budding and tumour necrosis has prognostic value for cancer specific survival in both ER positive and ER negative primary operable breast cancer [abstract]. In: Proceedings of the 2018 San Antonio Breast Cancer Symposium; 2018 Dec 4-8; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2019;79(4 Suppl):Abstract nr P2-08-23.

Structure-property relationships from universal signatures of plasticity in disordered solids

When deformed beyond their elastic limits, crystalline solids flow plastically via particle rearrangements localized around structural defects. Disordered solids also flow, but without obvious structural defects. We link structure to plasticity in disordered solids via a microscopic structural quantity, "softness," designed by machine learning to be maximally predictive of rearrangements. Experimental results and computations enabled us to measure the spatial correlations and strain response of softness, as well as two measures of plasticity: the size of rearrangements and the yield strain. All four quantities maintained remarkable commonality in their values for disordered packings of objects ranging from atoms to grains, spanning seven orders of magnitude in diameter and 13 orders of magnitude in elastic modulus. These commonalities link the spatial correlations and strain response of softness to rearrangement size and yield strain, respectively.

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSION

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

Abstract P1-07-06: The relationship between Klintrup-Makinen score and cancer-specific survival in primary operable breast cancer

Introduction

It is increasingly being recognised that cancer prognosis is dependent on a complex interaction of tumour factors and the host response. The degree of inflammatory response at the invasive tumour edge, as measured by the Klintrup-Makinen score, has been shown to have prognostic relevance in some cancers but its role in breast cancer remains unclear.

Aim

To evaluate the relationship between Klintrup-Makinen score and prognosis in primary operable breast cancer.

Methods

Patients who underwent surgery for primary operable invasive breast cancer between 1995 and 2007 were studied. Full section haematoxylin and eosin slides from surplus tissue from each breast cancer were analysed. Each was visually scored for the level of inflammatory infiltrate at the invasive edge of the tumour, according to Klintrup-Makinen criteria. Kaplan Meier survival analysis was performed using SPSS.

Results

1195 patients were included in the study, of which 298 had a Klintrup-Makinen score (KM) of 0 (no inflammatory cells at the invasive edge), 589 had a score of 1, 238 had a score of 2 and 70 had a Klintrup-Makinen score of 3 (high inflammatory cell infiltrate). 833 (69.7%) patients were ER positive and 172 (14.4%) patients were HER2 positive. Median follow up was 158 months (28-183) and there were 234 cancer deaths. Patients with the highest and lowest KM scores had the best prognosis (10 year breast cancer specific survival (BCSS) 84% for KM score 3 and 82% for KM score 0), while those with KM score 2 had the worst prognosis with 67% 10 year cancer specific survival (p=0.003). When analysed by subtype, in ER negative patients 10 year BCSS was 95% in KM 0 patients, 80% for KM 3, 72% for KM 1 and 67% for KM 2 (p=0.082). Conversely, in HER2 positive patients, the best prognosis was seen in patients with KM 3 with 86% 10 year BCSS but patients with KM 0 had the worst prognosis (BCSS 62%), but this did not reach significance (p=0.544).

Conclusion

The Klintrup-Makinen score appears to have a prognostic role in primary operable invasive breast cancer, however there is a suggestion that it varies between tumour subtypes. Further work is required to further define this role for each molecular subtype.

Citation Format: Morrow ES, Gujam F, Mohammed ZMA, McMillan DC, Edwards J. The relationship between Klintrup-Makinen score and cancer-specific survival in primary operable breast cancer [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 P1-07-06.

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

Introduction

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

Aim

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

Methods

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

Results

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

Conclusion

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

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

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

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

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

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

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

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

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

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

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

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

None of the authors have conflict of interest to declare.

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

Abstract P2-10-06: The long term outcomes of female patients treated with primary endocrine therapy for non-metastatic breast cancer

This abstract was withdrawn by the authors.

Perioperative considerations when operating on the very obese: tricks of the trade

Obesity is the leading public health concern in the industrialized world with the advent of the very obese or "super obese" increasing exponentially. Bariatric surgery remains the only effective and enduring treatment for morbid obesity and can be safely accomplished in experienced centers. Surgery in the very obese may be considered high-risk: however, this risk may be managed with an experienced bariatric surgery team, appropriate anesthetic consideration, preoperative risk assessment, employment of venothrombotic event prevention, preoperative weight loss, and understanding of particular anatomic considerations. With appropriate preparation, the very obese surgical patient can achieve safe and effective surgical outcomes.

Effects of cooking methods on peanut allergenicity

BACKGROUND

Allergy to peanut is a significant health problem. Interestingly, the prevalence of peanut allergy in China is much lower than that in the United States, despite a high rate of peanut consumption in China. In China, peanuts are commonly fried or boiled, whereas in the United States peanuts are typically dry roasted.

OBJECTIVE

The aim of this study was to examine whether the method of preparing peanuts could be a factor in the disparity of allergy prevalence between the 2 countries.

METHODS

Two varieties of peanuts grown in the United States were roasted, boiled, or fried. Proteins were analyzed by using SDS-PAGE and immunoblotting. Allergenicity was compared by using immunolabeling with sera from 8 patients with peanut allergy.

RESULTS

The protein fractions of both varieties of peanuts were altered to a similar degree by frying or boiling. Compared with roasted peanuts, the relative amount of Ara h 1 was reduced in the fried and boiled preparations, resulting in a significant reduction of IgE-binding intensity. In addition, there was significantly less IgE binding to Ara h 2 and Ara h 3 in fried and boiled peanuts compared with that in roasted peanuts, even though the protein amounts were similar in all 3 preparations.

CONCLUSION

The methods of frying or boiling peanuts, as practiced in China, appear to reduce the allergenicity of peanuts compared with the method of dry roasting practiced widely in the United States. Roasting uses higher temperatures that apparently increase the allergenic property of peanut proteins and may help explain the difference in prevalence of peanut allergy observed in the 2 countries.

Effect of isoproterenol on brown and white fat of the adult rat

The effects of isoproterenol on brown and white fat were studied by analyzing the total percentage lipid of the tissue and by the fluorescent histochemical method for catecholamines in sympathetic fibers. At dosages which were well below the LD50, isoproterenol selectively emptied brown fat without affecting the white fat at all. It was suggested that the rise in free fatty acids in the blood seen afer injection of isoproterenol is partly due to an emptying of brown fat.