Evaluating a novel patient pathway to manage symptomatic breast referrals (the blue flag clinic): a longitudinal observational study

INTRODUCTION

A novel referral pathway for exhibited breast symptom (EBS) referrals to manage increasing referrals of urgent suspected cancer (USC) was implemented in our trust. We report on the safety and effect on compliance with the 2-week-wait rule (2WW).

METHODS

A single-centre longitudinal observational study included all patients referred to a UK breast unit during 13 May 2019 to 27 March 2020 (period 1) and 8 February 2021 to 31 January 2022 (period 2). USC referrals were assessed in a one-stop clinic (red flag clinic [RFC]); EBS referrals were assessed in a new clinic in which clinical evaluation was performed and imaging occurred subsequently (blue flag clinic [BFC]). Patients were followed up to determine the symptomatic interval cancer rate.

RESULTS

There were 9,695 referrals; 1,655 referrals (17%) were assessed in the BFC after 63 exclusions. Some 95.9% of patients had a benign clinical examination (P1/P2), 80.1% had imaging (mammogram or ultrasound) and 4% had a tissue biopsy. In total, 16/1,655 (0.97%) BFC patients and 510/7,977 (8.2%) RFC patients were diagnosed with breast cancer (breast cancer detection rate). Some 1,631 patients (with 1,639 referrals) were discharged and followed up for a median of 17 months (interquartile range 12-32) with one subsequent cancer diagnosis (symptomatic interval cancer rate, 0.06%). Implementation of the BFC pathway increased 3-month average trust performance of USC referrals with 2WW standard from 8.5% to 98.7% (period 1) and from 30% to 66% (period 2).

CONCLUSIONS

The BFC pathway for EBS patients is safe and implementation led to improvement against the 2WW target for USC referrals, ensuring resources are prioritised to patients with the highest likelihood of breast cancer.

1576 Safeguarding Tools in Paediatric Burns

Introduction

When assessing paediatric patients presenting with burns, non-accidental injury always has to be considered. In our department, local policy dictates that all patients aged 18 or below should have a child safeguarding tool completed on initial clerking.

Method

A retrospective audit of all paediatric burns seen over one month was performed. Primary outcome measures included completion of a safeguarding tool and documentation of referral outcome. These results were presented locally and implementing changes were carried out. This was then re-audited over a further monthly period.

Results

Initial data collection showed a safeguarding tool completion rate of 69% and referral outcome documentation rate of 50% (n = 16). Implement changes included dissemination of initial audit results to the department, changing the layout of our clerking proformas and introducing posters in the unit which provided more information on risk assessing paediatric patients. The re-audit results showed a safeguarding tool completion rate of 100% and a referral outcome documentation rate of 100% (n = 14).

Conclusions

There was a significant improvement in both the safeguarding tool completion and referral outcome documentation rates following our interventions. Simple measures just such education and strategic adjustments of clerking proformas have been shown to be effective measures for increasing documental compliance of child safeguarding tools.

Solitary Cardiac Low-Grade Neuroendocrine Tumor: A Case Report and Review of the Literature

Introduction/Objective

Primary tumors of the heart are uncommon; even rarer are primary cardiac neuroendocrine tumors. To our knowledge, only two cases have been described to date, both being high-grade tumors. We report a solitary low-grade neuroendocrine tumor of the heart, unexpectedly discovered on the wall of the right ventricle in a 44-year-old man during aortic valve repair for infectious bacterial endocarditis.

Results

Frozen section was sent intraoperatively and showed a plasmacytoid neoplasm. Final pathology of the biopsies showed a tumor composed of both cohesive and discohesive plasmacytoid cells separated by a vascular network and strands of fibrosis. Neither necrosis nor a mitotic rate greater than 2 mitoses per 2 mm2 were seen. The tumor showed strong reactivity for AE1/3, synaptophysin and CDX2 with focal reactivity for chromogranin-A and CD56, confirming the diagnosis of a low-grade neuroendocrine tumor. Both an esophagogastroduodenoscopy and colonoscopy were performed and showed no evidence of a primary gastrointestinal tumor. PET-CT DOTATATE performed after complete resection of the tumor showed no abnormal radiotracer uptake. The possibility of an intestinal neuroendocrine tumor undetected by DOTATATE PET-CT with a single known metastasis to the heart was considered. This too, on the basis of the literature, was considered exceedingly rare. Complete resection of this patient’s tumor was considered sufficient treatment; the patient was advised to follow up annually with medical oncology.

Conclusion

The presentation and management of a solitary cardiac low-grade neuroendocrine tumor has not previously been described in the literature.

Pelvic exenteration for advanced malignancy in elderly patients

Background

Pelvic exenteration is an aggressive surgical procedure reserved for highly selected patients. Surgery in the elderly is often associated with increased morbidity and mortality. The aim of this study was to review outcomes following exenteration for advanced pelvic malignancy in this subgroup of patients.

Methods

All patients aged 70 years and over who underwent pelvic exenteration between 1999 and 2014 were included in the study. This comprised all primary rectal, gynaecological and bladder tumours. The primary outcome measure was 5-year overall survival. Secondary endpoints were postoperative morbidity and 30-day mortality.

Results

A total of 94 patients were included, with a median age of 76 (range 70–90) years. There were 65 rectal, 20 gynaecological and nine bladder tumours. The administration of neoadjuvant therapy was significantly different among tumour types (P = 0·002). A total of 32 patients (34 per cent) developed postoperative complications, and there were six deaths (6 per cent) within 30 days of surgery. Median survival was 64 months for patients with rectal cancer, 30 months for those with gynaecological tumours and 15 months for those with bladder cancer. Five-year survival rates in these groups were 47, 31 and 22 per cent respectively (P = 0·023).

Conclusion

Given the possibility of long-term survival, pelvic exenteration should not be withheld on the grounds of advanced age alone.

Outcome of salvage surgery for anal squamous cell carcinoma

AIM

The purpose of this study was to examine factors related to treatment failure following chemoradiotherapy for squamous cancer and to compare the outcome of salvage surgery in one unit with national audit standards published by the Association of Coloproctology of Great Britain and Ireland (ACPGBI) (ACPGBI position statement for management of anal cancer. Colorectal Disease 2011; 13(Suppl. 1): 1-52).

METHOD

Patients with squamous cell carcinoma of the anus treated with radical intent between 1997 and 2010 in a single tertiary referral oncology institute were prospectively identified. Multivariate analysis was used to establish factors associated with treatment failure. Cancer-specific end-points after salvage surgery were determined by Kaplan-Meier survival analysis.

RESULTS

Ninety-five patients received chemoradiotherapy with radical intent with a 5-year overall survival of 83% (all stages) at a median follow up of 35 months. Of these, 11 (12%) required salvage surgery, five of whom were Stage T4 at presentation. Six patients had failed to respond to chemoradiotherapy and five presented with recurrence at a median of 10 (10-36) months. Only Stage T4 disease at presentation was predictive of the need for salvage surgery (OR 5.6, CI 4.9-6.3, P = 0.015). There was no surgical mortality and no delayed perineal healing where a myocutaneous flap was used. The resection margin was involved in one (9%) patient. The 5-year survival rate was 64%. Audit standards for case selection, local control, survival and perineal complications were achieved.

CONCLUSION

Long-term survival was achieved in two- thirds of patients following salvage surgery after failed primary chemoradiotherapy for anal cancer in a multidisciplinary oncological unit. Stage T4 disease at presentation strongly predicted the need for subsequent salvage intervention.

P5-13-15: Proteomic Identification of Predictive Biomarkers of Resistance to Neoadjuvant Chemotherapy in Luminal Breast Cancer: A Possible Role for 14–3-3 and BID?

Background: Chemotherapy resistance is a major obstacle in effective neoadjuvant treatment for oestrogen receptor (ER)-positive breast cancer. The ability to predict tumour response would allow chemotherapy administration to be directed towards only those patients who would benefit, thus maximising treatment efficiency. We aimed to identify protein biomarkers associated with chemotherapy resistance, using proteomic analysis of fresh ER-positive breast cancer samples, and then to perform pilot clinical validation experiments. Materials and Methods: Chemotherapy resistant and chemotherapy sensitive tumour samples were collected from breast cancer patients who received standard anthracycline-based neoadjuvant therapy consisting of epirubicin with cyclophosphamide followed by docetaxel. Comparative proteomics experiments were performed using invasive ductal carcinomas which demonstrated ER-positivity (luminal subtype). Protein expression was compared between chemotherapy resistant and chemotherapy sensitive tumour samples using 2-dimensional gel electrophoresis (2-DE) with MALDI-TOF/TOF mass spectrometry (MS). In addition the Panorama XPRESS Profiler725 antibody microarray, containing 725 antibodies from a wide variety of cell signalling and apoptosis pathways, was employed in the discovery phase. Differentially expressed proteins (DEPs) were submitted to Ingenuity Pathway Analysis (IPA) to identify any canonical pathway links. A pilot series of archival breast cancer samples, from patients treated with neoadjuvant anthracycline-based chemotherapy, was used for preliminary clinical validation of putative predictive biomarkers.

Results: Five datasets were generated by antibody microarray analysis, revealing 41 targets. Of these, 7 DEPs were identified in at least 2 datasets and these included 14–3-3, BID and Bcl-xL. The top canonical pathway matched in IPA was “ERK5 signaling”, which involved 6 DEPs, including 14–3-3. The “PI3/AKT” pathway also involved 6 DEPs, including 14–3-3 and Bcl-xL. Three datasets were generated using 2-DE with MALDI-TOF/TOF MS, containing over 300 DEPs. These included several isoforms of 14–3-3. Differential expression of 14–3-3, BID and Bcl-xL was confirmed by immunoblotting in samples used for the discovery phase. A pilot clinical validation using immunohistochemical analysis of archival breast cancers revealed 14–3-3 tau and tBID to be significantly associated with chemotherapy resistance.

Discussion: We have successfully utilised clinical tumour samples for the discovery of putative biomarkers of chemotherapy resistance using two complementary proteomic platforms. We propose a potential role for 14–3-3 tau and BID as predictive biomarkers of chemotherapy resistance in ER-positive tumours and further validation in a larger sample series is now required.

Citation Information: Cancer Res 2011;71(24 Suppl):Abstract nr P5-13-15.

Multivisceral resection for primary locally advanced rectal carcinoma

BACKGROUND

Pelvic multivisceral resection offers the possibility of cure in patients with locally advanced rectal cancer. This study assessed the clinical outcome and determinants of survival and local recurrence in patients undergoing multivisceral resection for clinical T4 primary rectal cancer.

METHODS

This was a cohort study of consecutive multivisceral resections carried out in a single centre from 2000 to 2009. Determinants of local recurrence and survival were examined by means of Kaplan-Meier survival curves and Cox regression analysis.

RESULTS

The study included 42 patients, with a median age of 62 (range 41-83) years, who underwent surgery with a median follow-up of 30 (range 2-102) months. Thirty-one patients had preoperative chemoradiotherapy. Seven patients had rectal resection with en bloc radical prostatectomy. The 30-day mortality rate was zero. Thirty-nine of the 42 patients had a negative circumferential resection margin. The 5-year overall survival rate for those who had complete resection was 48 per cent. Local recurrence was predicted by metastatic disease (P < 0.001) and nodal disease (P < 0.001), but not positive resection margins (P = 0.077).

CONCLUSION

An aggressive surgical strategy with complete resection is predictive of long-term survival in selected patients with T4a rectal carcinoma. With optimal treatment local recurrence is a sign of systemic disease.

Minimally invasive excision of gynaecomastia--a novel and effective surgical technique

INTRODUCTION

More aesthetically acceptable treatment options have been sought to minimise the morbidity associated with open surgery for gynaecomastia. This study investigated the use of a vacuum-assisted biopsy device (VABD) and liposuction to provide minimally invasive approach.

PATIENTS AND METHODS

Patients diagnosed with idiopathic benign gynaecomastia referred to the Breast Care Unit of Castle Hill Hospital between June 2002 and April 2007 and requesting surgical intervention underwent VABD excision and liposuction. All patients underwent thorough investigations to exclude any underlying cause for their gynaecomastia. The procedure was carried out by a single consultant surgeon with special interest in breast surgery. An 8-G mammotome probe was advanced through a 4-mm incision positioned in the corresponding anterior axillary line to excise the glandular disc. Liposuction was performed through the same incision. Incision wounds were closed with Steristrips. A pressure dressing was applied over wound by corset and an inflatable device.

RESULTS

Thirty-six male patients with grade I and II gynaecomastia were recruited (22 bilateral, 14 unilateral). Average age was 33.3 years (range, 16-88 years). All underwent mammotome excision and liposuction. There were no conversions to an open procedure. The average procedure time was 50.3 min (range, 30-80 min). One intra-operative complication was recorded. The minimum follow-up time was 2 months. Thirty-four patients reported excellent satisfaction, two patients had residual gynaecomastia and needed a re-do procedure. Three patients developed small haematomas that resolved spontaneously.

CONCLUSION

This novel, minimally invasive, surgical approach for gynaecomastia gives excellent results with minimal morbidity.

Multicentre randomised controlled trial examining the cost-effectiveness of contrast-enhanced high field magnetic resonance imaging in women with primary breast cancer scheduled for wide local excision (COMICE)

OBJECTIVES

To determine whether the addition of magnetic resonance imaging (MRI) to current patient evaluation by triple assessment would aid tumour localisation within the breast and thus reduce the reoperation rate in women with primary breast tumours who are scheduled for wide local excision (WLE), and to assess whether the addition of MRI would be cost-effective for the UK NHS.

DESIGN

A multicentre, randomised controlled, open, parallel group trial with equal randomisation. The main design was supplemented with a qualitative study to assess patients' experiences of the treatment process and care pathway, and involved the development of a non-scheduled standardised interview (NSSI).

SETTING

The study took place at 45 hospitals throughout the UK.

PARTICIPANTS

Women aged 18 years or over with biopsy-proven primary breast cancer who had undergone triple assessment, were scheduled for WLE, and were capable of providing written informed consent.

INTERVENTIONS

Patients were randomised to receive MRI or no MR1. Randomisation was performed using minimisation, incorporating a random element. All MRI was performed at 1.5 T or 1.0 T with a dedicated bilateral breast coil.

MAIN OUTCOME MEASURES

The primary end point of the trial was the reoperation rate. Secondary outcome measures included discrepancies between imaging and histopathology, and the effectiveness of using both procedures; change in clinical management after using MRI; the clinical significance of MRI-only-detected lesions; the rate of interventions; the ipsilateral tumour recurrence rate; patient quality of life (QoL); and cost-effectiveness.

RESULTS

From a total of 1623 patients, 816 were randomised to MRI and 807 to no MRI. No differences in reoperation rates were found between the two groups of patients [MRI patients 18.75%, no MRI 19.33%, difference 0.58%, 95% confidence interval (CI) -3.24 to 4.40]. Therefore, the addition of MRI to conventional triple assessment was not found to be statistically significantly associated with a reduced reoperation rate (odds ratio = 0.96, 95% CI 0.75-1.24, p = 0.7691). The best agreement between all imaging modalities and histopathology with regard to tumour size and extent of disease was found in patients over 50 years old with ductal tumours NST and who were node negative. In the imaging arm, mastectomy was found to be pathologically avoidable for 16 (27.6%) out of 58 patients who underwent the procedure. There were no significant differences between the groups regarding the proportion of patients receiving chemotherapy, radiotherapy or additional adjuvant therapies, as well as for local recurrence-free interval rates and QoL. An acceptable NSSI was developed for use in this population of patients. Economic analysis found no difference in outcomes between the two trial arms.

CONCLUSIONS

The addition of MRI to triple assessment did not result in a reduction in operation rates, and the use of MRI would thus consume extra resource with few or no benefits in terms of cost-effectiveness or HRQoL. However, MRI showed potential to improve tumour localisation, and preoperative biopsy of MRI-only-detected lesions is likely to minimise the incidence of inappropriate mastectomy.

TRIAL REGISTRATION

Current Controlled Trials ISRCTN57474502.

Social health outcomes following thermal injuries: a retrospective matched cohort study

INTRODUCTION

Over 50% of children admitted with burns are aged under 3 years. US studies suggest that up to 26% of childhood burns are non-accidental, although UK reports are lower (1-16%).

OBJECTIVES

To determine the social health outcomes of burned children as regards the number of children abused, neglected or "in need" before the age of 6 years compared with matched controls.

METHODS

A retrospective matched cohort study. 145 children aged under 3 years admitted for burns in 1994-1997 were matched with controls for sex, age and enumeration district and followed up until 2003. Electronic routine databases provided study data on local authority care episodes and Social Services referrals by age 6 years.

RESULTS

89.0% of cases had accidental burns and four cases (2.8%) had non-accidental burns. No case was attributed to neglect. By their sixth birthday cases were statistically more likely to have been referred to Social Services with 14 (9.7%) of the burned children having been abused or neglected versus two (1.4%) controls (95% CI 0.030 to 0.13, p = 0.004). Forty six (32%) cases versus 26 (18%) controls were defined as "in need" (95% CI 0.047 to 0.23, p = 0.006).

CONCLUSION

Although most burns were deemed accidental, 2.8% were categorised as non-accidental at presentation. Almost a third of the burned children went on to be "in need". Children with a burn appear to be at higher risk of further abuse or neglect compared with controls. A burn therefore could be a surrogate marker indicating need for closer supervision and follow-up by professionals.

Effects of bilateral breast reduction on anxiety and depression: Results of a prospective randomised trial

We assessed the effects of bilateral breast reduction on anxiety and depression in women with mammary hypertrophy (macromastia). Seventy-three consecutive women referred for consideration for breast reduction were recruited. They were randomised to have either early operation (within six weeks of initial assessment) or delayed operation (within six months of recruitment). The Hospital Anxiety and Depression Score was given before randomisation and four months later. All 73 patients completed the study. The mean (SD) age was 39 (12) years. The groups were matched for age, smoking, social class, and educational achievement. There were highly significant improvements (p<0.001) in symptoms of anxiety and depression. Reduction mammaplasty significantly improved symptoms of clinical depression in women with macromastia.

Oestrogen and progesterone receptor status of individual foci in multifocal invasive ductal breast cancer

Widespread acceptance of breast conserving surgery for early breast cancer has led to renewed interest in multifocality, which is seen in 13-63% of breast cancers. According to current guidelines, oestrogen/progesterone receptor status is assessed on the sample obtained at initial core biopsy or the main tumour focus in multifocal breast cancer (more than one distinct tumour focus in a quadrant). We assessed receptor status of individual foci in multifocal breast cancer. Mastectomy specimens for 18 cases of multifocal breast cancer were identified. Immunohistochemical staining for oestrogen and progesterone receptors was performed on all tumour foci. On histological examination 11 patients demonstrated two independent tumour foci, three demonstrated three foci and four demonstrated four foci. Minor differences in oestrogen receptor score were seen between foci (attributed to the subjective nature of the scoring system), which did not affect the overall positive/negative classification. Sixteen patients (88%) were oestrogen receptor-positive. Progesterone receptor staining showed more variability between foci in two patients but, since the tumours were oestrogen receptor-positive this would not have affected clinical decision-making. No major differences in oestrogen receptor status between multiple tumour foci in the same quadrant were found in this pilot study.

Enhanced recovery in colorectal resections: a systematic review and meta-analysis

OBJECTIVE

The study aimed to produce a comprehensive up-to-date meta-analysis exploring the safety and efficacy of enhanced recovery (ER) programmes after colorectal resection.

METHOD

Key-word and MESH-heading searches of MEDLINE, EMBASE and the Cochrane Databases from 1966 to February 2007 were used to identify all available randomized and clinical controlled studies. Two independent reviewers assessed studies for inclusion and exclusion based on methodological quality criteria prior to undertaking data extraction. Summary estimates of treatment effects using a fixed effect model were produced with RevMan 1.0.2, using weighted means for length-of-stay data and relative risks of morbidity, mortality and readmission rates.

RESULTS

Analysis of four papers including 376 patients demonstrated primary and total length-of-stays (primary + readmission length-of-stay) to be significantly reduced (P < 0.001) with ER programmes [weighted mean differences of -3.64 days (95% confidence interval, 95% CI -4.98 to -2.29) and -3.75 days (95% CI-5.11 to -2.40)]. Analysis of controlled clinical trial data showed morbidity rates to be reduced and readmission rates increased. These trends were not seen amongst the randomized controlled trial data. There were no differences in mortality rates.

CONCLUSION

Enhanced recovery programmes after colorectal resections reduce length-of-stay and may reduce 30 days morbidity and increase 30 days readmission without increasing mortality.

Antibody microarray analysis identifies biomarkers associated with radioresistant breast cancer cell lines

Abstract #5072

Background: Resistance to radiotherapy may be a significant factor in the development of local recurrence following surgical resection and radiotherapy. In addition, if patients with radioresistant breast cancers can be identified, harmful side effects from exposure to unnecessary ionizing radiation could be prevented. We aimed to develop a novel in vitro model of radioresistance using breast cancer cell lines and to subsequently identify molecular biomarkers which may be associated with the radioresistant phenotype. Antibody microarrays offer a complementary approach for proteomic analysis in conjunction with standard screening methods such as two dimensional gel electrophoresis/ mass spectrometry and other quantitative proteomic techniques. We previously utilised the Panorama Cell Signalling Antibody Microarray Kit (Sigma-Aldrich) consisting of 224 antibodies (Smith et al Mol Cancer Ther 5:2115-20, 2006). In this study we utilised a novel high density 725 antibody microarray to screen for proteins associated with radioresistance.&#x2028; Material and Methods: We established novel breast cancer cell sublines which were significantly resistant to radiotherapy when compared with the parental cells (T47D; MCF-7). The radioresistant sublines were created by irradiating cells in fractionated doses of 2Gy up to a total dose of 40Gy. Sufficient time was allowed for the cells to recover between subsequent irradiations. A dose response curve was assessed at the end of treatment to demonstrate a statistically significant increase in radioresistance for the novel cell subline when compared with parental cells. The radioresistant/parental cell pairs were analysed using the Panorama Antibody Microarray XPRESS Profiler725 Kit (Sigma-Aldrich). The microarray comprised 725 different antibodies on nitrocellulose coated microscope slides. The antibodies were selected from a wide variety of pathways, including apoptotic and cell signalling pathways.&#x2028; Results: Utilising a Cy3/Cy5 labelling strategy the antibody microarray approach yielded a number of a total of 28 targets for further study. Of these, three proteins were identified independently from both of the radioresistant cell lines. These were GFI1 (Growth Factor Independence-1), DR4 (Death Receptor 4) and Importin a1. Immunoblotting and other proteomic approaches have confirmed the identities and differential expression of some candidate protein targets.&#x2028; Conclusion: High density antibody microarrays potentially offer a powerful new proteomic technique to allow the global analysis of many proteins simultaneously. This analysis has produced both complementary and confirmatory data in our proteomic screening for putative biomarkers associated with radiotherapy resistance. We successfully identified a number of protein targets which may be associated with a radioresistant phenotype. Further confirmatory and validation studies are ongoing.

Citation Information: Cancer Res 2009;69(2 Suppl):Abstract nr 5072.

Accuracy of DCE – MRI in predicting response in patients treated with taxane based neoadjuvant chemotherapy

Abstract #5120

Background: Neoadjuvant chemotherapy for locally advanced breast cancer is an established treatment option. Several studies have shown DCE-MRI scanning to be the most accurate investigation to assess response to EC chemotherapy. Recent trials have shown that addition of Taxanes increases the overall response rate and the rate of breast conserving surgery. Taxanes act by inhibiting angiogenesis in the tumour and this could potentially affect the quality of the post treatment scan images as DCE-MR scan and cause inappropriate decisions regarding the required surgery.&#x2028; Aim: To compare the accuracy of DCE-MR scan in identifying residual disease in patients treated with FEC (Fluoro uracil, Epirubicin, Cyclophosphamide) vs EC (Epirubicin, Cyclophosphamide) followed by Taxane.&#x2028; Methods: Patients treated with primary chemotherapy who subsequently underwent breast conserving surgery were identified from a prospectively maintained database. Clinical details including chemotherapy regimes, pre and post chemotherapy MRI data, number of surgical procedures and histological parameters of the excised specimen were obtained.&#x2028; Results: A total of 121 patients treated with primary chemotherapy were identified. Of these, 76 were treated with FEC or EC based chemotherapy and 45 were treated with EC+Taxane. DCE-MRI was significantly less accurate (p&lt;0.05) when predicting the size of residual disease in the Taxane group.&#x2028; &#x2028; Conclusion: DCE MR scan is not as accurate for quantifying size of residual disease in patients treated with taxane when compared with patients treated with traditional FEC/EC based primary chemotherapy. This should be considered when planning surgery after neoadjuvant therapy.

Citation Information: Cancer Res 2009;69(2 Suppl):Abstract nr 5120.

Lipomodelling of the breast

Abstract #4149

Background: Lipomodelling is the autologous transfer of fat to correct congenital and post-surgical deformities. Recent improvements in technique have provided the opportunity for a greater volume of fat transfer thus increasing its potential application following surgery for benign and malignant breast disease.&#x2028; Materials & methods: After injecting a solution of local anaesthetic, normal saline and 1:106 adrenaline into donor sites in the abdomen and thighs, fat was aspirated with 3mm cannulae and centrifuged for 5 minutes. The fat was then re-injected into pre-marked areas in the breast using a 3mm injection cannula. Patients were followed up in a specialist breast clinic.&#x2028; Results: 23 patients (22 female, 1 male) were treated between November 2007 and May 2008. The mean age was 50.6 years (36-61).&#x2028; &#x2028; Prior to lipomodelling, volume deficit was observed in all patients. A visible depression was identified in 43.5% (n=10), significant flap atrophy in 21.7% (n=5), skin tethering in 21.7% (n=5) and implant rippling in 13% (n=3). Ten patients (43.5%) required lipomodelling to the upper pole, while in 7 patients (30.4%), the location was closely associated with the surgical scar.&#x2028; The average volume of fat harvested was 210.7 ml (85-510), and that injected per breast was 107.1 ml (45-206). Injections were stopped when slight overfilling was observed. Excessive tissue tension was avoided. Operative time varied between 45-100 minutes.&#x2028; During the first follow up visit, satisfactory results were recorded. 3 patients were booked for their second operation.&#x2028; Nine patients were seen at 3-4 months (second follow up visit). Two patients had clinical and radiological evidence of fat necrosis. One patient had marked volume resorption and numbness at the donor site. Eight patients had good volume retention. Two patients were booked for further lipomodelling at this stage.&#x2028; One patient had further lipomodelling five months after the first session, with satisfactory results, and is awaiting a third session.&#x2028; &#x2028; Discussion: Early results have shown satisfactory cosmetic outcome and patient satisfaction. The technical simplicity and autologous nature make lipomodelling an attractive option to both surgeon and patient. However it is not universally successful and further follow-up is required before the long term effects of the technique in cancer patients can be confirmed.

Citation Information: Cancer Res 2009;69(2 Suppl):Abstract nr 4149.

A point prevalence survey of wounds in north-east England

OBJECTIVE

To review current wound-care practice and the standard of wound care in Hull and East Yorkshire; obtain information on prevalence, treatment and outcomes; provide a basis for estimating the extent of the problem, treatment modalities used, service provision and future needs; highlight areas of care in need of improvement; highlight areas with excellent wound practices and gain information for future research projects within the population of the region.

METHOD

Point prevalence interface audit of community and acute trusts.

RESULTS

The cumulative wound prevalence for the region was 12%. Community nurses were involved in caring for 70.1% of patients with wounds, with 52.7% of wounds being treated in the patient's home. The largest proportion of wounds were surgical wounds (n=699, 41.5%), followed by leg and foot ulcers (n=629, 37.3%) and pressure ulcers (n=294, 17.4%). Diabetes and cancer were related to 15.1% and 9.7% of the wounds respectively. 41.9% of the wounds were on the lower leg. The primary and secondary dressings used the most were low/non-adherent dressings at 25.9% and 27.3% respectively.Almost half of the patients with a venous leg ulcer (46%) did not receive multilayer compression and 7% of patients with an arterial ulcer did; 23.6% of the leg and foot wounds were not assessed with a Doppler.

CONCLUSION

Wounds represent a significant cause of morbidity in the general population.A systematic focus is necessary on effective and timely diagnosis, on ensuring treatment is appropriate to the cause and condition of the wound and on active measures to prevent complications.A number of initiatives have commenced in order to provide a effective and efficient wound care.

Recurrence rates after DCE-MRI image guided planning for breast-conserving surgery following neoadjuvant chemotherapy for locally advanced breast cancer patients

BACKGROUND

Neoadjuvant therapy results in a significant increase in breast-conserving surgery. However, traditional imaging methods are unable to accurately predict the extent of viable residual disease leading to uncertainty in surgical planning and some previous studies have shown a disproportionately high incidence of locoregional recurrence. Dynamic contrast enhanced-MRI (DCE-MRI) has been shown to provide a potentially more accurate prediction of residual disease.

RESULTS

Patients undergoing neoadjuvant chemotherapy for breast cancer in our unit are staged with the DCE-MRI of the breast performed at 1.5 T before, during and after treatment and the final result was used to plan surgery. Two hundred and four patients with breast cancer were treated with neoadjuvant chemotherapy between 1996 and April 2005. Eighteen of these patients had distant metastases at the time of initial diagnosis and so were excluded from the present study. Following neoadjuvant chemotherapy, 186 patients underwent surgical treatment. Of these, 68 patients had breast-conserving surgery. At a median follow up of 30 months (range: 5.6-72 months) 21 patients in this group developed subsequent recurrence (21/68 - 30%) of whom 9 (9/68 - 13%) had locoregional recurrence, 7 had local recurrence (7/68 - 10%), and 17 (17/68 - 25%) had distant recurrence. Logistic regression analysis revealed only vascular invasion (p=0.006) of the tumour to be significantly associated with overall recurrence. None of the pathological factors (ER, PR status, vascular invasion, lymph node metastases, pathological complete response to neoadjuvant chemotherapy) showed a significant association with locoregional recurrence.

CONCLUSION

Breast-conserving surgery with DCE-MRI planning after neoadjuvant chemotherapy provides an acceptable level of local recurrence without the need for mastectomy.

Breast reduction surgery in the UK and Ireland - current trends

INTRODUCTION

This paper reviews the current status of bilateral breast reduction surgery in the UK and Ireland. It examines the pre-operative, operative and postoperative management of women.

PATIENTS AND METHODS

A questionnaire established information about surgeons' experience, bilateral breast reduction work-load, pre-operative assessment, selection criteria, issues of operative technique and postoperative management. This was sent to 230 consultant plastic surgeons working in the NHS in the UK and Ireland.

RESULTS

There was a 61% response rate. Of respondent surgeons, 82% always perform pre-operative photography, 71% never do a mammogram even in patients above the age of 50 years. Body mass index (BMI) is the most commonly used criteria for patient selection (60%). Two-thirds of the surgeons use an inferior pedicle technique and 75% of surgeons work in health authorities that restrict breast reduction surgery.

CONCLUSIONS

There was significant variation in practice among surgeons performing bilateral breast reduction. This may reflect a lack of evidence base for practise. Published literature focuses almost exclusively on the description of different techniques. Further work is required to evaluate the role of pre-operative mammography, specimen mammography, antibiotics and selection criteria for surgery.

A pilot study on the effect of topical negative pressure on quality of life

OBJECTIVE

To discover the impact of topical negative pressure (TNP) on quality of life.

METHOD

An exploratory prospective cohort study was conducted on 26 patients undergoing TNP. The Cardiff Wound Impact Schedule (CWIS), a wound-specific tool, was used to investigate quality-of-life scores before therapy and four weeks after therapy or at wound closure. Wound dimensions were measured at both assessments, and the values for the CWIS domains (physical symptoms, social functioning, well-being and overall quality of life) were investigated using parametric and non-parametric tests.

RESULTS

The mean duration of TNP therapy was 3.3 +/- 1.7 weeks. Topical negative pressure therapy helped to achieve complete wound closure in 14 patients (54%), and there was a mean reduction in wound surface area from 52.2 cm2 (range 4-150) to 26.8 cm2 (0-120). While there was no significant change in quality of life in patients whose wounds healed (1 +/- 11.9), the physical-functioning domain improved in obese patients (20 +/- 21, p < 0.05) and worsened in ambulatory patients (-3 +/- 13, p < 0.05). The portableTNP system had no significant impact on quality of life (-3 +/- 16), while the global quality-of-life score worsened with surgical intervention (-0.5 +/- 2, p < 0.05).

CONCLUSION

Although TNP aids wound closure in patients with complex wounds, in selected cases their quality of life can worsen. This is the first exploratory cohort study of its kind, and has identified an urgent need to validate the use of patient-based outcome measures in TNP therapy. Such data can be useful in allocating resources and justifying funding in wound care.

Direct polymerase chain reaction amplification of formalin-fixed, paraffin-wax-embedded tissue after automated sequential laser microdissection and pressure catapulting

A robust method to facilitate rapid laser microdissection and pressure catapulting (LMPC) coupled with direct polymerase chain reaction (dPCR) to eliminate the need for extraction of DNA before a PCR-based assay is described. This sequential LMPC-dPCR method is rapid and decreases the number of processing steps, reducing the chance of tissue loss and contamination.

Cyclooxygenase-2 expression in squamous cell carcinoma of the esophagus

Increased cyclooxygenase-2 expression has been reported to be a poor prognostic indicator in a number of cancers. In this study we investigated the relationship between COX-2 expression in squamous cell carcinoma of the esophagus and tumor characteristics and patient survival. The study group consisted of 90 men and 48 women who underwent esophagectomy for squamous cell carcinoma of the esophagus between October 1984 and May 1985. COX-2 expression was measured by immunohistochemistry in 138 primary cancers, 23 metastatic lymph nodes and 21 normal esophageal stumps. The relationship between the extent of staining for COX-2 and clinicopathological features and survival was determined. The extent of staining for COX-2 in both primary and metastatic cancers was higher than in normal squamous epithelia (P = 0.002 and P < 0.0001 respectively), and the grade of staining in the primary tumor correlated positively with the finding of lymph node metastases (P = 0.03). The 5-year survival rate in patients with less than 10% COX-2 positive cells was 47.5% compared to 23.2% in patients with more than 10% COX-2 positive cells (P = 0.0036). The relationship between survival and COX-2 staining was not due to COX-2 being a surrogate marker for TNM stage. Our results show that the expression of COX-2 is elevated in squamous cell carcinoma of the esophagus compared to normal epithelium and correlates with lymph node metastases. Survival was longer in those patients whose tumors expressed lower levels of COX-2.

Potential prognostic and therapeutic roles for cytokines in breast cancer (Review)

Cytokines are known to have both stimulatory and inhibitory effects on breast cancer growth depending on their relative concentrations and the presence of other modulating factors in the tumour microenvironment. Certain cytokines appear to prevent an effective immune response being mounted, permitting cancer growth, whereas others promote the immune system's anti-tumour capability. Furthermore, the systemic levels of certain cytokines, e.g. IL-6 and IL-18, independently show promising correlations with disease stage and progression. With advances in methods for delivery of cytokines to a tumour site, the enhanced induction of anti-tumour immunity by targeted cytokine release is becoming a realistic option. Here, we review the role of cytokines in the immune response against breast cancer and assess their potential as prognostic indicators and/or use in immune therapy. A literature search was conducted using Medline, restricted to articles published in the English language, using combinations of the following MeSH terms: cytokines, breast cancer, immunology, immunotherapy and interleukins. Focused searches using keywords relevant to the role of cytokines in breast cancer immunology yielded >200 references.

MRI and conservative treatment of locally advanced breast cancer

AIMS

The objectives of this study were to compare the efficacy of dynamic contrast-enhanced magnetic resonance imaging (DCE-MRI) in assessing the response of primary breast carcinoma to neoadjuvant chemotherapy compared to conventional imaging modalities, and to see how surgical outcome was influenced as a result of these findings.

METHODS

Thirty-four patients with locally advanced primary breast cancer underwent conventional imaging and DCE-MRI following six cycles of neoadjuvant chemotherapy prior to surgery. Changes in surgical management based on the post-chemotherapy DCE-MRI findings were recorded.

RESULTS

Prior to neoadjuvant chemotherapy, 22 of the 34 patients were assessed as requiring mastectomy and the remaining 12 were considered inoperable. Following chemotherapy two patients were still considered inoperable. In 11 of the 34 patients, the final decision to proceed to either mastectomy or non-surgical management was based primarily on pre-treatment disease status or patient choice. DCE-MRI findings, therefore, contributed to the operative decision in 21 of 34 patients. Two of these 21 patients were spared surgery as DCE-MRI demonstrated complete response to chemotherapy and one declined surgery. The remaining 18 were able to undergo wide local excision, with only two patients subsequently requiring mastectomy for involved margins.

CONCLUSIONS

DCE-MRI is able to accurately predict those patients suitable for breast conserving surgery following neoadjuvant chemotherapy and should be the imaging modality of choice in assessing the response of patients with primary breast carcinoma to neoadjuvant chemotherapy.

Randomized clinical trial examining psychosocial and quality of life benefits of bilateral breast reduction surgery

Background

The aim was to determine the effects of bilateral reduction mammaplasty on quality of life and psychosocial functioning in women with mammary hypertrophy.

Methods

Seventy-three women who were referred to either the Hull Breast Unit or Hull Plastic and Reconstructive Surgery Unit were randomized to early or delayed surgery. Both groups had quality of life and psychosocial assessment. Each group underwent two sets of tests. Women who had early bilateral breast reduction were tested before and at 4 months after surgery, whereas those in the control group were tested at the time of randomization and 4 months later, before undergoing surgery.

Results

All 73 women completed the study. Mean age was 39 years, and the two groups were well matched for age, body mass index and breast dimension. There were highly significant differences between groups in scores measured on the Functional Assessment of Non-Life Threatening Conditions version 4, EuroQoL, and both mental and physical scales of Short Form 36 (P &lt; 0·001). The Eysenck Personality Questionnaire—Revised demonstrated a statistically significant increase in extroversion and emotional stability in the early treatment group.

Conclusion

Reduction mammaplasty significantly improved quality of life, and increased extroversion and emotional stability.

Patient demographics and treatment for early breast cancer: an observational study

This study aims to examine relationships between demographic factors and treatment choice for early breast cancer (T2/N<1). Two hundred and two patients were offered modified radical mastectomy (MRM), breast conserving therapy (BCT) or MRM and reconstruction and interviewed at a University Hospital and oncology centre in South Wales. Median age at treatment was 57 (32-90) years. Seventy-one patients (35%) choose MRM, 10 (5%) MRM and reconstruction and 121 (60%) BCT. Median age of women choosing MRM was 61 and 55 for BC (P<0.0001). Single women (P=0.009) and those with no family history of breast cancer (P=0.02) were more likely to choose MRM. There was no difference between treatment choice and method of cancer detection and the age at which the patient left education (P=0.065). Mean histological tumour diameter was smaller for women choosing BC (15 mm) than for women choosing mastectomy (17 mm; P=0.014). There was no association between tumour grade and treatment choice.

Primary carcinoma of the appendix - Hull series

BACKGROUND

Appendiceal carcinoma (AC) is a rare entity that does not have a well-defined treatment strategy. At presentation, most patients are clinically thought to have appendicitis and the diagnosis is made only by formal histology. Once the diagnosis of AC is made, patients are treated by various strategies including surgery, chemotherapy depending on nodal status of the disease.

AIM

To review the Hull hospitals' experience with AC.

METHODS

Between 1982 and 2002, 10 patients with primary AC were seen. The histopathology reports of all appendiceal specimens removed were traced. Follow-up was by chart review or patient follow-up as appropriate. We did not include patients with primary carcinoid tumours or secondary adenocarcinoma.

RESULTS

There was an equal sex distribution. All patients underwent surgery, 3 had post-operative chemotherapy. Complete follow-up information was available with a median follow-up time of 56 months, with a range of 12-168 months. Five patients survived at least 4 years from the time of diagnosis.

CONCLUSION

Long-term survival in patients with AC is possible.

Differentiation of benign from malignant breast disease associated with screening detected microcalcifications using dynamic contrast enhanced magnetic resonance imaging

Dynamic Contrast Enhanced Magnetic Resonance Imaging (DCE-MRI) is an effective diagnostic modality for symptomatic breast disease. However, its role in evaluating clinically occult disease associated with mammographically detected microcalcification remains unclear. Women recalled following screening mammography with microcalcification had DCE-MRI examination of the breast. The data were evaluated subjectively and objectively using both empirical and 2-compartment pharmacokinetic modelling techniques to evaluate signal intensity parameters. Eighty-eight patients aged 50-75 years (median 58) were recruited. Comparing malignant and benign lesions, the mean values in arbitrary units for the enhancement index at 1 min in the most enhancing 9-pixel square +/-1 standard deviation were 0.61+/-0.40 vs. 0.22+/-0.26 p=<0.001 with sensitivity, specificity, PPV, NPV and accuracy of 80.0%, 82.4%, 57.1%, 93.3% and 81.8%, respectively. The corresponding values attained by the radiologist were 75.0%, 89.7%, 68.2%, 92.4% and 86.4%. DCE-MRI is able to differentiate malignant from benign clinically occult lesions associated with microcalcification and may therefore offer an alternative to open surgical biopsy for women with equivocal findings following initial triple assessment for microcalcification in the breast.

Deskinning versus deepithelialization for inferior pedicle reduction mammoplasty: a prospective comparative analysis

BACKGROUND

Deepithelialization is time consuming, but has been performed traditionally in reduction mammaplasty to ensure a better blood supply to the transposed nipple-areolar complex.

METHODS

For this study, 18 patients were recruited, and each patient served as an individual control by undergoing both deskinning and deepithelialization of the contralateral breast. The patient's age, body mass index, specimen weight, complications, and subjective cosmetic assessment were recorded.

RESULTS

The mean age was 42 years, and the mean body mass index was 27.94 respectively. There were no differences recorded in terms of complications or patient perceived cosmetic outcomes. The only statistical difference involved the times required for deepithelialization (15.5 min) and deskinning (6 min). Deskinning thus saved approximately 9 min.

CONCLUSIONS

Deskinning is as effective as deepithelialization and is significantly more expedient, with no added risk to the patient.

Radioresistance in carcinoma of the breast

Radiotherapy plays an important role in the management of breast cancer. Whilst its role in achieving local control following surgery in patients with early stage cancer is well established, there is still unclear evidence to explain the factors governing radioresistance in patients who develop recurrences both in the breast and axilla. Radiotherapy induces damage to the DNA. Various cell cycle damage check points and DNA damage repair pathways have been demonstrated. Ataxia telangiectasia mutant (ATM) kinase, which is a member of phosphatidylinositol-3 kinase (PI-3K) family appears to play a central role in DNA damage check point pathways. Over-expression of Insulin like growth factor-I receptor (IGF-IR), Human Epidermal Growth factor receptors (HERS), Vascular Endothelial growth factor (VEGF) on the cell surface and increased concentration of Epidermal Growth factor in the extracellular fluid have been associated with radioresistance. Specific genes such as p53, BRCA, Bcl-2 and chromosomal characteristics like telomere lengths have also been identified as playing significant roles in radiation responsiveness of a cell. This article reviews the current data on general principles of radiotherapy, the cellular mechanisms that operate in response to radiation damage and various molecular markers, intranuclear and extranuclear which have been demonstrated to influence radiation sensitivity in breast cancer cells.

Chromosomal alterations in breast cancer revealed by multicolour fluorescence in situ hybridization

The aim of this study was to characterise cytogenetically, breast cancer cell lines and primary tumours to identify chromosomal regions of interest in breast cancer. Multicolour fluorescence in situ hybridization (MFISH) and comparative genomic hybridization (CGH) were used to karyotype five established breast cancer cell lines and two short-term primary tumour cultures. Chromosome 8 was identified as a frequent target for aberrations in all cell lines and one primary culture by MFISH and CGH. CGH identified frequent gains of 1q (all samples) and 14q (all cell lines) and deletion of 22q (all samples). MFISH revealed a t(9;17) translocation in both primary tumours and the T47D cell line. MFISH analysis of the cell lines revealed a significant number of translocations previously unidentified in other studies using similar techniques, highlighting the necessity of utilising data from both primary cultures and established cell lines when investigating complex cytogenetic aberrations using MFISH and CGH.

Artificial intelligence in medicine

INTRODUCTION

Artificial intelligence is a branch of computer science capable of analysing complex medical data. Their potential to exploit meaningful relationship with in a data set can be used in the diagnosis, treatment and predicting outcome in many clinical scenarios.

METHODS

Medline and internet searches were carried out using the keywords 'artificial intelligence' and 'neural networks (computer)'. Further references were obtained by cross-referencing from key articles. An overview of different artificial intelligent techniques is presented in this paper along with the review of important clinical applications.

RESULTS

The proficiency of artificial intelligent techniques has been explored in almost every field of medicine. Artificial neural network was the most commonly used analytical tool whilst other artificial intelligent techniques such as fuzzy expert systems, evolutionary computation and hybrid intelligent systems have all been used in different clinical settings.

DISCUSSION

Artificial intelligence techniques have the potential to be applied in almost every field of medicine. There is need for further clinical trials which are appropriately designed before these emergent techniques find application in the real clinical setting.

Gynaecomastia and the plant product “Tribulis terrestris”

Gynaecomastia is the commonest benign breast condition seen in men. It is well recognised that certain drugs that alter the normal sex hormonal profile in the body can induce gynaecomastia. Recently, an increasing use of androgenic-anabolic steroids among young men especially body-builders has increased the incidence of gynaecomastia. We report a case of a young weight-trainer who developed gynaecomastia due to oral intake of a herbal tablet which he used as a steroid alternative for body-building.

Pancolitis associated with docetaxel: a rare cause of megacolon

The toxic effects of chemotherapy have been noted to cause a range of acute necrotizing colonic inflammatory disorders but until recently these have not been associated with docetaxel chemotherapy. Here we report a case of pancolitis presenting as megacolon following the administration of docetaxel for recurrent breast cancer.