Abstract P3-13-11: The outcomes of ReFilx soft tissue filler as an immediate reconstruction technique for lumpectomy followed by radiotherapy

Introduction: Lumpectomy for breast cancer can often result in poor cosmetic outcomes which can lead to long-lasting impairment of quality of life. ReFilx is a synthetic porous degradable polyurethane scaffold that has mechanical properties comparable to that of native healthy breast tissue. It has been shown in two previous porcine studies to preserve breast shape and volume over 9 months when inserted into the cavities immediately after lumpectomy. We observed minimal foreign body reaction with good integration of the host tissue while the material degraded over time. In this study, we examined the healing process of lumpectomy treated with radiation. Radiotherapy is currently a standard adjuvant therapy after lumpectomy for breast cancers; and radiation is known to affect the healing process in general. Objective: To evaluate ReFilx, as soft tissue fillers for lumpectomy cavities in combination with standard radiotherapy. Hypothesis: ReFilx will preserve breast shape and volume by supporting tissue infiltration with minimal inflammation in the presence of clinically relevant radiotherapy. Methods: 3 female Yucatan minipigs received lumpectomies carried out using electrocautery to remove normal breast tissue of approximately 2 cm diameter, after which the cavities were filled with (case) or without ReFilx (sham control) (n=3 for each condition, each pig has 12-13 breasts). 6 weeks post-implantation, 2 of the pigs received radiation directed at the right half of their bodies (6 breasts per pig) for a total dose of 42.4 Gy delivered over 15 fractions using a clinical linear accelerator. The delivered doses to target sites and the adjacent tissue were confirmed with optically stimulated luminescent dosimeters (OSLDs). A third pig was maintained as a non-irradiated control. Ultrasound examinations were performed every 3 weeks post-implantation. At week 24 and 36, samples consisted of n=3 for irradiated and non-irradiated ReFilx and sham sites for the half-irradiated pigs, and n=3 for non-irradiated ReFilx and sham sites for the non-irradiated control pig were excised by mastecomy, the tissue samples were fixed in 10% buffered formalin for subsequent histological (H&E, Masson's Trichrome) studies. Potential side effects were monitored by vital signs, pain control, wound checks, ultrasound and blood tests. Necropsies were performed at the conclusion of the study. Results: Ultrasound examination indicated no difference between ReFilx's ability to maintain breast shape and volume with or without the presence of radiation treatment, in contrast to the collapse of the sham sites by 24 weeks. Similarly, the histology of irradiated and non-irradiated ReFilx samples showed similar levels of tissue infiltration, inflammatory changes and degradation of ReFilx. There was no significant side effects observed. Conclusions: ReFilx's ability to act as a soft tissue filler for breast volume restoration post-lumpectomy does not appear to be significantly impacted by the presence of clinically relevant radiation treatment. Longer-term follow-up is currently in progress for this study. Acknowledgements: Connaught Innovation Award (University of Toronto) and Joule Innovation Fund (Canadian Medical Association).

Citation Format: Leong WL, Battiston K, Cheung F, Fulton C, Lin A, Levin W, Done S, Santerre P. The outcomes of ReFilx soft tissue filler as an immediate reconstruction technique for lumpectomy followed by radiotherapy [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 P3-13-11.

Abstract P3-17-01: Long-term rates of breast preservation after breast-conserving therapy for ductal carcinoma in situ

Background: Despite evidence that radiotherapy (RT) after breast-conserving surgery (BCS) for ductal carcinoma in situ (DCIS) halves the risk of recurrence, the benefit of RT in the management of DCIS continues to be a matter of controversy. One argument against the use of RT after BCS is that patients who develop ipsilateral local recurrence (LR) can be salvaged with further breast-conserving surgery such that the omission of RT will lead to high rates of breast preservation while minimizing exposure to RT. Breast preservation is an important determinant of quality of life for women with early stage breast cancer and DCIS. Yet the management of LR and the impact of RT on the resultant long-term risks of bilateral breast preservation in a population of women with DCIS are unclear. We assessed the treatment of LR, the impact of RT on the use of salvage mastectomy and the long-term risks of bilateral breast preservation achieved in a population of women with DCIS treated with BCS alone or BCS+RT.

Methods: A population-based analysis of women diagnosed with DCIS from 1994-2003 treated with BCS alone or BCS+RT with pathology review. Treatment and outcomes, including the development of LR and contralateral breast events, were determined by administrative databases with validation by review of operative or pathology reports. Median follow-up was 10.2 years for cases treated by BCS alone, 11.6 years for those treated by BCS+RT. We used a propensity-adjusted Cox proportional hazards model to evaluate factors associated with the use of salvage mastectomy for LR and to evaluate factors associated with any mastectomy. We assessed the risk of long-term breast preservation by calculating the KM 10-year risk of ipsilateral mastectomy and any mastectomy.

Results: The population cohort includes 3303 women with pure DCIS;1649 (50%) were treated by BCS alone, 1654 (50%) received BCS+RT. Women treated with RT had more high risk features of DCIS than those treated by BCS alone. LR developed in 343 (21%) women treated by BCS alone and in 257 (15.5%) women treated by BCS+RT (p<0.01). Most women who developed LR received salvage mastectomy, irrespective of age at diagnosis and histology. Salvage mastectomy was used in 57.4% (197/343) of cases that recurred after BCS alone and in 67.6% (173/257) that recurred after BCS+RT. The likelihood of receiving salvage mastectomy for LR was similar in patients initially treated by BCS+RT vs. those initially treated BCS alone. Most (90%) of mastectomies were performed for a LR. Overall, individuals initially treated by BCS+RT had a 29% lower probability of having a mastectomy at 10 years compared to those treated by BCS alone (HR=0.71, 95%CI: 0.60,0.84,p<0.0001). The 10 year mastectomy-free survival rates are 82.7% for women initially treated by BCS alone and 87.3% for those treated by BCS+RT (p=0.0096).

Conclusion: Women who received RT after BCS for DCIS experience a greater likelihood of long-term bilateral breast preservation. This is attributable to the lower risks of LR and that most local recurrences after breast-conserving therapy are treated by salvage mastectomy. Long-term breast preservation should be considered in discussions weighing the benefits and risks of RT after conservative surgery for DCIS.

Citation Format: Rakovitch E, Nofech-Mozes S, Hanna W, Gu S, Fong C, Tuck A, Sengupta S, Elavathil L, Jani P, Done S, Miller N, Youngson B, Bonin M, Chang M, Paszat L. Long-term rates of breast preservation after breast-conserving therapy for ductal carcinoma in situ [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 P3-17-01.

Abstract P2-10-34: Development and validation of ClinicoMolecular Triad Classification (CMTC), a platform for breast cancer (BC) prognostic and predictive gene signature portfolios

Background: Numerous gene signatures have claimed prognostic significance in BCs. Each of these gene signatures was designed to answer a specific clinical or biological question, often by dichotomizing the targeted populations into a good and a bad risk group. None of these gene signatures on its own has sufficient degree of complexity to fully characterize this very heterogenous group of diseases, and hence lacks the flexibility to personalize treatments. To exploit the full potential of the genomic approach, we developed an 803-gene molecular classification, termed ClinicoMolecular Triad Classification (CMTC) that categorized BCs into 3 clinical treatment groups (triad) that can serve as a basic framework to guide management. CMTC also provide a detailed “portfolio” of 14 other gene signatures and 19 oncogenic pathways to allow further customization of the treatments. The ability to get CMTC portfolio results at the time of initial diagnosis offers the unique advantage of early treatment planning, including the use of pre-operative chemotherapy to improve breast conservation in selected patients. This study aimed to validate the CMTC classification using an independent BC cohort.

Study design/ results: RNA from fine needle aspirates were collected in a prospective BC cohort (n = 340) between 2008 and 2010 at Princess Margaret Hospital and Mount Sinai Hospital, Toronto, we included all newly diagnosed BC patients going for surgery who consented to join the study. DNA microarray analyses were carried out using genome-wide Illumina Human Ref-8 version 3 Beadarrays, which contained >24K oligonucleotide probes. After excluding tumors with low RNA yield (n = 8, success rate 97%), non-invasive cancers (n = 27), insufficient follow-up data (n = 21), CMTC divided the remaining 284 BCs into 3 similar sized groups (triad). At a median follow-up of 32 months (range 6.3–52 months), the short-term recurrence was significantly worse (p = 0.0048) in the poor prognostic groups. This result was similar to using an independent external validation cohort (n = 2100) with long-term follow-up reported before, CMTC outperformed all other gene signatures in predicting prognosis and treatment response.

Discussion/conclusion: This prospective validation cohort study demonstrated reproducibility of CMTC in classifying BCs into the three major treatment groups and its prognostic significance. CMTC can be used as a platform to personalize treatments: CMTC-1 BCs (ER+, low proliferation) in general can be treated with surgery and tamoxifen alone. CMTC-2 tumours (ER+, high proliferation) will require additional treatments, including chemotherapy, in addition to tamoxifen; other biologics can be prescribed based on the activities of additional oncogenic pathways. Neo-adjuvant chemotherapy should be considered for CMTC-3 tumours (triple negative and HER2+) with addition of trastuzumab in those that show activation of the HER2 pathway. CMTC portfolio is being further developed into a genomic platform to guide personalized BC treatments..

Citation Information: Cancer Res 2012;72(24 Suppl):Abstract nr P2-10-34.

Loss of ALX4 expression in epithelial cells and adjacent stromal cells in breast cancer

BACKGROUND

Loss of the stromally-restricted homeodomain transcription factor, Alx4, causes defective mouse mammary epithelial morphogenesis.

AIMS

To begin to define the role of ALX4 in the human breast and in breast cancer, the expression pattern of ALX4 in the normal human breast and changes in expression in breast cancer were determined.

METHODS

Cells expressing ALX4 in the human breast were identified by co-immunofluorescence using alpha-ALX4 antibodies and markers of specific mammary cell types. ALX4 expression in breast cancer was then determined by immunohistochemistry on tumour sections that also harboured regions of normal breast tissue. Using criteria that required ALX4 staining in both stromal and epithelial cells, changes in ALX4 expression in tumours on a tissue microarray were determined.

RESULTS

ALX4 was expressed in both stromal and luminal epithelial cells in the human breast. Scoring tissue sections of duct carcinoma in situ (DCIS) or invasive ductal carcinoma (IDC) that also harboured regions of normal breast tissue, a loss of ALX4 (p<0.001) in stromal and epithelial cells in breast tumours was observed. Analysis of ALX4 expression in 123 sections on a tissue microarray confirmed a highly significant loss (p<0.001) of ALX4 in breast cancer in the tumours themselves and in adjacent stromal cells.

CONCLUSIONS

These data show a distinct pattern of expression of ALX4 in the human breast relative to the murine mammary gland. Furthermore, characterisation of ALX4 in breast cancer showed that loss of ALX4 in tumours and the surrounding untransformed stroma is a basic characteristic of DCIS and IDC.

Amplification of the Prolactin Receptor Gene in Mammary Lobular Neoplasia

Background: Lobular carcinoma in situ (LCIS) has long been considered a marker of increased risk of cancer in both breasts. However, recent studies have shown that it can behave as a non-obligate precursor lesion as well. The biology and natural history of LCIS still remains ill defined in part because it is a challenging lesion to study as it usually does not have an identifiable gross appearance and is only recognized in fixed tissue specimens.Material and Methods: Using array comparative genomic hybridization (aCGH) we have analyzed regions of amplification found in LCIS and adjacent invasive lobular carcinoma (ILC) in a series of thirteen cases of archival patient samples from our institution. Degenerate oligonucleotide primed (DOP) PCR was performed for whole genome amplification of the extracted DNA from microdissected tissue samples prior to microarray analysis. Analysis of microarray data was performed using Significance Analysis of Microarrays (SAM). Of the ten most amplified genes in LCIS (highest SAM scores), one was selected for quantitative real time PCR (Q-PCR) validation due to the limited amount of material available from these cases. Q-PCR validation was performed on samples from 8 cases of LCIS and invasive lobular carcinoma and 12 archival cases of ductal carcinoma in situ (DCIS) and invasive ductal carcinoma (IDC) for comparison.Results: Amongst the 10 genes with the highest SAM scores, the prolactin receptor gene (PRLR) was selected for further Q-PCR validation in our limited samples. Amplification of PRLR was confirmed by Q-PCR in 4/8 (50%) of cases of LCIS and 4/8 (50%) cases of ILC, compared to 0/12 (0%) cases of DCIS and 3/12 (25%) cases of IDC. When LCIS and ILC were combined into one group, there was more amplification of the prolactin receptor gene when compared to the DCIS and IDC group (p= 0.01). The level of amplification between the two groups also differed in the range of copy number values, which was lower in the ductal group (0.78-1.58, n=24) compared to the lobular group (0.92-3.68, n=16) (p&lt;0.05).Conclusion: We have identified the prolactin receptor as a potential molecular target in lobular neoplasia using array comparative genomic hybridization. In contrast, we have shown that the prolactin receptor may not be as important for the progression of ductal lesions. These results support the view that lobular and ductal carcinoma evolve along separate pathways. Validation of the expression of PRLR in a larger number of LCIS cases is warranted.

Citation Information: Cancer Res 2009;69(24 Suppl):Abstract nr 4151.

Survey of pigs' kidneys with lesions consistent with PMWS and PDNS and ochratoxicosis. Part 1: concentrations and prevalence of ochratoxin A

One thousand condemned pigs' kidneys were collected in February 2002 from two pig abattoirs in England to assess the possible contribution of ochratoxicosis to postweaning multisystemic wasting syndrome (PMWS) and porcine dermatitis and nephropathy syndrome (PDNS); 250 of the kidneys with macroscopic lesions consistent with nephrosis/nephritis (pale or white cortical lesions) were selected, and the concentration of ochratoxin A was measured in samples of renal cortex by high-performance liquid chromatography (HPLC). Low concentrations were detected in 230 (92 per cent) of the kidneys tested, and in 41 (16.4 per cent) of them the concentration was below the limit of quantification of 0.2 microg/kg. In 187 (74.8 per cent) of the kidneys, the concentration was more than 0.2 microg/kg, and the highest concentration detected was 2.3 microg/kg. The mean (sd) concentration was 0.31 (0.33) microg/kg. The identification of ochratoxin A was confirmed by mass spectrometry. The concentrations of ochratoxin A did not exceed the threshold assessed by the Food Standards Agency to be safe for human food.

Survey of pigs' kidneys with lesions consistent with PMWS and PDNS and ochratoxicosis. Part 2: pathological and histological findings

One thousand condemned pigs' kidneys were collected in February 2002 from two pig abattoirs in England to assess the lesions due to postweaning multisystemic wasting syndrome (pmws) and porcine dermatitis and nephropathy syndrome (pdns) and the possible contribution of ochratoxicosis; 174 of the kidneys were pale, 295 were swollen and 81 were abnormally firm with the gross appearance of fibrosis. The main macroscopic finding was the presence of multifocal pale cortical lesions, observed in 446 of the kidneys, and there were large cysts in 266 of them. Histopathological lesions of non-suppurative tubulointerstitial nephritis, with degeneration and fibrosis of renal tubules, were identified in 213 of 250 (85.2 per cent) of the kidneys examined. These lesions were consistent with those reported in cases of pmws and pdns. The tubular degeneration and fibrosis were also consistent with ochratoxicosis. A higher mean concentration of ochratoxin A was significantly (P=0.020) associated with the presence of multifocal pale cortical lesions consistent with ochratoxicosis, but a causal relationship was not confirmed because histochemistry was not used to detect ochratoxin in the lesions directly. There was no significant correlation between the microscopic lesions and the concentration of ochratoxin. The degenerative lesions may have been caused by previous exposure to ochratoxin that had subsequently been excreted, but the microscopic lesions also included non-suppurative interstitial nephritis, which was unlikely to have been caused by ochratoxicosis.

Reproductive dysfunction in women with epilepsy: antiepileptic drug effects on sex-steroid hormones

Women with epilepsy are at risk for reproductive health dysfunction. Sex-steroid hormone abnormalities have been reported in women with epilepsy, but it has been difficult to determine whether these abnormalities are due to epilepsy-related hypothalamic-pituitary axis dysfunction, or to pharmacokinetic actions of antiepileptic drugs (AEDs). Sex-steroid hormones were evaluated in 84 reproductive-aged women with epilepsy receiving an AED in monotherapy, and in 20 nonepileptic controls. Estrone, free testosterone, and androstenedione were significantly lower in subjects receiving enzyme-inducing AEDs than in nonepileptic controls. Free testosterone was significantly elevated in subjects receiving valproate compared to nonepileptic controls. Subjects with epilepsy receiving gabapentin or lamotrigine were no different from the nonepileptic controls in any of the endocrine variables. Subjects with epilepsy who are receiving AEDs that alter cytochrome P450 enzymes are at risk for significant abnormalities in sex-steroid hormones. In contrast, subjects receiving AEDs that do not alter cytochrome P450 enzymes show no differences in sex-steroid hormones compared with nonepileptic controls. With new AEDs available that do not alter cytochrome P450 enzymes, physician selection of therapy should consider not only seizure control, but also potential effects on reproductive physiology.

Establishing clinically relevant standards for tachypnea in febrile children younger than 2 years

OBJECTIVE

To determine values for defining tachypnea in febrile children younger than 2 years that best identify those at risk for pneumonia.

DESIGN

Prospective case series.

STUDY PATIENTS

Children younger than 2 years presenting to the emergency department of a children's hospital with a temperature of 38 degrees C or higher.

INTERVENTIONS

Using a standardized method, respiratory rates were obtained on eligible children for 1 year. Study patients were classified as having pneumonia or no pneumonia based on clinical evaluation and chest radiograph findings. Receiver operating characteristic curves were constructed to select the values for respiratory rate that maximized sensitivity and specificity of tachypnea as a sign of pneumonia.

RESULTS

Data were analyzed for 572 children; pneumonia was present in 42 (7%). The diagnostic utility of tachypnea was maximal when cutoff values for respiratory rates of 59/min in infants younger than 6 months, 52/min in those aged 6 through 11 months, and 42/min in those aged 1 to 2 years were selected. Based on these definitions, tachypnea as a sign of pneumonia had a sensitivity of 73.8%, specificity of 76.8%, positive predictive value of 20.1%, and negative predictive value of 97.4%.

CONCLUSIONS

Tachypnea, as defined in this study, is an important predictive sign of pneumonia in febrile children younger than 2 years. Conversely, the absence of tachypnea obviates the need for chest radiography in most settings.

Endobronchial tuberculosis in children. A case report and review

Unilateral obstructive emphysema seen on chest X-ray in a pediatric patient is usually associated with a foreign body in a bronchus. We present a 31-month-old female who presented with a 2-week history of increasing expiratory stridor. Endoscopic examination revealed a polypoid mass in the right main bronchus. Biopsies and cultures were consistent with endobronchial tuberculosis. We review the presentation and treatment of tuberculosis in children. Endobronchial tuberculosis is a rare complication of pulmonary tuberculosis which may result in stenosis of the bronchus.

Congenital brain tumors: a review of 45 cases

Forty-five pathologically proved cases of neonatal brain tumors (diagnosed in neonates within 60 days after birth) were reviewed from the neuroradiology archives dating back to 1964. CT was performed in 24 cases, MR in five, sonography in six, and angiography in seven. Two-thirds of the lesions were supratentorial. The most common histology was a tumor composed of primitive or poorly differentiated tissues: 12 teratomas and 12 primitive neuroectodermal tumors, four of which were typical medulloblastomas. In addition, there were nine astrocytomas (grades I-III); four cases of glioblastoma multiforme (astrocytoma grade IV); three choroid plexus papillomas; and single cases each of ependymoma, medulloepithelioma, germinoma, angioblastic meningioma, and ganglioglioma. The dominant CT appearance, regardless of histology, was a large heterogeneous lesion with associated hydrocephalus. Coarse calcification was a constant feature in the teratomas. Prognosis was poor overall, with the longest survival seen in choroid plexus papilloma and astrocytoma. Imaging studies are most valuable in identifying and distinguishing potentially curable lesions such as choroid plexus papillomas (variably sized intraventricular lesions with homogeneous enhancement) from rapidly fatal tumors such as teratomas (large heterogeneous lesions with coarse calcifications and associated hydrocephalus).

Congenital brain tumors: a review of 45 cases

Forty-five pathologically proved cases of neonatal brain tumors (diagnosed in neonates within 60 days after birth) were reviewed from the neuroradiology archives dating back to 1964. CT was performed in 24 cases, MR in five, sonography in six, and angiography in seven. Two-thirds of the lesions were supratentorial. The most common histology was a tumor composed of primitive or poorly differentiated tissues: 12 teratomas and 12 primitive neuroectodermal tumors, four of which were typical medulloblastomas. In addition, there were nine astrocytomas (grades I-III); four cases of glioblastoma multiforme (astrocytoma grade IV); three choroid plexus papillomas; and single cases each of ependymoma, medulloepithelioma, germinoma, angioblastic meningioma, and ganglioglioma. The dominant CT appearance, regardless of histology, was a large heterogeneous lesion with associated hydrocephalus. Coarse calcification was a constant feature in the teratomas. Prognosis was poor overall, with the longest survival seen in choroid plexus papilloma and astrocytoma. Imaging studies are most valuable in identifying and distinguishing potentially curable lesions such as choroid plexus papillomas (variably sized intraventricular lesions with homogeneous enhancement) from rapidly fatal tumors such as teratomas (large heterogeneous lesions with coarse calcifications and associated hydrocephalus).

Ectopic vas deferens, imperforate anus and hypospadias: a new triad

An ectopic vas deferens is a rare congenital anomaly frequently associated with rectal abnormalities. We describe 2 patients with ectopic vas deferens associated with an imperforate anus and hypospadias. There are 19 previous reports of patients with ectopic vas deferens, 5 of which were bilateral. One of our patients, a child with bilateral ectopic vas deferens, had the highest reported insertion of an ectopic vas deferens. The embryology and management of this rare condition are reviewed.

Small carpal bone surface area, a characteristic of Turner's syndrome

An abnormality which has received little attention but may be easily recognized on radiographs of the hand of patients with Turner's syndrome is described. Eleven of thirty-one patients (35.5%) with Turner's syndrome were shown on radiographs of the hand to have a visually detectable smallness on the bone surface area of the carpus when compared to the area of the second through fifth metacarpals. Values for the "C/M" ratio (the area of the carpals divided by the area of the second through fifth metacarpals) were calculated for films of 31 individuals with gonadal dysgenesis and compared with those from bone age-matched films of seventy-six individuals with normal development of the hand and wrist. A consistent difference with minimal overlap was documented. For all of the films of patients with Turner's syndrome the C/M ratio averaged 89% of the value in the films of the controls. In the 11 patients in whose films smallness was visually apparent, the C/M ratio averaged 82% of controls while in those where the diminution was detected only by planimetry the C/M ratio averaged 91% of controls. The incidence of a diminished C/M ratio was compared with the incidence of four other previously described signs of Turner's syndrome; although not seen as often as the coarse reticular pattern or delayed bone age, the C/M sign was recognizable without planimetry at least as commonly as the "metacarpal sign," and a decreased carpal angle and/or Madelung's deformity. Taken together, these several criteria suggest the radiographic diagnosis of Turner's syndrome in more than 93% of cases.