Clinicopathologic predictors of sentinel lymph node metastasis in thin melanoma

PURPOSE

Indications for sentinel lymph node biopsy (SLNB) for thin melanoma are continually evolving. We present a large multi-institutional study to determine factors predictive of sentinel lymph node (SLN) metastasis in thin melanoma.

PATIENTS AND METHODS

Retrospective review of the Sentinel Lymph Node Working Group database from 1994 to 2012 identified 1,250 patients who had an SLNB and thin melanomas (≤ 1 mm). Clinicopathologic characteristics were correlated with SLN status and outcome.

RESULTS

SLN metastases were detected in 65 (5.2%) of 1,250 patients. On univariable analysis, rates of Breslow thickness ≥ 0.75 mm, Clark level ≥ IV, ulceration, and absence of regression differed significantly between positive and negative SLN groups (all P < .05). These four variables and mitotic rate were used in multivariable analysis, which demonstrated that Breslow thickness ≥ 0.75 mm (P = .03), Clark level ≥ IV (P = .05), and ulceration (P = .01) significantly predicted SLN metastasis with 6.3%, 7.0%, and 11.6% of the patients with these respective characteristics having SLN disease. Melanomas < 0.75 mm had positive SLN rates of < 5% regardless of Clark level and ulceration status. Median follow-up was 2.6 years. Melanoma-specific survival was significantly worse for patients with positive versus negative SLNs (P = .001).

CONCLUSION

Breslow thickness ≥ 0.75 mm, Clark level ≥ IV, and ulceration significantly predict SLN disease in thin melanoma. Most SLN metastases (86.2%) occur in melanomas ≥ 0.75 mm, with 6.3% of these patients having SLN disease, whereas in melanomas < 0.75 mm, SLN metastasis rates are < 5%. By using a 5% metastasis risk threshold, SLNB is indicated for melanomas ≥ 0.75 mm, but further study is needed to define indications for SLNB in melanomas < 0.75 mm.

Phase I trial of preoperative chemoradiation plus sorafenib for high-risk extremity soft tissue sarcomas with dynamic contrast-enhanced MRI correlates

PURPOSE

We conducted a phase I trial of the addition of sorafenib to a chemoradiotherapy regimen in patients with high-risk (intermediate/high grade, >5 cm) extremity soft tissue sarcoma undergoing limb salvage surgery. We conducted a correlative study of quantitative dynamic contrast-enhanced MRI (DCE-MRI) to assess response to treatment.

EXPERIMENTAL DESIGN

Patients were treated at increasing dose levels of sorafenib (200 mg daily, 400 mg daily, 400 mg twice daily) initiated 14 days before three preoperative and three postoperative cycles of epirubicin/ifosfamide. Radiation (28 Gy) was administered during cycle 2 with epirubicin omitted. The primary objective was to determine the maximum tolerated dose (MTD) of sorafenib. DCE-MRI was conducted at baseline, after 2 weeks of sorafenib, and before surgery. The imaging data were subjected to quantitative pharmacokinetic analyses.

RESULTS

Eighteen subjects were enrolled, of which 16 were evaluable. The MTD of sorafenib was 400 mg daily. Common grade 3-4 adverse events included neutropenia (94%), hypophosphatemia (75%), anemia (69%), thrombocytopenia (50%), and neutropenic fever/infection (50%). Of note, 38% developed wound complications requiring surgical intervention. The rate of ≥95% histopathologic tumor necrosis was 44%. Changes in DCE-MRI biomarker ΔK(trans) after 2 weeks of sorafenib correlated with histologic response (R(2) = 0.67, P = 0.012) at surgery.

CONCLUSION

The addition of sorafenib to preoperative chemoradiotherapy is feasible and warrants further investigation in a larger trial. DCE-MRI detected changes in tumor perfusion after 2 weeks of sorafenib and may be a minimally invasive tool for rapid assessment of drug effect in soft tissue sarcoma.

Breast cancer stem cells mutations: A new understanding of intratumoral heterogeneity

25

Background: Breast cancer has long been recognized as a heterogeneous disease. This has profound implications for diagnosis, treatment and disease recurrence. Oncogenic mutations have been identified in breast cancer cells with stem-like and progenitor properties (BCSC). We have previously reported that BCSC mutations correlated with axillary lymph node metastases. This was even more significant when micrometastatic disease was included. Our hypothesis is that tumor heterogeneity extends to the genetics of BCSC, and that BCSC mutations are better predictors of lymph node status than whole tumor genetics. Methods: BCSC from fresh tissue specimens were matched to their whole tumor specimens. BCSC and whole tumor DNA were sent for PCR-based mutation analysis. Patient data was collected by chart review. Results: Twenty-eight matched BCSC and whole tumor samples were analyzed. PI3K/Akt signaling mutations in PIK3CA, AKT1, HRAS, and MET were identified in BCSC from 10 tumors. In 4 of these, mutations were also identified in the corresponding whole tumor specimens. In 4 patients, mutations were identified in whole tumor samples only. Fourteen tumors had no mutations. Tumor stage, grade, receptor status, and age did not correlate with tumor or BCSC mutation status. In contrast to BCSC mutations, mutation status of the whole tumor did not correlate with micro or macro metastatic disease in the lymph node (p = 0.92). Conclusions: Mutations in BCSC are more predictive of lymph node metastases than mutations identified in the tumors. Thus, PI3K/Akt pathway mutations in tumor precursor cells may have a stronger influence on tumor metastatic potential than mutations identified in whole tumor samples. Whole tumors and BCSC populations demonstrate significant heterogeneity, as mutations identified in BCSC and tumors were not always concordant. Rare BCSC populations must be tested separately as they provide crucial prognostic and treatment information in conjunction with whole tumor genetic analyses.

Does the number of surgical excisions before delivering intraoperative radiotherapy (IORT) affect skin toxicity?

72

Background: The TARGIT-A trial allowed administration of IORT both pre- and post-pathology. The advantage of post-pathology is the ability to determine eligibility based on margins, pathologic tumor size and nodal status, prior to delivering radiation. However, it is unclear whether having more than one operation before IORT is associated with worse skin toxicity. In this study, we aimed to examine the relationship of the number of operations and skin toxicities in women receiving IORT. Methods: We conducted a retrospective analysis of 57 consecutive patients who underwent IORT from 2009-2013. All patients received 20 Gy in 1 fraction prescribed to the applicator surface using the Carl Zeiss Intrabeam System. Skin toxicities were determined using CTCAE 4.0 and RTOG criteria. In addition, infection, skin erythema, desquamation, symptomatic seroma, and necrosis were scored individually and used as outcome measures. Pearson’s Chi-squared test was used to assess the association of the number of operations and skin toxicities. A multivariate analysis was performed and included age, applicator size, max skin dose, number of operations, DM, HTN, BMI, co-morbidity, and depth from skin on mammogram as variables. Results: The median follow-up was 11 months (range 1-33). The median age and applicator size were 68 yrs (range 49-85) and 4 cm (range 2.5-5). 20 (35%) patients had 1 operation (lumpectomy, SLNB and Intrabeam all in 1 setting). 36 (63%) patients had 2 operations (initial surgery, followed by Intrabeam +/- margin re-excision). One (2%) patient had 3 operations (initial surgery, re-excision, followed by Intrabeam). On univariate analysis, the number of operations was associated with increased infection (p = 0.044), but not other skin toxicities. On multivariate analysis, the association was no longer significant (p = 0.97). Conclusions: Our study suggests that delivering IORT post-pathology was not associated with worse acute or late skin complications. Delivering IORT after the initial operation decreases the uncertainty of margin status and avoids the controversy of excising an irradiated positive margin and/or the need for additional whole breast radiation.

Effect of biopsy type on outcomes in the treatment of primary cutaneous melanoma

BACKGROUND

Surgical excision remains the primary and only potentially curative treatment for melanoma. Although current guidelines recommend excisional biopsy as the technique of choice for evaluating lesions suspected of being primary melanomas, other biopsy types are commonly used. We sought to determine the impact of biopsy type (excisional, shave, or punch) on outcomes in melanoma.

METHODS

A prospectively collected, institutional review board-approved database of primary clinically node-negative melanomas (stages cT1-4N0) was reviewed to determine the impact of biopsy type on T-staging accuracy, wide local excision (WLE) area (cm(2)), sentinel lymph node biopsy (SLNB) identification rates and results, tumor recurrence, and patient survival.

RESULTS

Seven hundred nine patients were diagnosed by punch biopsy (23%), shave biopsy (34%), and excisional biopsy (43%). Shave biopsy results showed significantly more positive deep margins (P < .001). Both shave and punch biopsy results showed more positive peripheral margins (P < .001) and a higher risk of finding residual tumor (with resulting tumor upstaging) in the WLE (P < .001), compared with excisional biopsy. Punch biopsy resulted in a larger mean WLE area compared with shave and excisional biopsies (P = .030), and this result was sustained on multivariate analysis. SLNB accuracy was 98.5% and was not affected by biopsy type. Similarly, biopsy type did not confer survival advantage or impact tumor recurrence; the finding of residual tumor in the WLE impacted survival on univariate but not multivariate analysis.

CONCLUSIONS

Both shave and punch biopsies demonstrated a significant risk of finding residual tumor in the WLE, with pathologic upstaging of the WLE. Punch biopsy also led to a larger mean WLE area compared with other biopsy types. However, biopsy type did not impact SLNB accuracy or results, tumor recurrence, or disease-specific survival (DSS). Punch and shave biopsies, when used appropriately, should not be discouraged for the diagnosis of melanoma.

A phase I trial of intratumoral administration of HF10 in patients with refractory superficial cancer: Immune correlates of virus injection

3099

Background: HF10 is a spontaneously occurring, oncolytic, mutant Herpes Simplex Virus type 1 (HSV-1). Several deletions/insertions in its genome render it nonpathogenic. HF10 has been tested in solid tumors accessible for injection. Methods: We report correlative studies from an open label, non-randomized, multicenter, single dose escalation phase I study in patients with refractory superficial cancer. The study was a “3 + 3” design with 4-dose cohorts at escalating doses of HF10 (1 x 105 TCID50/dose with incremental dose escalations up to 1 x 107 TCID50/dose), which has been completed. Body fluids (qPCR), peripheral blood (flow cytometry) and serum (30-plex cytokine assay) were examined for viral levels, quantitative immune cell variation, and cytokines, respectively. Results: Seventeen patients were enrolled and 15 treated (9 H/N; 4 melanoma; 1 colon; 1 sarcoma). Best response was stable disease in six patients and progressive disease in nine patients. Three of the 15 patients had an adverse event possibly related to the study therapy. These AEs were grade 1 hypotension (1) and flu-like symptoms (2): typical of treatment with oncolytic viruses. qPCR analysis transiently revealed virus in the saliva of two patients (day 2 and day 22); viral clearance was achieved after 1 and 7 days respectively. Comparing the two highest and two lowest dose HF10 cohorts, CD8+PD1+ cells were decreased with increasing HF10 dose (p=0.023). Increased monocyte population (CD14+CD11c+) appeared to correlate with increased HF10 dose (p=0.063). IL-8 increased in all samples (p=0.0078 Wilcoxon Signed rank test) post injection. Conclusions: Single dose intratumoral injection was well tolerated with mild-drug related AEs and rapid viral clearance. Six patients achieved stable disease during the study period. There appears to be a generalized IL-8 related inflammatory response coincident with increased peripheral blood monocytes after HF10 administration. Decreased CD8+PD1+ cells may indicate a shift towards a non-exhausted, functional CTL phenotype. These results justify the currently accruing study of multiple administrations of HF10 at the highest administered dose. Clinical trial information: NCT01017185.

Sentinel lymph node biopsy for melanoma: comparison of lymphocele rates by surgical technique

Lymphocele is a common wound complication of sentinel lymph node biopsy (SLNB). The surgical technique may play a key role in lymphocele formation. This study compared rates of postoperative lymphocele formation by different surgical techniques (Harmonic Scalpel [HS], LigaSure [LS], and traditional electrocautery with clips) after SLNB in the groin or axilla for the staging of clinically node-negative cutaneous melanoma. Patients were selected by convenience sample from a single-institution, single-surgeon, prospectively collected melanoma database over a 27-month period. One hundred fifty consecutive patients underwent SLNB, 70 with clips, 37 with HS, and 43 with LS. The median number of nodes removed was two and did not vary significantly between groups. Twenty-three lymphoceles occurred for an overall rate of 15 per cent; rates were 9.9 and 26.5 per cent for the axilla and groin, respectively. Sixteen (70%) were aspirated for size or symptoms; lymphoceles after groin SLNB were significantly (P = 0.03) more likely to require aspiration. Lymphocele rates for the clip, HS, and LS groups were 20.0, 18.9, and 4.7 per cent, respectively. The differences between the LS and other groups were statistically significant. Use of the LS may lead to lower lymphocele rates after groin and axillary SLNB compared with electrocautery and clips.

Phase III trial of high-dose interferon alpha-2b versus cisplatin, vinblastine, DTIC plus IL-2 and interferon in patients with high-risk melanoma (SWOG S0008): An intergroup study of CALGB, COG, ECOG, and SWOG

8504

Background: High-dose interferon for one year (HDI) is the FDA approved adjuvant therapy for patients (pts) with high-risk melanoma (HRM). Efforts to modify IFN dose or schedule have not improved efficacy. A meta-analysis demonstrated that biochemotherapy (BCT) produced superior response rates compared with chemotherapy in pts with stage IV melanoma (Wheatley et al J Clin Oncol 25:5426, 2007). We sought to determine whether a short course of BCT would be more effective than HDI as adjuvant treatment in pts with HRM. Methods: S-0008 (an Intergroup Phase III trial) enrolled pts who were high risk (Stage III A-N2a thru Stage III C N3) and randomized them to receive either HDI or BCT consisting of dacarbazine 800 mg/m2 day 1, cisplatin 20 mg/m2/ days 1-4, vinblastine 1.2 mg/m2 days 1-4, IL-2 9 MIU/m2/day continuous IV days 1-4, IFN 5 MU/m2/day sc days 1-4, 8,10,12, and G-CSF 5 ug/kg/day sc days 7-16. BCT cycles were given every 21 days x 3 cycles (9 weeks total). Pts were stratified for number of involved nodes (1-3 v ≥4), micro v macro metastasis, and ulceration of the primary. Co-primary endpoints were relapse free survival (RFS) and overall survival (OS) using a one-sided log rank test at p= 0.05. Results: 432 pts were enrolled between 8/2000 and 11/2007: 30 were ineligible or withdrew consent. Grade 3 and 4 adverse events occurred in 57% and 7% respectively of HDI pts and 36% and 40% of BCT pts. At a median f/up of 6 yrs, BCT improved RFS (p = 0.02, HR 0.77 [90% CI: 0.62 – 0.96]) with median RFS for BCT of 4.0 yrs (90% CI:1.9 – 5.9) v 1.9 yrs (90% CI: 1.4 – 2.5) and 5 yr RFS of 47% v 39%. Median OS was not different between the two arms (p = 0.49 HR 1.0 [90% CI: 0.78 – 1.27]) with median OS not yet reached for BCT v 8.4 yrs (90% CI: 4.5 – 9.3) for HDI and 5 yr survival 56% for both arms. Conclusions: In HRM pts, BCT provides a statistically significant improvement in RFS compared to HDI, but no discernable difference in OS and more grade IV toxicity. BCT represents a shorter, alternative treatment for pts with HRM, and a potential control arm and basis for future combinations in the adjuvant setting.

Impact of American College of Surgeons Oncology Group Z0011 and National Surgical Adjuvant Breast and Bowel Project B-32 trial results on surgeon practice in the Pacific Northwest

BACKGROUND

Recent clinical trials have suggested no survival benefit for completion axillary node dissection (CALND) after sentinel lymph node biopsy (American College of Surgeons Oncology Group Z0011) and no clinically meaningful benefit for the routine use of immunohistochemistry (National Surgical Adjuvant Breast and Bowel Project B-32) in clinically node-negative breast cancer.

METHODS

A 12-question electronic survey was distributed to members of 3 Pacific Northwest surgical societies. Surgeons were queried regarding the impact of the trial results on their surgical management of breast cancer.

RESULTS

The 181 respondents reported performing fewer CALNDs (63%), fewer intraoperative frozen sections (21%), and no immunohistochemistry (12%) because of trial data. However, 28% of surgeons continued to perform CALND in patients with 1 to 2 positive sentinel lymph nodes undergoing lumpectomy and postoperative radiation.

CONCLUSIONS

Recent trial data have impacted the performance of CALNDs and the pathological evaluation of sentinel lymph nodes among Pacific Northwest surgeons. Our results suggest a need for regional surgical societies to disseminate practice-changing trial data to members.

Trends in research time, fellowship training, and practice patterns among general surgery graduates

SUMMARY

A comparison of research experience, fellowship training, and ultimate practice patterns of general surgery graduates at a university-based surgical residency program. Research experience correlated with pursuing fellowship training and predicted an eventual academic career. More recently, graduates have been able to obtain fellowships without a dedicated research year, perhaps reflecting shifting fellowship training opportunities.

BACKGROUND

We hypothesized that the relationships among dedicated research experience during residency, fellowship training, and career choices is changing as research and fellowship opportunities evolve.

METHODS

Comparison of research experience, fellowship training, and ultimate practice patterns of general surgery graduates for 2 decades (1990-1999, n = 82; 2000-2009, n = 98) at a university-based residency program. Main outcome measures were number of years and area of research, fellowship training, and practice setting.

RESULTS

Compared by decade, graduates became increasingly fellowship-trained (51.2% vs 67.3%; p < 0.05) and pursuit of fellowship training increased for both research and nonresearch participating graduates. The number of residents completing more than 1 year of research doubled (9.8% vs 22.4%, p < 0.05). By decade, the percentage of female graduates increased significantly (22% vs 41%, p = 0.005), with more women participating in dedicated research (17% vs 51%, p < 0.001) and seeking fellowships. The number of graduates going into specialty practice and academic/clinical faculty positions increased over time.

CONCLUSIONS

Surgical residents have completed more dedicated research years and became increasingly fellowship-trained over time. The proportion of female graduates has increased with similar increases in research time and fellowship training in this subgroup. In the earlier decade, dedicated research experiences during surgical residency correlated with pursuing fellowship training, and predicted an eventual academic career. More recently, graduates have obtained fellowships and academic positions without dedicated research time, perhaps reflecting shifting fellowship opportunities.

Trends in the surgical treatment of ulcerative colitis over time: increased mortality and centralization of care

BACKGROUND

New medical therapies available to ulcerative colitis (UC) patients have influenced operative mortality for patients requiring colectomy. We sought to examine trends in treatment and outcome for UC patients treated surgically.

METHODS

A review of 36,447 UC patients from the Nationwide Inpatient Sample was performed, comparing the pre-monoclonal antibody era (1990-1996) to the present-day era (2000-2006). Patients treated with total colectomy with ileostomy or proctocolectomy with ileal pouch were reviewed for outcome measures and practice setting (rural, urban non-teaching, urban teaching). Our main outcome measures were in-hospital mortality, length of stay, and total charges.

RESULTS

Total colectomy (n = 30,362) was performed five times more often than proctocolectomy (n = 6,085). When comparing the two study periods, mortality after total colectomy increased 3.8% to 4.6% (p = 0.0003). This difference was primarily due to increasing mortality in later years; when 1995-1996 was compared to 2005-2006, mortality increased from 3.6% to 5.6% (p < 0.0001). There were no deaths in the proctocolectomy group (p < 0.0001). The distribution by practice setting shifted over the two study periods, decreasing in rural (7.0% to 4.8%) and urban non-teaching (43.7% to 28.4%) centers, and increasing in urban teaching centers (49.3% to 66.8%). The total inflation-adjusted charges per patient increased significantly ($34,638 vs. $43,621; p < 0.0001).

CONCLUSIONS

The mortality rate after total colectomy is increasing, and the difference is accentuated in the years since widespread use of monoclonal antibody therapy. The care of these patients is being shifted to urban teaching centers and is becoming more expensive.

False-Negative Sentinel Lymph Node Biopsy in Head and Neck Melanoma

Objective. The results of sentinel lymph node biopsy (SLNB) can be useful for staging and deciding on adjuvant treatment for patients with head and neck melanoma. False-negative SLNB can result in treatment delay. This study aimed to evaluate the characteristics and outcome of patients with false-negative SLNB in cutaneous melanoma of the head and neck.

Study Design. Longitudinal cohort study using a prospective institutional tumor registry.

Setting. Academic health center.

Subjects and Methods. Data from 153 patients who underwent SLNB for melanoma of the head and neck were analyzed. False-negative biopsy was defined as recurrence of tumor in a previously identified negative nodal basin. Statistical analysis was performed on registry data.

Results. Positive sentinel lymph nodes were identified in 19 (12.4%) patients. False-negative SLNB was noted in 9 (5.9%) patients, with a false-negative SLNB rate of 32.1%. Using multivariate regression analysis, only examination of a single sentinel lymph node was a significant predictor of false-negative SLNB ( P = .01). The mean treatment delay for the false-negative SLNB group was 470 days compared with 23 days in the positive SLNB group ( P < .001). The 2-year overall survival of patients with false-negative SLNB was 75% compared with 84% and 98% in positive and negative SLNB groups, respectively ( P = .02).

Conclusions. False-negative SLNB is more likely to occur when a single sentinel lymph node is harvested. There is significant treatment delay in patients with false-negative SLNB. False-negative SLNB is associated with poor outcome in patients with melanoma of the head and neck.

Factors predictive of the status of sentinel lymph nodes in melanoma patients from a large multicenter database

BACKGROUND

Numerous predictive factors for cutaneous melanoma metastases to sentinel lymph nodes have been identified; however, few have been found to be reproducibly significant. This study investigated the significance of factors for predicting regional nodal disease in cutaneous melanoma using a large multicenter database.

METHODS

Seventeen institutions submitted retrospective and prospective data on 3463 patients undergoing sentinel lymph node (SLN) biopsy for primary melanoma. Multiple demographic and tumor factors were analyzed for correlation with a positive SLN. Univariate and multivariate statistical analyses were performed.

RESULTS

Of 3445 analyzable patients, 561 (16.3%) had a positive SLN biopsy. In multivariate analysis of 1526 patients with complete records for 10 variables, increasing Breslow thickness, lymphovascular invasion, ulceration, younger age, the absence of regression, and tumor location on the trunk were statistically significant predictors of a positive SLN.

CONCLUSIONS

These results confirm the predictive significance of the well-established variables of Breslow thickness, ulceration, age, and location, as well as consistently reported but less well-established variables such as lymphovascular invasion. In addition, the presence of regression was associated with a lower likelihood of a positive SLN. Consideration of multiple tumor parameters should influence the decision for SLN biopsy and the estimation of nodal metastatic disease risk.

A phase 2 trial of complete resection for stage IV melanoma: results of Southwest Oncology Group Clinical Trial S9430

BACKGROUND

On the basis of retrospective experience at individual centers, it appears that patients with stage IV melanoma who undergo complete resection have a favorable outcome compared with patients with disseminated stage IV disease. The Southwest Oncology Group (SWOG) performed a prospective trial in patients with metastatic melanoma who were enrolled before complete resection of their metastatic disease and provided prospective outcomes in the cooperative group setting.

METHODS

Based on their physical examination and radiologic imaging studies, patients with a stage IV melanoma judged amenable to complete resection underwent surgery within 28 days of enrollment. All eligible patients were followed with scans (computed tomography or positron emission tomography) every 6 months until relapse and death.

RESULTS

Seventy-seven patients were enrolled from 18 different centers. Of those, 5 patients were ineligible; 2 had stage III disease alone; and 3 had no melanoma in their surgical specimen. In addition, 8 eligible patients had incompletely resected tumor. Therefore, the primary analysis included 64 completely resected patients. Twenty patients (31%) had visceral disease. With a median follow-up of 5 years, the median relapse-free survival was 5 months (95% CI, 3-7 months) whereas median overall survival was 21 months (95% CI, 16-34 months). Overall survivals at 3 and 4 years were 36% and 31%, respectively.

CONCLUSIONS

In a prospective multicenter setting, appropriately selected patients with stage IV melanoma achieved prolonged overall survival after complete surgical resection. Although median relapse-free survival was only 5 months, patients could still frequently undergo subsequent surgery for isolated recurrences. This patient population is appropriate for aggressive surgical therapy and for trials evaluating adjuvant therapy.

Surgical treatment of intrahepatic cholangiocarcinoma: outcomes and predictive factors

BACKGROUND

Intrahepatic cholangiocarcinoma (ICC) remains a rare tumour, although its incidence is increasing. Surgical resection is the mainstay of treatment. Published data regarding prognostic factors and optimal patient selection for resection are scant. We sought to determine the clinicopathologic characteristics of resectable ICC and outcomes following surgical treatment.

METHODS

We reviewed prospectively collected clinical data including patient, pathologic and operative details. Survival and recurrence outcomes were analysed using Cox hazard models and the Kaplan-Meier method.

RESULTS

We identified 31 surgically treated patients. Their 3-year overall survival rate (OS) was 40.1%; median follow-up was 16.2 months (range: 0.2-86.9 months). R0 resection was associated with significantly improved OS compared with R1/R2 resection (3-year OS was 68.6% in R0 vs. 24.0% in R1/R2; P= 0.042). The postoperative complication rate was 58.1%. Two patients died of postoperative liver failure within 30 days. Preoperative hypoalbuminaemia was significantly associated with worse survival.

CONCLUSIONS

Surgical therapy for ICC is associated with longterm survival in the subset of nutritionally replete patients in whom an R0 resection can be achieved. Surgical mortality is significant in patients undergoing extended resection. The margin involvement rate is high and surgeons should consider the infiltrative nature of the disease in operative planning.

Sentinel lymph node staging of cutaneous melanoma: predictors and outcomes

BACKGROUND

The authors updated their experience with sentinel lymph node (SLN) biopsy of clinically node negative (N0) melanoma to clarify indications, predictive factors, and outcomes.

METHODS

A review of patients from the authors' institution's prospective database (n = 397) was performed; survival statistics were obtained from the institutional tumor registry.

RESULTS

The SLN-positive (SLN+) rate was 16% (47 of 282) for lesions >1 mm thick; only 2 of 105 T1 lesions were SLN+. Thickness >2 mm, upper extremity primary, and ulceration predicted SLN+ status. Most SLN+ patients underwent completion node dissection; 12% had additional positive nodes. The false-negative SLN biopsy rate was 4.0%; the majority involved lower extremity and head and neck primaries. The overall complication rate was 26%; all were minor and resolved within 6 months. Overall 5-year survival rates were 73% and 92% for SLN+ and SLN-negative patients, respectively. SLN status was the most significant predictor of survival.

CONCLUSIONS

SLN status, the most important determinant of outcome for clinically N0 melanoma, correlated with T stage, ulceration, and site. Staging of T1 lesions had low yield. A minority of completion node dissections yielded additional positive nodes.

Gastric malignancies in breast cancer survivors: pathology and outcomes

BACKGROUND

As the number of breast cancer survivors increases, the appearance of second malignancies and unusual metastatic patterns likely also is increasing. In particular, we and others have observed gastric malignancies in breast cancer survivors.

METHODS

We reviewed 3 regional hospital system tumor databases, comprising 19,049 analytic breast cancer cases, to determine the number, types, and outcomes of subsequent gastric malignancies.

RESULTS

Twenty-eight patients developed subsequent gastric malignancies, representing .15% of breast cancer survivors; 82% of patients had gastric symptoms. Overall survival for the cohort was 39%. Twenty-four patients (86%) had gastric primaries and 13 died of their second cancers. Four patients had gastric metastases; all had lobular histology in both their primary tumors and metastatic lesions. Five patients had gastrointestinal stromal tumors; all patients underwent resection and currently are alive.

CONCLUSION

Gastric symptoms in breast cancer survivors may represent malignant lesions, often second primaries. All gastric metastases in our series were of lobular histology.

Role of imatinib in the management of early, operable, and advanced GI stromal tumors (GISTs)

Gastrointestinal stromal tumors (GISTs), the most common sarcoma of the GI tract, have unique kinase mutations that serve as targets for medical therapy. This article reviews the data supporting the use of the tyrosine kinase inhibitor (TKI) imatinib in GIST patients, and how this treatment should be combined with surgical resection (when possible) to optimize patient outcomes. Although surgical resection remains the mainstay of treatment for these tumors, patients with resected GISTs have high relapse rates that can be reduced by 1 year of adjuvant imatinib. Data also support the use of imatinib for patients with recurrent or unresectable GIST. In these patients the drug should be continued until progression, intolerance, or the patients are rendered resectable. Patients with advanced GIST who are successfully resected after imatinib treatment should be placed back on imatinib postoperatively. Patients who develop generalized progression (progression at 2 or more sites) on imatinib should move to other treatments, such as newer TKIs or other targeted approaches currently under study. Genotyping of the tumor should be considered in all pediatric GISTs and high risk adult GISTs, especially if there is progression on imatinib. Quality of life and the cost/benefit of new therapies are important issues for further study in patients with GIST.

Vitreo-retinal traction and anastrozole use

Abstract #1147

Background: Menopause is known to increase the risk of vitreo-retinal tractional events such as macular holes and posterior vitreous detachments (PVDs). This suggests that aromatase inhibitors (AIs), which virtually abolish estrogen synthesis in post-menopausal women, may lead to an increased degree of vitreo-retinal traction. To evaluate the hypothesis that AIs lead to heightened vitreo-retinal traction, this study tested the prediction that the foveal shapes of anastrozole users are distorted systematically.&#x2028; Material and Methods: Retinal thickness along the horizontal meridian through the fovea was measured using optical coherence tomography (OCT) for each of 3 groups of amenorrheic women ages 47-69 years: (1) anastrozole users and (2) tamoxifen users using their respective medications as adjuvant therapy for early-stage breast cancer, and (3) age-matched control subjects not using any hormonally acting medication. All subjects had 20/20 or better best-corrected visual acuity, no diabetes, and no high myopia, which itself is a risk factor for PVDs. Foveal shape indices were derived from the OCT data by normalizing each subject's retinal thickness data to her individually determined locus of minimal foveal thickness. OCT images were used to identify subjects with PVDs, which necessitated exclusion from most analyses. The information in the Results section is for subjects without PVDs.&#x2028; Results: For anastrozole users (n=13), the distance to the temporal side of the fovea was significantly less than the distance to the nasal side at a sufficient height above the foveal base. This effect did not exist for control subjects (n=24), and the between-group difference was significant (unadjusted p = .006). The data from tamoxifen users (n=19) appeared to be intermediate to the data of the other 2 groups, but the differences were not significant. At the base of the fovea, the distance to the temporal side minus the distance to the nasal side correlated significantly with the degree of myopia for the control subjects (r = -.54, p = .008) but not for the anastrozole users (r = -.23). However, the anastrozole users were observed to be significantly less myopic than the control subjects, which may have led to the negative result.&#x2028; Discussion: The foveas of women who use anastrozole are subjected to a greater amount of vitreo-retinal traction than are the foveas of women not using any hormonal medication. The data from control subjects reveal the action of an additional force that pulls on the fovea from its scleral side in the opposite direction, i.e., away from the optic nerve head, which not only anchors the vitreous but which also interferes asymmetrically with intraocular stretching related to myopia. The net result of the 2 forces may be retinal shear. The low prevalence of myopia among the anastrozole users suggests that our cross-sectional study may have excluded anastrozole users with vision change. Longitudinal studies with baseline data need to be conducted.

Citation Information: Cancer Res 2009;69(2 Suppl):Abstract nr 1147.

Case log review produces translational change in surgical oncology education

BACKGROUND

The recently mandated reduction in surgical resident work hours led to concerns that surgical cancer education would suffer, as measured by cancer case exposure.

METHODS

Final operative logs submitted to the American Board of Surgery by chief residents graduating from our program were compared for 2 time periods: prior to the mandate (2002-2003) and after (2006-2007).

RESULTS

Case logs from graduating residents (n = 36) showed a nonsignificant decrease in cancer as the percentage of total major cases, due to an actual increase in total major cases. Conversely, endoscopy and minor cancer case experience both decreased.

CONCLUSIONS

Exposure to minor cancer cases and endoscopies has decreased; this has led to a requirment for a minimum number of endoscopies/graduating resident, and to strategies for increasing exposure to minor cancer cases.

OX40 (CD134) expression in sentinel lymph nodes correlates with prognostic features of primary melanomas

BACKGROUND

The expression of OX40 (CD134) on activated CD4+ T cells has been associated with favorable cancer patient outcomes. Because of recent reports that sentinel lymph nodes (SLNs) may represent an immunosuppressive environment, we investigated the expression of OX40 in SLNs from patients with primary cutaneous melanoma.

METHODS

Samples of peripheral blood lymphocytes and a section of 71 SLNs from 53 patients with clinically node negative melanoma were purified for CD4+ T cells, stained for OX40, and analyzed by flow cytometry.

RESULTS

The mean percentage of OX40 on CD4 T cells in the SLNs versus peripheral blood lymphocytes was related indirectly to the T stage of the primary tumor and was decreased in ulcerated primary tumors and positive sentinel nodes.

CONCLUSIONS

The expression of OX40 on CD4+ T cells in SLNs draining primary melanomas decreased with more advanced tumor features (higher T stage, ulceration) and nodal involvement, suggesting that such tumors may have an immunosuppressive effect on the SLN microenvironment.

Evaluation of the tumor board as a Continuing Medical Education (CME) activity: is it useful?

BACKGROUND

Although it has been previously reported that offering continuing medical education (CME) credit is not a major factor in tumor board attendance, the results/utility of the Accreditation Council for Continuing Medical Education mandated evaluations of those tumor boards offering CME credit has not been studied.

METHODS

We reviewed the CME evaluations of our University Gastrointestinal Tumor Board; this meeting was chosen because it is multidisciplinary, well attended, and offers CME credit contingent on completing a standard CME evaluation form each session.

RESULTS

Of the 2736 attendees, 660 (24%) at the 79 consecutive conferences studied completed the evaluation for CME credit. Reported satisfaction was high; the average response on the 4-question satisfaction survey was 5 (Excellent) on a 5-point Likert scale, only 6% of attendees perceived any commercial bias, and only 3 attendees stated that the conference did not achieve the stated objectives. Of the respondents, 42% indicated that the tumor board information would change their practice, although few specific examples were given. A minority of responders provided specific feedback.

CONCLUSIONS

A minority of attendees at this tumor board utilized CME credit. Although satisfaction and impact ratings were high, potential response set bias, lack of specific feedback, and nonresponse bias were limitations to the evaluations.

Sentinel node staging of primary melanoma by the “10% rule”: pathology and clinical outcomes

BACKGROUND

Surgical staging of clinically node-negative primary melanoma involves identification and removal of "sentinel" lymph nodes (SLNs). Although some suggest removal of only the "hottest" SLN, the "10% rule" dictates that nodes are removed until the background count is 10% or less of the count of the "hottest" node.

METHODS

To determine the utility of the 10% rule, a university database of clinically node-negative melanomas surgically staged by using this rule was examined.

RESULTS

Twenty-two of 177 cases (12.5%; 15% of T2 and T3 lesions) were SLN positive. Among the SLN-positive cases, use of the rule resulted in removal of 21 additional nodes, 7 of which contained tumor. In 3 cases (14%), the positive SLN was not the "hottest" node. At 49 months of mean follow-up time, overall survival was 63% for SLN-positive patients versus 92% for SLN-negative patients (P = .01).

CONCLUSIONS

Sentinel node staging of melanoma by the 10% rule provides significant prognostic information and a modest increase in tumor detection compared with removal of only the "hottest" node.

Differential effects of tamoxifen and anastrozole on optic cup size in breast cancer survivors

Introduction

The main purpose of this study was to determine whether the optic cups of tamoxifen users and anastrozole users differ in size, with the cups of the tamoxifen users being smaller.

Methods

Optic nerve head (ONH) topography was measured using a commercially available, confocal scanning laser ophthalmoscope for three populations of amenorrheic women ages 40–69 years: subjects using (1) tamoxifen (20 mg/day) or (2) anastrozole (1 mg/day) for ≤ 2 years as adjuvant therapy after successful primary treatment for breast cancer, and (3) control subjects with no breast cancer histories and not using any hormonal medication. All subjects had excellent visual acuity and healthy eyes, based on conventional photographic assessment.

Results

The cup volumes of the tamoxifen users were shown to be significantly smaller than the cup volumes of the anastrozole users, which were indistinguishable from normal. Because the cup volumes of the tamoxifen users decreased markedly with age at about 50 years and because anastrozole is indicated only for post-menopausal women, comparisons were reassessed for subjects older than 50 years. For these subjects, the cup volumes of the tamoxifen users averaged less than half of the volumes for each of the other two subject groups, and significant between-group differences existed in both the lateral (cup area) and axial (cup depth) directions. In contrast, any between-group differences at the ONH margin were small and not significant.

Conclusions

The results of this study suggest that the ONH be assessed biomorphometrically for tamoxifen users reporting visual change that cannot be attributed to non-tamoxifen causes. The ability of modern intraocular imaging techniques to reveal anatomic change on the order of tens of microns may be useful for assessing tamoxifen-induced effects occurring simultaneously elsewhere in the brain, particularly since the presence of small cups is consistent with the possibility of tamoxifen-induced astrocytic swelling.

Cognitive dysfunction in cancer patients: an educational needs area improved by a single intervention

BACKGROUND

Chemotherapy-related cognitive dysfunction (CRCD) is increasingly recognized as an important cause of posttreatment morbidity, with significant impact on quality of life. We sought to evaluate the level of need for and awareness of information regarding CRCD among nurses involved with the care of persons receiving chemotherapy. We also hypothesized that educational interventions are useful in this increasingly important area of oncology nursing.

METHODS

Chemotherapy nurse providers were surveyed regarding CRCD beliefs and skills; a subset of individuals attending a CRCD educational session underwent pretesting and posttesting to assess CRCD knowledge.

RESULTS

Respondents perceived that CRCD is a serious problem and identified the following needs areas: general CRCD education, diagnostic skills, knowledge regarding behavioral and pharmacologic interventions, and availability of adequate CRCD practice protocols. With a single educational intervention, posttest scoring improved over pretest in most subjects, with a statistically significant overall improvement in mean scores.

CONCLUSIONS

Our results suggest the need for education in CRCD diagnosis, intervention, and protocol development. A single educational intervention improved knowledge. Our work underscores the importance of CRCD education for the Oncology Education Services and other oncology nurse educational resources.

Outcomes among women younger than age 40 in a state breast cancer screening program

BACKGROUND

The value of entering women younger than age 40 in breast cancer screening programs (SPs) remains unclear.

METHODS

Data from the Oregon Breast and Cervical Cancer Program (BCCP) for the period December 31, 2000 through July 1, 2003 were reviewed with a focus on women 39 years of age or younger. Information on cancers detected in this group was extracted from The Oregon State Cancer Registry.

RESULTS

Of the 13,636 women screened, 797 (5.8%) were younger than 40 (mean age 31.9 years). A total of 20.6% of the women were asymptomatic and therefore represented true incidence screening, while 79.4% were referred to the program for symptoms (prevalence screen). A total of 125 biopsies were done out of 797 women, which yielded 5 cancers. All 5 of these patients were symptomatic at presentation and had a negative family history.

CONCLUSIONS

There are as yet no data in our state breast cancer SP to support screening of asymptomatic women younger than 40.

Breast fine-needle aspirates with scant cellularity are clinically useful

INTRODUCTION

Fine-needle aspirates (FNAs) with scant cellularity are considered inadequate by current cytopathology standards. We hypothesized that such aspirates are clinically useful.

METHODS

A 10-year database of palpable breast lumps evaluated by FNA-based triple test (TT; FNA, breast imaging studies, and clinical breast examination) and triple test scores (TTSs; 3-9) was examined to identify FNAs with scant cellularity but without evidence of malignancy (negative SC-FNAs). These FNAs were correlated with the occurrence of any subsequent cancers (false-negative SC-FNAs) and with TTSs.

RESULTS

Among a total of 324 negative SC-FNAs, 9 cancers were subsequently found at sampled sites. Seven were associated with a suspicious or malignant TTS (scores of 5 or greater) and therefore still correctly diagnosed as malignant or suspicious for malignancy. The remaining two cancers were missed by both SC-FNA and TTS (false-negative rate for TTS of 0.6%); both had scores of 4 because of suspicious imaging.

CONCLUSIONS

Scantly cellular but negative FNAs are useful (can avoid unnecessary invasive breast biopsy) in the evaluation of palpable breast masses, especially when interpreted in the context of the TT and TTS.

Impact of the recent reduction in working hours (the 80 hour work week) on surgical resident cancer education

BACKGROUND

Resident work hours were recently reduced to 80 hours per week by a mandate from the Accreditation Council for Graduate Medical Education and subsequent Federal law (HR 3236). This mandate became effective July 1st, 2003. We sought to determine any impact this change had on perceived and real resident cancer education and knowledge.

METHODS

Of the total 85 residents in our large, university-based surgical training program, we focused on the 40 who had been in the clinical program (rather than research) before and after the work hour reduction. Perceived impact on cancer education was determined by survey, and real impact by before (2002) and after (2004) scores on the overall and cancer-specific portion of the annual American Board of Surgery In-Training Examination (ABSITE).

RESULTS

All eligible residents responded to the survey. The majority (83% to 85%) indicated that exposure to cancer patients on wards and in clinics remained the same. Thirty percent felt that their exposure to cancer operations and tumor boards had decreased; 60% to 65% felt that exposure to these activities were unchanged. Approximately half of residents reported an increase in their cancer-related reading and Internet learning activities--the other half felt they had not changed. The majority (88%) reported no change in their participation in extraprogrammatic cancer-related continuing medical education activities. Of the survey responders, 23 had completed the ABSITE in both 2002 and 2004; their mean scores between the 2 time periods increased by 7% for the overall test and decreased by 3% for the cancer-specific portion.

CONCLUSIONS

Overall, the recent reduction in work hours does not appear to have changed residents' experience with cancer patient care, although possible early reductions in attendance at cancer operations and tumor boards merits further study and possibly future schedule changes. The reported perceived increase in cancer-related reading and Internet learning has not yet translated into improved test scores.

Sentinel lymph node biopsy

The introduction of sentinel lymph node biopsy (SLNB) has been an important development in the management of malignant melanoma. Lymph nodes have long been known to play a key role in melanoma metastasis. The importance of nodal staging accounted for the previous surgical practice of elective lymph node dissection (ELND) even with its controversial impact on final outcomes and associated morbidity. Although this morbidity has been reduced with the ability to identify the SLN, numerous questions have subsequently surfaced with respect to this procedure's utility and therapeutic efficacy. This chapter will focus on the indications for SLNB, as well as the current controversies surrounding this procedure.

Fine-needle aspiration diagnosis of plasmacytoma presenting as breast masses in a patient on estrogen therapy for prostate cancer

We describe a 79-yr-old man with a history of androgen-independent metastatic prostate cancer treated with exogenous estrogens presenting with bilateral breast masses associated with bilateral axillary lymphadenopathy. Although the findings on physical examination with the concomitant history of estrogen therapy for metastatic prostate cancer raised the clinical suspicion of breast cancer, fine-needle aspiration (FNA) cytology identified the lesions as multiple myeloma.

Surgical outcomes of a breast cancer-screening program for low-income women

HYPOTHESIS

Surgical outcomes from a breast cancer-screening program of low-income women are similar to those of other screening programs.

DESIGN

Prospective cohort.

SETTING

Federally funded screening program.

PATIENTS

A total of 15730 women.

INTERVENTIONS

A total of 23149 mammograms, 20396 with concomitant clinical breast examination, from January 1, 1997, through December 31, 2001.

OUTCOME MEASURES

American College of Radiology scores; associated surgery consultations, biopsies, operations, and pathology results.

RESULTS

Most (20868) of the 21296 mammograms assigned an American College of Radiology score were benign; only 428 (2%) were suspicious. Resulting from suspicious clinical breast examinations, the group with American College of Radiology scores of 1 to 3 accounted for 45%, 18%, and 10% of recommended surgical consultations, biopsies, and cancers detected, respectively. A rate of 12.3 cancers per 1000 women was found, greater than with other screening programs. Compliance with therapy was 97%.

CONCLUSIONS

This screening program had a higher rate of advanced cancers. Clinical breast examination was an important component, and compliance with surgical recommendations was excellent.

Comparing the cost-effectiveness of the triple test score to traditional methods for evaluating palpable breast masses

BACKGROUND

Physical examination, mammography, ultrasonography, and fine needle aspiration are traditionally used to guide further management of palpable breast masses, often leading to open biopsy of benign masses. The triple test score (TTS) integrates physical examination, mammography, and fine needle aspiration in the initial evaluation, limiting open biopsy.

OBJECTIVE

To compare cost-effectiveness of TTS and traditional methods.

METHODS

The primary measure of clinical effectiveness, frequency of missed malignancy, was determined for each strategy using probabilities and outcomes from a systematic literature review. Costs were calculated using the Medicare resource-based relative-value scale. A decision-analytic model compared costs of initial work-up, costs per mass evaluated, and costs per malignancy diagnosed. Sensitivity analyses assessed the influence of variations in model assumptions.

RESULTS

In the base case, neither strategy led to undiagnosed breast cancer. However, open biopsy was required in 13% of benign masses using TTS versus 88% using the traditional strategy. The cost of the initial work-up using traditional management was less than TTS (377 US dollars vs. 627 US dollars), but cost per mass evaluated and cost per malignancy diagnosed (1793 US dollars vs. 925 US dollars and 5670 US dollars vs. 2925 US dollars) favored TTS, due to substantially reduced open biopsy.In sensitivity analyses, TTS cost varied most with changes in cost of initial evaluation, whereas the traditional strategy cost varied most with changes in open biopsy cost.

CONCLUSIONS

The TTS provides equivalent diagnostic effectiveness but substantially lower cost than traditional management. Cost savings are based on decreased open biopsy, a major contributor to the cost of traditional evaluation in this model.

A new score for the evaluation of palpable breast masses in women under age 40

BACKGROUND

The purpose of this study was to develop a rapid and accurate diagnostic test for palpable breast masses in women under age 40.

METHODS

Masses were evaluated utilitzing a modified triple test score (MTTS), which assigned scores of 1 point for benign, 2 points for suspicious, or 3 points for malignant findings from physical examination, ultrasonography, and fine needle aspiration. The MTTS was the sum of the three scores and was correlated with biopsy or follow-up.

RESULTS

Among 113 masses, 100 scored 3 points, 8 scored 4 points; all were benign. Three scored 5 points; 1 was malignant. Two scored >or=6 points: both were malignant.

CONCLUSIONS

The MTTS has 100% diagnostic accuracy when other than 5 points. Masses scoring <or=4 points are benign. Masses scoring >or=6 points may proceed to definitive therapy. Masses scoring 5 points (3%) require biopsy. This approach avoids open biopsy in the majority of cases, while capturing all malignancies.

Metastatic breast cancer manifested as refractory anemia and gastric polyps

Gastric metastasis from breast cancer is uncommon and typically occurs in patients with disseminated disease. The vast majority of patients with gastric lesions have a known preexisting diagnosis of breast cancer. In contrast, we describe a case in which a minimal breast cancer was found to be the primary tumor during the workup of a patient first diagnosed with carcinoma of unknown primary and subsequently presumed to have metastatic gastric cancer. Our case illustrates that a diagnosis of breast cancer metastatic to the stomach may require a high index of suspicion, as well as a meticulous breast workup. It also emphasizes that even tiny breast cancers have a small but real risk of metastatic spread. Determination of the correct primary source in these cases may not be only an academic exercise, since the treatment and prognosis of metastatic breast cancer (especially receptor positive) and metastatic gastric cancer are different.

Survival in human colorectal cancer correlates with expression of the T-cell costimulatory molecule OX-40 (CD134)

BACKGROUND

The T-cell costimulatory molecule OX-40 (CD134) is expressed on activated CD4(+) ("helper") T cells. Such cells have been detected in human cancers, and engagement of OX-40 improves colon cancer immunity in an animal model.

METHODS

Sections of primary colon cancers, normal margins, mesenteric lymph nodes, and metastases were stained for OX-40 by immunohistochemistry. Cancer registry data were reviewed.

RESULTS

High levels of OX-40 positive tumor-infiltrating lymphocytes were found in 15 of 72 primary tumors. Thirty-one cases had prominent lymphocytic infiltrates expressing OX-40 at the invasive margin of the tumor. Overall, 50% of primary tumors showed high expression of OX-40. Nearly all mesenteric lymph nodes expressed OX-40, whether tumor was present or not. Normal margins of colon did not show high levels of OX-40. High OX-40 expression in the primary tumor correlated with better survival (mean survival high OX-40, 47 months, low OX-40, 35 months, P <0.05), although this correlation was not stage-independent.

CONCLUSIONS

High levels of OX-40 positive lymphocytes are present in half of primary colon cancers, and this expression in primary tumors significantly correlates with better survival. This correlation with survival and our previous preclinical research suggest a basis for an OX-40 immunotherapy trial.