Added value of dedicated axillary hybrid 18F-FDG PET/MRI for improved axillary nodal staging in clinically node-positive breast cancer patients: a feasibility study

Purpose

To investigate the feasibility and potential added value of dedicated axillary 18F-FDG hybrid PET/MRI, compared to standard imaging modalities (i.e. ultrasound [US], MRI and PET/CT), for axillary nodal staging in clinically node-positive breast cancer.

Methods

Twelve patients with clinically node-positive breast cancer underwent axillary US and dedicated axillary hybrid 18F-FDG PET/MRI. Nine of the 12 patients also underwent whole-body PET/CT. Maximum standardized uptake values (SUVmax) were measured for the primary breast tumor and the most FDG-avid axillary lymph node. A positive axillary lymph node on dedicated axillary hybrid PET/MRI was defined as a moderate to very intense FDG-avid lymph node. The diagnostic performance of dedicated axillary hybrid PET/MRI was calculated by comparing quantitative and its qualitative measurements to results of axillary US, MRI and PET/CT. The number of suspicious axillary lymph nodes was subdivided as follows: N0 (0 nodes), N1 (1–3 nodes), N2 (4–9 nodes) and N3 (≥ 10 nodes).

Results

According to dedicated axillary hybrid PET/MRI findings, seven patients were diagnosed with N1, four with N2 and one with N3. With regard to mean SUVmax, there was no significant difference in the primary tumor (9.0 [±5.0] vs. 8.6 [±5.7], p = 0.678) or the most FDG-avid axillary lymph node (7.8 [±5.3] vs. 7.7 [±4.3], p = 0.767) between dedicated axillary PET/MRI and PET/CT. Compared to standard imaging modalities, dedicated axillary hybrid PET/MRI resulted in changes in nodal status as follows: 40% compared to US, 75% compared to T2-weighted MRI, 40% compared to contrast-enhanced MRI, and 22% compared to PET/CT.

Conclusions

Adding dedicated axillary 18F-FDG hybrid PET/MRI to diagnostic work-up may improve the diagnostic performance of axillary nodal staging in clinically node-positive breast cancer patients.

TNM classification and the need for revision of pN3a breast cancer

BACKGROUND

According to the seventh edition of tumour-node-metastasis (TNM) classification, pN3a status in breast cancer patients consists of presence of an infraclavicular lymph node metastasis (LNM) and/or presence of ≥10 axillary LNMs. The aim of this study was to determine whether prognosis of pN3a based on at least an infraclavicular LNM differs from ≥10 axillary LNMs.

METHODS

Data were obtained from the Netherlands Cancer Registry. All patients were diagnosed between 2005 and 2008 with primary invasive epithelial breast cancer and pN2a or pN3a status as pathologic result. Patients with pN3a were subdivided in pN3a based on at least an infraclavicular LNM or ≥10 axillary LNMs. Disease-free survival (DFS) included any local, regional or contralateral recurrence, distant metastasis or death within 5 years. Kaplan-Meier curves provided information on 5-year DFS and 8-year overall survival (OS). In addition, Cox proportional hazards model was used to measure the effect of relevant clinicopathological variables on DFS and OS.

RESULTS

A total of 3400 patients with pN2a and 1788 patients with pN3a were included. In 83 patients, pN3a was based on at least an infraclavicular LNM (4.6%) and in 1705 patients because of ≥10 axillary LNMs (95.4%). After multivariable analyses, DFS and OS were inferior in patients with pN3a based on ≥10 axillary LNMs compared to infraclavicular LNM (DFS 48.8% versus 63.8%, hazard ratio [HR] 1.59, p = 0.036; OS 46.6% versus 63.9%, HR 1.46, p = 0.042). Furthermore, pN2a and pN3a based on infraclavicular LNM had comparable DFS and OS.

CONCLUSION

PN3a status based on an at least an infraclavicular LNM is rare, yet its prognosis is superior to ≥10 axillary LNMs. Reclassification of infraclavicular LNM in the next TNM should therefore be considered into pN2a.

Developing a patient decision aid for the treatment of women with early stage breast cancer: the struggle between simplicity and complexity

Background

A patient decision aid (PtDA) can support shared decision making (SDM) in preference-sensitive care, with more than one clinically applicable treatment option. The development of a PtDA is a complex process, involving several steps, such as designing, developing and testing the draft with all the stakeholders, known as alpha testing. This is followed by testing in ‘real life’ situations, known as beta testing, and then finalising the definite version.

Our aim was developing and alpha testing a PtDA for primary treatment of early stage breast cancer, ensuring that the tool is considered relevant, valid and feasible by patients and professionals.

Methods

Our qualitative descriptive study applied various methods including face-to-face think-aloud interviews, a focus group and semi-structured telephone interviews. The study population consisted of breast cancer patients facing the choice between breast-conserving therapy with or without preceding neo-adjuvant chemotherapy and mastectomy, and professionals involved in breast cancer care in dedicated multidisciplinary breast cancer teams.

Results

A PtDA was developed in four iterative test rounds, taking nearly 2 years, involving 26 patients and 26 professionals. While the research group initially opted for simplicity for the sake of implementation, the clinicians objected that the complexity of the decision could not be ignored. Other topics of concern were the conflicting views of professionals and patients regarding side effects, the amount of information and how to present it.

Conclusion

The development was an extensive process, because the professionals rejected the simplifications proposed by the research group. This resulted in the development of a completely new draft PtDA, which took double the expected time and resources. The final version of the PtDA appeared to be well-appreciated by professionals and patients, although its acceptability will only be proven in actual practice (beta testing).

Trial registration

NTR TC 5721.

Electronic supplementary material

The online version of this article (doi:10.1186/s12911-017-0505-6) contains supplementary material, which is available to authorized users.

Clinically node negative breast cancer patients undergoing breast conserving therapy, sentinel lymph node procedure versus follow-up: a Dutch randomized controlled multicentre trial (BOOG 2013-08)

BACKGROUND

Studies showed that axillary lymph node dissection can be safely omitted in presence of positive sentinel lymph node(s) in breast cancer patients treated with breast conserving therapy. Since the outcome of the sentinel lymph node biopsy has no clinical consequence, the value of the procedure itself is being questioned. The aim of the BOOG 2013-08 trial is to investigate whether the sentinel lymph node biopsy can be safely omitted in clinically node negative breast cancer patients treated with breast conserving therapy.

METHODS

The BOOG 2013-08 is a Dutch prospective non-inferiority randomized multicentre trial. Women with pathologically confirmed clinically node negative T1-2 invasive breast cancer undergoing breast conserving therapy will be randomized for sentinel lymph node biopsy versus no sentinel lymph node biopsy. Endpoints include regional recurrence after 5 (primary endpoint) and 10 years of follow-up, distant-disease free and overall survival, quality of life, morbidity and cost-effectiveness. Previous data indicate a 5-year regional recurrence free survival rate of 99% for the control arm and 96% for the study arm. In combination with a non-inferiority limit of 5% and probability of 0.8, this result in a sample size of 1.644 patients including a lost to follow-up rate of 10%. Primary and secondary endpoints will be reported after 5 and 10 years of follow-up.

DISCUSSION

If the sentinel lymph node biopsy can be safely omitted in clinically node negative breast cancer patients undergoing breast conserving therapy, this study will cost-effectively lead to a decreased axillary morbidity rate and thereby improved quality of life with non-inferior regional control, distant-disease free survival and overall survival.

TRIAL REGISTRATION

The BOOG 2013-08 study is registered in ClinicalTrials.gov since October 20, 2014, Identifier: NCT02271828. https://clinicaltrials.gov/ct2/show/NCT02271828.

Prognosis of residual axillary disease after neoadjuvant chemotherapy in clinically node-positive breast cancer patients: isolated tumor cells and micrometastases carry a better prognosis than macrometastases

PURPOSE

The aim of this study was to compare disease-free survival (DFS) and overall survival (OS) between clinically node-positive breast cancer patients, treated with neoadjuvant chemotherapy (NAC), with axillary pathologic complete response (ypN0), residual axillary isolated tumor cells or micrometastases (ypNitc/mi), and residual axillary macrometastases (ypN1-3).

METHODS

All patients diagnosed with clinically node-positive primary invasive breast cancer treated with NAC and subsequent axillary lymph node dissection between 2005 and 2008 were retrospectively analyzed. Data were obtained from the Netherlands Cancer Registry. Patients were stratified by final pathological axillary status: ypN0, ypNitc/mi, or ypN1-3. The main outcome measures DFS and OS were analyzed using Kaplan-Meier survival analysis. Uni- and multivariable cox regression analyses were used to determine independent predictors for DFS and OS.

RESULTS

A total of 1347 patients were included. Pathologic nodal status was ypN0 in 22.2%, ypNitc/mi in 3.8%, and ypN1-3 in 74.0% of patients. Overall, 5-year DFS was 57.8% and mean OS was 7.4 years. DFS and OS were comparable between ypN0 and ypNitc/mi (HR 1.38 (0.40-4.79, p = 0.613) and HR 0.92 (0.27-3.09, p = 0.889), respectively), but significantly different between ypN0 and ypN1-3 (HR 1.78 (1.06-3.00, p = 0.031) and HR 1.70 (1.07-2.71, p = 0.026), respectively).

CONCLUSIONS

Clinically node-positive patients, treated with NAC, with axillary nodal status ypN0 or ypNitc/mi carry similar prognosis regarding DFS and OS. Axillary nodal status ypN1-3 is associated with a less favorable prognosis. Future studies should consider ypN0 and ypNitc/mi as one entity.

Does the TNM classification of solitary internal mammary lymph node metastases in breast cancer still apply?

PURPOSE

TNM classification of solitary internal mammary lymph node metastases (IMLNMs) in breast cancer varies depending on their method of detection: sentinel lymph node biopsy (pN1b) or clinical examination including radiological and/or physical examination (pN2b). This study aimed to evaluate whether there is a difference in prognosis between both groups.

METHODS

Data of all patients diagnosed with primary invasive epithelial breast cancer between 2005 and 2008 were obtained from the Netherlands Cancer Registry. Patients with IMLNMs were divided in groups according to their pN1b and pN2b status. The main outcome measures disease-free survival (DFS) after 5 years and overall survival (OS) after 8 years were analyzed using Kaplan-Meier survival analysis. Cox regression analysis was used to determine independent predictors for DFS and OS.

RESULTS

A total of 73 patients with pN1b status and 28 patients with pN2b status were included. DFS rate was 74.1% in the pN1b group compared to 85.0% in the pN2b group (p = 0.211). Regarding OS, 20.5% (pN1b) and 25.0% (pN2b) of the patients deceased within 8 years of follow-up (p = 0.589). In multivariable cox regression analysis, nodal status was not statistically significant for DFS (HR 0.29 [95% CI 0.04-2.33], p = 0.244) or OS (HR 1.04 [95% CI 0.37-2.89], p = 0.947).

CONCLUSIONS

Although the TNM classification considers pN1b and pN2b to be distinct prognostic entities, we did not observe any prognostic differences between these groups. Therefore, solitary IMLNMs may be regarded as a single category in the future and revision of TNM classification should be considered.

In vitro Sequential Selection and Characterization of Human Immunodeficiency Virus Type 1 Variants with Reduced Sensitivity to Hydroxyethylurea Protease Inhibitors

In vitro resistance to the human immunodeficiency virus (HIV) protease inhibitors SC-52151 and SC-55389A was evaluated in an in vitro sequential selection scheme. HIVRF variants were selected for reduced sensitivity to SC-52151 and subsequently passaged in both SC-52151 and a structurally different hydroxyethylurea protease inhibitor, SC-55389A, to select for dual-resistant virus. SC-52151 selection alone resulted in a 23-fold reduction in virus sensitivity whereas selection in both inhibitors resulted in 34- and eightfold reductions in virus sensitivity to SC-52151 and SC-55389A, respectively. Sequence analysis of the protease gene revealed that SC-52151 -resistant virus had a Gly to Val substitution at residue 48 (G48V) and, in 58% of subclones, an accompanying Val to Ala substitution at residue 82 (V82A). Dual-resistant virus had both G48V and V82A substitutions present and, in the majority of subclones, an lle to Thr and/or Leu to Pro substitution at residues 54 and 63, respectively. Drug susceptibility assays with limiting dilution-cloned HIVRFR (G48V/V82A) and HIVRFRR (G48V/154T/L63P/V82A) viruses demonstrated moderate to high-level cross-resistance to additional structurally non-related protease inhibitors. Recombinant HIVHXB2 proviral clones with G48V, L63P and V82A substitutions showed that one active site mutation was permissible, but the presence of both G48V and V82A substitutions together significantly reduced infectious virus production. Insight into the contributions of the observed substitutions to drug resistance is presented in molecular modelling studies.

Sentinel lymph node biopsy can be omitted in DCIS patients treated with breast conserving therapy

Breast cancer guidelines advise sentinel lymph node biopsy (SLNB) in patients with ductal carcinoma in situ (DCIS) on core biopsy at high risk of invasive cancer or in case of mastectomy. This study investigates the incidence of SLNB and SLN metastases and the relevance of indications in guidelines and literature to perform SLNB in order to validate whether SLNB is justified in patients with DCIS on core biopsy in current era. Clinically node negative patients diagnosed from 2004 to 2013 with only DCIS on core needle biopsy were selected from a national database. Incidence of SLN biopsy and metastases was calculated. With Fisher exact tests correlation between SLNB indications and actual presence of SLN metastases was studied. Further, underestimation rate for invasive cancer and correlation with SLN metastases was analysed. 910 patients were included. SLNB was performed in 471 patients (51.8 %): 94.5 % had pN0, 3.0 % pN1mi and 2.5 % pN1. Patients undergoing mastectomy had 7 % SLN metastases versus 3.5 % for breast conserving surgery (BCS) (p = 0.107). The only factors correlating to SLN metastases were smaller core needle size (p = 0.01) and invasive cancer (p < 0.001). Invasive cancer was detected in 16.7 % by histopathology with 15.6 % SLN metastases versus only 2 % in pure DCIS. SLNB showed metastases in 5.5 % of patients; 3.5 % in case of BCS (any histopathology) and 2 % when pure DCIS was found at definitive histopathology (BCS and mastectomy). Consequently, SLNB should no longer be performed in patients diagnosed with DCIS on core biopsy undergoing BCS. If definitive histopathology shows invasive cancer, SLNB can still be considered after initial surgery.

Abstract P4-02-01: Only in lobular breast cancer MRI use is associated with a lower risk of positive surgical margins and a reduced number of mastectomies. A real-world analysis in The Netherlands

Background

The value of magnetic resonance imaging (MRI) for patients with breast cancer remains under debate. Breast MRI may contribute to the planning of local therapy, but also bears the risk of overtreatment. We analyzed the use of MRI and its impact on surgical treatment and risk of detecting contralateral breast cancer in the Netherlands.

Patients and methods

All patients who underwent primary surgery for stage I-III invasive breast cancer in the years 2011-2013 were identified through the Netherlands Cancer Registry. The following data were documented: year of diagnosis, hospital type and volume, age at diagnosis, clinical T and N stage, histological type and grade, presence of multifocality in resection specimen, hormone receptor status, HER2 status and use of MRI. We analyzed whether MRI use was related to type of surgery (primary or secondary mastectomy or breast conserving surgery), surgical margin involvement, and diagnosis of synchronous contralateral breast cancer.

Results

MRI was performed in 10,819 (29,8%) out of 36,333 patients newly diagnosed with invasive breast cancer and treated with primary surgery in the years 2011-2013 in the Netherlands. Use of MRI did not clearly increase in this period.

In the multivariate analysis, patients younger than 50 years of age compared to patients aged 70 years or older (OR 6.34, 95% CI 5.86-6.87), patients with lobular breast cancer compared to those with ductal carcinoma (OR 3.46; 95% CI 3.23-3.70) and patients with multifocal tumors compared to those without multifocality (OR 2.30, 95% CI 2.15-2.45) were more likely to undergo MRI. Hospital volume (&lt;150 versus &gt;150) was only marginally related to MRI use (OR 0.93; 95% CI 0.87-0.99).

Patients with invasive breast cancer undergoing MRI were more likely to undergo primary mastectomy than those without MRI (OR 1.21; 95% CI 1.15-1.28), but the subgroup with invasive lobular cancer undergoing MRI were less likely to undergo primary mastectomy (OR 0.85; 95% CI 0.75-0.98). A significantly lower risk of positive surgical margins was seen in patients with lobular breast cancer and breast conserving surgery who had undergone MRI as compared to those without MRI (OR 0.58, 95% CI 0.44-0.78) and, consequently, also a lower risk of secondary mastectomy (OR 0.60, 95% CI 0.41-0.87). Risk of positive surgical margins was not reduced by MRI use in patients with invasive ductal carcinoma (OR 0.91; 95% CI 0.77-1.07). Patients who underwent MRI were almost four times more frequently diagnosed with contralateral breast cancer, compared to those in whom MRI was not performed (OR 3.60, 95% CI 3.06-4.24).

Conclusion

Breast MRI was significantly more often used in younger patients, patients with lobular and/or multifocal breast cancer. Interestingly, MRI use was associated with less primary and secundary mastectomies in lobular invasive breast cancer, in contrast to an increased number of primary mastectomies in patients with invasive ductal cancer. MRI was further associated with an almost fourfold higher incidence of contralateral breast cancer.

Citation Format: Tjan-Heijnen VC, Lobbes MB, Vriens IJ, van Bommel AC, Nieuwenhuijzen GA, Smidt ML, Boersma LJ, van Dalen T, Smorenburg CH, Siesling S, Voogd AC. Only in lobular breast cancer MRI use is associated with a lower risk of positive surgical margins and a reduced number of mastectomies. A real-world analysis in The Netherlands. [abstract]. In: Proceedings of the Thirty-Eighth Annual CTRC-AACR San Antonio Breast Cancer Symposium: 2015 Dec 8-12; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2016;76(4 Suppl):Abstract nr P4-02-01.

The value of completion axillary treatment in sentinel node positive breast cancer patients undergoing a mastectomy: a Dutch randomized controlled multicentre trial (BOOG 2013-07)

BACKGROUND

Trials failed to demonstrate additional value of completion axillary lymph node dissection in case of limited sentinel lymph node metastases in breast cancer patients undergoing breast conserving therapy. It has been suggested that the low regional recurrence rates in these trials might partially be ascribed to accidental irradiation of part of the axilla by whole breast radiation therapy, which precludes extrapolation of results to mastectomy patients. The aim of the randomized controlled BOOG 2013-07 trial is therefore to investigate whether completion axillary treatment can be safely omitted in sentinel lymph node positive breast cancer patients treated with mastectomy.

DESIGN

This study is designed as a non-inferiority randomized controlled multicentre trial. Women aged 18 years or older diagnosed with unilateral invasive clinically T1-2 N0 breast cancer who are treated with mastectomy, and who have a maximum of three axillary sentinel lymph nodes containing micro- and/or macrometastases, will be randomized for completion axillary treatment versus no completion axillary treatment. Completion axillary treatment can consist of completion axillary lymph node dissection or axillary radiation therapy. Primary endpoint is regional recurrence rate at 5 years. Based on a 5-year regional recurrence free survival rate of 98 % among controls and 96 % for study subjects, the sample size amounts 439 per arm (including 10 % lost to follow-up), to be able to reject the null hypothesis that the rate for study and control subjects is inferior by at least 5 % with a probability of 0.8. Results will be reported after 5 and 10 years of follow-up.

DISCUSSION

We hypothesize that completion axillary treatment can be safely omitted in sentinel node positive breast cancer patients undergoing mastectomy. If confirmed, this study will significantly decrease the number of breast cancer patients receiving extensive treatment of the axilla, thereby diminishing the risk of morbidity and improving quality of life, while maintaining excellent regional control and without affecting survival.

TRIAL REGISTRATION

The BOOG 2013-07 study is registered in the register of ClinicalTrials.gov since April 10, 2014, Identifier: NCT02112682 .

The diagnostic performance of sentinel lymph node biopsy in pathologically confirmed node positive breast cancer patients after neoadjuvant systemic therapy: A systematic review and meta-analysis

PURPOSE

To provide a systematic review and meta-analysis of studies investigating sentinel lymph node biopsy after neoadjuvant systemic therapy in pathologically confirmed node positive breast cancer patients.

METHODS

Pubmed and Embase databases were searched until June 19th, 2015. All abstracts were read and data extraction was performed by two independent readers. A random-effects model was used to pool the proportion for identification rate, false-negative rate (FNR) and axillary pCR with 95% confidence intervals. Subgroup analyses affirmed potential confounders for identification rate and FNR.

RESULTS

A total of 997 abstracts were identified and eventually eight studies were included. Pooled estimates were 92.3% (90.8-93.7%) for identification rate, 15.1% (12.7-17.6%) for FNR and 36.8% (34.2-39.5%) for axillary pCR. After subgroup analysis, FNR is significantly worse if one sentinel node was removed compared to two or more sentinel nodes (23.9% versus 10.4%, p = 0.026) and if studies contained clinically nodal stage 1-3, compared to studies with clinically nodal stage 1-2 patients (21.4 versus 13.1%, p = 0.049). Other factors, including single tracer mapping and the definition of axillary pCR, were not significantly different.

CONCLUSION

Based on current evidence it seems not justified to omit further axillary treatment in every clinically node positive breast cancer patients with a negative sentinel lymph node biopsy after neoadjuvant systemic therapy.

The role of MRI in axillary lymph node imaging in breast cancer patients: a systematic review

Objectives

To assess whether MRI can exclude axillary lymph node metastasis, potentially replacing sentinel lymph node biopsy (SLNB), and consequently eliminating the risk of SLNB-associated morbidity.

Methods

PubMed, Cochrane, Medline and Embase databases were searched for relevant publications up to July 2014. Studies were selected based on predefined inclusion and exclusion criteria and independently assessed by two reviewers using a standardised extraction form.

Results

Sixteen eligible studies were selected from 1,372 publications identified by the search. A dedicated axillary protocol [sensitivity 84.7 %, negative predictive value (NPV) 95.0 %] was superior to a standard protocol covering both the breast and axilla simultaneously (sensitivity 82.0 %, NPV 82.6 %). Dynamic, contrast-enhanced MRI had a lower median sensitivity (60.0 %) and NPV (80.0 %) compared to non-enhanced T1w/T2w sequences (88.4, 94.7 %), diffusion-weighted imaging (84.2, 90.6 %) and ultrasmall superparamagnetic iron oxide (USPIO)- enhanced T2*w sequences (83.0, 95.9 %). The most promising results seem to be achievable when using non-enhanced T1w/T2w and USPIO-enhanced T2*w sequences in combination with a dedicated axillary protocol (sensitivity 84.7 % and NPV 95.0 %).

Conclusions

The diagnostic performance of some MRI protocols for excluding axillary lymph node metastases approaches the NPV needed to replace SLNB. However, current observations are based on studies with heterogeneous study designs and limited populations.

Main Messages

• Some axillary MRI protocols approach the NPV of an SLNB procedure.

• Dedicated axillary MRI is more accurate than protocols also covering the breast.

• T1w/T2w protocols combined with USPIO-enhanced sequences are the most promising sequences.

Inconsistent selection and definition of local and regional endpoints in breast cancer research

BACKGROUND

Results in breast cancer research are reported using study endpoints. Most are composite endpoints (such as locoregional recurrence), consisting of several components (for example local recurrence) that are in turn composed of specific events (such as skin recurrence). Inconsistent endpoint selection and definition might lead to unjustified conclusions when comparing study outcomes. This study aimed to determine which locoregional endpoints are used in breast cancer studies, and how these endpoints and their components are defined.

METHODS

PubMed was searched for breast cancer studies published in nine leading journals in 2011. Articles using endpoints with a local or regional component were included and definitions were compared.

RESULTS

Twenty-three different endpoints with a local or regional component were extracted from 44 articles. Most frequently used were disease-free survival (25 articles), recurrence-free survival (7), local control (4), locoregional recurrence-free survival (3) and event-free survival (3). Different endpoints were used for similar outcomes. Of 23 endpoints, five were not defined and 18 were defined only partially. Of these, 16 contained a local and 13 a regional component. Included events were not specified in 33 of 57 (local) and 27 of 50 (regional) cases. Definitions of local components inconsistently included carcinoma in situ and skin and chest wall recurrences. Regional components inconsistently included specific nodal sites and skin and chest wall recurrences.

CONCLUSION

Breast cancer studies use many different endpoints with a locoregional component. Definitions of endpoints and events are either not provided or vary between trials. To improve transparency, facilitate trial comparison and avoid unjustified conclusions, authors should report detailed definitions of all endpoints.

The impact of the pathological lymph node status on adjuvant systemic treatment recommendations in clinically node negative breast cancer patients

Several independent randomized controlled trials are initiated to investigate whether sentinel lymph node biopsy can be safely omitted in clinically node negative breast cancer patients with negative axillary ultrasound findings, who are treated with breast conserving therapy. A consequence of omitting sentinel lymph node biopsy is absence of pathological lymph node status information. We aimed to investigate the impact of omitting sentinel lymph node biopsy on adjuvant systemic treatment recommendations. Data from all consecutive patients with invasive breast cancer and negative axillary ultrasound findings treated with breast conserving therapy and sentinel lymph node biopsy between 2008 and 2012 were collected from a prospective database. Two methods, Adjuvant! Online and the Dutch breast cancer guideline 2012, were used to determine the adjuvant systemic treatment recommendations of every patient. At first, each patient was considered to be lymph node negative, and secondly the patients' true pathological lymph node status was used. A total of 303 patients were consecutively included. Pathological lymph node status was pN0 in 72.3 %, pN0(i+) in 12.9 %, pN1mi+ in 5.6 %, pN1 in 7.3 %, and pN2 in 2.0 % of the patients. The decision to recommend adjuvant systemic treatment changed due to the pathological lymph node status in 1.0 % of the patients (3/303) when using Adjuvant! Online and in 3.6 % (11/303) when using the 2012 Dutch breast cancer guideline. The impact of the pathological lymph node status on adjuvant systemic treatment recommendations in clinically node negative breast cancer patients with negative axillary ultrasound findings treated with breast conserving therapy is limited. The safety of omitting the sentinel lymph node biopsy should be confirmed by the initiated randomized controlled trials.

No increase of local recurrence rate in breast cancer patients treated with skin-sparing mastectomy followed by immediate breast reconstruction

BACKGROUND

The aim of this study was to evaluate the incidence of local recurrence after SSM with IBR and to determine whether complications lead to postponement of adjuvant therapy.

METHOD

Patients that underwent IBR after SSM between 2004 and 2011 were included.

RESULTS

A total of 157 reconstruction procedures were performed in 147 patients for invasive breast cancer (n = 117) and ductal carcinoma in situ (n = 40). The median follow-up was 39 months [range 6-97]. Estimated 5-year local recurrence rate was 2.9% (95% CI 0.1-5.7). The median time to start adjuvant therapy was 27.5 days [range 19-92] in 18 patients with complications, and 23.5 days [range 8-54] in 46 patients without complications (p = 0.025).

CONCLUSION

In our single-institution cohort, IBR after SSM carried an acceptable local recurrence rate. Complications caused a delay of adjuvant treatment but this was within guidelines and therefore not clinically relevant.

The role of magnetic resonance imaging in assessing residual disease and pathologic complete response in breast cancer patients receiving neoadjuvant chemotherapy: a systematic review

OBJECTIVES

This systematic review aimed to assess the role of magnetic resonance imaging (MRI) in evaluating residual disease extent and the ability to detect pathologic complete response (pCR) after neoadjuvant chemotherapy for invasive breast cancer.

METHODS

PubMed, the Cochrane Library, MEDLINE, and Embase databases were searched for relevant studies published until 1 July 2012. After primary selection, two reviewers independently assessed the content of each eligible study using a standardised extraction form and pre-defined inclusion and exclusion criteria.

RESULTS

A total of 35 eligible studies were selected. Correlation coefficients of residual tumour size assessed by MRI and pathology were good, with a median value of 0.698. Reported sensitivity, specificity, positive predictive value and negative predictive value for predicting pCR with MRI ranged from 25 to 100 %, 50-97 %, 47-73 % and 71-100 %, respectively. Both overestimation and underestimation were observed. MRI proved more accurate in determining residual disease than physical examination, mammography and ultrasound. Diagnostic accuracy of MRI after neoadjuvant chemotherapy could be influenced by treatment regimen and breast cancer subtype.

CONCLUSIONS

Breast MRI accuracy for assessing residual disease after neoadjuvant chemotherapy is good and surpasses other diagnostic means. However, both overestimation and underestimation of residual disease extent could be observed.

MAIN MESSAGES

• Breast MRI accuracy for assessing residual disease is good and surpasses other diagnostic means. • Correlation coefficients of residual tumour size assessed by MRI and pathology were considered good. • However, both overestimation and underestimation of residual disease were observed. • Diagnostic accuracy of MRI seems to be affected by treatment regimen and breast cancer subtype.

Abstract OT2-1-03: The Z11 design for breast cancer patients undergoing a mastectomy

Background: The diagnostic work-up and treatment of axillary lymph nodes in breast cancer patients is an ongoing topic of research. The ACOSOG-Z0011 study demonstrated no additional value of complementary axillary lymph node dissection (cALND) in case of limited axillary sentinel lymph node (SLN) metastases in breast cancer patients undergoing breast conserving therapy1. It is questionable whether these results can be applied to patients undergoing a mastectomy2.

Trial design: A prospective non-inferiority randomized multicenter trial was designed.

Breast cancer patients with cT1-2N0 disease treated with mastectomy and limited axillary SLN metastases will be randomized for follow-up versus complementary axillary treatment. To assess the Quality of Life and morbidity benefits of this experimental treatment, 3 validated questionnaires will be used: QLQ-C30, QLQ-BR 23 and Lymph-ICF3-5.

Eligibility criteria: – Women with histological confirmed cT1-2 invasive unilateral breast carcinoma– Clinical node negative: no palpable nodes in physical examination and the axillary ultrasound without signs of lymph node metastases (cyto-/histology if indicated)– Sentinel lymph node biopsy must contain at least one and a maximum of 3 (micro)metastases– Neoadjuvant systemic therapy is allowed

Specific aims: Primary endpoint is the axillary recurrence rate. The number of delayed axillary dissections will be registered. Secondary endpoints are distant-disease free survival, overall survival, local recurrence, morbidity and Quality of Life.

Statistical methods: Based on 5-year axillary recurrence free survival rate, a failure rate of 0.98 among controls and a true failure rate of 0.96 for study subjects are considered acceptable. Overall, 1114 patients will be included to be able to reject the null hypothesis that the failure rate for experimental and control subjects is inferior by at least 5% (D = −5%) with probability of 0.8 and alpha of 5%.

Present accrual and target accrual: This study is expected to start in late 2012 after approval by the Ethical Medical Committee.

References

1. Giuliano, A.E., et al., Axillary dissection vs no axillary dissection in women with invasive breast cancer and sentinel node metastasis: a randomized clinical trial. JAMA, 2011. 305(6): p. 569–75. 2. Morrow, M. and A.E. Giuliano, To cut is to cure: can we really apply Z11 in practice? Ann Surg Oncol, 2011. 18(9): p. 2413–5. 3. Aaronson, N.K., et al., The European Organization for Research and Treatment of Cancer QLQ-C30: a quality-of-life instrument for use in international clinical trials in oncology. J Natl Cancer Inst, 1993. 85(5): p. 365–76. 4. Sprangers, M.A., et al., The European Organization for Research and Treatment of Cancer breast cancer-specific quality-of-life questionnaire module: first results from a three-country field study. J Clin Oncol, 1996. 14(10): p. 2756–68. 5. Devoogdt, N., et al., Lymphoedema Functioning, Disability and Health questionnaire (Lymph-ICF): reliability and validity. Phys Ther, 2011. 91(6): p. 944–57.

Citation Information: Cancer Res 2012;72(24 Suppl):Abstract nr OT2-1-03.

Abstract P5-01-13: Flat Epithelial Atypia: Management and outcome in three Dutch teaching hospitals

Background: Flat Epithelial Atypia (FEA) is a presumably neoplastic alteration of terminal duct-lobular units, characterized by the replacement of native luminal epithelium by ductal cells demonstrating low-grade cytologic atypia. The architecture shows stratification of epithelial cells. FEA is often accompanied by microcalcifications and therefore discovered in biopsies following screening mammography. FEA is frequently seen in association with ADH (atypical ductal hyperplasia), DCIS (ductal carcinoma in situ), lobular neoplasia and invasive tubular carcinomas. There is emerging evidence suggesting FEA may represent a precursor to DCIS. The risk of subsequent breast carcinoma remains to be defined. The aim of this study is therefore to inventorise the management and outcome of solitary FEA in histological biopsies in three Dutch teaching hospitals.

Materials and Methods: Data of this retrospective multicentre study were collected in a database. Local pathology databases were screened with the terms: ‘FEA’, ‘Flat Epithelial Atypia’, ‘columnar atypia’ and Dutch equivalents. Results were manually screened, only including solitary FEA.

Patient files were viewed for information on presentation, mammography, ultrasound and management: surgery vs follow-up. In case of excision, definitive pathology was added.

Results: We included 103 patients showing only solitary FEA in the primary biopsy. Management of these patients consisted of follow-up for 60 patients (58,3%) and surgery for 43 patients (41,7%, 49 excisions): lumpectomy (42) or mastectomy (7). Reason for choosing mastectomy was preventive in case of contralateral breast cancer or increased familial or genetic risk.

Definitive pathology of lumpectomy or mastectomy showed no abnormalities or solitary FEA in 31 patients; other findings were ADH in 7, LCIS in 4 and DCIS in 7 patients. Some patients showed more than one finding. Invasive breast cancer (IBC) was detected in 3 patients. Only one mastectomy showed invasive disease, located in a different lobe, however.

No incidents occurred in the follow-up group.

Conclusions: No consistent management exists concerning solitary FEA in these three hospitals. Also, one hospital used the diagnosis of FEA inconsistently and interchangingly with other terms. Lack of this study is the retrospective gathering of data, making it difficult to detect the reasons for the chosen management. DCIS or IBC was discovered in 20,4% of all surgical specimens. It was concluded that FEA should be seen as a red flag, indicating the possible presence of a more malignant lesion. Additional research is warranted concerning long term follow-up for this patient group.

Citation Information: Cancer Res 2012;72(24 Suppl):Abstract nr P5-01-13.

Abstract P3-02-08: Is repetition of the contralateral mammogram of patients referred from breast cancer screening for unilateral findings necessary?

Introduction - The Netherlands started a nationwide breast cancer screening program in 1989, including women from the age of 50 until 75. Screening mammograms are performed two yearly in a mobile unit and consist of a bilateral two-view mammogram of the breast (mediolateral oblique and craniocaudal views).

If indicated, patients are referred to a breast clinic for diagnostic analysis. This work-up consist of among others repeating the bilateral two-view mammogram. Since the screening is digitalized, repeating of at least the mammogram of the non suspicious side might be unnecessary.

The aim of this study is to determine the additional value of repeating the contralateral mammogram in patients referred for a suspicious unilateral lesion.

Material and methods – 395 patients were referred from breast screening program to our institution for unilateral findings between October 2009 and August 2011. In all patients a bilateral mammogram was repeated and analyzed by an experienced breast radiologist. In the case of breast cancer a breast magnetic resonance imaging (MRI) was performed for preoperative staging. Anonymised data concerning the date of registration of the screening mammogram, the referred side (left/right or bilateral), age, screening's BI-RADS classification, breast density, biopsy results and breast MRI results were collected.

Results - Of the 395 patients referred for a suspicious unilateral finding, a malignancy on the referred side was observed in 144 patients (36.5%). In five patients bilateral breast cancer was detected. In one patient no malignancy was detected on the referred side, though on the contralateral side. Three of these six contralateral malignancies were directly mammographically detected. All six malignancies were detected with preoperative breast MRI.

Conclusion - Repetition of the two-view mammogram of the contralateral side in patients referred with a unilateral suspicious finding seems unnecessary, since all contralateral malignancies were depicted on the preoperative staging breast MRI recommended according to the EUSOBI-guidelines. Omission of the contralateral mammogram could lead to reduction of associated health care costs, radiation exposure, and patient discomfort caused by the exam.

Citation Information: Cancer Res 2012;72(24 Suppl):Abstract nr P3-02-08.

Pre-treatment differences and early response monitoring of neoadjuvant chemotherapy in breast cancer patients using magnetic resonance imaging: a systematic review

OBJECTIVES

To assess whether magnetic resonance imaging (MRI) can identify pre-treatment differences or monitor early response in breast cancer patients receiving neoadjuvant chemotherapy.

METHODS

PubMed, Cochrane library, Medline and Embase databases were searched for publications until January 1, 2012. After primary selection, studies were selected based on predefined inclusion/exclusion criteria. Two reviewers assessed study contents using an extraction form.

RESULTS

In 15 studies, which were mainly underpowered and of heterogeneous study design, 31 different parameters were studied. Most frequently studied parameters were tumour diameter or volume, K(trans), K(ep), V(e), and apparent diffusion coefficient (ADC). Other parameters were analysed in only two or less studies. Tumour diameter, volume, and kinetic parameters did not show any pre-treatment differences between responders and non-responders. In two studies, pre-treatment differences in ADC were observed between study groups. At early response monitoring significant and non-significant changes for all parameters were observed for most of the imaging parameters.

CONCLUSIONS

Evidence on distinguishing responders and non-responders to neoadjuvant chemotherapy using pre-treatment MRI, as well as using MRI for early response monitoring, is weak and based on underpowered study results and heterogeneous study design. Thus, the value of breast MRI for response evaluation has not yet been established.

KEY POINTS

Few well-validated pre-treatment MR parameters exist that identify responders and non-responders. Eligible studies showed heterogeneous study designs which hampered pooling of data. Confounders and technical variations of MRI accuracy are not studied adequately. Value of MRI for response evaluation needs to be established further.

P5-14-18: Today's Estrogen Receptor Positive/Her-2-neu Receptor Negative Breast Cancer Patients Do Significantly Better Than Yesterday's Estrogen Receptor Positive Breast Cancer Patients

Background: Her-2-neu receptor (Her2) positive and triple negative breast cancer patients have a poor prognosis. The majority of cancers are characterized as estrogen receptor (ER)+/Her2- and these patients may now have a better prognosis compared to before the introduction of the Her-2-neu receptor.

Material and methods: Since 1997 3424 patients were treated for cT1-2N0 breast cancer in three hospitals. Determination of Her2-neu status was introduced between 1999 and 2004. Trastuzumab treatment has been given routinely since 2005. Survival was evaluated for the different groups; ER+/Her2-, ER+/Her2+, ER+/Her2 unknown (status not determined).

Results: 2284 patients had ER+/Her2- tumors, 259 had ER+/Her2+ tumors and 262 had ER+/Her2 unknown tumors. Systemic treatment was given to 48.4%, 71.0% and 43.9% respectively. Estimated 5-and 10-year overall survival was 92.0% and 82.2% for ER+/Her2-, 91.6% and 70.8% ER+/Her2+ and 83.4% and 72.2% for ER+/Her2 unknown (p &lt; 0.001). The outcome differences between ER+/Her-2- and ER+/Her-2 unknown tumors remained following adjustment for tumor malignancy grade, nodal status and adjuvant systemic treatment (OR 0.8: CI 0.72 — 0.88; p&lt;0.001). For patients with ER+/Her2+ tumors 5 year overall survival was comparable with ER+/Her2- tumors but 10 year overall survival was comparable with ER+/Her2 unknown tumors.

Discussion: Patients with ER+/Her2- tumors have a significantly better outcome than patients who were classified as ER+ before the assessment of Her-2-neu over-expression. Current prognostic models do not take this effect into account.

The branching off of the survival curve for patients with ER+/Her2+ tumors can be explained by the standard use of trastuzumab during the last five years.

Citation Information: Cancer Res 2011;71(24 Suppl):Abstract nr P5-14-18.

Axillary Recurrence after Negative Sentinel Lymphnode Biopsy; a Multicentre Cohort Study

IntroductionSentinel Lymphnode Biopsy (SLNB) is generally excepted as a minimal invasive technique to stage the axilla in clinically node negative breast cancer patients. Though the reported clinically overt axillary recurrences after negative SLNB is low (0-2,8%), these false negative results after SLNB remain a concern in the treatment of pN0(slnb) breast cancer patients. In this respect many have investigated factors that may influence the risk of developing an axillary recurrence, either to explain the unexpected low incidence or to try to identify subgroups of patients with higher risk of developing an axillary recurrence. Downside to many of these studies is the single-centre study design, mostly presenting small numbers of patients with relatively short follow-up making it difficult to extrapolate the results to the every-day practice.We conducted this multicentre cohort study to identify prognostic factors for developing axillary recurrences after negative SLNB.Patients and MethodsProspectively collected data from seven large volume hospitals in the Netherlands were analyzed. Patients underwent surgery including SLNB between January 2000 and December 2002. Pathological work-up of the sentinel node, local and systemic treatment, and follow-up were performed according to Dutch National guidelines. Statistical analysis was performed to test homogeneity between the institutes. Multivariate analysis was performed to identify prognostic factors. A p-value of &lt;0,05 was considered significant.ResultsA total of 1597 patients were identified; 569 (35,6%) had positive SLNB (including micrometastasis &lt;2mm and &gt;0,2mm) and underwent Axillary Lymphnode Dissection (ALND). In the remaining 1028 patients, 986 (61,7%) were SLN negative and 42 (2,6%) patients were found to have isolated tumor cells (i.e. metastases &lt;0,2mm). In 81 of these 1028 pN0 staged patients ALND was however performed, i.e. a total of 947 SLN negative patients did not receive further axillary treatment.After a median follow-up of 77 months, eighteen patients were identified that developed clinically overt axillary recurrence (recurrence rate 1,9%). The median interval between SLNB and detection of the axillary recurrence was 37 months. Median follow-up post-recurrence was 33 months. One patient developed contra lateral breast recurrence and 9 patients developed distant metastasis (including 4 visceral metastasis). Three patients died during follow-up.Multivariate analysis showed that younger age increases (p=0,0004) and external beam radiation therapy to the breast reduces (p= 0,0012) the risk of developing an axillary recurrence. T-stage, receptor-status and number of nodes removed were not statistically significant. Adjuvant systemic therapy did not significantly influence the risk of developing an axillary recurrence in multivariate analysis.ConclusionYoung age and the absence of external beam radiation therapy to the breast both increase the risk of developing an axillary recurrence after negative SLNB.

Citation Information: Cancer Res 2009;69(24 Suppl):Abstract nr 1006.