Abstract P3-03-12: SentiDose interim analysis. A dose optimizing study with a super paramagnetic iron oxide for sentinel node detection

Background

Superparamagnetic iron oxide nanoparticles (SPIO) is a novel tracer for axillary mapping in breast cancer with comparable performance to the dual standard of isotope and blue dye. The earlier SPIO (Sienna+®) required 2 ml of SPIO diluted in 3 ml NaCl and was injected retro-areolarly. This was considered to be associated with the discoloration observed in 40% of breast conservation cases. Subsequently, a new form was developed (SiennaXPTM) in a volume of 2 ml without dilution. The aim of the ongoing SentiDose study is to compare smaller doses of SiennaXPTM injected in different time-frames (1.5 ml periareolarly on the operation day vs 1 ml peritumourally 1-7 days preoperatively) and compare it to the performance of the original SPIO (Sienna+®). A background mapping with isotope and blue dye was performed for assessment of concordance.

Method

In all, 330 patients will be recruited from six sites in Sweden, divided in two isonumerical cohorts injected as described above. Results from the 1.5 ml cohort are presented and compared on a patient-level analysis to the SentiMag Nordic trial that used Sienna+®, on a 2-sided non-inferiority margin of 5%. Study endpoints are detection rate per patient, number of sentinel nodes (SN) retrieved and discoloration at 3 weeks postoperatively.

Results

Detection rate for SiennaXPTM, 1.5 ml, was comparable with Sienna+® (96.9 vs 97.6%, p=0.76), even in multivariate analysis adjusting for age and metastasis rate (Exp(B)=0.68; 95% CI; 0.18-2.60, p=0.58). with a high concordance between isotope and SiennaXPTM. The number of SNs were similar (1.91 vs. 1.83, p=0.08) for Sienna+® and SiennaXPTM. Discoloration rate was lower for SiennaXPTM compared to Sienna+® (14.3% vs. 38.2%, p<0.001) after breast conserving surgery. Furthermore, two patients were excluded in the SentiDose cohort due to protocol violation.

Demographics and outcomes are illustrated in

Table 1 Nordic SentiMag Trial (n=206)SentiDose 1.5ml Cohort (n=163)p-valueAge (yrs)61.864.30.03BMI (kg/m2)26.927.20.84Size (mm)19.220.00.64Type of Surgery (BCS/Mx)154 (74.8%) / 52 (25.2%)130 (79.8%) / 33 (20.2%)0.26SPIO Detection Rate (per patient)97.6%96.9%0.76SPIO-Tc Concordance97.5%97.5%0.42Mean SPIO detected SN1,831,910.08Metastasis Rate26.2%16.0%0.01SPIO nodal rate in malignancy91.2%81.6%0.21Discoloration in BCS38.2%14.3%<0.001

Conclusion

The periareolar injection of 1.5 ml SiennaXPTM on the day of the operation provides comparable detection rates with much less skin discoloration, providing effectivity and flexibility. The completion of the SentiDose study will allow for more definitive results on the dose, timeframe and injection site of SPIO.

Citation Format: Hersi A-F, Obondo C, Pistioli L, Abdsaleh S, Nilsson F, Mohammed I, Eriksson S, Wärnberg F, Karakatsanis A. SentiDose interim analysis. A dose optimizing study with a super paramagnetic iron oxide for sentinel node detection [abstract]. In: Proceedings of the 2018 San Antonio Breast Cancer Symposium; 2018 Dec 4-8; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2019;79(4 Suppl):Abstract nr P3-03-12.

P2-12-30: Pre-Operative Haematological Markers and Prognosis in Early Breast Cancer

Background

Systemic inflammation may influence survival in women with breast cancer. Both the platelet lymphocyte ratio (PLR) and the neutrophil lymphocyte ratio (NLR) have been shown to be associated with survival in a number of solid tumours. The aim of this study was to assess the role of PLR and NLR in survival of women with early breast cancer.

Methods: Women diagnosed with early breast cancer at two centres between 2003 and 2006 were included. All women had measured white cells, neutrophils, lymphocytes and platelets. NLR and PLR were calculated. Cox regression survival analysis was performed with breast cancer specific survival used as the primary end point. Significant associations of NLR and PLR with pathological variables was assessed using the Chi squared test.

Results: 707 women were included with a median follow up of 3.7yrs. On univariate analysis neither NLR (HR 1.08, 95% CI 0.66−1.79) or PLR (HR 0.96, 95% CI 0.58−1.59) were significantly associated with breast cancer specific survival. An increased PLR was found to be associated with significantly fewer grade 1 tumours (P<0.05) but no other significant associations with pathology was demonstrated for either PLR or NLR.

Conclusions: This study would suggest that the NLR and PLR are not prognostic of survival in women with early breast cancer.

Citation Information: Cancer Res 2011;71(24 Suppl):Abstract nr P2-12-30.

P2-16-11: Role of Proper Patient Counselling in Combination with Effect of Socioeconomic Deprivation on the Rate of Immediate Breast Reconstruction after Mastectomy

Introduction: current guidelines in the United Kingdom suggest that the possibility of breast reconstruction should be discussed with all patients prior to mastectomy. However, the majority of patients are still treated with mastectomy alone and no reconstruction is carried out. It has also been suggested that women from more deprived areas are less likely to undergo immediate breast reconstruction (IBR). We investigated potential pitfalls in patient counselling and consequent decision making contributing to present IBR rate in combination with the effect of socioeconomic deprivation.

Methods: data from 89 consecutive mastectomy patients was prospectively collected in a single centre in Glasgow between August 2010 and March 2011. Each patient was scored for deprivation based on The Scottish Index of Multiple Deprivation. The patients were then divided into two groups: high and low deprivation levels. Consultations about IR and patients’ acceptance of counselling were analysed. For statistical calculations Fischer's exact test was applied. Results: IBR was offered to 41 (46%) patients, but it was not to 42 (47%) (6 were excluded due to incomplete data). 25 patients accepted IBR, and of those 24 (27%) underwent IBR. 16 of 41 patients refused to undergo IBR due to lack of interest (10), not feeling ready for it (2), preference of delayed procedure (2) and fear of delaying adjuvant therapy (2). Of 42 patients whom IBR was not offered, only 10 were documented in the notes, while there was no reference for discussing reconstruction in 32 (36%) cases. Reasons for not even discussing reconstruction were the following: age (15), co-morbidities (18), locally advanced cancer (2), co-morbidities with age (5), and locally advanced cancer with age (2). As regards to socioeconomic deprivation; 44 (49%) patients were from deprived areas and 39 (44%) from affluent areas. 41 patients were offered IBR and of these 23 (26%) were from affluent areas compared to 18 (20%). Of the 42 patients who were not offered IR, 26 (29%) were from deprived while 16 (18%) from affluent areas (p<0.05). Of the 44 deprived patients, 18 were offered IBR but 26 were not. 15 of 25 patients, who accepted IBR, were from affluent areas. The 16 patients who refused IBR had equal distribution of deprivation.

Conclusions: while none of the reasons for not offering IBR represent absolute contraindication to IBR, decisions about refusal are based mostly on patients’ subjective intuitions. Further, a greater proportion of the patients who were not offered IBR were from more deprived areas, and it seems that patients from affluent areas are more likely to be offered IBR compared to ones from deprived areas. However, confounding factors such as co-morbidities may contribute to the above. We believe, therefore, that detailed counselling about reconstruction of each patient requiring mastectomy is necessary, which is likely to further increase IBR rate.

The Relationship between Pre-Operative Biomarkers of Inflammation, Clinicopathological Characteristics and Cancer Specific Survival in Early Breast Cancer

Breast cancer is the second most common malignancy in women. Established prognostic factors include tumour size, grade, nodal involvement, and hormonal receptor status. Recently, the systemic inflammatory response (as evidenced by elevated C-reactive protein and low serum albumin) has been established as an independent predictor of survival in patients with metastatic breast cancer (1). However, the relationship between these systemic inflammatory markers, clinicopathological characteristics and cancer specific survival has not been established in early breast cancer.During the period June 2001 to May 2008, patients with early breast cancer presenting to two hospitals in the West of Scotland were prospectively included into this study (n=959). Preoperative C-reactive protein, albumin and clinico-pathological data were recorded for each patient. The thresholds for normal C-reactive protein and albumin were taken as <6 mg/l and >43g/l respectively.The median follow-up of the survivors was 4.1yrs. During this period, 93 patients died of their cancer. On multivariate analysis, tumour size (HR 2.03; 95%CI 1.41-2.91, P<0.001), lymph node status (HR 2.23; 95%CI 1.45-3.41, P<0.001), hormone receptor status (HR 1.58; 95%CI 1.24-2.00, P<0.001) and albumin <43g/l (HR 1.97; 95%CI 1.28-3.01, P=0.002) were significant independent predictors of cancer-specific survival. Lower serum albumin concentrations (<43g/l) were associated with deprivation (P=0.019) and significantly poorer 5-year cancer-specific survival (85 vs 92% P=0.005).The results of the present study show that lower preoperative albumin concentrations, but not elevated C-reactive protein concentrations, predict cancer-specific survival, independent of clinico-pathologic status in early breast cancer. Further, evaluation of the pre-operative systemic inflammatory response and outcome in patient subsets is warranted.1. Al Murri AM, Wilson C, Lannigan A, Doughty JC, Angerson WJ, McArdle CS, McMillan DC. Evaluation of the relationship between the systemic inflammatory response and cancer-specific survival in patients with primary operable breast cancer.Br J Cancer. 2007;96:891-5

Citation Information: Cancer Res 2009;69(24 Suppl):Abstract nr 6033.

The relationship between tumour NF-kB expression, hormone status and survival in primary invasive breast cancer

Abstract #4041

Breast cancer is one of the most common and lethal malignancies in the UK. Conventionally, prognosis is based on hormone status, tumours size, grade and lymph node involvement. We have recently observed that NF-kB expression and activation was associated with progesterone receptor (PR) expression irrespective of oestrogen receptor (ER) status in primary invasive breast cancer (Tannahill et al., unpublished observations). The aim of the present study was to examine the relationship between NF-kB, PR and survival in a selected cohort of ER positive tamoxifen treated primary invasive breast cancer.
 Immunohistochemistry was performed on 372 breast tumours, with full clinicopathological characteristics. Antibodies were directed total NF-kB and NF-kB phosphorylated at serine 536 (phospho NF-kB). Two observers independently scored expression using the weighted histoscore technique, and grouped expression as tertiles. There was a minimum follow-up period of 4.9 years and a median follow-up of 6.8 years. During follow-up 104 patients died, 65 of which died of their disease, 96 patients recurred, 70 of which was while on tamoxifen.
 Nuclear NF-kB, either total or phosphorylated, expression was not associated with recurrence or survival. However, when the cohort was subdivided into PR positive (n=220) and PR negative tumours (n=140), increased nuclear phospho NF-kB expression was associated with increased recurrence (p<0.05) and increased recurrence on tamoxifen therapy (p<0.05) in PR positive tumours. In contrast, increased nuclear phospho NF-kB expression was associated with decreased recurrence (p<0.05) and decreased recurrence on tamoxifen therapy (p<0.05) in PR negative tumours.
 The results of the present study suggest that the effect of nuclear expression of phospho NF-kb on outcome in ER positive primary invasive breast cancer is dependent on PR status. The study highlights the importance of patient selection for the evaluation of the use of NF-kb inhibitors in patients with breast cancer.

Citation Information: Cancer Res 2009;69(2 Suppl):Abstract nr 4041.

The relationship between tumour NF-kB expression, hormone status, and clinicopathological factors in primary invasive breast cancer

Abstract #4038

Breast cancer is one of the most common and lethal malignancies in the UK. Conventionally, prognosis is based on hormone status, tumour size, grade and lymph node involvement. Recently it has been proposed that Nuclear Factor Kappa B (NF-kB) is associated with breast cancer development and progression (1). The aim of the present study was to examine the relationship between NF-kB, hormone status and clinicopathological factors in primary invasive breast cancer.
 Immunohistochemistry was performed on 168 breast tumour sections, with full clinicopathological characteristics. Antibodies were directed against total NF-kB and NF-kB phosphorylated at serine 536 (phospho NF-kB). Two observers independently scored expression using the weighted histoscore technique and grouped tumours as having high or low expression according to the median value.
 Cytoplasmic and nuclear NF-kB expression, either total or phosphorylated did not correlate with grade, size or lymph node involvement. However, nuclear phospho NF-kB expression was inversely associated with Ki67 proliferation index (p<0.05). In addition an association between total nuclear NF-kB (p<0.050) and total cytoplasmic NF-kB (p<0.05) was observed with oestrogen (ER) and progesterone receptor (PR) status, total NF-kB expression was higher in ER and PR positive tumours (n=53) compared with ER negative and PR negative tumours (n=34). This association was also observed for nuclear phospho NF-kB (p<0.001) but not cytoplasmic phospho NF-kB (p=0.292). In addition, ER positive and PR negative tumours (n=78) had reduced nuclear phospho NF-kB (p<0.001) and cytoplasmic phospho NF-kB (p<0.001) expression when compared with ER positive and PR positive tumours (n=53).
 These results suggest that reduced tumour expression of phospho NF-kb is associated with increased cell proliferation and PR negativity but not ER negativity in primary invasive breast cancer. The impact of such differential tumour expression of phospho NF-kB on outcome in breast cancer remains to be determined.
 1. Cao Y, Karin M. NF-kappaB in mammary gland development and breast cancer.J Mammary Gland Biol Neoplasia. 2003;8:215-23.

Citation Information: Cancer Res 2009;69(2 Suppl):Abstract nr 4038.