Abstract P3-12-02: Patient prognostic score and survival benefit offered by radiotherapy for ductal carcinoma in situ

Background: In general, radiotherapy (RT) follows breast-conserving surgery (BCS) and remains the standard of care for the surgical management of both invasive carcinoma and ductal carcinoma in situ (DCIS). Although it is associated with better local control, the magnitude of survival benefit conferred by RT for DCIS has not yet been established. We sought to evaluate whether a survival benefit exists with the addition of RT for patients with DCIS and to validate a patient prognostic score to predict survival benefit.

Methods: We performed a retrospective longitudinal cohort study by using the Surveillance Epidemiology and End Results database (SEER 17). Between 1988-2007, we identified 32,144 eligible patients who underwent BCS for DCIS. Using age, year of diagnosis, race, tumor size, hormone receptor status, tumor grade, marital status and SEER region, we calculated propensity score weights to balance clinicopathologic factors between patients receiving only surgery and those receiving surgery and RT. This cohort was divided into seven groups according to the previously validated patient prognostic score proposed by Smith et al. Breast cancer mortality (BCM) was assessed using a log-rank test and a multivariable Cox proportional hazards model.

Results: Of 32,144 cases of DCIS, 20,329 cases (63%) were treated with RT (+RT group) and 11,815 cases (37%) were treated with surgery alone (-RT group). There were 304 breast cancer-specific deaths observed over the follow-up period (median 96 months). The weighted cumulative incidence of BCM at ten-years was 1.8% for the +RT group compared to 2.1% for the -RT group (p= 0.003). The effect of RT on survival differed by nuclear grade (p= 0.007), age (p= 0.004), and tumor size (p=0.02). We found that the survival benefit for the +RT group was significantly greater than for the –RT group in subgroups of patients with higher nuclear grade, younger age, and larger tumor size, whereas a statistical reduction of BCM with RT was not observed among patients without these prognostic factors. Moreover, the magnitude of survival benefit was significantly correlated with the patient prognostic score [p<0.0001, Table].

Conclusion: In this population-based cohort study, the patient prognostic score for DCIS accurately estimated the magnitude of survival benefit offered by radiotherapy after BCS, suggesting that decisions for RT could be tailored based on prognostic score and patient preference. Limitations of this study include unmeasured confounders such as a lack of information about patients' comorbidities, margin status and endocrine therapy, and further external validation is needed to confirm our results.

Patient Prognostic Score and Hazard Ratio (HR) Comparing Mortality between Radiotherapy Group and non-Radiotherapy GroupPatient Prognostic ScoreNumber of patients in -RT groupNumber of patients in +RT groupWeighted HR of BCM95% CIWeighted HR of OM95% CI078213881.20.67 - 2.10.910.76 - 1.11267744801.00.70 - 1.50.880.78 - 0.992410570800.690.51 - 0.940.710.63 - 0.793304854170.730.48 - 1.10.680.58 - 0.81496517010.310.16 - 0.580.420.30 - 0.5852232480.290.09 - 0.910.430.21 - 0.9161515N.A. N.A. Abbreviation: RT, Radiotherapy; BCM, Breast Cancer Mortality; OM, Overall Mortality: N.A., not available

Citation Format: Sagara Y, Freedman RA, Vaz-Luis I, Mallory MA, Wong S, Aydogan F, DeSantis S, Barry WT, Golshan M. Patient prognostic score and survival benefit offered by radiotherapy for ductal carcinoma in situ. [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 P3-12-02.

Blood-pool SPECT in addition to bone SPECT in the viability assessment in mandibular reconstruction

INTRODUCTION

The assessment of the postoperative viability of vascularized and non-vascularized grafts used in the reconstruction of mandibular defects due to trauma and surgical reasons is a major problem in maxillofacial surgery.

AIM

In the present study, we evaluated the feasibility and image quality of blood-pool SPECT, which is used for the first time in the literature here in the assessment of mandibular reconstruction, in addition to non-invasive bone scintigraphy and bone SPECT. We also evaluated whether it would be useful in clinical prediction.

PATIENTS AND METHODS

Micro-vascularized and non-vascularized bone grafts were used in 12 Syrian men with maxillofacial trauma. Between days 5-7 after surgery, three-phase bone scintigraphy, blood-pool SPECT and delayed bone SPECT scans were performed. After month 6, the patients were assessed by control CT scans.

RESULTS

Of the non-vascularized grafts, one graft was reported as non-viable at week one. At month 6, graft resorption was demonstrated on the CT images. The remaining non-vascularized grafts and all of the micro-vascularized grafts were considered to be viable according to delayed bone SPECT and blood-pool SPECT images. However, only the anterior and posterior ends could be clearly assessed on delayed SPECT images, while blood-pool SPECT images allowed the clear assessment of the entire graft.

CONCLUSIONS

The combined use of blood-pool and delayed SPECT scans could allow for better assessment of graft viability in the early period, and can provide more detailed information to clinicians about prognosis in the follow-up of patients undergoing mandibular graft reconstruction.

Modified DCF (mDCF) regimen seems to be as effective as original DCF in advanced gastric cancer (AGC)

PURPOSE

The aim of this retrospective study (from January 2007 to December 2011) was to investigate the efficacy and tolerability of mDCF schedule for chemotherapy-naïve AGC patients.

PATIENTS

Patients (n = 54) with locally inoperable or distant metastasis and performance status of 0-2 were eligible. The triplet combination chemotherapy consisting of docetaxel 60 mg/m(2) on day 1, cisplatin 60 mg/m(2) on day 1, and 5-fluorouracil 600 mg/m(2) for 5 days of continuous infusion were administered every 21 days, up to nine cycles. Prophylactic G-CSF was not allowed.

RESULTS

In all, 36 (67 %) patients were male and 18 (33 %) were female; median age was 59 years. The majority of patients (n = 46, 85 %) had metastatic disease and 8 (15 %) of them had locally advanced disease. Liver metastasis and peritonitis carcinomatosa were found in 20 (43 %) and 18 (39 %) of the 46 cases, respectively. The median cycle of chemotherapy was 6. In assessing 50 patients for response evaluation, one had complete response. Partial response was achieved in 27 (54 %) patients. Seventeen patients (34 %) had stable disease and 5 (10 %) had progressive disease, while 4 % (n = 2) and 11 % (n = 6) of the patients developed severe (grade 3-4) neutropenia and anemia, respectively. During the median follow-up time (6.9 months, range 0.4-24), 28 (52 %) patients died. The overall and progression-free survival were 10.7 [95 % CI 8.9-12.4] and 6.8 [95 % CI 5.8-7.8] months, respectively.

CONCLUSIONS

Although this was not a prospective comparative study, the mDCF regimen seems to be as effective as the original DCF in AGC with acceptable and manageable side effects.

The scintigraphic evaluation and genetic correlation of joint involvements in pediatric patients with familial Mediterranean fever

PURPOSE

We aimed to evaluate the articular involvements in pediatric patients with familial Mediterranean fever (FMF) with joint symptoms by bone scintigraphy and to correlate the involved joints with the gene mutations.

MATERIALS AND METHODS

A total of 41 newly diagnosed patients in pediatric age group (28 girls and 13 boys; mean age 9.14 ± 2.91 years) with joint involvement symptoms were included in this study. Scintigraphic images were obtained at 5th min (blood pool or early phase) and starting at 3 h (late phase) after (after tracer injection) intravenous administration of technetium-99m (99mTc)-methylendiphosphonate (MDP). Genomic DNA was isolated from leukocytes using standard salting out procedure. The sequencing data were analyzed.

RESULTS

Of the 41 patients, arthritis was found in 21 (51.2%) patients. Of the 21 patients, there was single joint involvement in 15 (71.4%) patients and multiple joint involvement in six (28.6%) patients. The mean age of patients with joint involvement (8 ± 2.3 years) were considerably lower than the patients without joint involvement (10.35 ± 3.04 years), and this was statistically significant (p = 0.008). The most commonly involved joints were ankles and knees. Multiple joint involvements were most frequently observed in the M694V and M694I gene mutations (16.7%).

CONCLUSIONS

We use and recommend the bone scintigraphy in patients with FMF to determine the presence and distribution of arthritis, since bone scintigraphy is inexpensive, noninvasive, easy-to-use, and also is more sensitive in the diagnosis and distribution of arthritis than conventional radiological methods and clinical examination.

Modified DCF (mDCF) regimen seems to be as effective as original DCF in advanced gastric cancer (AGC)

PURPOSE

The aim of this retrospective study (from January 2007 to December 2011) was to investigate the efficacy and tolerability of mDCF schedule for chemotherapy-naïve AGC patients.

PATIENTS

Patients (n = 54) with locally inoperable or distant metastasis and performance status of 0-2 were eligible. The triplet combination chemotherapy consisting of docetaxel 60 mg/m(2) on day 1, cisplatin 60 mg/m(2) on day 1, and 5-fluorouracil 600 mg/m(2) for 5 days of continuous infusion were administered every 21 days, up to nine cycles. Prophylactic G-CSF was not allowed.

RESULTS

In all, 36 (67 %) patients were male and 18 (33 %) were female; median age was 59 years. The majority of patients (n = 46, 85 %) had metastatic disease and 8 (15 %) of them had locally advanced disease. Liver metastasis and peritonitis carcinomatosa were found in 20 (43 %) and 18 (39 %) of the 46 cases, respectively. The median cycle of chemotherapy was 6. In assessing 50 patients for response evaluation, one had complete response. Partial response was achieved in 27 (54 %) patients. Seventeen patients (34 %) had stable disease and 5 (10 %) had progressive disease, while 4 % (n = 2) and 11 % (n = 6) of the patients developed severe (grade 3-4) neutropenia and anemia, respectively. During the median follow-up time (6.9 months, range 0.4-24), 28 (52 %) patients died. The overall and progression-free survival were 10.7 [95 % CI 8.9-12.4] and 6.8 [95 % CI 5.8-7.8] months, respectively.

CONCLUSIONS

Although this was not a prospective comparative study, the mDCF regimen seems to be as effective as the original DCF in AGC with acceptable and manageable side effects.

Radio-guided occult lesion localisation for breast lesions under computer-aided MRI guidance: the first experience and initial results

OBJECTIVE

The purpose of this study was to present an alternative technique for the pre-operative localisation of solely MRI-detected suspicious breast lesions using a computer-assisted MRI-guided radio-guided occult lesion localisation (ROLL) technique.

METHODS

Between January 2009 and June 2010, 25 females with a total of 25 suspicious breast lesions that could be detected only by MRI, and for whom breast surgery was planned, underwent the computer-assisted MRI-guided ROLL technique. A seven-channel biopsy breast array coil and computerised diagnostic workstation were used for the localisation procedure. Three-phase dynamic contrast-enhanced axial images were taken. After investigating the localisation co-ordinates with the help of intervention software on a workstation, an 18 G coaxial cannula was placed in the exact position determined. Following verification of the cannula position by additional axial scans, (99m)Tc-labelled macroalbumin aggregate and MRI contrast material were injected. Post-procedure MRI scans were used to confirm the correct localisation.

RESULTS

All the procedures were technically successful. The mean lesion size was 10.8 mm (range: 4-25 mm). The mean total magnet and the mean localisation times were 28.6 min (range: 18-46 min) and 13.1 min (range: 8-20 min), respectively. Grid and pillar methods were used for localisation in 24 procedures and 1 procedure, respectively. On histopathological examination, 6 malignant, 10 high-risk and 9 benign lesions were identified. All patients tolerated the procedure well. There were no major complications.

CONCLUSION

This is the first report documenting the application of MRI-guided ROLL. Based on our preliminary results, this technique is very efficient and seems to be a good alternative to wire localisation.

The access rate to diagnosis and treatment modalities in breast cancer patients in Turkey; multicenter observational study

PURPOSE

To determine the time elapsed between the first notification of the disease and the access to the diagnosis and treatment modalities and the associated factors in female patients with breast cancer in Turkey.

METHODS

Data was acquired from a questionnaire involving 535 patients who applied to 14 various oncology clinics in Turkey between 1st and 28th of February 2010. Analyses were performed by the participating clinics and were divided into 3 groups: centers located in metropolitan areas formed group 1 (n=161), those located in Marmara and central Anatolia region formed group 2 (n=189), and centers located in Karadeniz and East-Southeast Anatolia region formed group 3 (n=185). The groups of these centers were formed according to the socioeconomic development of the provinces.

RESULTS

The median patient age was 48 years, 56.1% of patients were less than 50 years of age. Eighty-five percent of the patients detected a mass in their breast by self examination and 27% of the patients older than 50 years never had breast imaging until the definite diagnosis was established. The median time elapsed between disease noticed by the patient and application to a health care center was 10 days, between application and biopsy 19 days, between biopsy and surgery 10 days, and between surgery and systemic therapy 31 days. The median time elapsed between patients applying for surgery in groups 1 and 2 centers was 11 and 21 days, respectively (p=0.01). The median time elapsed between biopsy and surgery in groups 1,2 and 3 centers was 14,1.5, and 12 days, respectively (p<0.05).

CONCLUSION

A high level of awareness regarding breast cancer in our country is related with the time that is defined as 10 days between disease recognition and medical application. The time elapsed between the application and biopsy, surgery and systemic therapy was longer compared with the corresponding figures in developed countries.

What has changed in the management of breast cancer in the past 25 years at the Istanbul University Hospital?

184

Background: There have been important changes in diagnosis and treatment of the breast cancer during the last century. Diagnosing the cancer in early stages brought the new approaches such as breast conserving surgery instead of mastectomy and sentinel lymph node biopsy instead of direct axillary disection. In this study our purpose is to compare the operations which were performed in 1983 and 2008 on breast cancer patients of our clinic and to search the differences in their ages and tumor characteristics.

Methods: In each group the files of 100 patients, who were operated in 1983 and 2008, were compared with each other including the variabilities such as size of the tumor, age of the patient and operation technique.

Results: There were 100 patients in both of the groups. Six of the patients (6%), who were operated on in 1983, were found to be between the ages of 20-39 and this percentage was found to be much higher as 19% (19 patients) in 2008. In 1983, there wasn't any patient at stage 0 and the number of patients at stage 1 was 15 (15%), in 2008 the number of stage 0 patient was 9 (9%) and stage 1 patient was 25 (25%). Breast conserving surgery rate was found to be 9% in 1983 and 41% in 2008.

Conclusions: According to the data of this study, breast cancer is now being seen at younger ages when compared to 25 years ago. Currently the patients have diagnosis at earlier stages and the breast conserving surgery is much more prevalent. Earlier-stage diagnosis can be explained by widespread use of screening mamographies and increasing consciousness of the patients.

Extraction of a foreign body from the breast parenchyma using radioguided occult lesion localisation (ROLL) technique: a new approach

The radioguided occult lesion localisation (ROLL) technique is used for the excision of non-palpable breast lesions. This technique has not been described previously for the extraction of foreign bodies from the breast parenchyma. We report here a female patient who was admitted to our hospital with a foreign body in her right breast. The ROLL technique was used for the extraction of the foreign body.

Validation of breast cancer nomograms for predicting the non-sentinel lymph node metastases after a positive sentinel lymph node biopsy in a multi-center study

OBJECTIVE

In the study, our aim was to evaluate the predictability of four different nomograms on non-sentinel lymph node metastases (NSLNM) in breast cancer (BC) patients with positive sentinel lymph node (SLN) biopsy in a multi-center study.

METHODS

We identified 607 patients who had a positive SLN biopsy and completion axillary lymph node dissection (CALND) at seven different BC treatment centers in Turkey. The BC nomograms developed by the Memorial Sloan Kettering Cancer Center (MSKCC), Tenon Hospital, Cambridge University, and Stanford University were used to calculate the probability of NSLNM. Area under (AUC) Receiver Operating Characteristics Curve (ROC) was calculated for each nomogram and values greater than 0.70 were accepted as demonstrating good discrimination.

RESULTS

Two hundred and eighty-seven patients (287) of 607 patients (47.2%) had a positive axillary NSLNM. The AUC values were 0.705, 0.711, 0.730, and 0.582 for the MSKCC, Cambridge, Stanford, and Tenon models, respectively. On the multivariate analysis; overall metastasis size (OMS), lymphovascular invasion (LVI), and proportion of positive SLN to total SLN were found statistically significant. We created a formula to predict the NSLNM in our patient population and the AUC value of this formula was 0.8023.

CONCLUSIONS

The MSKCC, Cambridge, and Stanford nomograms were good discriminators of NSLNM in SLN positive BC patients in this study. A newly created formula in this study needs to be validated in prospective studies in different patient populations. A nomogram to predict NSLNM in patients with positive SLN biopsy developed at one institution should be used with caution.

Is intraluminal clip application an appropriate treatment for iatrogenic gastric perforation?

BACKGROUND

The standard treatment of iatrogenic perforation has been an urgent operation. Recently, endoscopic clip application was recommended particularly for iatrogenic perforations. This study was designed to investigate the usage of surgical clips for gastric perforations.

METHOD

Forty male rats were allocated to four groups. Following a midline laparotomy, a 5-mm gastrotomy was made at the fundic part of the stomach and through this ostomy a pre-pyloric perforation was created in all groups. In group I, the perforation site was closed with polypropylene sutures. In group II, the perforation site was closed extraluminally by vascular surgical clips. In group III, the perforation site was closed intraluminally by the same number of clips. In group IV, control group, the perforation site was left open. The animals were sacrificed on the 4th postoperative day. The healing of the perforation site was evaluated by the bursting pressure and the hydroxyproline content of the suture line.

RESULTS

Measurements revealed no differences in bursting pressure and hydroxyproline levels between the intraluminal clip application group (group III) and the group in which the perforation site was left open (group IV) (p > 0.05). Higher bursting pressures and hydroxyproline levels were observed in groups I and II compared to control group (p < 0.05).

CONCLUSIONS

These results suggest that gastric perforations are not strengthened by intraluminal clip application. Further detailed clinical studies are necessary in order to conclude that intraluminal clip application is an appropriate treatment for iatrogenic perforation.