The importance of tattoo pigment in sentinel lymph nodes

BACKGROUND

The presence of pigment in axillary lymph nodes (LN) secondary to migration of tattoo ink can imitate the appearance of a blue sentinel lymph node (SLN) on visual inspection, causing the operator to either miss the true SLN or excise more than is needed.

OBJECTIVE

We present patients with tattoos ipsilateral to an early stage breast cancer who underwent a SLN biopsy.

METHODS

Patients were retrospectively reviewed from medical records and clinicopathologic data was collected. A total of 52 LNs were retrieved from 15 patients for sentinel mapping and 29 of them had tattoo pigmentation on pathologic evaluation.

RESULTS

Of those 29 SLNs, 2 of them (6.9%) were pigmented, but did not contain either blue dye or Tc-99m (pseudopigmented SLN). Two (3.8%) SLNs were positive for metastasis; both of these had either blue dye or Tc99m uptake, and 1 demonstrated tattoo pigment in the node.

CONCLUSIONS

In this cohort of patients with ipsilateral tattoos, removed more LNs lead to unnecessary excision which may important for increasing the risk of arm morbidity from SLN biopsy. However, the presence of tattoo pigment did not interfere with understaging for axillary mapping and it did not effect of pathological identification of SLNs positivity.

A Prospective Study of Nausea and Vomiting After Breast Cancer Surgery

PURPOSE

Postoperative nausea and vomiting (PONV) and post-discharge nausea and vomiting (PDNV) continue to be common and disturbing complications experienced after surgery, particularly in women and especially in women undergoing breast cancer surgery. The purpose of this study was to assess the incidence and risk factors associated with PONV and PDNV from preoperative to 48 hours postoperatively in 97 women scheduled for breast cancer surgery.

DESIGN

Prospective, comparative design.

METHODS

After informed consent was obtained, women scheduled for breast cancer surgery were evaluated for incidence of vomiting, as well as the presence and severity of nausea from the preoperative holding area for 48 hours following surgery. Vomiting was assessed as both a nominally scaled, binary variable (Yes/No) and as a continuous variable to measure separate emetic events. Nausea was measured on an 11point verbal numeric scale with 0 being the absence of nausea and 10 representing the highest level of nausea ever experienced.

RESULTS

Twenty-nine (29.8%) women experienced nausea, and nine (9%) women experienced nausea and vomiting while in the post-anesthesia care unit despite close attention to the need for prophylactic antiemetic medications. Women who experienced PONV had higher levels of pain and received more opioids than those women who did not experience PONV. Women who received intravenous acetaminophen did not experience less PONV in this study. PDNV occurred more frequently than PONV, with 34 women (35%) reporting occurrence after discharge. About 13 women who did not experience PONV while in the PACU subsequently experienced PDNV after leaving the hospital, evidence for the importance of patient discharge teaching regarding these symptoms. Although clinical guidelines are necessary, our observation is that nurses in the PACU setting continuously challenge themselves to individualize the combination of medications and activities for each patient to reduce PONV after surgery.

Breast Tumor Resembling Tall Cell Variant of Papillary Thyroid Carcinoma: A Solid Papillary Neoplasm With Characteristic Immunohistochemical Profile and Few Recurrent Mutations

OBJECTIVES

Breast tumor resembling tall cell variant of papillary thyroid carcinoma (BTRPTC) is a rare breast lesion that is unrelated to thyroid carcinoma. Morphologically, it shows a solid papillary lesion with bland cytology, eosinophilic/amphophilic secretions, nuclear grooves, reversal of nuclear polarity (recently described), and nuclear inclusions. Clinical course is often uneventful with few exceptions reported in the literature. Herein, we report three additional cases.

METHODS

Immunohistochemical staining and next-generation sequencing was performed on all three cases.

RESULTS

The lesional cells on all cases were positive for cytokeratin 5 and S100, with weak expression/lack of estrogen receptor. No staining was observed for myoepithelial markers (p63 and myosin heavy chain) around the lesion. IDH2 mutations were identified in two cases at nucleotide 172 (cases 1 and 3). ATM gene mutation was identified in cases 2 and 3 and PIK3CA mutation in case 3. All patients are currently without disease.

CONCLUSIONS

BTRPTC is a slow-growing neoplastic lesion that needs to be distinguished from other papillary lesions for optimizing therapy.

The impact of Oncotype DX® recurrence score of paraffin-embedded core biopsy tissues in predicting response to neoadjuvant chemotherapy in women with breast cancer

BACKGROUND

Oncotype DX® test is beneficial in predicting recurrence free survival in estrogen receptor positive (ER+) breast cancer. Ability of the assay to predict response to neoadjuvant chemotherapy (NCT) is less well-studied.

OBJECTIVE

We hypothesize a positive association between the Oncotype DX® recurrence score (RS) and the percentage tumor response (%TR) after NCT.

METHODS

Pre-therapy RS was measured on core biopsies from 60 patients with ER+, HER2- invasive breast cancer (IBC) who then received NCT. Pre-therapy tumor size was measured using imaging. %TR, partial response (PR; >50%), pathologic complete response (pCR) and breast conserving surgery (BCS) rates were measured.

RESULTS

Median RS was 20 (2-69). Median %TR was 42 (0-97)%. PR was observed in 43% of patients. There was no association between %TR and pre-NCT tumor size, age, Nottingham score or nodal status (p > 0.05). No statistically significant association with %TR was seen with RS as a categorical or continuous variable (p = 0.21 and 0.7, respectively). Response to NCT improved as ER (p = 0.02) by RT-PCR decreased. Lower ER expression by IHC correlated with response (p = 0.03).

CONCLUSIONS

In patients with ER+ IBC receiving NCT, RS did not predict response to NCT using %TR. The benefit of the assay prior to NCT requires further study.

Abstract P6-09-14: Prognostic significance of a modified residual disease in breast and nodes (mRDBN) algorithm after neoadjuvant therapy for breast cancer

Background: Patients achieving pathologic complete response to neoadjuvant chemotherapy have excellent disease free and overall survival. For patients with residual disease, the residual disease in breast and lymph node (RDBN) method provides useful prognostic information. RDBN is calculated as follows: 0.2*tumor size (in cm)+lymph node status (0-3) + tumor grade (1-3). pCR, low, intermediate and high risk of recurrence categories correspond to RDBN index of 0, 0.1 to 2.9, 3 to <4.4, and ≥ 4.4, respectively. We hypothesized that the prognostic accuracy of RDBN may be improved by also taking into account the residual tumor cellularity.

Methods: Retrospective review of 614 consecutive patients who underwent neoadjuvant therapy for breast cancer was performed. At our institution, tumor size/volume reduction in the breast is determined using the equation:

Estimated % tumor size reduction = [(pre-therapy clinical size – “revised” pathology tumor size)/pre-therapy clinical size]*100.

“Revised” pathology tumor size is calculated by multiplying the largest dimension of the gross tumor bed by the invasive tumor cellularity of the tumor bed (in comparison to the pre-therapy core biopsy sample). For example, if a 3 cm tumor bed has only 50% cellularity for invasive cancer (in comparison to pre-therapy core biopsy), the revised tumor size is 1.5 cm. Hence, we were able to use the “revised tumor size” for calculating the modified RDBN index (mRDBN). We also used gross tumor bed size for gross RDBN (gRDBN) to compare with mRDBN. mRDBN and gRDBN could be calculated on 459 of the 514 cases. Chi-Square statistical analysis was performed.

Results: Mean follow up was 33.1 months (median 31, range 4-70).

The results are shown in Table 1 & 2.

Table 1. Overall Recurrence and MortalityRDBN Score Category Overall Recurrence Mortality  nn (%)RR95% CI; pn (%)RR95% CI; pmRDBN (n=459)High5829 (50.0)19.63[7.22, 53.40]; p=<0.000118 (31.0)16.24[4.97, 53.10]; p=<0.0001Intermed16433 (20.1)7.9[2.86, 21.78]; p=<0.000115 (9.1)4.79[1.41, 16.21]; p=0.006Low803 (3.8)1.47[0.34, 6.42]; p=0.694 (5.0)2.62[0.60, 11.41]; p=0.23pCR1574 (2.5)REF 3 (1.9)REF gRDBN (n=459)High8131 (38.3)15.02[5.49, 41.09]; p=<0.000119 (23.5)12.28[3.74, 40.26]; p=<0.0001Intermed14932 (21.5)8.43[3.05, 23.26]; p=<0.000116 (10.7)5.62[1.67, 18.89]; p=0.003Low722 (2.8)1.09[0.20, 5.82]; p=12 (2.8)1.45[0.25, 8.51]; p=1pCR1574 (2.5)REF 3 (1.9)REF 

Table 2; Reclassification of gRDBN categoriesgRDBN mRDBN ReclassificationClassificationnLow (%)Intermed (%)High (%)Low7272 (100)0 (0)0 (0)Intermed1498 (5.4)140 (93.9)1 (0.7)High810 (0)24 (29.6)57 (70.4)

Conclusions: Both mRDBN and gRDBN provide prognostic information; however, separation of categories is improved with mRDBN (Table 1). mRDBN reclassified 30% of the high risk-gRDBN patients into intermediate risk category with a recurrence rate of 20%, leaving the 'true' high risk subgroup with a revised recurrence rate of 50% (Table 2). RDBN index also identified a group of low risk patients who have prognosis similar to patients with pCR.

Citation Format: Farrugia DJ, Landmann A, McAuliffe PF, Diego EJ, Johnson R, Bonaventura M, Soran A, Dabbs DJ, Clark B, Lembersky BC, Puhalla SL, Brufsky A, Jankowitz R, Davidson NE, Ahrendt GM, Bhargava R. Prognostic significance of a modified residual disease in breast and nodes (mRDBN) algorithm after neoadjuvant therapy for breast cancer [abstract]. In: Proceedings of the 2016 San Antonio Breast Cancer Symposium; 2016 Dec 6-10; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2017;77(4 Suppl):Abstract nr P6-09-14.

Exploring the multifactorial nature of postoperative nausea and vomiting in women following surgery for breast cancer

BACKGROUND

Postoperative nausea and vomiting (PONV) are two of the most frequent and distressing complications following surgical procedures, with as many as 80% of patients considered to be at risk. Despite recognition of well-established risk factors and the subsequent use of clinical guidelines, 20-30% of women do not respond to antiemetic protocols, indicating that there may be a genetic risk.

OBJECTIVE

The purpose of this pilot study was to describe the incidence and explore the risk factors associated with PONV after surgery in women diagnosed with early stage breast cancer.

METHODS

A prospective cohort design was employed to measure PONV in women recruited prior to surgery. DNA was extracted from saliva samples collected prior to discharge. Polymorphisms for seven candidate genes with a known role in one of the neural pathways associated with PONV were included in this study; serotonin receptor (HTR3A), serotonin transport (SLC6A4), tryptophan (TPH), dopamine receptors (DRD2/ANKK and DRD3), catechol-O-methyltransferase (COMT) and histamine (H1).

RESULTS

Twenty-nine (29.8%) women experienced nausea and 10 (11%) experienced nausea and vomiting while in the PACU despite administration of multiple antiemetic medications. Women who experienced PONV had higher levels of pain and received more opioids than those women who did not experienced PONV. Odds ratios demonstrated that alleles for the COMT, DRD3, and TPH genes were associated with decreased PONV.

CONCLUSION

The understanding of the multifactorial nature of PONV and the recognition of genetic risk will ultimately lead to the development of personalized interventions to manage these frequent and often debilitating symptoms.

Abstract P3-05-14: A neoadjuvant window trial of endocrine response in women with invasive lobular carcinoma

Background:

Patients with invasive lobular carcinoma (ILC) would be expected to have favorable outcomes compared to patients with invasive ductal carcinoma (IDC) given that ILC is more often hormone receptor-positive (HR+), human epidermal growth factor receptor 2 (HER2)-negative, of lower grade, and displays decreased proliferation markers. Based on our preclinical studies showing differential hormone response in HR+ ILC vs. IDC and on recent studies suggesting differences in endocrine treatment response between patients with ILC vs. IDC, we designed a biomarker-driven, neoadjuvant window trial for newly diagnosed women with HR+, HER2-negative ILC. We hypothesize that Ki67 will be reduced by 85% in the fulvestrant arm compared with 60% and 75% reduction in the tamoxifen and anastrozole arms, respectively, and that Ki67 reduction will correlate with alterations in expression of ER and ER-regulated genes. Differential Ki67 effect will serve as a surrogate for outcome of patients with ILC on endocrine therapy.

Trial Design: This multicenter study (NCT02206984) will enroll 150 women with HR+ and HER2-negative ILC. A mandatory research breast tumor biopsy will be performed at baseline. Fifty patients will be randomized to each of three open-label treatment arms for 21 days: fulvestrant (two 250 mg IM injections on both day 1 and day 14), anastrozole (1mg orally daily), or tamoxifen (20 mg orally daily). Biomarkers of response will be assessed on baseline and post-treatment tumor tissue. Patients will proceed to definitive surgery on day 21 after study drug exposure, or they will undergo a second research breast core biopsy if further neoadjuvant treatment is planned.

Eligibility Criteria: Eligible patients include postmenopausal women with newly diagnosed, HR+, HER2-negative ILC (excluding pleomorphic subtype) measuring ≥ 1cm, with adequate organ function, ECOG PS ≥ 2, and agreeable to baseline research breast tumor biopsy.

Specific Aims: The primary endpoint is percent change from baseline to post-treatment Ki67 values in ILC tissue after 21 days of endocrine treatment. Comparisons across study arms will be made using a general linear model adjusting for institutional effect, with 80% power estimated for pairwise comparisons of log2(% staining) between treatment arms, allowing for 10% attrition. Secondary endpoints include post-therapy Ki67, and change in ER and PR protein expression by IHC. Finally, planned correlative studies include evaluation of gene expression, epigenetic markers, and DNA sequence variants in ILC tissues in an effort to identify biomarkers of endocrine response and putative drivers of endocrine resistance in ILC.

Target Accrual: This study will be open to enrollment by August 2015 at the University of Pittsburgh. Additional sites will be opened through the Translational Breast Cancer Research Consortium (TBCRC). We anticipate an accrual rate of 8 patients per month.

(Funding from Susan G. Komen® and AstraZeneca).

Citation Format: Jankowitz RC, McAuliffe PF, Sikora MJ, Butler L, Ahrendt G, Johnson R, Diego E, Bonaventura M, Puhalla S, Lembersky B, Clark B, Brufsky A, Kurland BF, Davidson NE, Dabbs DJ, Oesterreich S. A neoadjuvant window trial of endocrine response in women with invasive lobular carcinoma. [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 P3-05-14.

Axillary Staging After Neoadjuvant Chemotherapy for Breast Cancer: A Pilot Study Combining Sentinel Lymph Node Biopsy with Radioactive Seed Localization of Pre-treatment Positive Axillary Lymph Nodes

BACKGROUND

Neoadjuvant chemotherapy (NAC) downstages axillary disease in 55 % of node-positive (N1) breast cancer. The feasibility and accuracy of sentinel lymph node biopsy (SLNB) after NAC for percutaneous biopsy-proven N1 patients who are clinically node negative (cN0) by physical examination after NAC is under investigation. ACOSOG Z1071 reported a false-negative rate of <10 % if ≥3 nodes are removed with dual tracer, including excision of the biopsy-proven positive lymph node (BxLN). We report our experience using radioactive seed localization (RSL) to retrieve the BxLN with SLNB (RSL/SLNB) for cN0 patients after NAC.

METHODS

We performed a retrospective review of a single-institution, prospectively maintained registry for the years 2013 to 2014. Patients with BxLN who received NAC and had RSL/SLNB were identified. All BxLNs were marked with a radiopaque clip before NAC to facilitate RSL.

RESULTS

Thirty patients with BxLN before NAC were cN0 after NAC and underwent RSL/SLNB. Median age was 55 years. Disease stage was IIA-IIIB. Twenty-nine of 30 had ductal cancer (12 triple negative and 16 HER-2 positive). One to 11 nodes were retrieved. Twenty-nine of 30 BxLN were successfully localized with RSL. Note was made of the BxLN-containing isotope and/or dye in 22 of 30. Nineteen patients had no residual axillary disease; 11 had persistent disease. All who remained node positive had disease in the BxLN.

CONCLUSIONS

RSL/SLNB is a promising approach for axillary staging after NAC in patients whose disease becomes cN0. The status of the BxLN after NAC predicted nodal status, suggesting that localization of the BxLN may be more accurate than SLNB alone for staging the axilla in the cN0 patient after NAC.

Association between serotonin transport polymorphisms and postdischarge nausea and vomiting in women following breast cancer surgery

PURPOSE/OBJECTIVES

To examine the association of the serotonin transport gene and postdischarge nausea and vomiting (PDNV) in women following breast cancer surgery.

DESIGN

A cross-sectional study.

SETTING

A comprehensive cancer center in Pittsburgh, PA.

SAMPLE

80 post-menopausal women treated surgically for early-stage breast cancer.

METHODS

Data were collected using standardized instruments after surgery but before the initiation of chemotherapy. Blood or saliva were used for DNA extraction and analyzed following standardized protocols. Data were analyzed using descriptive statistics and logistic regression.

MAIN RESEARCH VARIABLES

Serotonin transport gene (SLC6A4), nausea, vomiting, pain, and anxiety.

FINDINGS

Women who inherited the LA/LA genotypes were at greater risk for nausea and vomiting when compared to women who carried any other combination of genotypes. Twenty-one percent of women reported nausea and vomiting an average of one month following surgery and prior to initiation of adjuvant therapy. Those women who experienced PDNV reported significantly higher anxiety and pain scores.

CONCLUSIONS

Findings of this study suggest that variability in the genotypes of the serotonin transport gene may help to explain the variability in PDNV in women following breast cancer surgery and why 20%-30% of patients do not respond to antiemetic medications.

IMPLICATIONS FOR NURSING

Nurses need to be aware that women who do not experience postoperative nausea and vomiting following surgery for breast cancer continue to be at risk for PDNV long after they have been discharged from the hospital, and this frequently is accompanied by pain and anxiety.

A tattoo pigmented node and breast cancer

Over the last decade, the axillary SLNB has replaced routine ALND for clinical staging in early breast cancer. Studies describe a potential pitfall in the identification of a true sentinel node during surgery due to lymph node pigmentation secondary to migration of tattoo dye. These pigmented “pseudo-sentinel” nodes, if located superficially in the axilla, may mimic the blue sentinel node on visual inspection, therefore missing the true sentinel node and potentially understaging the patient. Here, we present a case report of a breast cancer patient with a tattoo and discuss the importance of tattoo pigment in the LN (Fig. 1, Ref. 8).

Factors affecting cosmesis after breast conserving surgery without oncoplastic techniques in an experienced comprehensive breast center

We aimed to study the factors affecting cosmetic outcome (CO) in breast conserving surgery (BCS) without oncoplastic techniques in our center with a BCS rate higher than 60% in more than 1000 breast cancer surgeries a year. In this study 284 patients who underwent BCS without oncoplastic techniques were included. Surgeries were performed by two experienced breast surgeons with more than 25 years of experience. These patients were followed in our established Wellness Clinic postoperatively. The CO is evaluated according to the "Harvard Breast Cosmesis Grading Scale" by a breast surgeon who did not participate in the patient's surgery. The correlation among patient factors (age, breast volume, menopausal status), tumor factors (size, location, distance to areola) and treatment factors (excision volume, breast skin excision, axillary surgery, adjuvant therapy) and CO were evaluated. The mean age was 57.6 [33-98] years in the successful CO group and 58.1 [34-85] years in the unsuccessful CO group (p > 0.05). The mean follow-up time was 37.9 [24-84] months. The CO was successful in 88.7% (n:252) of the patients. Tumor size, retroareolar location of the tumor, adjuvant chemotherapy administration and whole breast radiation therapy (WBRT) were correlated with a poorer CO (p < 0.05). We were able to attain a successful CO in approximately 90% of our patients. Adding oncoplastic techniques to the surgical management of larger tumors and retroareolar tumors, may increase the percentage of good CO. In selected patients choosing balloon brachytherapy instead of WBRT, may also have positive effects on CO.

The impact of recurrence score (RS) performed on pretreatment (Tx) core biopsies (CB) in predicting response to neoadjuvant chemotherapy (NCT) in patients (Pts) with ER+ breast cancer (BC)

63

Background: The Oncotype DX 21-gene assay is beneficial in predicting disease-free survival and local regional relapse in hormone receptor BC. The ability of the assay to predict response of primary BC to NCT is less well studied. We hypothesize a (+) association exists between the RS result on pre-Tx CB and % tumor response (%TR) after NCT on final pathology. Methods: Pre-Tx RS was measured on paraffin-embedded CB from 60 pts with ER+ Her2(-) BC who then received NCT and for whom post-Tx pathology was available. %TR is calculated as 100 x (pre-Tx size – post-Tx size)/pre-Tx size. Pre-Tx tumor size was determined using imaging measurements selected in the following preferential order: MRI, US or mammogram. Post-Tx tumor size was calculated as the product of: maximum dimension of tumor-bed/fibrosis and % change in cellularity (compared with pre-therapy biopsy). Partial response (PR) is defined as ≥50% reduction in TR. Results: Mean pre-Tx tumor sizewas 4.8 (range 1-23) cm. 83% of pts were clinically lymph node (-). Nottingham Score was >6 in 93%. Breast conserving surgery was performed in 17 (28%) pts. Median RS was 20 (range 3-69). Median %TR was 42 (range 0-97)%. There were no pCRs. PR was observed in 43% of pts. No association was found between %TR and pre-NCT tumor size, age, Nottingham score or node status (p>0.05). No association for the RS as a continuous or categorical variable with %TR (p>0.05) was seen. There is a non-significant (p=0.07) trend toward increased response to NCT with increasing RS. Response to NCT improved as values of ER (p=0.02) and HER2 (p=0.007), by RT-PCR as reported with the RS, decreased. Conclusions: In the subset of patients with ER+ BC, where NCT was recommended to affect tumor downstaging, RS did not successfully discriminate pts that would respond to NCT as measured by %TR. While there was a trend toward better response with higher scores, the result was nonsignificant. The use of this genetic assay to discriminate between NCT and hormonal therapy requires further study. [Table: see text]

The efficacy of subclinical lymphedema detection in high-risk breast cancer survivors

9643

Background: Lymphedema (LE) is associated with profound functional, psychosocial and medical consequences. Early intervention may decrease morbidity from LE. Bioimpedance spectroscopy (BIS) allows subclinical diagnosis by detecting subtle differences in extracellular fluid volume between the limbs. In our lymphedema program, we prospectively monitor BIS in patients (pts) undergoing axillary lymph node dissection (ALND). The aim of this study is to investigate whether early diagnosis of LE after ALND using BIS can allow early intervention. Methods: BIS in the “Pre-Operative Group,” measurements using L-Dex U400 were obtained pre-operatively (n=123) and at 3-6 month intervals thereafter. In the “Follow-up Group" pts who had ALND previously (n=89) had baseline measurements and monitoring at the same intervals. Age, BMI, dominant hand use, side of ALND, type of breast surgery, receipt of radiation therapy, and number of LN removed were recorded. L-Dex values > 10 units or increase > 10 units above the initial measurement was treated with LE education, an over-the-counter compression sleeve, less intensive physical therapy sessions and daily exercise. Results: The mean age was 58 (27-90). The mean BMI was 28.5 (17.1-65.7)kg/m2. ALND was on the side of the dominant hand in 56% of pts (n=119). The mean number of LNs removed was 16 (5-49). The majority of pts underwent mastectomy (59%; n=126), 73% (n=55) received RT, and 80% (n=191) received neo- or adjuvant chemotherapy. 87 pts (41%) were followed for more than 1 year from initial measurement. Since the monitoring began, 18% (n=22) in the Preoperative Group and 23% (n=20) in the Follow-up group were diagnosed with subclinical LE and received early intervention. 41 pts (97.6%) remain stable with no worsening of LE 1 yr after diagnosis. One pt advanced to stage 2 LE but declined further monitoring at 6 mo. Conclusions: Subclinical detection of LE with BIS and timely intervention reduced the incidence of late-stage LE among women undergoing ALND to <3% compared with historical incidence of >25%. Periodic monitoring of women at high risk for LE can minimize costly and intensive LE treatment such as custom made sleeves, pump and surgery while anticipating elimination of more advanced LE.

Improved outcome and selection bias in primary breast surgery for patients with metastatic breast cancer

1098

Background: Retrospective studies showing improved survival in patients with metastatic breast cancer (MBC) who undergo surgical treatment of the primary tumor have been criticized for bias in favor of younger, healthier women with lower disease burden. We attempted to identify these biases in our population. Methods: Our institutional cancer registry was queried for patients with MBC from 1994-2010. Demographics, clinical, radiologic and pathologic staging, as well as treatments and outcomes were recorded. Surgical and non-surgical groups were compared for differences in overall survival (OS) and clinicopathologic variables, including comorbidities, using uni- and multivariate analysis. Results: Ninety-one patients with metastatic disease identified within 3 months of initial diagnosis were eligible. 53% (48 pts) had primary breast surgery and 47% (43 pts) did not undergo surgery. Patients in the surgery group were younger on univariate analysis (mean age 53 vs. 62, p<0.01). Neither BMI (mean 30 vs. 29 kg/m²) nor Charlson comorbidity score (mean 6 in both groups) were significantly different, p=NS. Bone metastases were more common in the surgery group (48 vs. 26%) and multiple metastases in the non-surgery group (35 vs. 17%), p<0.05. Patients in the non-surgery group had ≥ 1 visceral metastasis when compared to the surgery group (62 vs. 35%), p<0.05. Higher OS was demonstrated in the surgery group both with Kaplan Meier curves (p<0.05) and univariate analysis (mean 3 vs. 2 yrs, 95% CI 2.6, 3.7), p<0.05. Survival was higher in the surgery group (p<0.01), at 1 year, but this difference did not persist at 3 and 5 years. On multivariate analysis, only difference in age remained significant (p<0.01). Conclusions: Our study supports existing data that women with MBC who have surgical treatment of the primary tumor have an improved survivorship. However, it also suggests a bias towards increased use of surgery in patients who are younger with smaller burden of metastatic disease. We did not find a bias in favor of healthier patients. Further study to determine the mechanism and magnitude of benefit of primary tumor extirpation is still needed.

MRI staging after neoadjuvant chemotherapy for breast cancer: does tumor biology affect accuracy?

BACKGROUND

A discrepancy often exists between the post-neoadjuvant chemotherapy (NAC) breast tumor size on magnetic resonance imaging (MRI) and pathologic tumor size. We seek to quantify this MRI/pathology discrepancy and determine if the accuracy of MRI post NAC varies with tumor subtype.

METHODS

The University of Pittsburgh Medical Center (UPMC) Cancer Registry and radiology database were searched for patients with breast cancer who underwent NAC and MRI staging between 2004 and 2009. We compared radiologic to pathologic staging and stratified differences based on tumor biology using univariate, multivariate, and receiver operating characteristic (ROC) analysis.

RESULTS

Two hundred three of 592 patients undergoing surgery after NAC for breast cancer had MRI staging pre and post chemotherapy. All patients had intact tumors prior to the initiation of chemotherapy. Average tumor size by MRI was 4.0 cm pre chemotherapy and 1.2 cm post chemotherapy. The average pathologic tumor size was 1.7 cm (range 0-13 cm). The difference between MRI and pathologic tumor size was greatest in luminal (1.1 cm) and least in triple-negative (TN) and human epidermal growth factor receptor 2 (HER2)-positive tumors (<0.1 cm) (p = 0.015). MRI was a good discriminator for pathologic complete response (pCR) [area under the curve (AUC) 0.777]. Its predictive value for pCR was much greater in TN and estrogen receptor(ER)-/HER2+ than in luminal tumors (73.6 vs. 27.3%).

CONCLUSIONS

MRI is an effective tool for predicting response to NAC. The accuracy of MRI in estimating postchemotherapy tumor size varies with tumor subtype. It is highest in ER-/HER2+ and TN and lowest in luminal tumors. Knowledge of how tumor subtype affects MRI accuracy can guide recommendations for surgery following NAC.

The predictive probability of four different breast cancer nomograms for non-sentinel axillary lymph node metastasis in positive sentinel lymph node biopsy

Abstract #204

Introduction: Although completion axillary lymph node dissection (CALND) is the standard for evaluating axillary status after identification of a positive sentinel lymph node (SLN) in breast cancer (BC), almost 50% of SLN positive patients will have negative non-SLN and undergo a non-therapeutic axillary dissection. Accurate estimates of the likelihood of additional disease in the axilla can assist decision-making about further treatment. In order to predict non- sentinel lymph node metastases (NSLNM) in patients with a positive SLN biopsy, four different nomograms have been created. The Memorial Sloan Kettering Cancer Center (MSKCC) nomogram was created in 2003 and validated at sources outside that institution. The other nomograms were developed by the Tenon Hospital, the Cambridge University and the Stanford University group recently, but have not been validated yet. The aim of this study was to evaluate the accuracy of 4 different nomograms in our SLN positive BC patients. Methods: We identified 319 patients who had a positive SLN biopsy and CALND at Magee-Womens Hospital of the University of Pittsburgh Medical Center over an 8 year period. The BC nomograms developed by the MSKCC, the Tenon Hospital, the Cambridge University and the Stanford University were used to calculate the probability of NSLNM. Area Under (AUC) Receiver Operating Characteristics Curve (ROC) was calculated for each nomogram a value more than 0.70 was accepted as providing considerable discrimination. Results: One hundred-seven of 319 patients (33.5%) had positive axillary NSLNM. The mean predicted probability of positive NSLNM was 28.1 % (3-93), 67.1% (4.8-100) and, 39.1% (3.6-97.5) for the MSKCC, the Cambridge, and the Stanford nomograms, respectively. The mean point for the Tenon model was 4.45 (0-7). The AUC values were 0.70, 0.69, 0.69 and 0.64 for the MSKCC, the Tenon, the Cambridge and, the Stanford models, respectively. Conclusion: Breast nomograms can be used in the current practice to provide an accurate prediction for identifying low or high risk for NSLNM in BC. In our study, we found the MSKCC nomogram is more predictive than the other nomograms but the Cambridge model and the Tenon model reached borderline values for the good prediction. A model can provide more accurate results with its original group, but may be insufficient on the different groups. Nomograms developed at other institutions should be used with caution when counseling patients regarding the risk of additional nodal disease.

Citation Information: Cancer Res 2009;69(2 Suppl):Abstract nr 204.

Predicting the burden of axillary disease in breast cancer patients with a positive sentinel node

Abstract #1010

Background: Current practice is to perform a completion axillary lymph node dissection (ALND) for breast cancer (BC) patients with tumor-positive sentinel lymph nodes (SLNs). However, not all patients with positive SLNs have further ALND. Katz et al suggested a nomogram for predicting having four or more positive nodes for SLN-positive BC which could change the adjuvant radiation treatment fields. Our goal is to validate the accuracy in predicting &gt; 4 positive axillary lymph nodes in BC patients with a positive SLN in our institution. Methods: Katz nomogram was developed from the multivariate logistic regression model using tumor histology, primary tumor size, lymphovascular space invasion, extranodal extension, the number of involved SLNs, the number of uninvolved SLNs, and the size of the largest SLN metastasis. Area Under (AUC) Receiver Operating Characteristics Curve (ROC) was calculated for the nomogram and a value more than 0.70 was accepted as providing considerable discrimination. Results: We reviewed the records of 319 patients with invasive BC and positive SLNs who underwent completion ALND at MWH of UPMC. None of these patients received neoadjuvant chemotherapy The mean age was 54.2 (30-84) years. Eighty-nine patients (27.8%) had four or more positive nodes. Histology was invasive ductal carcinoma for 86.2 % of patients. The median tumor size was 2.22 (0.5-8.0) cm. Seventy percent of patients had only one involved SLN. The median size of the largest SLN metastasis on H&E staining was 9.7 mm (range, &lt; 0.2 to 35 mm), and 24.4% of the patients had micrometastases (2 mm). Ninety nine patients (31%) had extranodal extension. The mean predicted probability of having ≥ 4 involved axillary LNs was 31.9 % (range, 1 to 99) in patients with ≥ 4 involved axillary LNs while it was it is 9.1% (range, 0.5 to 80) in patients having &lt; 4 axillary LN metastases (P&lt;0.001). The AUC value was 0.809. Conclusions: The Katz nomogram developed to predict having ≥ 4 involved axillary lymph nodes in BC patients with a positive SLNs is validated in our patients. Nomograms developed at other institutions should be used with caution when counseling patients regarding the risk of additional nodal disease. This nomogram will be helpful to clinicians making adjuvant treatment recommendations in practice.

Citation Information: Cancer Res 2009;69(2 Suppl):Abstract nr 1010.

Predictive probability of four different breast cancer nomograms for nonsentinel axillary lymph node metastasis in positive sentinel node biopsy

BACKGROUND

Although completion axillary lymph node dissection (CALND) is the gold standard for evaluating axillary status after identification of a positive sentinel lymph node (SLN) in breast cancer, almost 40% to 70% of SLN-positive patients will have negative non-SLNs. To predict non-SLN metastases (NSLNM) in patients with a positive SLN biopsy, four different nomograms have been created. The aim of this study was to evaluate the accuracy of four different nomograms in our SLN-positive breast cancer patients.

STUDY DESIGN

We identified 319 patients who had a positive SLN biopsy and CALND at our hospital during an 8-year period. Breast cancer nomograms developed by Memorial Sloan-Kettering Cancer Center, Tenon Hospital, Cambridge University, and Stanford University were used to calculate the probability of NSLNM. The area under the receiver operating characteristics curve was calculated for each nomogram, and values greater than 0.70 were accepted as demonstrating considerable discrimination.

RESULTS

One hundred seven of 319 patients (33.5%) had positive axillary NSLNM. The mean number of SLNs was 2.01 (range, 1 to 11 nodes), and the mean number of positive SLNs was 1.44 (range, 1 to 9 nodes). The area under the curve values were 0.70, 0.69, 0.69, and 0.64 for the Memorial Sloan-Kettering Cancer Center, Tenon, Cambridge, and Stanford models, respectively.

CONCLUSIONS

We found that the Memorial Sloan-Kettering Cancer Center nomogram was more predictive than the other nomograms, but the Cambridge model and the Tenon model reached borderline values for accurate prediction. Nomograms developed at other institutions should be used with caution when counseling patients about the risk of additional nodal disease.

Models for predicting non-sentinel lymph node positivity in sentinel node positive breast cancer: the importance of scoring system

BACKGROUND

Although delayed axillary lymph node dissection is the gold standard for evaluating axillary status after identification of a positive sentinel lymph node (SLN), between 40% and 70% of sentinel lymph node positive patients will have negative non-sentinel nodes and undergo a non-therapeutic axillary dissection. Accurate estimates of the likelihood of additional disease in the axilla can assist decision-making about further treatment. To predict non-SLN metastases in patients with a positive SLN biopsy, four different nomograms have been created.

METHOD

This paper reviews the scoring systems and nomograms reported in the literature and compares their predictive probability of non-SLN involvement in patients with SLN positive breast cancer.

RESULT

There are several published scoring systems that contain different parameters to estimate the rate of non-SLN metastases in SLN positive patients. We reviewed Memorial Sloan-Kettering Cancer Center (MSKCC), Tenon, Stanford and Cambridge nomograms published and used scoring systems including three to eight variables. We found that the MSKCC nomogram is the most validated model in the literature to predict non-SLN status accurately. The other three models have not yet been verified in outside institutions.

CONCLUSION

Despite having some limitations, the MSKCC nomogram is the most validated model in the literature. These models should be tested and verified in different programs and different patient groups before they are widely accepted.

The predicted probability of having positive non-sentinel lymph nodes in patients who received neoadjuvant chemotherapy for large operable breast cancer

The accuracy of the nomogram in women with positive sentinel nodes following neoadjuvant chemotherapy (NCT) is unknown. The aim of this study was to evaluate the accuracy of the nomogram in patients receiving NCT. Between December 1999 and December 2005, we identified 233 patients who had a positive sentinel lymph node biopsy (SLNB) and complete axillary lymph node dissection at Magee-Womens Hospital of University of Pittsburgh Medical Center. Thirty-two patients (14%) had presented with clinically N0 breast cancer (BC) for which NCT was administered. The computerised BC nomogram was used to calculate the probability of non-sentinel node metastases utilising tumour size before NCT and after NCT for the same patient. The discrimination of the nomogram was assessed by calculating the area under (AUC) the receiver operating characteristic curve (ROC). The median patient age was 51.5 (range: 39-66) years in the NCT group of patients. Twelve patients (37%) had positive axillary non-sentinel lymph nodes (NSLNs). The nomogram was first validated in our institution for 201 patients without NCT and the predicted accuracy of the nomogram by the AUC was 0.73. The area under the ROC was identical regardless of whether pre- or posttreatment tumour size was used to determine predicted probability of NSLN metastases (0.66). The predictive accuracy of the nomogram was found to have less power for patients receiving NCT (0.66) than the non-NCT group of patients.

Does Failure to Visualize a Sentinel Node on Preoperative Lymphoscintigraphy Predict a Greater Likelihood of Axillary Lymph Node Positivity?

BACKGROUND

Sentinel lymph node (SLN) mapping has become the standard of care for axillary staging in women with early-stage breast cancer. The purpose of the study was to investigate the hypothesis that nonvisualization of SLN on lymphoscintigraphy (LSG) predicts a subset of patients at risk of having a substantial burden of axillary tumor as evidenced by higher rate of lymph node involvement.

STUDY DESIGN

We retrospectively reviewed the records of 1,500 patients who underwent dual-tracer SLN mapping for breast cancer between 1999 and 2004. LSG were reported as negative or positive.

RESULTS

Ninety-one percent had axillary SLN(s) identified on LSG imaging. In 133 of 134 (99.3%) patients with a negative LSG, SLN(s) was identified intraoperatively either by blue dye or hand-held gamma detection. SLN was positive in 28.4% of LSG nonvisualized group and was positive in 29.1% of LSG visualized group (p>0.05). A significantly higher percentage of women older than 50 years of age had nonvisualization of SLN (p<0.0001). Body mass index (calculated as kg/m2) was >30 in 42.5% of LSG nonvisualized group and in 26.3% in LSG visualized group (p<0.0001).

CONCLUSIONS

Failure to demonstrate axillary uptake by LSG appears to be related to technical factors and patient-related factors, such as body mass index and older age, but does not adversely affect SLN identification. The equivalent rate of positive SLNs in patients with a positive or negative LSG supports the null hypothesis that "failure to visualize" on LSG does not identify a subset of patients at higher risk of being axillary lymph node positive.

Is Routine Sentinel Lymph Node Biopsy Indicated in Women Undergoing Contralateral Prophylactic Mastectomy? Magee-Womens Hospital Experience

INTRODUCTION

The routine use of sentinel node biopsy (SLNB) at the time of prophylactic mastectomy remains controversial. This retrospective study was undertaken to determine if SLNB is justified in patients undergoing CPM.

METHODS

Between 1999 and 2004, 155 patients underwent contralateral prophylactic mastectomy (CPM) at the Magee-Womens Hospital of University of Pittsburgh Medical Center. Eighty patients (51.6%) had SLNB performed at the time of CPM. The therapeutic mastectomy and the CPM specimens were evaluated for histopathology. Goldflam's classification was used to determine the risk of malignancy in the CPM specimens.

RESULTS

Pathology in the therapeutic mastectomy specimens included 105 (68%) invasive carcinomas and 50 (32%) in-situ carcinomas. Multicentricity and/or multifocality were reported in 49.7%, and 70% were estrogen receptor positive. Two invasive breast cancers and three cases of DCIS were diagnosed in 155 CPM specimens (n = 5, 3.2%). The median number of SLN identified was 2 (range 1-6) from the CPM axilla. Two patients had positive SLNB for metastatic carcinoma (n = 2/80, 2.5%) with no primary tumor identified in the prophylactic mastectomy specimen. In both patients the therapeutic mastectomy was for recurrent invasive carcinoma in patients with a prior history of axillary node dissection. Occult carcinoma was found in five prophylactic mastectomy specimens: two invasive and three DCIS. Only 1 out of the 75 patients not undergoing SLNB at the time of their initial surgery would have required axillary staging for a previously undiagnosed invasive cancer in the CPM specimen on final pathology. Of all 155 patients undergoing CPM, only 4 (2.5%) had identified final pathologic findings where axillary staging with SLNB was beneficial. There was no evidence of arm lymphedema in any patient who had undergone CPM and SLNB at a median follow-up of 24 months.

CONCLUSION

Although SLNB is a minimally invasive method of axillary staging, this retrospective study does not support its routine use in patients undergoing CPM.

Selective intraoperative consultation for the evaluation of sentinel lymph nodes in breast cancer

BACKGROUND

Routine intraoperative evaluation of sentinel lymph nodes (SLNs) in breast cancer suffers from lack of sensitivity and consumes both time and resources. Failure to perform immediate consultation requires node-positive patients to return for delayed dissection.

METHODS

We sought to determine whether selective use of intraoperative pathology consultation (IOC), based on the surgeon's clinical suspicion for metastases, would be accurate, avoid unnecessary consultations, and have a similar rate of delayed axillary dissection. We performed a retrospective chart review of two cohorts of clinically node-negative patients with invasive breast cancer undergoing axillary lymph node dissection (ALND). Selective pathology evaluation was performed in the study group and mandatory evaluation in the control group.

RESULTS

The axillary basins of 327 patients undergoing routine IOC were compared with those of 91 patients in whom selective IOCs were requested. Twenty-eight consultations (31%) were obtained in the selective group. Selective consultation changed intraoperative management in 11 of 28 patients (39%) compared to 46 of 327 (14%) in the routine group (P = 0.005). The mean SLN metastasis size was 9.6 mm compared to 1.5 mm in patients in whom consultation was deferred (P = 0.003). The need for delayed ALND (17% vs. 14%) was similar in both groups, and was determined by occult metastases that were not detected by either method.

CONCLUSIONS

Selective use of IOC detects the majority of SLN macrometastases, avoids consultation that does not alter intraoperative management, and is not associated with an increased need for delayed ALND.

Whipple's disease presenting as chronic wastage and abdominal lymphadenopathy

We describe a 24-year-old man who presented with chronic wastage and massive abdominal lymphadenopathy which strongly resembled a malignant neoplasm. Biopsy of mesenteric lymph nodes with ancillary studies led to the correct diagnosis of Whipple's disease. These symptoms began 2 months after the patient returned from military service in the Persian Gulf.

Smoke inhalation and airway management at a regional burn unit: 1974 to 1983. II. Airway management

According to criteria established to define patients with smoke inhalation, the airway management of all victims of smoke and burns (1974 to 1984; n = 805) was reviewed. Fourteen percent of all patients were intubated (n = 117); patients intubated on the day of injury (n = 41) were more likely to extubate themselves or have technical problems with the endotracheal tube. Twelve percent of patients with smoke inhalation without burns required endotracheal intubation versus 62% of those with burns. An endotracheal tube was required for a median of 5 days. Tracheotomies were performed in 48 patients: 40% of those intubated and 6% of all patients. The mean postburn day for tracheotomy was day 15. There was no difference in the mortality rate for patients with an endotracheal tube only and those who had a tracheotomy as well: 42% and 37%, respectively. The prolonged length of stay for patients with a tracheotomy relates to the severity of the burn. Tracheotomy was not the cause of death in any patient. The strategy of grafting the neck before tracheotomy was used successfully in eight patients.

Cannulation of inferior vena cava for long term central venous access

Nineteen patients had a Silastic (silicone rubber) catheter placed into the inferior vena cava (IVC) by way of a vein of a lower extremity. All patients needed long term venous access but had conditions precluding access to the superior vena cava (SVC) or access sites of the upper torso. Precautions regarding operative technique for the placement of the catheter include incisions through healthy skin, maintenance of aseptic technique at the site of access, an atraumatic subcutaneous tunnel at least 25 centimeters in length and a long acting local analgesic effect. Catheters were in situ for a total of 2,215 days (a mean of 111 days per catheter). Catheters were also used to administer intravenously medications, blood and blood products, chemotherapeutic agents, parenteral nutrition and for sampling of blood. Four complications occurred: one instance each of catheter sepsis and infection of the subcutaneous tract and two of thromboses of the IVC. No deaths occurred. The complication rate was 0.18 per cent per catheter-day. Long term access to the IVC is feasible without undue concern in conditions in which access to the SVC is precluded but long term central access is essential.

Smoke inhalation and airway management at a regional burn unit: 1974-1983. Part I: Diagnosis and consequences of smoke inhalation

Victims of smoke inhalation with and without burns and burn patients with respiratory insufficiency for reasons other than smoke at a regional burn unit are profiled in terms of age, burn size, length of stay, and mortality. The diagnostic characteristics of patients with an inhalation injury (N = 108) are listed; 7% of all patients (N = 52) have known smoke exposure with equivocal evidence for injury to the airway or pulmonary parenchyma. The degree of respiratory (visceral) failure experienced by patients with inhalation injury is not uniformly severe. Many of the clues to this diagnosis are indirect and not always related to the severity of pulmonary injury. Timing and degree of visceral failure control the severity of the injury, which increases progressively from that in patients with a burn only (parietal injury) through those with a visceral injury only (smoke without burn), those with both smoke and burn, to those with a burn and uniformly severe respiratory failure on the basis of sepsis.

Diagnosis and management of intestinal endometriosis. A report of five cases

Five cases of intestinal endometriosis presented with infertility and pelvic pain. Rectal bleeding occurred in two patients and diarrhea in one. A diagnosis was achieved with a barium enema study and colonoscopy. All the patients had pelvic endometriosis as documented by laparoscopy. Endometriosis was present in the sigmoid colon in three patients and in the cecum in one; it was pericecal in the fifth. Bowel resection and pathologic study are necessary to relieve the symptoms and avoid neglecting a malignant tumor or other lesions.

Intravenous leiomyomatosis: a rare cause of right sided cardiac obstruction

Intravenous leiomyomatosis involving the right side of the heart is an unusual cause of outflow obstruction. Evaluation of the patient should be directed not only at intracardiac chambers but also at the inferior vena cava. This should include angiography and MRI or CAT scanning. Echocardiography is an important contributory investigation. Surgical therapy should be directed at complete removal of the tumor as recurrence has been reported if a less than complete resection has been performed. Hormonal manipulation has been attempted with variable results.

The effect of exogenous fibronectin on wound breaking strength

Experimental wounds in rats were tested for breaking strength at 4, 7, 11, 14, and 21 days to determine whether incisions treated with homogenous fibronectin differed from control incisions. At 7, 11, 14, and 21 days after wounding, the fibronectin-treated incisions were significantly stronger than the control incisions.