Society of Surgical Oncology Breast Disease Site Working Group Statement on Contralateral Mastectomy: Indications, Outcomes, and Risks

Rates of contralateral mastectomy (CM) among patients with unilateral breast cancer have been increasing in the United States. In this Society of Surgical Oncology position statement, we review the literature addressing the indications, risks, and benefits of CM since the society's 2017 statement. We held a virtual meeting to outline key topics and then conducted a literature search using PubMed to identify relevant articles. We reviewed the articles and made recommendations based on group consensus. Patients consider CM for many reasons, including concerns regarding the risk of contralateral breast cancer (CBC), desire for improved cosmesis and symmetry, and preferences to avoid ongoing screening, whereas surgeons primarily consider CBC risk when making a recommendation for CM. For patients with a high risk of CBC, CM reduces the risk of new breast cancer, however it is not known to convey an overall survival benefit. Studies evaluating patient satisfaction with CM and reconstruction have yielded mixed results. Imaging with mammography within 12 months before CM is recommended, but routine preoperative breast magnetic resonance imaging is not; there is also no evidence to support routine postmastectomy imaging surveillance. Because the likelihood of identifying an occult malignancy during CM is low, routine sentinel lymph node surgery is not recommended. Data on the rates of postoperative complications are conflicting, and such complications may not be directly related to CM. Adjuvant therapy delays due to complications have not been reported. Surgeons can reduce CM rates by encouraging shared decision making and informed discussions incorporating patient preferences.

Factors Associated With Node-Positive Disease in Estrogen Receptor-Positive Breast Cancer Patients

INTRODUCTION

Larger tumor size and shorter tumor-to-nipple distance at diagnosis are associated with greater risk of lymph node involvement in breast cancer. However, the relationship between receptor subtype status and lymph node metastasis remains unclear. Our objective was to examine the association between primary tumor size, location, and nodal metastasis across estrogen receptor (ER)+/ progesterone receptor (PR)+/ human epidermal growth factor receptor 2 (HER2)-, ER+/PR-/HER2-, ER+/PR+/HER2+, and ER+/PR-/HER2+ tumors.

METHODS

A single-institution retrospective chart review was conducted of breast cancer patients diagnosed between 1998 and 2019 who underwent nodal evaluation during primary surgery. Neoadjuvant chemotherapy, pure ductal carcinoma in situ, inflammatory, recurrent, metastatic, bilateral, multicentric, and multifocal disease were excluded. Descriptive statistics (proportions and frequencies for categorical variables and medians [Q1-Q3] for continuous variables) were used to summarize patient characteristics. Kruskal-Wallis test was applied to test the association of outcome variables and continuous variables. Chi-square test or Fisher exact test was applied to test the association of outcome variables and categorical variables.

RESULTS

Six hundred eighteen ER + patients had a median tumor size of 1.7 cm (1.1-2.5 cm). Two hundred ninety six out of 618 (47.9%) were node-positive and 188/618 (30.4%) had axillary dissection. Eighty four point three percent of patients were ER+/PR+/HER2-, 6.31% were ER+/PR-/HER2-, 6.96% were ER+/PR+/HER2+, and 1.13% were ER+/PR-/HER2+. Median tumor size was significantly larger in node-positive cases compared to node-negative cases in ER+/PR+/HER2-, ER+/PR+/HER2+, and ER+/PR-/HER2- subgroups. In ER+/PR+/HER2-patients, median tumor-nipple distance was significantly shorter in node-positive patients compared to node-negative patients. Upper outer quadrant location was significantly associated with nodal positivity in ER+/PR-/HER2- patients.

CONCLUSIONS

Across ER + patients, the significance between tumor size, location, and lymph node positivity varied significantly when differentiating by PR and HER2 status.

Factors Predictive of Positive Lymph Nodes for Breast Cancer

BACKGROUND

Axillary node status is an important prognostic factor in breast cancer. The primary aim was to evaluate tumor size and other characteristics relative to axillary disease.

MATERIALS AND METHODS

Single institution retrospective chart review of stage I-III breast cancer patients collected demographic and clinical/pathologic data from 1998-2019. Student's t-test, Chi-squared test (or Fisher exact test if applicable), and logistic regression models were used for testing the association of pN+ to predictive variables.

RESULTS

Of 728 patients (mean age 59 yrs) with mean follow up of 50 months, 86% were estrogen receptor +, 10% Her2+, 78% ER+HER2-negative, and 10% triple-negative. In total, 351/728 (48.2%) were pN+ and mean tumor size was larger in pN+ cases compared to pN- cases (mean = 27.7 mm versus 15.5 mm) (p < 0.001). By univariate analysis, pN+ was associated with lymphovascular invasion (LVI), higher grade, Her2, and histology (p < 0.005). Tumor-to-nipple distance was shorter in pN+ compared to pN- (45 mm v. 62 mm; p< 0.001). Age < 60, LVI, recurrence, mastectomy, larger tumor size, and shorter tumor-nipple distance were associated with 3+ positive nodes (p < 0.05).

CONCLUSIONS

Larger tumor size and shorter tumor-nipple distance were associated with higher lymph node positivity. Age less than 60, LVI, recurrence, mastectomy, larger tumor size, and shorter tumor-nipple distance were all associated with 3+ positive lymph nodes.

Surgeon and Radiologist Evaluation of Electromagnetic Chip Localization for Benign and Malignant Breast Lesions

BACKGROUND

SmartClipTM is a food and drug administration-approved, electromagnetic chip (EMC) localization system that provides three-dimensional navigation for the excision of soft tissue lesions. The purpose of this study was to analyze the accuracy and feasibility of EMC radiologic and surgical localization for benign and malignant breast lesions.

PATIENTS AND METHODS

An institutional review board-approved, single institution, prospective study from October 2020 to September 2022 of 38 women undergoing breast conserving surgery with EMC localization of a single lesion > 5 mm on mammogram (MMG) or ultrasound (US) imaging. Surveys from performing breast radiologists and breast surgeons were collected after image-guided localization and surgical excision.

RESULTS

Seventy-six survey responses from nine radiologists and four surgeons were received. The deployment needle and EMC were highly visible in 86.8% and 76.3% of procedures, respectively. There was no difficulty in deployment for 92.1% of procedures. The EMC was in the correct location on postdeployment MMG in 97.4% of cases. Three instances of EMC migration occurred, one 1 cm from target lesion. The targeted mass and EMC were within the surgical specimen in 97.4% of cases. On specimen radiograph, 39.5% of the EMCs were 0-1 mm from the center of the target lesion, 18.4% were within 2-4 mm, and 23.7% were within 5-10 mm. Mean operating room time for all cases was 65 min. One case required US to localize the target due to console malfunction.

CONCLUSION

There was successful EMC deployment by radiologists with accurate visualization and successful surgical excision in most cases. The EnVisioTM SmartClipTM system is a reproducible and accurate localization method for benign and malignant breast lesions.

Tumor Characteristics Associated with Axillary Nodal Positivity in Triple Negative Breast Cancer

Larger-size primary tumors are correlated with axillary metastases and worse outcomes. We evaluated the relationships among tumor size, location, and distance to nipple relative to axillary node metastases in triple-negative breast cancer (TNBC) patients, as well as the predictive capacity of imaging. We conducted a single-institution, retrospective chart review of stage I-III TNBC patients diagnosed from 1998 to 2019 who underwent upfront surgery. Seventy-three patients had a mean tumor size of 20 mm (range 1-53 mm). All patients were clinically node negative. Thirty-two patients were sentinel lymph node positive, of whom 25 underwent axillary lymph node dissection. Larger tumor size was associated with positive nodes (p < 0.001): the mean tumor size was 14.30 mm in node negative patients and 27.31 mm in node positive patients. Tumor to nipple distance was shorter in node positive patients (51.0 mm) vs. node negative patients (73.3 mm) (p = 0.005). The presence of LVI was associated with nodal positivity (p < 0.001). Tumor quadrant was not associated with nodal metastasis. Ultrasound yielded the largest number of suspicious findings (21/49), with sensitivity of 0.25 and specificity of 0.40. On univariate analysis, age younger than 60 at diagnosis was also associated with nodal positivity (p < 0.002). Comparative analyses with other subtypes may identify biologic determinants.

Breast Conservation Surgery and Mastectomy Have Similar Locoregional Recurrence After Neoadjuvant Chemotherapy: Results From 1462 Patients on the Prospective, Randomized I-SPY2 Trial

Neoadjuvant chemotherapy (NAC) increases rates of successful breast-conserving surgery (BCS) in patients with breast cancer. However, some studies suggest that BCS after NAC may confer an increased risk of locoregional recurrence (LRR). We assessed LRR rates and locoregional recurrence-free survival (LRFS) in patients enrolled on I-SPY2 (NCT01042379), a prospective NAC trial for patients with clinical stage II to III, molecularly high-risk breast cancer. Cox proportional hazards models were used to evaluate associations between surgical procedure (BCS vs mastectomy) and LRFS adjusted for age, tumor receptor subtype, clinical T category, clinical nodal status, and residual cancer burden (RCB). In 1462 patients, surgical procedure was not associated with LRR or LRFS on either univariate or multivariate analysis. The unadjusted incidence of LRR was 5.4% after BCS and 7.0% after mastectomy, at a median follow-up time of 3.5 years. The strongest predictor of LRR was RCB class, with each increasing RCB class having a significantly higher hazard ratio for LRR compared with RCB 0 on multivariate analysis. Triple-negative receptor subtype was also associated with an increased risk of LRR (hazard ratio: 2.91, 95% CI: 1.8-4.6, P < 0.0001), regardless of the type of operation. In this large multi-institutional prospective trial of patients completing NAC, we found no increased risk of LRR or differences in LRFS after BCS compared with mastectomy. Tumor receptor subtype and extent of residual disease after NAC were significantly associated with recurrence. These data demonstrate that BCS can be an excellent surgical option after NAC for appropriately selected patients.

Intraoperative Fluorescence Guidance for Breast Cancer Lumpectomy Surgery

Fluorescence Guidance for Lumpectomy SurgeryThis prospective trial of 406 patients assessed margin status with and without pegulicianine fluorescence-guided surgery (pFGS) for stages 0 to 3 breast cancers. The use of pFGS met prespecified thresholds for removal of residual tumor and specificity but did not meet the prespecified threshold for sensitivity.

A125 TANDEM STUDY DESIGN IS LESS LIKELY TO DEMONSTRATE IMPROVED ADENOMA DETECTION RATE THAN PARALLEL STUDY DESIGN IN THE ASSESSMENT OF ARTIFICIAL INTELLIGENCE-ASSISTED COLONOSCOPY

Background

Randomized controlled trials have reported that artificial intelligence (AI) improves adenoma detection rate (ADR). Different methodologies, namely parallel and tandem study designs, have been employed to evaluate the efficacy of AI-assisted colonoscopy in randomized controlled trials. In systematic reviews and meta-analyses, a pooled effect that includes both study designs have been reported. However, it is unclear whether there are inconsistencies in the reported results of these two designs.

Purpose

To determine if there are differences in ADR using AI-aided technologies during colonoscopy between parallel and tandem study designs

Method

A systematic search of Ovid MEDLINE (1946 to October 2022) and EMBASE (1947 to October 2022) for randomized controlled trials comparing AI-assisted colonoscopy with routine high-definition colonoscopy in polyp detection was conducted. Reference lists of systematic reviews were searched for additional studies. The publications were divided based on trial design: parallel vs. tandem. Analysis was conducted using Review Manager 5.4.1 using a random effects model.

Result(s)

The search identified 540 articles. After screening the title and abstract for relevance, 19 randomized controlled trials involving a total of 14 657 patients were included for full-text review. Fourteen were parallel studies (14 136 patients) and 5 were tandem studies (521 patients). ADR was reported in 17 studies, and there was overall improvement in ADR with AI-assisted colonoscopy (risk ratio [RR] 1.33, 95% CI 1.22-1.44; p<.0001). Based on a separate pooled analyses of 13 parallel studies and 4 tandem studies, ADR significantly improved with AI assistance compared to routine colonoscopy, regardless of study design (RR 1.35, 95% CI 1.24-1.47 and p<.0001; RR 1.15, 95% CI 1.03-1.28; p=0.02, respectively). A significant increase in ADR with AI assistance were found in 84.6% (11/13) of parallel design studies, but in only 25% (1/4) of tandem studies.

Image

Conclusion(s)

AI assistance during colonoscopy significantly increased ADR in both parallel and tandem studies; however, improvement in ADR was less likely to be seen in tandem compared to parallel studies. It remains unclear why this difference exists, but some hypotheses include smaller sample sizes in the tandem studies, significant heterogeneity in the tandem design, and differences in operator bias depending on study design. Better understanding the differences in these study designs will inform future studies of new endoscopic technologies.

Disclosure of Interest

None Declared

Association of Residual Ductal Carcinoma In Situ With Breast Cancer Recurrence in the Neoadjuvant I-SPY2 Trial

Importance

Pathologic complete response (pCR) after neoadjuvant chemotherapy (NAC) in breast cancer strongly correlates with overall survival and has become the standard end point in neoadjuvant trials. However, there is controversy regarding whether the definition of pCR should exclude or permit the presence of residual ductal carcinoma in situ (DCIS).

Objective

To examine the association of residual DCIS in surgical specimens after neoadjuvant chemotherapy for breast cancer with survival end points to inform standards for the assessment of pathologic complete response.

Design, Setting, and Participants

The study team analyzed the association of residual DCIS after NAC with 3-year event-free survival (EFS), distant recurrence-free survival (DRFS), and local-regional recurrence (LRR) in the I-SPY2 trial, an adaptive neoadjuvant platform trial for patients with breast cancer at high risk of recurrence. This is a retrospective analysis of clinical specimens and data from the ongoing I-SPY2 adaptive platform trial of novel therapeutics on a background of standard of care for early breast cancer. I-SPY2 participants are adult women diagnosed with stage II/III breast cancer at high risk of recurrence.

Interventions

Participants were randomized to receive taxane and anthracycline-based neoadjuvant therapy with or without 1 of 10 investigational agents, followed by definitive surgery.

Main Outcomes and Measures

The presence of DCIS and EFS, DRFS, and LRR.

Results

The study team identified 933 I-SPY2 participants (aged 24 to 77 years) with complete pathology and follow-up data. Median follow-up time was 3.9 years; 337 participants (36%) had no residual invasive disease (residual cancer burden 0, or pCR). Of the 337 participants with pCR, 70 (21%) had residual DCIS, which varied significantly by tumor-receptor subtype; residual DCIS was present in 8.5% of triple negative tumors, 15.6% of hormone-receptor positive tumors, and 36.6% of ERBB2-positive tumors. Among those participants with pCR, there was no significant difference in EFS, DRFS, or LRR based on presence or absence of residual DCIS.

Conclusions and Relevance

The analysis supports the definition of pCR as the absence of invasive disease after NAC regardless of the presence or absence of DCIS.

Trial Registration

ClinicalTrials.gov Identifier NCT01042379.

The Breast Cancer Screening and Timing of Breast MRI—Experience in a Genetic High-Risk Screening Clinic in a Comprehensive Cancer Center

For women with genetic risk of breast cancer, the addition of screening breast MRI to mammography has become a standard. The order and interval of annual imaging can be variable among providers. To evaluate the clinical implications related to the timing, we conducted a chart review on a cohort of women (N = 276) with high-risk (BRCA1, BRCA2, CDH1, PTEN and TP53) and moderate high-risk (ATM and CHEK2) predisposition to breast cancer in a 48-month follow up. The estimated MRI detection rate in the entire group is 1.75% (18 per 1000 MRI tests). For the high-risk group, the estimated rate is 2.98% (30 per 1000 MRI tests). Many women discovered their genetic risk at an age much older (average age of the high-risk group was 48 years) than the age recommended to initiate enhanced screening (age 20 to 25 years). In total, 4 of the 11 primary breast cancers detected were identified by screening MRI within the first month after initial visit, which were not detected by previous mammography, suggesting the benefit of initiating MRI immediately after the discovery of genetic risk. Breast screening findings for women with Lynch syndrome and neurofibromatosis type 1 were also included in this report.

Abstract OT2-12-03: Pivotal study of the Lum imaging system for assisting intraoperative detection of residual cancer in the tumor bed of female patients with breast cancer: The INCITE trial

Background Breast-conserving surgery is a critical step in treatment with the goal of removing all cancer cells while minimizing the removal of healthy tissue. 15% to 25% of lumpectomy patients have positive margins and require a second surgery to achieve negative margins and reduce the risk of local recurrences. These positive margins are poorly predictive (35% PPV) of cancer left in the cavity, so most second surgeries find no residual cancer. Better detection tools are needed to guide in real-time the removal of cancer missed during the initial lumpectomy to reduce the number of second operations. The pegulicianine imaging agent is injected intravenously before surgery and its fluorescence signal is activated by proteases in tumor cells and cells at the tumor margin. The LUM Imaging System visualizes activated pegulicianine in the lumpectomy cavity via a hand-held detector and proprietary tumor detection software. This system was previously tested in multiple single-site studies and a prospective multi-site study that enrolled 234 patients and showed good ability to detect residual cancer in the lumpectomy cavity. Trial Design and Specific Aims: The current prospective, multi-center, randomized, blinded study was designed to show the clinical efficacy, system accuracy, and safety of the LUM Imaging System. It aims to demonstrate guided removal of residual cancer in the lumpectomy missed during the initial procedure and potentially reduce the rates of positive margins. This study is powered by an event-driven design that requires 70 truth-standard positive events. It is expected that approximately 390 women at fourteen medical centers across the US will be enrolled to achieve the number of events. Pegulicianine is injected 2-6 hours prior to the lumpectomy procedure. Surgeons perform standard of care (SOC) lumpectomy followed by blinded intraoperative imaging of the lumpectomy cavity with the LUM Imaging System in regions where SOC shaves will be taken. The patient is then randomized. If the random assignment is to the device arm, the surgeon is directed to excise margins that have positive LUM signal. Pathologists are blinded to the source of tissue removed (SOC vs. LUM) when conducting the pathology assessment. The amount of additional tissue volume resected is also evaluated. Patient reported outcome data is collected as a quality-of-life survey before and after the subject’s lumpectomy.Eligibility Criteria: This study seeks to enroll women with primary invasive breast cancer (IBC), ductal carcinoma in situ (DCIS) or a combination of IBC/DCIS undergoing a lumpectomy for their breast malignancy. Patients must not have a history of allergic reaction to polyethylene glycol, contrast agents, or have received neoadjuvant therapy to treat their current breast cancer. Use of blue dyes before imaging with the LUM System are not allowed. Additional detailed eligibility criteria are listed in the protocol. Accrual and Study Progress To date, 350 subjects have participated in this trial. This study is funded in part by the National Cancer Institute (5R44CA211013). This trial is registered as NCT03686215.

Citation Format: Jorge Ferrer, David Carr, Peter Blumencranz, Irene Wapnir, Donna Dyess, Shelly Hwang, Nayana Dekhne, Daleela Dodge, Beth-Ann Lesnikoski, Kelly Hunt, Patricia Clark, Stephanie Valente, Marie Catherine Lee, Lynne Clark, Brian Schlossberg, Sean Madden, Alejandra Rodriguez, Kate Smith, Manna Chang, Barbara Smith. Pivotal study of the Lum imaging system for assisting intraoperative detection of residual cancer in the tumor bed of female patients with breast cancer: The INCITE trial [abstract]. In: Proceedings of the 2021 San Antonio Breast Cancer Symposium; 2021 Dec 7-10; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2022;82(4 Suppl):Abstract nr OT2-12-03.

Identification of Immunogenic MHC Class II Human HER3 Peptides that Mediate Anti-HER3 CD4+ Th1 Responses and Potential Use as a Cancer Vaccine

The HER3/ERBB3 receptor is an oncogenic receptor tyrosine kinase that forms heterodimers with EGFR family members and is overexpressed in numerous cancers. HER3 overexpression associates with reduced survival and acquired resistance to targeted therapies, making it a potential therapeutic target in multiple cancer types. Here, we report on immunogenic, promiscuous MHC class II-binding HER3 peptides, which can generate HER3-specific CD4⁺ Th1 antitumor immune responses. Using an overlapping peptide screening methodology, we identified nine MHC class II-binding HER3 epitopes that elicited specific Th1 immune response in both healthy donors and breast cancer patients. Most of these peptides were not identified by current binding algorithms. Homology assessment of amino acid sequence BLAST showed >90% sequence similarity between human and murine HER3/ERBB3 peptide sequences. HER3 peptide-pulsed dendritic cell vaccination resulted in anti-HER3 CD4⁺ Th1 responses that prevented tumor development, significantly delayed tumor growth in prevention models, and caused regression in multiple therapeutic models of HER3-expressing murine tumors, including mammary carcinoma and melanoma. Tumors were robustly infiltrated with CD4⁺ T cells, suggesting their key role in tumor rejection. Our data demonstrate that class II HER3 promiscuous peptides are effective at inducing HER3-specific CD4⁺ Th1 responses and suggest their applicability in immunotherapies for human HER3-overexpressing tumors.

A phase 2 trial of talimogene laherparepvec (TVEC) in combination with neoadjuvant chemotherapy for the treatment of nonmetastatic triple-negative breast cancer

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Background: TVEC is a modified oncolytic herpes simplex 1 (HSV1) virus currently FDA approved for the treatment of unresectable cutaneous and nodal melanoma. TVEC is designed to preferentially lyse tumor cells over normal tissue to release tumor associated antigens, produces GM-CSF to activate dendritic cells, and stimulates T cells to infiltrate the tumor (TILs). TILs in breast cancer are associated with better response to neoadjuvant chemotherapy (NAC), so we hypothesized that intratumoral TVEC may enhance response to NAC. We report results of a phase 2 trial combining NAC with TVEC in stage 2-3 TNBC. Methods: Stage II-III TNBC pts (N = 37) were to be enrolled into a single arm, optimal Simon 2 stage phase 2 trial with TVEC (10^6 PFU 1st dose then 10^8 PFU x 4 doses) weeks 1,4,6,8,10 + weekly paclitaxel (80mg/m2) IV x 12, followed by dose dense AC (doxorubicin/cyclophosphamide 60/600 mg/m2) IV q2weeks x 4 alone given preoperatively. Primary endpoint was residual cancer burden 0 rate (RCB0). Trial meets primary endpoint with ≥15 RCB0 responses out of 37 evaluable pts, assuming p1 = 45% vs. p0 = 30% with one sided type I error rate at 0.10 and power at 70%. Results: Forty pts were enrolled at Moffitt (5/2018 – 4/2020) and evaluable for safety with 3 pts non-evaluable for efficacy due to incomplete treatment. Study demographics: median age 49 (27-66), 67.5% White, 10% Black, 15% Hispanic, clinical stage II 83% and III 17%, node + 42%. The RCB0 rate = 16/37 (43%, 95% CI 27-61%) and additional 9 pts with RCB-1 (RCB0/1 rate 68%, 95% CI 50-82%). Toxicities did not differ significantly from expected NAC toxicities except for increased brief G1-2 fevers, chills, injection site pains. Four pts had G2-3 thromboembolic events (10%) slightly greater than expected 6% rate on NAC. Conclusions: Addition of TVEC to NAC increased RCB0 rates with manageable toxicities and warrants additional investigation in TNBC. Immune correlates and updated survival data will be presented at the meeting. Clinical trial information: NCT02779855.

Abstract PS3-04: Breast tumor targeted fluorescence guidance for intraoperative margin assessment

BACKGROUND: A majority of the 270,000 women diagnosed with breast cancer in the United States annually are candidates for breast conserving surgery (lumpectomy), however, up to 30% of patients require reoperation due to positive margins. The ideal resolution is to make residual in-breast disease visible at the time of surgery. The goal of this research is to develop a systemically administered fluorescent molecular imaging agent that is targeted to breast tumors for intraoperative margin assessment using fluorescence guided surgery (FGS). METHODS: To identify targetable cell-surface markers for use in FGS, gene expression profiling of publicly available Affymetrix mRNA microarray data from patients with invasive ductal or invasive lobular carcinoma tumors (n=34) and surrounding normal breast tissues (n=32) was performed. Protein expression of select targets was determined by immunohistochemistry (IHC) staining of patient tissue specimens. A humanized CEACAM6 (carcinoembryonic cell adhesion molecule 6) specific antibody fragment (scFv-Fc [IgG4]) was conjugated to the near-infrared IRDye800CW fluorescent dye (LiCor) by NHS-ester linkage to create CEACAM6-800. The conjugate was characterized for in vitro specificity by immunocytochemistry (ICC) and live cell uptake studies. As proof-of-principle, the conjugate (15 µg) was intravenously injected into nude mice bearing orthotopic human MCF-7 breast cancer mammary fat pad (MFP) xenograft tumors with endogenous expression of CEACAM6. FGS was performed using the “SurgVision” clinical imaging platform (approved for clinical use in Europe) at 24 h post-injection.RESULTS: We identified 263 genes with higher mRNA expression in tumor relative to normal. From this list, we selected 9 genes for confirmation of protein expression by IHC. Of the 9 targets, only CEACAM6 had no protein expression in normal breast tissues and robust expression in ~50% of tumors. ICC staining using the CEACAM6-800 conjugate and multiple human ductal carcinoma tumor cell lines confirmed the cell surface localization of CEACAM6. In live-cell uptake studies, CEACAM6-800 accumulated on the cell surface as early as 10 min after addition to the media and was internalized after 90 min. Blocking studies demonstrated specificity. In the proof-of-principal FGS study, we observed high fluorescence in MCF-7 MFP tumors relative to background and the tumors and their residuals were completely removed in the first attempt. CONCLUSION: We have confirmed CEACAM6 protein as a cell-surface adhesion receptor target for breast cancer FGS. The CEACAM6-800, fluorescent-dye to antibody-fragment conjugate was prepared and tested in vitro for sub-cellular localization and specific uptake. In vivo studies demonstrated specific uptake into MFP tumors and FGS for tumor resection. We are currently performing studies to determine the in vivo pharmacokinetics of CEACAM6-800 uptake and clearance in tumor and normal tissues and pre-clinical post-surgery survival using our pre-clinical models. These studies will enable future translational studies.

Citation Format: Narges Tafreshi, Mikalai Budzevich, Weihong Sun, Daruka Mahadevan, Marie Catherine Lee, David L Morse. Breast tumor targeted fluorescence guidance for intraoperative margin assessment [abstract]. In: Proceedings of the 2020 San Antonio Breast Cancer Virtual Symposium; 2020 Dec 8-11; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2021;81(4 Suppl):Abstract nr PS3-04.

Influential Factors on Risk-reduction Mastectomy in a High-risk Breast Cancer Population With Genetic Predispositions

BACKGROUND

Carriers of deleterious mutations in breast cancer predisposition genes are presented with critical choices regarding cancer risk management. Risk-reduction mastectomy is a major preventative strategy in this population. Understanding the decision-making process for prophylactic mastectomy is essential in patient-centered care for high-risk carriers and patients with breast cancer. We sought to provide insight into influential factors underlying preventative surgery decisions among individuals with high breast cancer risk.

MATERIALS AND METHODS

We conducted a retrospective chart review of pathogenic carriers of high-risk breast cancer genes who presented to the Moffitt GeneHome clinic between March 2017 and June 2020. Associations between preventative mastectomy choice and influence variables were analyzed via unadjusted and adjusted logistic regression models.

RESULTS

Of 258 high-risk mutation carriers, 104 (40.3%) underwent risk-reduction mastectomy. A significantly higher proportion of mastectomy patients reported prior history of breast cancer (68.9% vs. 16.5%; P < .001) and history of other risk-reduction or noncancer-related surgeries (61.7% vs. 25.8%; P < .001). Significant predictors affecting surgery decision included previous breast cancer history (adjusted odds ratio [aOR], 10.48; 95% confidence interval [CI], 5.59-19.63; P < .0001), other risk-reduction or noncancer-related surgical history (aOR, 4.65; 95% CI, 2.28-9.47; P < .0001), and age at presentation to the genetics clinic (< 35 years old: aOR, 2.77; 95% CI, 1.04-7.4; P = .042; 35-55 years old: aOR, 2.48; 95% CI, 1.19-5.18; P = .016).

CONCLUSIONS

Preventive mastectomy decisions are highly personal and complex. In our sample, we observed prior history or concurrent breast cancer, history of other risk-reduction surgery or noncancer-related surgery, and younger age at presentation to the GeneHome clinic to be predictive of mastectomy uptake.

Abstract CT281: Pivotal study of the LUM Imaging System for assisting intraoperative detection of residual cancer in the tumor bed of female patients with breast cancer

Background: For many women with breast cancer, breast-conserving surgery is a critical first step in treatment with the goal of removing all cancer cells while minimizing the removal of healthy tissue. 15% to 25% or more of lumpectomy patients have positive margins and require a second surgery to achieve negative margins and reduce the risk of local recurrences. These positive margins are poorly predictive (35% PPV) of cancer left in the cavity, so most second surgeries find no residual cancer. Better detection tools are needed to identify residual cancer in real time during the initial lumpectomy to reduce the number of second operations. LUM015 is a protease-activated fluorescent imaging agent that accumulates in tumor cells and tumor associated macrophages. The LUM Imaging System camera visualizes the intravenously injected LUM015 in the lumpectomy cavity via a hand-held wide field detector and proprietary tumor detection software. This imaging system was previously tested in multiple single-site studies and a large, prospective multi-site study that enrolled 234 patients and showed good ability to detect residual cancer in the lumpectomy cavity. Trial Design: The current prospective multi-center, two-arm randomized, blinded study was designed to demonstrate the clinical efficacy, system accuracy, and safety of the LUM Imaging System. It aims to identify residual cancer in the lumpectomy cavity in order to reduce the rates of positive margins. This study seeks to enroll women with confirmed primary invasive breast cancer (IBC), ductal carcinoma in situ (DCIS) or a combination of IBC/DCIS undergoing a lumpectomy for their breast malignancy. The planned enrollment is 170 women being treated at fifteen medical centers across the US. To be eligible, patients must not have a history of allergic reaction to polyethylene glycol, intravenous contrast agents, or systemic therapies to treat their cancer. Use of blue dyes before imaging with the LUM System are not allowed. LUM015 is injected prior to the lumpectomy procedure. Surgeons perform standard of care (SOC) lumpectomy and perform blinded intraoperative imaging of the lumpectomy cavity with the LUM Imaging System in any regions where SOC shaves will be taken. The patient is then randomized either the further use of device or not. If the random assignment is to the device arm, the surgeon is directed to excise margins that the LUM System indicates are positive for cancer. Pathologists are blinded to the type of tissue removed when conducting the pathology assessment. Patient reported outcome data is collected as a quality of life survey before and after the subject's surgery. Additional detailed eligibility criteria are listed in the protocol. To date, 22 subjects have participated in this trial. This trial is registered as NCT03686215.

Citation Format: Jorge Ferrer, David Carr, Irene Wapnir, Kelly Hunt, Peter Blumencranz, Nayana Dekhne, Daleela Dodge, Donna Lynn Dyess, Shelley Hwang, Stephanie Valente, Lynne Clark, Beth-Ann Lesnikoski, Anees Chagpar, Paticia Clark, Marie Catherine Lee, Brian Schlossberg, Sean Madden, Livia Gjylameti, Manna Chang, Kate Smith, Barbara Smith. Pivotal study of the LUM Imaging System for assisting intraoperative detection of residual cancer in the tumor bed of female patients with breast cancer [abstract]. In: Proceedings of the Annual Meeting of the American Association for Cancer Research 2020; 2020 Apr 27-28 and Jun 22-24. Philadelphia (PA): AACR; Cancer Res 2020;80(16 Suppl):Abstract nr CT281.

A Framework for Pilot Testing Health Risk Video Narratives

Narrative messages may be superior to didactic messages when providing educational information due to their natural format for information sharing, ability to engage audiences, and engender positive thoughts about the message. Although narrative messages are gaining popularity in health promotion, little guidance exists regarding the development phase. Our team created a psychosocial narrative video intervention grounded in the Health Belief Model to increase breast cancer survivors' attendance at genetic counseling after treatment. Here we report the use of Learner Verification (LV) during an iterative video development process. Using LV, we conducted individual semi-structured interviews with patients and providers, after they viewed the video. Demographic information was analyzed using descriptive statistics, and verbatim interview transcripts were used to conduct a two-phase qualitative content analysis. Patient and provider participants (n = 30) believed the video was attractive, relatable, and informative, and they identified areas for improvement including narrative coherence, changes to text and graphical information, and including more specific information. LV framework elicited audience feedback on the video intervention relevant to theoretical principles of narrative interventions, and highlighted audience preferences. In this study, LV interviews tapped into theoretical constructs of narratives and facilitated the iterative intervention design process.

Metabolic reprogramming augments potency of human pSTAT3-inhibited iTregs to suppress alloreactivity

Immunosuppressive donor Tregs can prevent graft-versus-host disease (GVHD) or solid-organ allograft rejection. We previously demonstrated that inhibiting STAT3 phosphorylation (pSTAT3) augments FOXP3 expression, stabilizing induced Tregs (iTregs). Here we report that human pSTAT3-inhibited iTregs prevent human skin graft rejection and xenogeneic GVHD yet spare donor antileukemia immunity. pSTAT3-inhibited iTregs express increased levels of skin-homing cutaneous lymphocyte-associated antigen, immunosuppressive GARP and PD-1, and IL-9 that supports tolerizing mast cells. Further, pSTAT3-inhibited iTregs significantly reduced alloreactive conventional T cells, Th1, and Th17 cells implicated in GVHD and tissue rejection and impaired infiltration by pathogenic Th2 cells. Mechanistically, pSTAT3 inhibition of iTregs provoked a shift in metabolism from oxidative phosphorylation (OxPhos) to glycolysis and reduced electron transport chain activity. Strikingly, cotreatment with coenzyme Q10 restored OxPhos in pSTAT3-inhibited iTregs and augmented their suppressive potency. These findings support the rationale for clinically testing the safety and efficacy of metabolically tuned, human pSTAT3-inhibited iTregs to control alloreactive T cells.

Narrowing the focus: Therapeutic cell surface targets for refractory triple-negative breast cancer

Triple-negative breast cancer (TNBC) is defined as a type of breast cancer with lack of expression of estrogen receptor, progesterone receptor and human epidermal growth factor 2 protein. In comparison to other types of breast cancer, TNBC characterizes for its aggressive behavior, more prone to early recurrence and a disease with poor response to molecular target therapy. Although TNBC is identified in only 25%-30% of American breast cancer cases annually, these tumors continue to be a therapeutic challenge for clinicians for several reasons: Tumor heterogeneity, limited and toxic systemic therapy options, and often resistance to current standard therapy, characterized by progressive disease on treatment, residual tumor after cytotoxic chemotherapy, and early recurrence after complete surgical excision. Cell-surface targeted therapies have been successful for breast cancer in general, however there are currently no approved cell-surface targeted therapies specifically indicated for TNBC. Recently, several cell-surface targets have been identified as candidates for treatment of TNBC and associated targeted therapies are in development. The purpose of this work is to review the current clinical challenges posed by TNBC, the therapeutic approaches currently in use, and provide an overview of developing cell surface targeting approaches to improve outcomes for treatment resistant TNBC.

Evaluation of 2014 margin guidelines on re-excision and recurrence rates after breast conserving surgery: A multi-institution retrospective study

Introduction

A 2014 consensus statement from the Society of Surgical Oncology and American Society for Radiation Oncology supported “no ink on tumor” as an adequate margin for breast conserving therapy (BCT). This study evaluates this statement in a multi-institution cohort.

Methods

A retrospective review of BCT cases at 3 comprehensive cancer centers was performed. Women age >18 receiving BCT for T1-2 breast cancer from 2008-2012 were included. Pre-2014, all sites considered 2 mm adequate. Estimated re-excision rates using the 2014 guidelines were calculated and factors predictive of re-excision were analyzed.

Results

542 patients (545 lumpectomies) were eligible. Using a ≥2 mm margin standard, 32.8% of patients underwent re-excision compared to 14.1% after 2014 (p < 0.0001). Tumor size (p= 0.003), grade (p=0.015), and lymphovascular invasion (p=0.021) were predictive of re-excision. Patients with additional intraoperative margins excised were less likely to require reoperation (p=0.002). Local recurrence was unaffected by re-excision after mean followup of 66 months.

Conclusions

The 2014 margin guidelines markedly reduce re-excision rates. There is no difference in local recurrence for patients after re-excision for a close margin versus without Powered.

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Multi-institution review 2014 consensus statement on margins for invasive breast cancer.

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Pooled results demonstrated a 32.8% re-excision rate reduced to 14.1% if the "no tumor on ink" guidelines were applied.

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No difference in local recurrence rates, including patients with close margins, after median followup of 67 months.

Identifying key gait features associated with the radiological grade of knee osteoarthritis

PURPOSE

Knee osteoarthritis (KOA) is characterized by pain and decreased gait function. This study assessed key features that can be used as mechanical biomarkers for KOA severity and progression. The identified features were validated statistically and were further examined by developing a classification model based on a machine-learning algorithm.

METHODS

The study included 227 volunteers with various grades of KOA. The severity of KOA was graded using the Kellgren-Lawrence (KL) system. A total of 165 features were extracted from the gait data. The key features were selected using neighborhood component analysis. The selected features were validated using the t-test. Then, the features were examined by building a classification model using a random forest algorithm.

RESULTS

Twenty features were identified that could discriminate the grade of KOA, including nine features extracted from the knee joint, seven from the hip, two from the ankle and two from the spatiotemporal gait parameters. The t-test showed that some features differed significantly between health and sever group, while some were significantly different among the severe group, and others were significantly different for all KL grades. The areas under the receiver operating characteristic curves for classification were 0.974, 0.992, 0.845, 0.894, and 0.905 for KL grades 0 through 4, respectively.

CONCLUSION

Key gait features reflecting the grade of KOA were identified. The results of the statistical analysis and machine-learning algorithm show that the features can discriminate the severity of disease according to the KL grade.

Implant-sparing Mastectomy: An Alternative for Women Undergoing Mastectomy With Retropectoral Implants

INTRODUCTION

Implant-sparing mastectomy (ISM) is a skin-sparing mastectomy that preserves a retropectoral implant and potentially eliminates the need for tissue expansion or complex reconstruction. This study aimed to determine oncologic and surgical outcomes and reconstructive patterns in patients undergoing ISM.

PATIENTS AND METHODS

A single-institution, retrospective review of patients undergoing ISM from 2006 to 2018 was performed. Patient/tumor characteristics, stage, adjuvant therapy use, 90-day complication rates, reconstruction type, and disease recurrence were collected.

RESULTS

A total of 121 ISMs in 73 women were performed. Seventy (57.9%) ISMs were for breast cancer (BC) treatment and 51 (42.1%) for prophylaxis. Among BC cases, 72.3% were cT1/cT2 and 73.8% were cN0; 72.3% received systemic therapy and 33.8% received radiation therapy. There were 3 deaths owing to BC at the median follow-up of 35 months. Among 5 recurrences, only 1 was local. There was no BC identified after prophylactic ISM. Total 90-day complication rate per ISM was 15.7%. Rates were 0.8% for both seroma and wound infection, 2.5% for wound dehiscence, 3.3% for hematoma, and 8.2% for skin necrosis. The majority (72.6%) of patients required only implant exchange for reconstruction. Overall use of autologous reconstruction was low (12.3%); 77.8% of flaps were performed in patients receiving radiation therapy.

CONCLUSION

ISM is a unique approach for patients pursuing mastectomy for BC treatment or prevention with equivalent oncologic outcomes and complication rates to mastectomy with reconstruction. Reconstruction for the majority was markedly simplified by elimination of tissue expansion while maintaining a low rate of flap reconstruction.

A cross-sectional evaluation of opt-in testing for sexually transmitted and blood-borne infections in three Canadian provincial correctional facilities: a missed opportunity for public health?

PURPOSE

Incarceration provides an opportunity for screening and treatment of sexually transmitted and blood-borne infections (STBBIs) in high-risk groups. The purpose of this paper is to determine positivity rates of STBBI screening within correctional facilities using opt-in strategies and estimate the proportion of admissions tested.

DESIGN/METHODOLOGY/APPROACH

A cross-sectional, retrospective review of testing data from January 2012 to August 2015 from three provincial correctional facilities located in Alberta, Canada was completed. Analysis variables included STBBI, gender, facility, collection year and age. STBBI-stratified analysis was performed to identify correlates for positivity using univariate and logistic regressions.

FINDINGS

Overall prevalence of chlamydia was 11.2 percent and gonorrhea was 3.5 percent; correlates for both were younger age and facility type. The syphilis prevalence rate was 3.2 percent; correlates included being female, older age, adult facilities, with later years being protective. In total, 14 (0.3 percent) newly diagnosed HIV cases were found, prevalence increased with age. HBV prevalence was 1.7 percent with no significant correlations. Nearly one-tenth (n=422) of those screened for HCV antibody were positive; all variables were significantly correlated. Overall estimates of the proportion of admissions tested by STBBI were low and ranged from 4.8 to 16.1 percent.

ORIGINALITY/VALUE

This study found high rates of STBBI in correctional facilities and showed that only a small proportion of the population was tested using an opt-in strategy. Shifting to an "opt-out" strategy may be warranted.

Abstract OT2-04-05: Phase II trial of pre-operative stereotactic ablative radiotherapy (SABR) in early-stage breast cancer

Background:

Post-operative accelerated partial breast irradiation (APBI) has demonstrated efficacy in preventing in-breast tumor recurrence. Pre-operative administration of APBI may be advantageous as an intact breast tumor is smaller than its corresponding lumpectomy cavity, is easier to distinguish on treatment-planning images, and results in smaller and more accurately delineated target volumes. Pre-operative APBI may reduce the incidence of positive margins following breast-conserving surgery (BCS). Investigation is needed in the correlation of MR imaging with pathologic response 6 weeks after SABR. Also, evidence suggests that SABR induces immune activation in the tumor microenvironment; evaluation of excised tumor tissue will give insight into these processes.

Trial Design:

Treatment Planning and Delivery: CT simulation and treatment are performed in the prone position. Diagnostic MRI is fused to planning CT. GTV is delineated on registered breast MRI and includes the intact breast tumor. CTV is 15mm expansion of GTV. PTV is 3 mm expansion of CTV. VMAT or IMRT are permitted. Daily image-guidance aligning to tumor and biopsy-fiducial is mandatory. All subjects undergo pre-operative SABR to 28.5 Gy in 3 fractions of 9.5 Gy on different days separated by ≤48 hours. CTCAE v4 is used to assess toxicity 4-5 weeks after SABR. Pre-operative diagnostic MRI is performed 5-6 weeks following SABR. Imaging parameters to be evaluated include changes in tumor size, enhancement, and tumor margin description. BCS will be 6-8 weeks following SABR.

Tissue pathology: Margin status and degree of pathologic response are recorded from breast-conserving excisions, specimens are archived for future analysis.

Eligibility Criteria:

Inclusion criteria are women age ≥50 with biopsy proven invasive breast adenocarcinoma with tumor size ≤2cm on MRI, cN0 M0, ER+/HER2-, without history of invasive malignancy or prior breast/thoracic radiotherapy.

Exclusion criteria are active scleroderma or lupus erythematosus with skin involvement, MRI defined tumor within 10 mm of skin, implanted hardware prohibiting appropriate treatment planning or delivery, neoadjuvant chemotherapy, carrier of BRCA1 or 2 gene mutation, pregnancy.

Specific Aims:

The primary endpoint is pathologic complete response (pCR) in the breast tumor, secondary endpoints are incidence of adequate surgical margins (defined as “no tumor on ink”) and MRI response following SABR. Analyses of tumor immune response and microenvironment on pathologic specimens following SABR will also be performed.

Statistical Methods:

Fisher's exact test will be performed to examine associations between patient/tumor characteristics and pCR and surgical margins; these associations will be explored with multivariable logistic and linear regressions.

Accrual:

Present accrual is 9 subjects.

Expected accrual is 22 subjects; if ≥3 pCR are noted in the initial cohort, accrual will be expanded to 40 subjects.

Citation Format: Liveringhouse CL, Diaz R, Ahmed KA, Lee MC, Czerniecki B, Laronga C, Khakpour N, Weinfurtner RJ, Rosa M, Montejo ME. Phase II trial of pre-operative stereotactic ablative radiotherapy (SABR) in early-stage breast cancer [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 OT2-04-05.

Secretion-mediated STAT3 activation promotes self-renewal of glioma stem-like cells during hypoxia

High-grade gliomas (HGGs) include the most common and the most aggressive primary brain tumor of adults and children. Despite multimodality treatment, most high-grade gliomas eventually recur and are ultimately incurable. Several studies suggest that the initiation, progression, and recurrence of gliomas are driven, at least partly, by cancer stem-like cells. A defining characteristic of these cancer stem-like cells is their capacity to self-renew. We have identified a hypoxia-induced pathway that utilizes the Hypoxia Inducible Factor 1α (HIF-1α) transcription factor and the JAK1/2-STAT3 (Janus Kinase 1/2 - Signal Transducer and Activator of Transcription 3) axis to enhance the self-renewal of glioma stem-like cells. Hypoxia is a commonly found pathologic feature of HGGs. Under hypoxic conditions, HIF-1α levels are greatly increased in glioma stem-like cells. Increased HIF-1α activates the JAK1/2-STAT3 axis and enhances tumor stem-like cell self-renewal. Our data further demonstrate the importance of Vascular Endothelial Growth Factor (VEGF) secretion for this pathway of hypoxia-mediated self-renewal. Brefeldin A and EHT-1864, agents that significantly inhibit VEGF secretion, decreased stem cell self-renewal, inhibited tumor growth, and increased the survival of mice allografted with S100β-v-erbB/p53-/- glioma stem-like cells. These agents also inhibit the expression of a hypoxia gene expression signature that is associated with decreased survival of HGG patients. These findings suggest that targeting the secretion of extracellular, autocrine/paracrine mediators of glioma stem-like cell self-renewal could potentially contribute to the treatment of HGGs.

Treatment of the Pregnant Patient with Breast Cancer

Pregnancy-associated breast cancer is defined as invasive breast cancer diagnosed during gestation, within 1 year postpartum, or during lactation. Of particular interest is the treatment of invasive breast cancer during gestation; standard treatment protocols must take into account the health of the fetus. This article reviews the literature and emerging data regarding the treatment of pregnancy-associated breast cancer. Existing staging and treatment practices need slight modification in the setting of pregnancy. The timing of surgery and the administration of cytotoxic chemotherapy must take into account age of gestation, but these modalities are safe in pregnancy.

Use of axillary lymph node dissection (ALND) in patients with micrometastatic breast cancer

BACKGROUND

Sentinel lymph node (SLN) biopsy is the current prognostic tool for clinically node-negative breast cancer patients. If the SLN reveals macrometastasis, axillary lymph node dissection (ALND) is recommended. However, the use of ALND in patients with micrometastasis is debated. The objective of this study was to assess the utilization of ALND in the treatment of micrometastatic breast cancer.

METHODS

An IRB approved, retrospective study of a pooled dataset of breast cancer patients with micrometastatic disease on SLN biopsy was performed. Patients diagnosed from 1999-2016 were identified via query of a single-institution National Comprehensive Cancer Network (NCCN) breast cancer database as well as a prospective tumor board.

RESULTS

A total of 91 patients were diagnosed with micrometastatic nodal disease. The median age at diagnosis was 56 y (range: 31-85); median follow-up time was 47 mo (range: 0-203 mo). 42/91(46.2%) patients had ALND of which 37/42 (88.1%) were a second operation; 3/42(7.1%) patients had additional positive nodes found at ALND. 44/91 (48.4%) patients received radiation. 7/91 (7.7%) patients had a recurrence, 5/7 local, including one axillary (2.1%; patient declined ALND).

CONCLUSIONS

Given that the risk of lymphedema after ALND ranges between 20%-53%, the morbidity of ALND may far exceed the likelihood of detecting further nodal involvement in women with micrometastatic disease: 7.1% in this series.

Factors predictive of failure to complete planned intraoperative breast radiation using the intrabeam® system

PURPOSE

Intraoperative radiation therapy (IORT) is a form of breast irradiation that is delivered in a single session at the time of partial mastectomy. In up to 10% of patients, planned IORT is not completed; this leads to wasted resources and decreased patient satisfaction. Our objective was to evaluate factors associated with failure to complete planned IORT.

METHODS AND MATERIALS

An IRB-approved review of planned IORT cases from 2011 to 2015 was conducted. Eligibility criteria included: age ≥60, invasive ductal or mammary carcinoma, tumor <3.0 cm, ER positive, and clinically node negative. Discontinuation of planned IORT was at the discretion of the breast surgical and radiation oncologists.

RESULTS

Twenty-one (15%) of one hundred and forty-five planned IORT cases were not completed. Reasons for failure to complete IORT included inadequate applicator to skin distance (n = 15, 71%), altered wire localization findings the day of surgery (n = 4, 19%), equipment failure (n = 1, 5%), and hemodynamic instability (n = 1, 5%). Significant surgeon variability was associated with failure to complete planned IORT (P < 0.001).

CONCLUSIONS

Insufficient skin-to-applicator spacing is the most common reason for failure to complete IORT. In this series, higher volume surgeons completed a greater proportion of IORT cases, suggesting a learning curve to patient selection or intraoperative technique. J. Surg. Oncol. 2016;114:930-932. © 2016 Wiley Periodicals, Inc.

Dual energy X-ray absorptiometry spine scans to determine abdominal fat in postmenopausal women

Body composition may be a better predictor of chronic disease risk than body mass index (BMI) in older populations.

OBJECTIVES

We sought to validate spine fat fraction (%) from dual energy X-ray absorptiometry (DXA) spine scans as a proxy for total abdominal fat.

METHODS

Total body DXA scan abdominal fat regions of interest (ROI) that have been previously validated by magnetic resonance imaging were assessed among healthy, postmenopausal women who also had antero-posterior spine scans (n = 103). ROIs were (1) lumbar vertebrae L2-L4 and (2) L2-Iliac Crest (L2-IC), manually selected by two independent raters, and (3) trunk, auto-selected by DXA software. Intra-class correlation coefficients evaluated intra and inter-rater reliability on a random subset (N = 25). Linear regression models, validated by bootstrapping, assessed the relationship between spine fat fraction (%) and total abdominal fat (%) ROIs.

RESULTS

Mean age, BMI, and total body fat were 66.1 ± 4.8 y, 25.8 ± 3.8 kg/m² and 40.0 ± 6.6%, respectively. There were no significant differences within or between raters. Linear regression models adjusted for several participant and scan characteristics were equivalent to using only BMI and spine fat fraction. The model predicted L2-L4 (Adj. R² : 0.83) and L2-IC (Adj. R² : 0.84) abdominal fat (%) well; the adjusted R² for trunk fat (%) was 0.78. Model validation demonstrated minimal over-fitting (Adj. R² : 0.82, 0.83, and 0.77 for L2-L4, L2-IC, and trunk fat, respectively).

CONCLUSIONS

The strong correlation between spine fat fraction and DXA abdominal fat measures make it suitable for further development in postmenopausal chronic disease risk prediction models. Am. J. Hum. Biol. 28:918-926, 2016. © 2016Wiley Periodicals, Inc.

Canine Adenovirus Type 1 Infection of a Eurasian River Otter (Lutra lutra)

A 10-year-old female Eurasian river otter ( Lutra lutra) died after prolonged anorexia and weight loss in the Seoul Grand Park Zoo, Seoul, Republic of Korea. On necropsy, the liver was found to be swollen and friable with 1 lobe enlarged and necrotic. The other organs showed no significant alterations except for mild atrophy of the right kidney. Microscopically, there was multifocal hepatic necrosis. The hepatocytes around the necrotic areas were swollen and contained large basophilic intranuclear inclusions. Periportal infiltration by plasma cells and lymphocytes was also evident. Transmission electron microscopy revealed characteristic hexagonal virus particles sized approximately 70 nm in diameter in the nuclei of the hepatocytes, which were consistent with an adenovirus. Polymerase chain reaction of the formalin-fixed, paraffin-embedded liver sections was used to determine whether the virus was either the canine adenovirus type 1 (CAV-1), canine adenovirus type 2 (CAV-2), or some other viral agent. The results of these tests showed that the virus was CAV-1. To our knowledge, this is the first report on a CAV-1 infection in an otter.

Hyperleptinemia Is a Risk Factor for the Development of Central Arterial Stiffness in Kidney Transplant Patients

BACKGROUND

Arterial stiffness could cause adverse outcomes in kidney transplant (KT) patients. Leptin has a role in influencing vascular smooth muscle that may contribute to atherosclerosis. The aim of this study was to evaluate the relationship between fasting serum leptin concentration and carotid-femoral pulse wave velocity (cfPWV) in KT patients.

MATERIALS AND METHODS

Fasting blood samples were obtained from 55 KT patients and 65 subjects from the outpatient department were enrolled as the control group. The cfPWV values of >10 m/s were used to define as the high arterial stiffness group and <10 m/s as the low arterial stiffness group. The predictive ability of leptin for arterial stiffness of KT was assessed using receiver operating characteristic (ROC) curve and multivariate logistic regression analyses.

RESULTS

Kidney transplant patients had lower hemoglobin, but higher blood urea nitrogen, creatinine, total cholesterol, diastolic blood pressure, intact parathyroid hormone levels, and leptin levels than controls. Although cfPWV levels were higher in KT patients, there is no difference of cfPWV levels between KT patients and control (P = .595). Fifteen KT patients (27.3%) were defined in the high arterial stiffness group, and serum leptin level was higher in the high arterial stiffness group compared with the low arterial stiffness group in KT patients (P < .001). Multivariate logistic regression analysis showed that leptin (odds ratio: 1.044, 95% confidence interval [CI]: 1.016-1.072, P = .002) was an independent predictor of arterial stiffness in KT patients. The sensitivity, specificity, positive predictive value, negative predictive value, and area under the ROC curve predicting arterial stiffness in KT patients were 73.33%, 87.5%, 68.7%, 89.7%, and 0.828 (95% CI: 0.703-0.917, P < .001), and the leptin cut-off value was 74.14 ng/mL.

CONCLUSION

Serum fasting leptin level could predict the development of central arterial stiffness of KT patients.

Brain potentials evoked by intraepidermal electrical stimuli reflect the central sensitization of nociceptive pathways

Secondary mechanical punctate hyperalgesia is a cardinal sign of central sensitization (CS), an important mechanism of chronic pain. Our study demonstrates that hyperalgesia from intraepidermal electrical stimulation coexists with mechanical punctate hyperalgesia and elicits electroencephalographic (EEG) potentials that predict the occurrence of punctate hyperalgesia in a human experimental model of CS. These findings inform clinical development of EEG-based biomarkers of CS.

Central sensitization (CS), the increased sensitivity of the central nervous system to somatosensory inputs, accounts for secondary hyperalgesia, a typical sign of several painful clinical conditions. Brain potentials elicited by mechanical punctate stimulation using flat-tip probes can provide neural correlates of CS, but their signal-to-noise ratio is limited by poor synchronization of the afferent nociceptive input. Additionally, mechanical punctate stimulation does not activate nociceptors exclusively. In contrast, low-intensity intraepidermal electrical stimulation (IES) allows selective activation of type II Aδ-mechano-heat nociceptors (II-AMHs) and elicits reproducible brain potentials. However, it is unclear whether hyperalgesia from IES occurs and coexists with secondary mechanical punctate hyperalgesia, and whether the magnitude of the electroencephalographic (EEG) responses evoked by IES within the hyperalgesic area is increased. To address these questions, we explored the modulation of the psychophysical and EEG responses to IES by intraepidermal injection of capsaicin in healthy human subjects. We obtained three main results. First, the intensity of the sensation elicited by IES was significantly increased in participants who developed robust mechanical punctate hyperalgesia after capsaicin injection (i.e., responders), indicating that hyperalgesia from IES coexists with punctate mechanical hyperalgesia. Second, the N2 peak magnitude of the EEG responses elicited by IES was significantly increased after the intraepidermal injection of capsaicin in responders only. Third, a receiver-operator characteristics analysis showed that the N2 peak amplitude is clearly predictive of the presence of CS. These findings suggest that the EEG responses elicited by IES reflect secondary hyperalgesia and therefore represent an objective correlate of CS.

Prospective evaluation of skin and nipple-areola sensation and patient satisfaction after nipple-sparing mastectomy

BACKGROUND

Sensation and quality of life (QOL) before and after nipple sparing mastectomy (NSM) are poorly understood.

METHODS

Women electing mastectomy with immediate reconstruction and eligible for NSM were prospectively enrolled in a sensation and satisfaction/QOL study. Women self-selected skin-sparing mastectomy (SSM) or NSM. Skin sensation testing using Semmes Weinstein monofilaments and patient satisfaction/QOL surveys were administered preoperatively and at 1 year postoperatively.

RESULTS

53 patients were enrolled (n = 38, 72% NSM and n = 15, 28% SSM). Both groups had significant reduction in postoperative skin sensation. For NSM, measurable NAC sensation was preserved in both NAC for 26% of patients and in one NAC for 68%. QOL and satisfaction was similar between groups. Neither group was satisfied with sexual arousal with breast or nipple stimulation after surgery.

CONCLUSION

Patients undergoing SSM and NSM have considerable loss in skin and NAC sensation following surgery. Satisfaction and QOL did not differ between groups. J. Surg. Oncol. 2016;114:11-16. © 2016 Wiley Periodicals, Inc.

Primary malignant mucosal melanoma of the larynx: A case report and literature review

Malignant mucosal melanoma is very rare entity. It comprises about 1% of all malignant melanoma and exhibit more aggressive behaviour than that of skin melanomas. Mucosal melanoma arises mainly from the mucous membranes of head and neck, the female genital organs or the anorectal and the urinary tracts.  Laryngeal malignant melanoma constitutes 3.8% to 7.4% of all cases of malignant mucosal melanoma of head and neck. In this article we report a case of primary malignant mucosal melanoma of larynx in 27 years old male who was treated with radical surgery and adjuvant chemotherapy in BPKM Cancer Hospital, Chitwan.

A placebo-controlled randomised trial to assess the effect of TGF-ß1-expressing chondrocytes in patients with arthritis of the knee

The aim of this study was to assess the effect of injecting genetically engineered chondrocytes expressing transforming growth factor beta 1 (TGF-β1) into the knees of patients with osteoarthritis. We assessed the resultant function, pain and quality of life.

A total of 54 patients (20 men, 34 women) who had a mean age of 58 years (50 to 66) were blinded and randomised (1:1) to receive a single injection of the active treatment or a placebo. We assessed post-treatment function, pain severity, physical function, quality of life and the incidence of treatment-associated adverse events. Patients were followed at four, 12 and 24 weeks after injection.

At final follow-up the treatment group had a significantly greater improvement in the mean International Knee Documentation Committee score than the placebo group (16 points; -18 to 49, vs 8 points; -4 to 37, respectively; p = 0.03). The treatment group also had a significantly improved mean visual analogue score at final follow-up (-25; -85 to 34, vs -11 points; -51 to 25, respectively; p = 0.032). Both cohorts showed an improvement in Western Ontario and McMaster Osteoarthritis Index and Knee Injury and Osteoarthritis Outcome Scores, but these differences were not statistically significant. One patient had an anaphylactic reaction to the preservation medium, but recovered within 24 hours. All other adverse events were localised and resolved without further action.

This technique may result in improved clinical outcomes, with the aim of slowing the degenerative process, leading to improvements in pain and function. However, imaging and direct observational studies are needed to verify cartilage regeneration. Nevertheless, this study provided a sufficient basis to proceed to further clinical testing.

Cite this article: Bone Joint J 2015;97-B:924–32.

Providing instrumental social support is more beneficial to reduce mortality risk among the elderly with low educational level in Taiwan: a 12-year follow-up national longitudinal study

BACKGROUND

To evaluate whether the effects of providing or receiving social support are more beneficial to reduce mortality risk among the elderly with different educational levels.

METHODS

In this long-term prospective cohort study, data were retrieved from the Taiwan Longitudinal Study on Aging. This study was initiated from 1996 until 2007. The complete data from 1492 males and 1177 females aged ≥67 years were retrieved. Participants received financial, instrumental, and emotional support, and they actively provided instrumental and emotional support to others and involved in social engagement. Education attainment was divided into two levels: high and low. The low education level included illiterate and elementary school. The high education level included junior high school to senior high school and above college. Cox regression analysis was used to examine the association between providing or receiving social support on mortality with different educational levels.

RESULTS

The average age of the participants in 1996 was 73.0 (IQR=8.0) years, and the median survival following years (1996-2007) of participants was 10.3 (IQR=6.7) years. Most participants were low educational level including illiterate (39.3%) and elementary school (41.2%). Participants with high educational level tend to be younger and more male significantly. On the contrary, participants with low educational level tend to have significant more poor income, more depression, more cognition impairment, more with IADL and ADL disability than high educational level. Most participants received instrumental support from others (95.5%) and also provided emotional support to others (97.7%). Providing instrumental support can reduce 17% of mortality risk among the elderly with a low level of education after adjusting several covariates [Hazard ratio (HR) = 0.83; 95% confidence interval (CI) = 0.70-0.99; p = 0.036].

CONCLUSIONS

Providing instrumental social support to others confer benefits to the giver and prolong life expectancy among the elderly with low educational levels.