Analysis of Time Between Skin Lesion and Lymph Node Biopsies and Lymph Node Metastasis in Patients With Melanoma

This cohort study assesses whether increasing time to surgery is associated with sentinel lymph node status in patients with cutaneous melanoma stage T1b or higher.

Adjuvant Therapy for Stage III Melanoma Without Immediate Completion Lymph Node Dissection

INTRODUCTION

For patients with stage III melanoma with occult lymph node metastasis, the use of adjuvant therapy is increasing, and completion lymph node dissection (CLND) is decreasing. We sought to evaluate the use of modern adjuvant therapy and outcomes for patients with stage III melanoma who did not undergo CLND.

METHODS

Patients with a positive SLNB from 2015 to 2020 who did not undergo CLND were evaluated retrospectively. Nodal recurrence, recurrence-free survival (RFS), distant metastasis-free survival (DMFS), and melanoma-specific survival were evaluated.

RESULTS

Among 90 patients, 56 (62%) received adjuvant therapy and 34 (38%) underwent observation alone. Patients who received adjuvant therapy were younger (mean age: 53 vs. 65, p < 0.001) and had higher overall stage (Stage IIIb/c 75% vs. 54%, p = 0.041). Disease recurred in 12 of 34 patients (35%) in the observation group and 11 of 56 patients (20%) in the adjuvant therapy group. The most common first site of recurrence was distant recurrence alone (5/34 patients) in the observation group and nodal recurrence alone (8/90 patients) in the adjuvant therapy group. Despite more adverse nodal features in the adjuvant therapy group, 24-month nodal recurrence rate and RFS were not significantly different between the adjuvant and observation cohorts (nodal recurrence rate: 26% vs. 20%, p = 0.68; RFS: 75% vs. 61%, p = 0.39). Among patients with stage IIIb/c disease, adjuvant therapy was associated with a significantly improved 24-month DMFS (86% vs. 59%, p = 0.04).

CONCLUSIONS

In this early report, modern adjuvant therapy in patients who forego CLND is associated with longer DMFS among patients with stage IIIb/c disease.

Utility of Quantitative SPECT/CT Lymphoscintigraphy in Guiding Sentinel Lymph Node Biopsy in Head and Neck Melanoma

PURPOSE

To investigate the use of advanced SPECT/CT quantification in guiding surgical selection of positive sentinel lymph nodes (SLNs) in head and neck melanoma.

METHODS

We retrospectively reviewed data from patients with cutaneous head and neck melanoma who underwent lymphoscintigraphy with SPECT/CT prior to SLN biopsy (SLNB). Quantification of radiotracer uptake from SPECT/CT data was performed using in-house segmentation software. SLNs identified using SPECT/CT were compared to SLNs identified surgically using an intraoperative γ-probe. A radioactivity count threshold using SPECT/CT for detecting a positive SLN was calculated.

RESULTS

One hundred and five patients were included. Median number of SLNs detected was 3/patient with SPECT/CT and 2/patient with intraoperative γ-probe. The hottest node identified by SPECT/CT and intraoperative γ-probe were identical in 85% of patients. All 20 histologically positive SLNs were identified by SPECT/CT and γ-probe. On follow-up, all nodal recurrences occurred at lymph node levels with the hottest node identified by SPECT/CT and either the hottest or second hottest node identified by γ-probe during SLNB. Using our data, a SPECT/CT radioactivity count threshold of 20% would eliminate the unnecessary removal of 11% of SPECT/CT identified nodes and 12% of intraoperatively detected nodes.

CONCLUSION

Utilizing SPECT/CT quantification, we propose that a radioactivity count threshold can be developed to help guide the selective removal of lymph nodes in head and neck SLNB. Furthermore, the nodal level containing the hottest node identified by SPECT/CT quantification must be thoroughly investigated for SLNs and undergo careful follow-up and surveillance for recurrence.

Frequency and implications of occipital and posterior auricular sentinel lymph nodes in scalp melanoma

BACKGROUND

Patients with scalp melanoma have poor oncologic outcomes compared with those with other cutaneous sites. Sentinel lymph node (SLN) biopsy provides prognostic information but is challenging in the head and neck. We explore the anatomic distribution of scalp melanoma and describe the most common sites of SLN drainage and of SLN metastatic disease.

METHODS

Retrospective review of scalp melanoma patients who underwent SLN biopsy. Melanoma location was classified as frontal, coronal apex, coronal temporal, or posterior scalp. SLN location was classified by lymph node level and region.

RESULTS

We identified 128 patients with scalp melanoma. The most common primary tumor location was the posterior scalp (43%) and the most frequent SLN drainage site was the level 2 lymph node basin (48%). Total 31 patients (24%) had metastatic disease in an SLN. Scalp SLNs, classified as being in the posterior auricular or occipital region, were localized in 26% of patients. For patients in which a scalp SLN was identified, 30% had a positive scalp SLN (n = 10).

CONCLUSIONS

Scalp SLNs are frequent drainage sites for scalp melanoma and, when found, have a 30% chance of harboring metastatic disease. Surgeons, radiologists, and pathologists should be vigilant in identifying, removing, and analyzing scalp SLNs.

A nomogram to predict node positivity in patients with thin melanomas helps inform shared patient decision making

OBJECTIVE

To develop a nomogram to estimate the probability of positive sentinel lymph node (+SLN) for patients with thin melanoma and to characterize its potential impact on sentinel lymph node biopsy (SLNB) rates.

METHODS

Patients diagnosed with thin (0.5-1.0 mm) melanoma were identified from the National Cancer Database 2012 to 2015. A multivariable logistic regression model was used to examine factors associated with +SLN, and a nomogram to predict +SLN was constructed. Nomogram performance was evaluated and diagnostic test statistics were calculated.

RESULTS

Of the 21 971 patients included 10 108 (46.0%) underwent SLNB, with a 4.0% +SLN rate. On multivariable analysis, age, Breslow thickness, lymphovascular invasion, ulceration, and Clark level were significantly associated with SLN status. The area under the receiver operating curve was 0.67 (95% confidence interval, 0.65-0.70). While 15 249 (69.4%) patients had either T1b tumors or T1a tumors with at least one adverse feature, only 2846 (13.0%) had a nomogram predicted probability of a +SLN ≥5%. Using this cut-off, the indication for a SLNB in these patients would be reduced by 81.3% as compared to the American Joint Committee on Cancer 8th edition staging criteria.

CONCLUSIONS

The risk predictions obtained from the nomogram allow for more accurate selection of patients who could benefit from SLNB.

Increasing omission of radiation therapy and sentinel node biopsy in elderly patients with early stage, hormone-positive breast cancer

Prospective evidence demonstrates that there is limited benefit of axillary staging with sentinel lymph node biopsy (SLNB) or radiation therapy (RT) in patients over age 70 with clinical stage I, hormone-positive breast cancer. The clinical impact of this literature is unknown. Our hypothesis is that omission of SLNB and RT has increased over time in these patients, and patient and tumor characteristics can predict when omission strategies are used. A single-center tumor registry was queried for all patients over age 70 with ER+, Her2/neu-negative, clinical T1N0 invasive breast cancer from 2009 to 2017, who underwent breast conservation (n = 141). Date of treatment, age, tumor characteristics, use of SLNB, and use of RT were evaluated. The trend of treatment strategy over time was evaluated. Multivariable analysis was performed on the subgroup of patients after publication of the long-term follow-up CALGB 9343 data¹ . Patients undergoing treatment with omission of RT and SLNB increased over the study period (P = .0006). Patients who did not receive RT were older (78.76 years ± 5.48 vs 73.37 ± 3.63, P < .01). There was no difference between tumor grade and size between uses of RT. Of patients who received SLNB (n = 84), only 3 (3.5%) had a positive LN. On multivariable analysis of patients who were treated after publication of the CALGB 9343 data (2014-2017), only age was predictive of being treated with RT (OR, 0.77; 95% CI, 0.67-0.88). Omission of both RT and SLNB are increasing in clinical practice in appropriately selected patients. The likelihood that patients are offered omission of these interventions increases with age. Low nodal positivity rates suggest that this strategy may be underutilized. Tumor grade and size were not predictive of omission of RT in this group of low-risk patients. Long-term data are needed as these approaches are increasingly adopted.

Postbiopsy Pigmentation is Prognostic in Head and Neck Melanoma

PURPOSE

To assess postbiopsy pigmentation (PBP) as a prognostic feature in patients with cutaneous head and neck (H&N) melanoma.

METHODS

Retrospective review of patients undergoing sentinel lymph node biopsy (SLNB) for H&N melanoma (1998-2018). PBP was defined as visible remaining pigment at the scar or biopsy site that was documented on physical exam by both a medical oncologist and a surgeon at initial consultation. Variables associated with disease-free survival (DFS) and overall survival (OS) were analyzed using multivariable Cox proportional hazards models.

RESULTS

Among 300 patients, 34.3% (n = 103) had PBP and 44.7% (n = 134) had microscopic residual disease on final pathology after wide local excision. Prognostic factors associated with DFS included advanced age, tumor depth, ulceration, PBP, and positive SLNB (p < 0.05). Patients with PBP fared worse than their counterparts without PBP in 5-year DFS [44.1% (31.1-56.3%) vs. 73.0% (64.1-80.0%); p < 0.001] and 5-year OS [65.0% (50.0-76.6%) vs. 83.6% (75.7-89.2%); p = 0.005]. After multivariable adjustment, PBP remained associated with shorter DFS [hazard ratio (HR) 1.72, 95% confidence interval (CI) 1.01-2.93; p = 0.047], but was not prognostic of OS.

CONCLUSIONS

In patients with H&N melanoma, PBP is associated with significantly shorter DFS. Patients with PBP may warrant greater consideration for SLNB and closer postoperative surveillance.

SPECT/CT Adds Distinct Lymph Node Basins and Influences Radiologic Findings and Surgical Approach for Sentinel Lymph Node Biopsy in Head and Neck Melanoma

BACKGROUND

Planar lymphoscintigraphy (PL) has a lower detection rate of sentinel lymph nodes (SLNs) in head and neck melanoma compared with other sites. We assessed situations when single-photon emission computed tomography/computed tomography (SPECT/CT) identified nodes not seen by PL. We also evaluated the impact of SPECT/CT on surgical approach and oncologic outcomes.

METHODS

Patients who underwent SLN biopsy (SLNB) for head and neck melanoma with PL and SPECT/CT between November 2011 and December 2016 were included. Surgeons and radiologists completed a real-time survey inquiring about the utility of SPECT/CT. Patients were divided into two groups: patients with nodal basins identified by both PL and SPECT/CT ('PL + SPECT/CT'), and patients in whom SPECT/CT identified additional nodal basins not seen on PL ('SPECT/CT only'). Patient demographics and long-term outcomes including follow-up duration, recurrence, and survival are described.

RESULTS

In the PL + SPECT/CT group, 73 (61.9%) patients were included and 45 (38.1%) patients were included in the SPECT/CT-only group. SPECT/CT added 51 basins to those seen on PL, primarily in the supraclavicular region (43.1%). Eighteen patients had positive node(s) in the PL + SPECT/CT group compared with two patients in the SPECT/CT-only group. Surgeons reported that 81% of the time, SPECT/CT influenced the location of incision for SLNB.

CONCLUSIONS

SPECT/CT influences the location of incision and contributes most to identification of nodes in the supraclavicular region. It also detects additional SLN basins when compared with PL. Further studies are necessary to determine when these additional basins require sampling.

Patterns of Fractionation and Boost Usage in Adjuvant External Beam Radiotherapy for Ductal Carcinoma in Situ in the United States

BACKGROUND

While the roles of hypofractionated (HFxn) radiotherapy and lumpectomy boost in the adjuvant management of invasive breast cancer are supported by the results of clinical trials, randomized data supporting their use for ductal carcinoma in situ (DCIS) are forthcoming. We sought to evaluate current national trends and identify factors associated with HFxn and boost usage using the National Cancer Database.

PATIENTS AND METHODS

We queried the National Cancer Database for women diagnosed with DCIS from 2004 to 2014 undergoing external beam radiotherapy after breast conservation surgery. Patients were categorized as receiving either conventional fractionation (CFxn) or HFxn and as either receiving or not receiving a boost. Multiple logistic regression was performed to identify demographic, clinical, and treatment factor associations.

RESULTS

A total of 101,615 women were identified, with 87,641 (86.2%) receiving CFxn, 13,974 (13.8%) receiving HFxn, and most patients in each group (84.9% and 57.7%, respectively) receiving a boost. Implementation of HFxn increased from 4.3% in 2004 to 33.0% in 2014, and the use of a boost declined from 83.3% to 74.6%. HFxn receipt was independently associated with later year of diagnosis, older age, higher income, greater distance from treatment facility, greater facility volume, academic facility type, Western residence, smaller lesions, and nonreceipt of a boost. Factors associated with boost receipt included earlier year of diagnosis, younger age, higher income, community facility type, adverse pathologic features, and nonreceipt of HFxn.

CONCLUSION

Although CFxn with a boost remains the most common external beam radiotherapy strategy for DCIS, implementation of HFxn without a boost appears to be increasing. Practice patterns at present seem to be driven by guidelines for invasive breast cancer and nonclinical factors.

Breast Cancer Following Radiation for Hodgkin Lymphoma: Clinical Scenarios and Risk-Reducing Strategies

Since most patients with Hodgkin lymphoma survive their disease, long-term issues such as development of second primary malignancies arise, especially in patients treated with multimodal therapy including radiation therapy plus chemotherapy. The risk of breast cancer is significantly elevated in women exposed to high-dose ionizing radiation to the chest before age 40. The case of a 48-year-old patient with a lump in her right breast is presented as a clinical scenario in this article. We review available strategies for screening and risk reduction through chemoprevention or risk-reducing surgery, as well as challenges for management of breast cancer in patients with prior exposure to radiation for Hodgkin lymphoma. The Children's Oncology Group clinical practice guidelines for long-term follow-up care of pediatric cancer survivors provide recommendations that have been endorsed by American and European oncologists.

Association of sentinel lymph node diameter with melanoma metastasis

BACKGROUND

Lymph nodes are an important part of the immune system and the size of the lymph node reflects local immunologic activity. The purpose of this study was to examine the association between sentinel lymph node (SLN) size and the presence of nodal metastasis in patients with melanoma.

METHODS

Retrospective review of a prospectively maintained database of patients undergoing SLN biopsy for cutaneous melanoma between February 1995 and January 2013. The maximum pathologic diameter and the volume of the largest node was used. A nodal diameter of 1.5 cm, included in 2 interquartile ranges of both positive and negative SLNs, was used as the cutoff for multivariate regression.

RESULTS

Of 1,017 SLN biopsies, 826 (81%) had complete size measurements and were included in the analysis. Patients with a positive SLN were younger (median 50 vs 53 years, P = .032), had deeper primary lesions (2 vs 1.4 mm, P < .001), and had larger SLN volume (.8 vs .6 cc, P = .009) or maximum diameter (1.9 vs. 1.6 cm, P = .03). Sex, pathologic ulceration, mitosis, and the type or location of the primary was not statistically different. On multivariate analysis; age, depth of primary, and both SLN volume and maximum diameter remained significant. An SLN greater than 1.5 cm in maximum diameter has a 60% increased odds ratio of being positive after adjusting for age, sex, and depth of primary lesion (P = .046).

CONCLUSIONS

Larger SLN maximum diameter is associated with nodal positivity independent of age, sex, depth of primary lesion, and location of SLN biopsy. The etiology and significance of larger SLNs warrant further analysis.

SPECT/CT Improves Detection of Metastatic Sentinel Lymph Nodes in Patients with Head and Neck Melanoma

BACKGROUND

A positive sentinel lymph node (SLN) is the most important prognostic factor for predicting survival in cutaneous melanoma. This study aimed to evaluate how the addition of single-photon emission computed tomography (SPECT) and computed tomography (CT) to planar lymphoscintigraphy (PL) alters SLN identification, yield, and localization of metastatic nodes in head and neck melanoma.

METHODS

This retrospective review examined patients undergoing SLN biopsy for cutaneous melanoma of the head and neck between July 2003 and December 2015. Patient demographics and pathologic outcomes were compared for patients undergoing SPECT-CT versus PL. A multivariable logistic regression analysis was used to identify factors associated with the identification of a positive SLN.

RESULTS

Among 176 patients undergoing SLN biopsy, 91 underwent PL and 85 underwent SPECT-CT and PL. The patients in the SPECT-CT group were older than the PL patients (p = 0.050) but the groups did not differ in gender (p = 0.447), Breslow thickness (p = 0.744), or total number of SLNs identified (p = 0.633). As shown by the multivariate regression analysis, only Breslow thickness [odds ratio (OR) 1.47; 95 % confidence interval (CI) 1.17-1.84] and SPECT-CT (OR 3.58; 95 % CI 1.24-10.4) were associated with a positive SLN.

CONCLUSION

The use of SPECT-CT for patients with head and neck cutaneous melanoma significantly increases the likelihood of retrieving a positive SLN. Long-term follow-up evaluation is needed for further definition of the impact that SPECT-CT has on recurrence and survival.

Analysis of melanoma recurrence following a negative sentinel lymph node biopsy

Little attention has been paid to the characteristics and outcomes of patients who experience distant, local or regional recurrence of melanoma following a negative sentinel lymph node biopsy. This article aims to review the published literature on the topic and presents some general summaries regarding this patient population. Patients who experience a disease recurrence following a negative sentinel lymph node biopsy have a worse overall survival compared with patients with a positive sentinel lymph node biopsy. The implications and possible explanations for these findings are discussed in order to both underscore the need for in-depth investigation of local, regional or distant melanoma recurrence among patients following a true negative sentinel lymph node biopsy, as well as increased efforts to minimize the rate of false negative sentinel lymph node biopsies.

Breast Cancer Risk Reduction, Version 2.2015

Breast cancer is the most frequently diagnosed malignancy in women in the United States and is second only to lung cancer as a cause of cancer death. To assist women who are at increased risk of developing breast cancer and their physicians in the application of individualized strategies to reduce breast cancer risk, NCCN has developed these guidelines for breast cancer risk reduction.

The integration of locoregional with systemic adjuvant therapy for early-stage breast cancer: the shifting sands of decision-making

SUMMARY Given the generally excellent outcomes for modern breast cancer treatment, the recognition that overtreatment is commonplace is the driving force to reduce the treatment impact of surgery, radiation therapy and chemotherapy. Many recent trials have demonstrated that fewer axillary lymph node dissections, smaller radiation field sizes and less administration of chemotherapy are all feasible without compromising the long-term outcomes. However, each of these trials has studied a single modality while maintaining the intensities of the other modalities. There is a natural tendency, albeit controversial, to reduce more than one modality at a time. We review the literature, and counsel the breast cancer oncologist to work as a multimodality team to decide with the patient which modality can be reduced, and which should be preserved in its intensity.

Long-term follow-up and survival of patients following a recurrence of melanoma after a negative sentinel lymph node biopsy result

OBJECTIVE

To analyze the predictors and patterns of recurrence of melanoma in patients with a negative sentinel lymph node biopsy result.

DESIGN

Retrospective chart review of a prospectively created database of patients with cutaneous melanoma. SETTING Tertiary university hospital.

PATIENTS

A total of 515 patients with melanoma underwent a sentinel lymph node biopsy without evidence of metastatic disease between 1996 and 2008.

MAIN OUTCOME MEASURES

Time to recurrence and overall survival.

RESULTS

Of 515 patients, 83 (16%) had a recurrence of melanoma at a median of 23 months during a median follow-up of 61 months (range, 1-154 months). Of these 83 patients, 21 had melanoma that metastasized in the studied nodal basin for an in-basin false-negative rate of 4.0%. Patients with recurrence had deeper primary lesions (mean thickness, 2.7 vs 1.8 mm; P < .01) that were more likely to be ulcerated (32.5% vs 13.5%; P < .001) than those without recurrence. The primary melanoma of patients with recurrence was more likely to be located in the head and neck region compared with all other locations combined (31.8% vs 11.7%; P < .001). Median survival following a recurrence was 21 months (range, 1-106 months). Favorable characteristics associated with lower risk of recurrence included younger age at diagnosis (mean, 49 vs 57 years) and female sex (9% vs 21% for males; P < .001).

CONCLUSION

Overall, recurrence of melanoma (16%) after a negative sentinel lymph node biopsy result was similar to that in previously reported studies with an in-basin false-negative rate of 4.0%. Lesions of the head and neck, the presence of ulceration, increasing Breslow thickness, older age, and male sex are associated with increased risk of recurrence, despite a negative sentinel lymph node biopsy result.

Abstract A98: Young women's breast cancer demonstrates increased immune suppression through ciculating regulatory T cells and myeloid-derived supressor cells independent of stage or subtype

Background: Women age 20-40 have a higher ten year risk for developing breast cancer than the five other leading cancers in this gender and age group combined. Women currently in their 30s have a 1/203 risk for breast cancer in the ensuing ten years. Cancers diagnosed in this age population of breast cancer have a higher risk for death for reasons that are not fully identified. Regulatory T cell (Tregs) and myeloid derived suppressor cells (MDSC) have a role in suppressing anti-tumor immunity. MDSC function through Jak/Stat pathway activation by generation of reactive oxygen species and/or arginase-1, and have been correlated pre-clinically with cancer progression and poorer prognostic features and outcomes. Our Young Women's Breast Cancer Translational Program seeks to identify immunologic differences potentially contributing to the poorer prognosis and potential targets for development of immunomodulatory treatment. Hypothesis: We hypothesized that newly diagnosed, treatment-naive young breast cancer cases would have higher percentage of circulating Tregs and MDSC with T cell suppressive function that similar age women without breast cancer. Methods: We conducted an IRB-approved, prospective translational study of women age 40 and under both affected and unaffected by breast cancer. Exclusion criteria included pregnancy, known autoimmunity or immunosuppressive medications, or other cancers. Tregs and MDSC were isolated from peripheral blood and phenotyped through standard protocols. The ability of MDSC to suppress T cell function were tested in co-culture assays for expression of activation marker CD25, production of gamma-interferon and production of arginase-1 and generation of reactive oxygen species. Results: As expected, Tregs were in higher number in young women with breast cancer than unaffecteds. Contrary to prior publications no difference was detected in number of MDSC identified in breast cancer (n=61) versus unaffected subjects (n=18). However, statistically significant increase in the MDSC ability to suppress T cell activation was identified in the breast cancer cohort with decreased CD25 expression and gamma-interferon production. MDSC from young women with breast cancer also secreted higher arginase-1 but not ROS from their MDSC. Level of MDSC suppression was independent of stage or biologic subtype of the breast cancer and did not correlate with the level of Tregs in the patient.

Conclusions: The presence of equal rather than higher numbers of MDSC circulating in young onset breast cancer versus unaffected subjects was unexpected in comparison to prior publications. Our results may differ due to our larger sample size or the alignment by gender and age between the cohorts. Also, these are the first data on Tregs and MDSC to specifically focus on a young female population. Despite the equal numbers, MDSC from the breast cancer cohort demonstrated increased ability to suppress T cell function which was independent of cancer stage, biologic subtype or number of Tregs in the subject. These data suggest a functional difference to MDSC in the young breast cancer-bearing woman that could be exploited in even early stage breast cancer and that is not directly dependent on Tregs numbers. Moreover, the data indicate that unaffected young women have a higher than expected number of MDSC available for cancer to usurp and induce immune suppression. Identification of secretion of arginase-1 as a potential mechanism of immune suppression in young women's breast cancer warrants further investigation.

Citation Format: Virginia F. Borges, Oscar Ramirez, Michelle Borakove, Elizabeth Manthey, Christina Finlayson, Anthony Elias, Martin McCarter, Kimberley Jordan, Jennifer Diamond, Nicole Kounalakis. Young women's breast cancer demonstrates increased immune suppression through ciculating regulatory T cells and myeloid-derived supressor cells independent of stage or subtype. [abstract]. In: Proceedings of the AACR Special Conference on Tumor Immunology: Multidisciplinary Science Driving Basic and Clinical Advances; Dec 2-5, 2012; Miami, FL. Philadelphia (PA): AACR; Cancer Res 2013;73(1 Suppl):Abstract nr A98.

Abstract P4-04-06: Young women's breast cancer is characterized by increased immune suppression through circulating myeloid derived supressor cells

Background: Women age 20–40 have a higher ten-year risk for developing breast cancer than the five other leading cancers in this gender and age group combined. Women currently in their 30s have a 1/203 chance of developing breast cancer over the next ten years. Moreover, cancers diagnosed in younger women have a signficantly higher risk of death for reasons that are not fully identified. Myeloid derived suppressor cells (MDSC) have a role in suppressing anti-tumor immunity through Jak/Stat pathway activation by generation of reactive oxygen species (ROS) and arginase-1, and correlate preclinically with cancer progression and in human canceres with poorer prognositic features and outcomes. Our Young Women's Breast Cancer Translational Program seeks to identify immunologic differences potentially contributing to the poorer prognosis and potential targets for development of immunomodulatory treatment.

Hypothesis: We hypothesized that newly diagnosed, treatment-naive young breast cancer cases would have higher percentage of circulating MDSC with T cell suppressive function than similar age women without breast cancer.

Methods: We conducted IRB approved, prospective translational studies of women age 40 and under both affected and unaffected by breast cancer. Exclusion criteria included pregnancy, known autoimmunity or immunosuppressive medications, or other cancers. MDSC were isolated from peripheral blood and phenotyped through standard protocols. T cell suppressive abilites were tested in coculture assays for expression of activation markers CD25 and CD69, and production of gamma-interferon. Identification of mechanism of suppression was assayed through secretion of arginase-1and generation of ROS.

Results: No difference in percentage of MDSC was identified between young women with breast cancer (n = 61) and unaffected subjects (n = 18). However, a statistically significant increase in the MDSC ability to suppress T cell activation was identified in the breast cancer cohort with diminished CD25 and CD69 expression and diminished production of gamma-interferon. MDSC from young breast cancer subjects secreted significantly more arginase-1 from MDSC. No significant difference in generation of ROS was found between the two cohorts.

Conclusions: The presence of equal rather than higher numbers of circulating MDSCs between the young breast cancer versus unaffected subjects was unexpected in comparison to prior publications on MDSC in cancer. Our results may differ due to our larger sample size or the alignment by gender and age the cohorts being more representative. Also, these are the first data on MDSC in a young female population. Despite equal numbers of MDSCs, the functional analyses demonstrate MDSC isolated from breast cancer have enhanced T cell suppression capabilities compared with normal controls. These data provacatively suggest a functional difference inherent to MDSC in the young breast cancer-bearing host. Moreover, they indicate that normal young women have realtively high levels of MDSC that are available for cancer to ursurp and induce immune suppression. Identification of secretion of arginine-1 as a potential mechanism of immune supporession in young women's breast cancer warrants further investigation.

Citation Information: Cancer Res 2012;72(24 Suppl):Abstract nr P4-04-06.

A neoadjuvant biochemotherapy approach to stage III melanoma: analysis of surgical outcomes

AIMS

Completion lymph node dissection (CLND) and adjuvant therapy are recommended for node-positive melanoma patients. We sought to analyze our institution's experience with neoadjuvant biochemotherapy in stage III patients.

METHODS

Clinical information was extracted from a retrospective database on stage III melanoma patients. Eligible patients received two cycles of biochemotherapy prior to their CLND.

RESULTS

There were 153 patients available for analysis. The average tumor depth was 2.5 mm. More than half of all patients presented with sentinel lymph node-positive disease. Surgical complications occurred in 23% of patients. Patients who experienced an adverse event during their neoadjuvant therapy had a worse overall survival when compared with those who did not (p = 0.005).

CONCLUSION

Our data suggest that aggressive neoadjuvant treatment prior to CLND does not impact surgical complications. Our surgical outcomes are similar to the current literature when adjuvant therapy is used in stage III melanoma. The inability to tolerate neoadjuvant therapy in stage III melanoma is a negative prognostic indicator.

Abstract C78: A variant of the oncogene RET might be a molecular target in BRAFwt melanoma cells

Desmoplastic malignant melanomas (DMM) are clinically, pathologically, and molecularly different from other melanomas. Patients with this subset of melanoma are generally older, with tumors exhibiting deeper levels of invasion, a low incidence of nodal involvement, and tend to track along nerves. Previous studies indicate that DMM tumors have a low prevalence of BRAFV600E mutations making them ineligible for targeted therapies with BRAF inhibitors. The oncogene RET is a tyrosine kinase receptor mainly associated with neuroendocrine cancers and is activated by the ligand glial cell-derived neurotrophic factor (GDNF). Numerous studies suggest that given the neurotrophic features of DMM, a variant of RET (G691S, designated RETp) may be a potential molecular target. We examined human melanoma cell lines for RETp and the BRAFV600E mutation and demonstrated that these molecular changes were usually discordant suggesting that RETp might be an attractive molecular target in BRAFwt cells. Further we hypothesized that in tumors with the RETp genotype, certain TKIs may be more effective in inhibiting cell growth in environments rich with GDNF. We screened various melanoma cell lines with and without the RETp genotype and determined their response to clinically available small molecular weight inhibitors. The cell viability effects were accessed in the presence and/or absence of the RET co-receptor, GFRa1, and ligand, GDNF. We show that in cell lines carrying the RETp genotype, GDNF alone increases cell proliferation, and certain small molecular weight inhibitors may be more effective at inhibiting melanoma cell growth in environments rich in GDNF.

Citation Format: {Authors}. {Abstract title} [abstract]. In: Proceedings of the AACR-NCI-EORTC International Conference: Molecular Targets and Cancer Therapeutics; 2011 Nov 12-16; San Francisco, CA. Philadelphia (PA): AACR; Mol Cancer Ther 2011;10(11 Suppl):Abstract nr C78.

Partial breast irradiation in a patient with bilateral breast cancers and CREST syndrome

PURPOSE

To describe the first documented use of partial breast irradiation (PBI) in a patient with calcinosis, Raynaud's phenomenon, esophageal dysmotility, sclerodactyly, and telangiectasias (CREST) syndrome.

METHODS AND MATERIALS

A 50-year-old woman with well-controlled CREST syndrome for 6 years was diagnosed with bilateral early-staged breast cancers. She underwent bilateral lumpectomies, sentinel lymph node biopsies, and PBI delivered via bilateral MammoSite catheters (Cytyc Corp., Marlborough, MA) followed by chemotherapy. She was monitored perioperatively, at 6 months and at 1 year for worsening of her CREST-related symptoms and complications associated with surgery and radiation therapy. Both surgeon and patient's opinion of her cosmetic outcome were also recorded at 1-year followup.

RESULTS

The patient experienced mild acute cellulitic changes in the perioperative period, which resolved with antibiotics. At 6 months, she exhibited a Grade 1 late toxicity, which has remained stable at 1-year followup. The patient and surgeon are very pleased with her cosmetic outcome.

CONCLUSIONS

Accelerated PBI was delivered safely to a patient with collagen vascular disease. By decreasing the surface area receiving radiation with accelerated PBI, we believe that the toxicity associated with the treatment was minimized. Future studies will be necessary to clarify the use of PBI in patients with collagen vascular disease.

A pilot study to compare FXR expression in normal and malignant tissue in receptor-positive early-stage breast cancer

e14645

Background: Farnesoid X receptor (FXR), a nuclear receptor, is a ligand dependent transcriptional factor regulating cholesterol and carbohydrate metabolism. Recently, FXR was shown to have a contributing role in colorectal cancer. We hypothesize that FXR expression changes from normal to premalignant to malignant tissue in patients with breast cancer. Methods: We identified 16 paired formaldehyde fixed, paraffin embedded tissue (normal, premalignant, and malignant) from patients with receptor positive, early stage breast cancer. Clinical information was extracted from a prospective database initiated in 2006 under institutional approval. Immunohistochemical staining of FXR using a validated polyclonal antibody was completed with appropriate positive and negative controls. The slides were graded independently by two investigators using an agreed upon scale to detect the percentage of positively stained cells to the nearest 10th percentile. Statistical analysis was performed by ANOVA and Student's t-test. A p-value of 0.05 was considered significant in all analyses. Results: Normal tissue and invasive cancer was identified in all 16 patient specimens. Of the 16 invasive cancers, 12 were ductal and 4 were lobular. 8/16 (50%) of the specimens also contained non-invasive cancer. 5/16 patients (31%) had N1 disease. FXR expression did not correlate with grade, histology, stage, or lymph node status. However, FXR expression increases with malignant transformation of the breast cancer cell. The mean percentage of cells staining positive for FXR in normal breast tissue was 58%, non-invasive 72% and invasive 79%. FXR staining in normal breast tissue was significantly less when compared to both invasive and noninvasive cancer (p< 0.007). Conclusions: FXR expression is upregulated in breast cancer when compared with expression in normal tissue and appears to progressively increase along the continuum of malignancy. Our pilot study results warrant further evaluation into FXR as a predictive biomarker for breast cancer, given the ability to target FXR via development of non-toxic oral ligands.

No significant financial relationships to disclose.

Abdominal perineal resection improves survival for nonmetastatic adenocarcinoma of the anal canal

BACKGROUND

There remains a lack of consensus regarding the optimal treatment for patients with curable adenocarcinoma of the anal canal (AAC). We sought to determine the role of definitive surgical resection and radiation in a large cohort of patients with AAC.

MATERIALS AND METHODS

We queried the Surveillance, Epidemiology, and End Results (SEER) registry to identify all patients with nonmetastatic AAC from 1988 to 2004 and analyzed clinical factors, treatment modalities, and overall survival in this cohort. Kaplan-Meier survival curves were constructed to compare 5-year overall survival based on treatment groups: abdominal perineal resection (APR) only, APR and external beam radiation (APR and EBR), and EBR only. We performed a Cox regression analysis to determine factors predictive of outcome.

RESULTS

A total of 165 patients were identified with nonmetastatic AAC. Of these, 30 patients were treated with an APR only, 42 patients with an APR and EBR, and 93 patients with EBR only. The 5-year survival for APR only, APR and EBR, and EBR only was 58%, 50%, and 30%, respectively. The difference in survival was statistically significant (APR vs. EBR, P = .02; APR and EBR vs. EBR, P = 0.04). Multivariate analysis completed on 86 patients in this cohort confirmed that factors accounting for the survival differences included age (P = 0.004), nodal stage (P = 0.001), and treatment groups (P = 0.03). The hazard ratio between EBR only compared with APR only was 2.78.

CONCLUSIONS

Definitive surgical treatment in the form of an APR with or without EBR is associated with improved survival in patients with AAC.

Tumor cell and circulating markers in melanoma: Diagnosis, prognosis, and management

The search is on for biomarkers for use in the diagnosis, staging, prognosis, and management of patients with melanoma. As with many types of cancer, the hematogenous spread of melanoma is a bad prognostic sign, and many groups have attempted to detect circulating melanoma cells in patients with different stages of melanoma. Some studies have used direct extraction of intact tumor cells from the peripheral blood and others the detection of surrogate markers of circulating melanoma cells, such as tyrosinase or MART-1. However, a correlation between the detection of intact melanoma cells in the circulation and prognosis is controversial. Many other biomarkers have also been studied, including lactate dehydrogenase, S100, TA90, and C-reactive protein. Much progress has been made, and preliminary studies have shown promise with many of these markers. Finally, the detection of tumor-specific circulating DNA has shown promise as a prognostic and diagnostic marker of disease in melanoma as well. In this review we examine the most promising biomarkers for use in patients with cutaneous melanoma.

Regulation of pharyngeal motility by FMRFamide and related peptides in the medicinal leech, Hirudo medicinalis

The medicinal leech possesses FMRFamide-like immunoreactivity in neural processes and somata associated with the pharynx and pharyngeal ganglia. The pharynx possessed about 25 immunoreactive somata; about half of the approximately 20 neurons of the pharyngeal ganglia were immunoreactive. We provide brief descriptions of several neurons located in the first neuromere of the subesophageal ganglion involved in controlling pharyngeal motility. Double-labeling experiments indicate that one of these cells, named Swallow neuron 1 (SW1), contains a FMRFamide-like peptide. Stimulation of SW1 caused the mouth to open and the pharynx to dilate. Upon termination of SW1 stimulation, the mouth closed, and a peristaltic wave progressed from the mouth down the length of the pharynx. Stimulation of SW1 did not produce 1:1 postsynaptic potentials in pharyngeal muscle cells. Thus, SW1 is apparently not a motor neuron. The pharynx responded to application of FMRFamide and related peptides by producing a series of 20- to 35-s phasic contractions superimposed upon an increase in basal tonus. The peptide-induced response was quantified by measuring increases in basal tonus, peak tension, and integrated area. Although there were some differences in the order of potency depending upon which parameter was considered, the approximate order of potency of RFamide peptides tested was: pQDPFLRFamide > or = FMRFamide approximately YGGFMRFamide > or = YMRFamide approximately FLRFamide approximately GGKYMRFamide approximately YLRFamide > leucomyosuppressin approximately perisulfakinin. Except for differences in potency, each of the RFamide peptides produced similar contractile waveforms. FMRFamide-induced responses were reduced by the protein kinase C inhibitor bisindolylmaleimide I (10 microM), the nonspecific protein kinase inhibitor H-7 (50 microM), and were increased by the protein phosphatase inhibitor okadaic acid (1 microM). However, the FMRFamide-induced response was unaffected by the protein kinase A inhibitor H-89 (1 microM), the phosphodiesterase inhibitor theophylline (1 mM), the phospholipase A(2) inhibitor OBAA (0.1 microM) or the cation channel blocker amiloride (100 microM).