Abstract P2-01-23: Long-term follow-up of persistent breast dermopigmentation after sentinel lymph node identification using superparamagnetic iron oxide particles (SIENNA+®)

Background

The French Sentimag study evaluated a non-invasive method for the localization of breast cancer sentinel lymph nodes (SLN) using SIENNA+®, a superparamagnetic iron oxide particles (SPIO), in addition to conventional techniques (radiotracer and blue dye). SIENNA+® was injected subcutaneously into the breast and detected by the SENTIMAG® handheld magnetometer probe. The results showed a good SLN identification performance but a skin discoloration was noted during this study after the SIENNA+® injection. This aim of this study was to assess the long-term duration and appearance of this dermopigmentation.

Methods:

56 patients had participated in Sentimag study in our Center, 6 patients who had undergone mastectomy were excluded. We selected 50 patients who had undergone breast conservative surgery. For these patients, SLN localization was performed by both the conventional method (radiotracer and /or blue dye) and magnetic tracer, SIENNA+®. 47 patients were reviewed retrospectively from January 2015 to April 2015, 1.5 to 2 years after surgery and were assessed for skin discoloration.

Results :

Of the 47 patients, a dermopigmentation, from grade 1 (light yellowing) to grade 3 (dark browning) remained visible at the site of injection of SIENNA+® after 20.2 months [14.4-25.9] in 36.1% of the patients (17/47). 6.4% of 47 patients seen had grade 3 skin discoloration and 29.7% had grade 1 or 2 skin discoloration. Interestingly, no patients reported that persistent staining was a cosmetic or psychological problem.

Conclusions :

The use of SIENNA+® appears as an alternative method to radioisotopes for SLN identification in early breast cancer, but it may result in a prolonged-dermopigmentation at the injection site. To avoid dermopigmentation, it would be interesting to compare different techniques of SIENNA+® injection into the breast (intra-tumoral injection or a deeper periareolar injection) through a randomized trial.

Citation Format: Hannebicque K, Boulanger L, Bogart E, Giard S, Chauvet MP, Houpeau JL. Long-term follow-up of persistent breast dermopigmentation after sentinel lymph node identification using superparamagnetic iron oxide particles (SIENNA+®) [abstract]. In: Proceedings of the 2016 San Antonio Breast Cancer Symposium; 2016 Dec 6-10; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2017;77(4 Suppl):Abstract nr P2-01-23.

Abstract P1-01-21: Sentinel Lymph Node detection after previous breast tumour surgical resection: identification rate and false negative rate through a prospective multi institutional study

Background: Large multi institutional studies have pointed that previous surgical resection of breast tumours before axillary sentinel node detection (ASLND) was the main criteria of failure of this technique. Screening campaigns provide small tumours and despite efforts to obtain a diagnosis of early breast cancer, this is not always obtained, due to small tumours or false negative results of micro biopsies. The aim of our series was to assess identification rates and false negative rates of ASLND after previous surgical resection of breast tumours.

Material and Methods: In a prospective multi institutional setting (14 multidisciplinary teams), we have included patients with a previous breast tumour surgical resection for the diagnosis of infiltrative breast adenocarcinoma. Patients with only a core biopsy and no surgical removal of the tumor before axillary surgery were not included. Each patient underwent a secondary surgical procedure for ASLND and axillary lymphadenectomy, and sometimes a breast secondary surgical procedure for margins. ASLND was performed with the combined method, with blue dye and technetium. Pathology was performed with serial sectioning, eosin safron and immune histo chemistry (IHC).

Results: From July 2006 to November 2011, 138 patients where included. The median tumor size was 9mm. Identification rate was 86% (118/138). A macrometastasis was found in 11 cases, in a sentinel node (9), or in a non sentinel node(2). False negative rate was 9% (1 false negative sentinel node with macrometastasis in non sentinel node from lymphadenectomy/11 cases with a macrometastasis in either a sentinel node or a non sentinel node). In 1 case a micrometastasis was found in a sentinel node through IHC, with a macrometastasis in a non sentinel node from lymphadenectomy. Without IHC or without the decision of performing a complementary lymphadenectomy in the case of micrometastasis, the false negative rate would have been 18%.

Conclusions: After previous surgical resection of early breast cancer, ASLND remains feasible with a low identification rate of 86%, despite the use of the combined method. The False negative rate is acceptable with the use of IHC.

Citation Information: Cancer Res 2012;72(24 Suppl):Abstract nr P1-01-21.

Abstract OT2-1-01: Feasibility of sentinel node detection after neoadjuvant chemotherapy for patient with proved axillary lymph node involvement: the French prospective multiinstitutional GANEA 2 ongoing trial

Background: Half of the patient treated with neoadjuvant chemotherapy (NAC) for a large operable breast cancer have no axillary lymph node involvement at the time of surgery. Sentinel lymph node detection (SLND), performed after NAC, would select patient who might be spared of an axillary lymphadenectomy (AL). In a previous study, we assessed the feasibility of SLND after NAC in the case of patients without axillary involvement1. Previous published series have shown that, for patients with an axillary lymph node involvement before treatment, SLND after NAC bring a low detection rate and a high false negative rate (FNR), making this technique contra indicated in this situation.

The aim of GAEA 2 study is to assess the FNR of SLND after NAC in the particular case of patients with a proven axillary lymph node involvement before NAC.

Patients and Method: Prospective study validated by scientific and ethical National boards.

Inclusion criteria: FIGO stage T2-T3 infiltrating breast carcinoma, indication of NAC, surgery (radical or conservative) after NAC and signature of the consent form,

Exclusion criteria: locally advanced, inflammatory breast cancer, local relapse, previous surgical removal of the tumour, mental disorder, pregnancy or no contraceptive method, contra-indication to NAC, NAC interrupted due to progressive disease.

Design of the study: Indication to plan a NAC, control of inclusion and exclusion criteria, consent form signature, axillary sonography before NAC to select the patient in group 1 (patient with a proven lymph node involvement treated with SLND and complementary AL) or 2 (no involvement proven treated with SLND + AL only if detection failure or involvement). Surgery, breast and axilla, performed 4 to 6 weeks after NAC.

Pathological procedure: No intraoperative histopathological examination. Pathological analysis, of sentinel and non sentinel nodes, carried out according to standard methods and classified according the last American Joint Committee staging system and Sataloff classification.

FNR is defined as the ratio of patients with a false negative case of SLNB to the patients with at least one involved node, SLN or not, among patients with SLN detected.

The hypothesis: Taking into account results of lymph node involvement rate found in GANEA 1, to estimate our hypothesis of a FNR between 10 and 15% with a 95% confidence interval will require to include 858 patients in order to obtain 260 patient with a proven axillary lymph node involvement (group 1).

A standard follow up is planned for each patient, with a clinical breast and axillary examination two times/ year and an annual mammography, for five years. In case of clinical axillary relapse a fine needle aspiration must be performed guided with sonography.

Results: On May 31, 2012, 341 patients were included from 16 French institutions; 130 patients with a proven SLN involvement before NAC and 211 with SLN free of metastasis.

1Classe JM, Bordes V, et al. Sentinel lymph node biopsy after neoadjuvant chemotherapy for advanced breast cancer: results of Ganglion Sentinelle et Chimiotherapie Neoadjuvante, a French prospective multicentric study. J Clin Oncol. 2009 Feb.

Citation Information: Cancer Res 2012;72(24 Suppl):Abstract nr OT2-1-01.

Abstract P4-14-10: Atypical Ductal Hyperplasia diagnosed on directional vacuum-assisted biopsy: is surgical excision mandatory?

Background: The incidence of atypical ductal hyperplasia (ADH) is increasing due to mass screening. Because of the underestimation risk of malignancy, the management remains controversial. Our goal was to analyze clinicopathologic features of patients with ADH diagnosed on directional vacuum-assisted biopsy (DVAB). The objectives of this continuous retrospective study were to evaluate the underestimation rate of malignancy and to identify predictors of upgrade to carcinoma.

Methods: Between 2003 and 2010, 3159 patients underwent stereotactic DVAB in our institute. We retrospectively evaluate clinical, mammographic and pathological features of 298 cases of ADH who underwent surgical excision in our center (93.1%). Patients with concurrent history of breast cancer, intraductal carcinoma (DCIS) associated, or with no follow-up or surgical excision on place were excluded. Histological scar of macrobiopsy was systematically searched in surgical specimens. A pathologic upgrade was defined by presence of invasive cancer or DCIS on surgical specimen. Statistical tests used were the chi-square or Fisher's exact test.

Results: Among the 298 studied DVAB, 224 ADH were isolated (75.2%), 46 associated to flat epithelial atypia (15.4%) and 28 to lobular neoplasia (9.4%). 98.4% patients presented microcalcifications at diagnosis. In 52 cases, lesions were upgraded to DCIS (n = 38) or invasive cancer (n = 14). The underestimated rate was 17.5%. In 67.3% cases, upgrade lesions were low or intermediate grade DCIS. Only the history of contralateral breast cancer was significantly correlated with the underestimated rate (p = 0.04). There was no statistical difference between these 52 cases and the 246 others for: family history, size of calcification, sampling number, histological lesion, and quality of calcifications removal.

Conclusions: In this study, DVAB may not be considered a therapeutic procedure in case of ADH, even in the case of complete removal of microcalcifications. It is still challenging to identify a subgroup of ADH cases with a low upgrade rate.

Citation Information: Cancer Res 2012;72(24 Suppl):Abstract nr P4-14-10.

Totally implantable venous access port systems and risk factors for complications: a one-year prospective study in a cancer centre

BACKGROUND

Totally Implantable Venous Access Port Systems (TIVAPS) are widely used in oncology, but complications are frequent, sometimes necessitating device removal and consequently delays in chemotherapy. The aim of this study was to investigate possible risk factors for morbidity.

METHODS

A total of 815 consecutive cancer patients (median age: 56.2 years [0.8-85.2]; 522 female) were enrolled in this observational, single-centre study between May 2nd 2006 and April 30th 2007. TIVAPS implantation involved principally cephalic or external jugular vein access. Patients were followed up for one year unless the device was removed earlier.

RESULTS

The overall morbidity rate was 16.1% (131/815). Complications necessitated device removal in 55 patients a mean of 3.7 months [0.2-12.0] after implantation. These comprised TIVAPS-related infection (19), port expulsion (14), catheter migration (6), venous thrombosis (5), mechanical problems (3), skin disorders (2), pain (2), drug extravasation (2) infection unrelated to TIVAPS (1) and inflammation (1). No patient died during the study. The factor most strongly predictive of complications was the interval between insertion and first use of the TIVAPS, ranging from 0 to 135 days (median: 8.0 days). The morbidity rate was 24.4% when this interval was 0-3 days, 17.1% when it was 4-7 days and 12.1% when it exceeded 7 days (p < 0.01; Chi(2) test). The median interval was 6 days (0-53) and 8 days (0-135), respectively, in patients with and without complications (p < 0.001).

CONCLUSION

To reduce complications, an interval of at least 8 days between placement of the TIVAPS and its first use may be advisable.

[Intraoperative molecular assessment of sentinel nodes in the breast cancer using the Gene Search BLN Assay technique: our experience about 126 patients]

INTRODUCTION

Intraoperative molecular assay Gene Search BLN Assay (BLN) detects sentinel lymph node (SLN) metastasis in breast cancer. Our objective was to compare BLN to the definitive conventional histologic methods and to experiment the management of BLN in routine.

MATERIAL AND METHODS

Each SLN was cut into alternate slabs. Half slabs were analysed with the intraoperative BLN molecular method, and the other slabs with the definitive histologic method.

RESULTS

Two hundred and thirty four SLN have been analysed (124 patients). Thirty-five SLN had metastasis for 29 patients (23.4%). BLN correctly identified 28 patients. Two cases of discordance between BLN and standard method were found, probably explained by a sample bias. The sensibility of BLN is 96.4%, the sensitivity is 99%, the predictive positive value is 96.4%, the predictive negative value is 99% and the concordance is 98.4%. The surgery time increases and there is a need to adapt the theatre organization accordingly.

CONCLUSION

The Gene Search BLN Assay gives a great interest for the patient, the surgeon and the pathologist because it increases the quality of the intraoperative analysis by comparison with the intraoperative conventional histology.

Métastase ovarienne d'un mélanome malin : à propos d'un cas

The diagnosis of malignant melanoma metastatic to the ovary is rare. The primary lesion can be followed by metastasis site after few years. We describe the case of a 31 year-old woman who presented an acute pelvic pain in relation with a right ovarian cyst. This patient presented many metastatic melanoma few years ago. The ovarian metastatic diagnosis is strongly suspected by the use of preoperative magnetic resonance imaging. The operating piece immunohistochemical studies demonstrated the positivity for S-100 protein, HMB-45 and negativity for keratin in cytoplasm cells. The surgical treatment (right salpingo-oophorectomy) would be followed by chemotherapy. The patient had a good postoperative recovery. She is in good health at six months.

Le ganglion sentinelle sans curage systématique dans le cancer du sein : bilan d'une expérience de 1000 interventions

OBJECTIVE

To assess daily practice of 1000 sentinel node (SN) biopsies in breast cancer.

PATIENTS AND METHOD

Prospective review of 1000 consecutive sentinel node biopsies between February 2001 and June 2004. Analyses concerned technical aspects of sentinel node detection, pathologic results of the tumor and sentinel node, treatment and follow-up.

RESULTS

Nine hundred and seventy-eight SN were detected (98.7%). In univariate analyses, age, pathologic tumor size (20 mm) and method of detection (blue dye or isotopic vs. combined) were statistically significant. One hundred and fifty-six cases (16%) underwent immediate axillary dissection (AD), whereas 116 (12%) had a delayed AD. There were 923 invasive or micro-invasive carcinoma with detected SN: 282 SN (30.5%) were involved, either with macrometastases (166) or with micrometastases (116), 34% had positive non-sentinel node. Age and metastasis size were predictive for AD involvement. Sixteen percent of micrometastatic SN had positive AD, there was no predictive factor for axillary involvement. After a median follow-up of 20 months, there were 4 axillary recurrences: 1 (0.1%) after negative SN without AD, 1 (0.1%) after positive SN with positive AD, 1 (4.3%) after micrometatastatic SN without AD, and 1 (8.3%) after macrometastatic SN without AD. There were 55 ductal carcinoma in situ and 54 micro-invasive cancer: positive SN (with negative AD) were detected in only 2 cases (2.3%). There were initially 112 ductal carcinoma in situ diagnosed by percutaneaous biopsy, 25 of them (22%) had invasive disease on definitive histology. Among there, 12 had involved SN (with 4 positive AD).

DISCUSSION AND CONCLUSION

With a high detection rate and low recurrence rate, SN biopsy is considered in our institute as a reliable procedure and is used to evaluate regional nodal status of early breast cancer. Thus, 70% of AD can be omitted.

Antiphospholipid syndrome and recurrent miscarriages

Sixty percent of recurrent spontaneous abortions are unexplained. Antiphospholipid syndrome is a multisystem disease with the predominant features of venous and arterial thrombosis, recurrent pregnancy loss, foetal death and the presence of antiphospholipid antibodies. Many epidemiological studies focus on antiphospholipid autoantibodies syndrome (APS) as a cause of recurrent spontaneous abortion (RSA). It is found that 7-25% of RSA would have APS as the main risk factor. 'Association not being synonymous with cause', the proportion of abortions due to the APS is difficult to estimate for several reasons: definition of recurrent abortion is variable, the assays for antiphospholipid antibodies are not well standardised, inclusion of patients in the study group according to the antibodies titre is author dependent. Recent studies suggest association of antiphospholipid antibodies syndrome not only with recurrent abortions but also with infertility. New mechanisms are described by which antiphospholipid antibodies could cause placental thrombosis and infarction, acting directly on the surface anticoagulant expressed on trophoblastic cells. Only lupus anticoagulant (LA) and anticardiolipin antibodies (aCL) assays are sufficiently standardised to be usable in routine. Testing for other antiphospholipid antibodies (aPLs) should remain investigational. Several treatments have been proposed: low doses of aspirin, low or immunosuppressive doses of corticosteroids, and preventive or effective dose of heparin, intravenous immunoglobulin.