Abstract P3-17-09: Resolution of DCIS in patients with early breast cancer receiving primary chemotherapy for invasive breast cancer

Background

Ductal Carcinoma in Situ (DCIS) plays a pivotal role in surgical planning for patients who are to undertake primary chemotherapy. As DCIS is not thought to be responsive to chemotherapy, many women with large primaries or extensive DCIS on initial diagnosis will be planned for and undergo mastectomy. To investigate the role of chemotherapy in invasive breast cancer with concomitant ductal carcinoma in situ (DCIS), we examined patients who had primary systemic therapy for a primary invasive cancer with either radiologically or histologically proven DCIS to see if there were patients in whom there was no evidence of DCIS at resection.

Methods

This was a retrospective single centre study. Examining the records of all patients who had received primary chemotherapy between January 2010 and October 2014.

Patients were identified through the Guy's breast cancer database and chemotherapy prescribing system. To fully assess the DCIS status, all patients were cross-referenced with the electronic notes on our electronic noting system (MOSAIQ), radiology on Patient Archiving and Communication System (PACS) and histology on our Electronic Patient Record (EPR).

Results

1526 patients were identified, of whom 156 underwent primary chemotherapy. Of these, 46 patients had a pre-chemotherapy biopsy confirming DCIS, of whom 30 also had radiological evidence of DCIS. A further 26 had micro-calcification on their initial imaging which was presumed to be DCIS.

Twelve of the 46 patients with biopsy proven DCIS at presentation did not have DCIS at resection. Of these 9 had a mastectomy, with 5 achieving a pathological complete response (pCR), of whom 4 had a complete radiological response (rCR).

Of the 26 who had micro-calcification pre-chemotherapy, 15 did not have DCIS in the resection specimen. Of these, 10 had a mastectomy, with 6 having a pCR of whom 3 also had rCR.

Conclusion

This retrospective study suggests that chemotherapy can influence DCIS, with 12 biopsy proven having a pCR post treatment. This may indicate that some patients may be spared mastectomy.

Although there were patients with radiological evidence of DCIS, without a confirmatory biopsy we cannot be sure that these were malignant. This highlights the need to ensure that all suspicious areas distant from the primary tumour should be biopsied before treatment.

In conclusion, for patients who have an excellent clinical and radiological response, even in the presence of DCIS at presentation, more intensive evaluation is indicated if conservative surgery is a possibility.

Citation Format: Chowdhury MHR, Thillai K, Lucey A, Michalarea V, Mera A, Karapanagiotou E, Sandri I, Mansi J. Resolution of DCIS in patients with early breast cancer receiving primary chemotherapy for invasive breast cancer [abstract]. In: Proceedings of the 2016 San Antonio Breast Cancer Symposium; 2016 Dec 6-10; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2017;77(4 Suppl):Abstract nr P3-17-09.

Abstract P2-01-13: Can axillary lymph node clearance be avoided in women with node positive breast cancer receiving primary chemotherapy?

Background

For patients who receive primary chemotherapy for their early breast cancer the current practice for lymph node positive (LN) disease at presentation is in transition, with a drive towards sentinel LN biopsy (SLNB) rather than axillary node clearance (ANC) for patients who achieve a good response to primary chemotherapy. Boileau et al initially reported that approximately 30% of patients could potentially avoid clearance, but with a recommendation for further evaluation before including SLNB in guidelines for biopsy proven node-positive disease prior to primary chemotherapy for early breast cancer.

Methods

This was a retrospective single centre study. Examining the records of all patients who had received primary chemotherapy between January 2010 and October 2014.

Patients were identified through the Guy's Breast Cancer Database and chemotherapy prescribing system. To fully assess the LN status, all patients were cross-referenced with the electronic notes on our electronic noting system (MOSAIQ), radiology on Patient Archiving and Communication System (PACS) and histology on our Electronic Patient Record (EPR).

Results:

1526 patients were identified, of whom 156 underwent primary chemotherapy. 111 patients had suspicious nodes on imaging (ultrasound and/or MRI) and underwent LN biopsy. 69 patients had positive nodes pre-chemotherapy. 28 of these 69 patients (40.6%) had negative nodes at ANC, of these 14 (50%) had complete pathological complete response (pCR) in their primary tumour(s) of whom 12 (86%) had radiological CR prior to surgery. Of the 41 who remained positive only three achieved pCR of their primary tumour after chemotherapy.

22 patients were LN positive post primary chemotherapy, despite having been identified as initially LN negative. Of these 9 had a negative pre chemotherapy biopsy, and only 1 of these 22 patients had a pCR.

Discussion:

We have confirmed that ANC may be avoided in selected patients with LN involvement at presentation. In our series over 40% could have had SLNB instead. Factors supporting this approach include those patients who have an excellent radiological response to primary chemotherapy. Conversely, 22 of 87 (25%) had positive LN after chemotherapy having been initially thought to be LN negative at presentation, highlighting the possible need for multiple nodal sampling prior to chemotherapy as well as further nodal assessment after chemotherapy for complete staging.

Citation Format: Chowdhury MHR, Thillai K, Lucey A, Michalarea V, Mera A, Karapanagiotou E, Sandri I, Mansi J. Can axillary lymph node clearance be avoided in women with node positive breast cancer receiving primary chemotherapy? [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 P2-01-13.

Clinical outcomes for patients with liver-limited metastatic colorectal cancer: Arguing the case for specialist hepatobiliary multidisciplinary assessment

In patients with liver-limited metastatic colorectal cancer, hepatic resection can offer a significant survival benefit over systemic therapy alone. Specialist hepatobiliary multidisciplinary meetings are currently believed to provide the best forum to discuss the management for these patients. A retrospective analysis was undertaken of patients diagnosed with liver-limited metastatic colorectal cancer over 6 months within a cancer network in the United Kingdom. In addition, patients who were diagnosed but not referred to the hepatobiliary meeting were discussed within a virtual multi-disciplinary setting. Contributors were blinded and proposed management recorded. 159 newly diagnosed patients with liver-limited metastatic colorectal cancer were identified. 68 (43%) were referred at initial diagnosis and 38 (24%) referred following systemic treatment. 35 (51%) who were discussed at baseline underwent a subsequent hepatectomy or radiofrequency ablation, as did 18 (47%) patients referred after chemotherapy. Of the remaining 53 (33%) patients not referred, imaging was available for 31 (58%). Decisions regarding potential liver-directed therapy were discussed within a multi-disciplinary setting. 13 (42%) were identified as resectable or potentially resectable and 11 (36%) may have been suitable for a clinical trial. In reality, none of these 31 patients (100%) underwent surgery or ablation. Whilst the majority of patients with liver-limited metastatic colorectal cancer were referred appropriately, this study demonstrates that a significant number with potentially resectable disease are not being discussed at specialist meetings. A review of all diagnosed cases would ensure that an increased number of patients are offered hepatic resection or ablation.