Abstract P6-16-01: The importance of loco-regional tumor burden and surgery on survival in patients with de novo stage IV breast cancer; post-hoc analyses of protocol MF07-01

Background: The MF07-01 trial is a multicenter phase III randomized controlled trial of treatment naive stage IV BC patients comparing loco-regional surgery (LRS) followed by appropriate systemic therapy (ST) versus ST alone.

Aims: To evaluate the importance of loco-regional tumor burden and surgery on overall survival rate in patients with de novo stage IV breast cancer.

Methods: At initial diagnosis patients were randomized 1:1 to LRS group or ST group. The surgery was a lumpectomy (L) or mastectomy (M) and sentinel lymph node biopsy (SLNB) ± axillary lymph node dissection (ALND). After surgery all patients received systemic treatment + endocrine treatment (ET) and Trastuzumab based on pathology results. The demographic, pathologic, and clinical characteristics of the patients were recorded.

Results:274 patients were accrued; 138 in the LRS group and 136 in the ST group. The groups were comparable regarding age, BMI, HER2 neu, tumor type and size, histologic grade, and bone and visceral metastasis (all p>0.05). In the LRS group 36 patients (26%) had L+ALND, 92 patients (67%) had M+ALND and 10 patients (7%) had M+SLNB, respectively.

The patients and tumor characteristicsPatients and Tumors Characteristics and Surgical TreatmentSurgerySystemic TherapyP ValueAge (mean /year±SD)51.8 ±12.651.5±13.6NSMedian follow-up (25%,75%)41.0 (24,54)37 (18,49) Tumor Size (%)   T18.7 (12) NST252.2 (72) NST321.7 (30) NST417.4 (24) NSHistologic Grade (%)   I4.4 (6)9.6 (10)NSII39.9 (55)31.7 (33)NSIII55.8 (77)58.9 (61)NS    Surgical Treatment   Lumpectomy+ ALND26 (36)--M + SLNB7 (10)--M + ALND67 (92)---SLNB17 (23)--ALND92.8 (128)--pN+89.1 (123)--30-day mortality1.4 (2)1.5 (2)0.98SLNB-Sentinel Lymph Node Biopsy; ALND-Axillary Lymph Node Dissection; M-Mastectomy

The axillary positivity rate was 89.1%. There were 76 (55%) deaths in the LRS group and 101 (74%) in the ST group during the median 40 (20-51) month follow-up. Overall survival (OS) was 34% higher in the LRS group compared to the ST group (HR: 0.66, 95%CI 0.49-0.88: p = 0.005).

Overall survival rate was higher in LN (+) (p=0.01), tumor size<5cm (p<0.0001), and high histologic grade (HG III, p<0.008) patients who underwent axillary surgery than ST group ; OS rate was with a marginal significant level in patients without axillary involvement (pN0) in the LRS group compared with ST group (p=0.05).

Conclusion: In this subgroup analysis, we observed that patients with high grade tumor, without skin or chest wall involvement and positive axilla who underwent surgery for primary breast tumor and axilla had better overall survival than ST in de novo stage IV breast. These results can be considered in clinical research design for stratification.

Citation Format: Ozmen V, Ozbas S, Karanlik H, Muslumanoglu M, Igci A, Canturk Z, Utkan NZ, Ozaslan C, Evrensel T, Uras C, Aksaz E, Soyder A, Ugurlu UM, Col C, Cabioglu N, Bozkurt B, Sezgin E, Dagoglu T, Uzunkoy A, Dulger M, Koksal N, Cengiz O, Gulluoglu B, Unal B, Atalay C, Yildirim E, Erdem E, Salimoglu S, Sezer A, Koyuncu A, Gurleyik G, Alagol H, Ulufi N, Berberoglu U, Soran A. The importance of loco-regional tumor burden and surgery on survival in patients with de novo stage IV breast cancer; post-hoc analyses of protocol MF07-01 [abstract]. In: Proceedings of the 2016 San Antonio Breast Cancer Symposium; 2016 Dec 6-10; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2017;77(4 Suppl):Abstract nr P6-16-01.

Abstract P6-07-24: miR-19b-3p and miR-4687-5p as novel circulating miRNAs as potential prognostic biomarkers in breast cancer

Background

Circulating microRNAs (miRNAs) as regulators of gene expression have recntly been promising suitable potential biomarkers due to their stability and ease of detection in blood. In this study, we aimed to determine the plasma expression levels of 372 different miRNAs in patients with invasive ductal breast cancer (IDC).

Methods

The expression levels of 372 circulating miRNAs in plasma samples of 20 patients with operable stage 1-III IDC and 10 healthy controls were determined using RT-PCR arrays. Mean ages of patients and healthy controls were 45.9+/-8.8) and 45.4+/- 5) respectively. Of 20 breast tumors, 12 were luminal breast cancer, whereas 8 were non-luminal as pure HER2-neu or triple negative breast cancer. RNA was isolated using miRNeasy Serum/Plasma Kit (Qiagen, Hilden, Germany, Cat. No: 217004). cDNA synthesis was performed according to manufacturer's instructions with miScript II RT Kit (Qiagen,Hilden, Germany, Cat. No: 218161). Serum/Plasma 384 HC PCR arrays with miScript SYBR Green PCR Kit (Qiagen, Hilden, Germany, Cat. No:218076) were used RT-PCR analysis. These assays included 372 miRNAs in additon to housekeeping genes and reaction controls. All reactions were performed in triplicates. Ct values were analyzed via an online software developed by Sabiosciences. P values were calculated using Student's t-test and p values lower than 0.05 were considered significant.

Results

Among 372 miRNAs, 19 were found to be deregulated in plasma samples of patients with IDC. 8 miRNAs were upregulated, and the other 11 were downregulated.

Upregulated and Downregulated Circulating miRNAs in Patients with Invasive Ductal CarcinomaUpregulated miRNAsFold regulationp valueDownregulated miRNAsFold Regulationp valuemiR-29a-3p2.0240.032miR-19b-1-5p-2.3750.048miR-101-3p2.4000.040miR-4732-5p-2.0910.015miR-542-3p2.2910.042miR-4687-5p-4.6230.005miR-199b-3p2.0190.020miR-3135b-2.7920.0005miR-98-5p2.4830.003miR-4770-2.4150.0103miR-424-5p3.0550.034miR-4301-2.6680.007miR-374c-5p2.1100.049miR-1247-5p-2.8130.0003miR-19b-3p3.7590.048miR-1287-5p-2.2020.0007   miR-197-3p-4.090.023   miR-126-5p-2.0520.029   miR-671-3p-2.5350.014Table 1

miR-19b-3p was the most upregulated miRNA with a fold change of 3.759 (95%CI:1.83- 5.68, p=.048) while miR-4687-5p was the most downregulated with a fold change of 0.216 (95%CI:0.00001-0.43, p=.005).

Conclusion

Our findings indicate that these 19 deregulated circulating miRNAs might be promising biomarker candidates for detection of IDC. The two most deregulated miRNAs were miR-19b-3p and miR-4687-5p. miR19b-3p belongs to a cluster of miRNAs which has been shown to function as oncogenes resulting in the downregulation of tissue factor expression in breast cancer cells. Further validation studies are ongoing in order to determine their clinicopathological prognostic value in breast cancer.

Citation Format: Tiryakioglu NO, Cabioglu N, Coskunpinar E, Tukenmez M, Ozturk D, Ozkurt E, Igci A, Pence S, Muslumanoglu M. miR-19b-3p and miR-4687-5p as novel circulating miRNAs as potential prognostic biomarkers in breast cancer [abstract]. In: Proceedings of the 2016 San Antonio Breast Cancer Symposium; 2016 Dec 6-10; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2017;77(4 Suppl):Abstract nr P6-07-24.

Appendiceal mucocele: clinical and imaging features of 14 cases

PURPOSE

Appendiceal mucocele as a cystic dilatation filled with mucinous material is a very rare disease of the appendix vermiformis. Its preoperative diagnosis is still acking behind common use of imaging techniques.

METHODS

Retrospective analysis of the patients with a pathological diagnosis of appendiceal mucocele with regard to clinical and imaging features.

RESULTS

The study group included 14 patients with a mean age of 51 years (range from 17 to 82 years). Predominant symptoms were pain and feeling of fullness in the right iliac fossa in 9(64%) and 5 (36%) patients, respectively. For imaging purposes, use of computed tomography resulted in preoperative diagnosis of appendiceal mucocele in half of the patients(50%). 93% of the cases underwent appendectomy, and righth emicolectomy was performed in one patient (7%). Mucocele and cystadenoma were detected in 11 (79%) and 3 (21%)patients, respectively. Presence of acute appendicitis and coloncarcinoma were confirmed afterwards histologically in 4 (29%)and one (7%) patients, respectively.

CONCLUSIONS

Despite the common use of imaging studies,preoperative diagnosis of appendiceal mucocele is still not possible in most of the cases. During surgical treatment,which is tailored according to imaging and intraoperative findings, precautionary measures to avoid intraperitoneal rupture and dissemination should be taken.

The use of Ligasure vessel sealing system in axillary dissection; effect on seroma formation

BACKGROUND

Seroma formation is the most frequent postoperative complication after axillary dissection for breast surgery with an incidence of 10 - 50 %. This prospective clinical randomized study was carried out to evaluate the Ligasure vessel sealing system and its effect on seromaformation and other complications for axillary dissection.

METHODS

Between January 2006 and November 2007, the patients with histopathological diagnosis of breast cancer were analysed prospectively. The patients with positive sentinel lymph node biopsy or clinical axillary involvement were included in the study, and the patients who underwent neoadjuvant therapy or using anticoagulants have been excluded from the study. Patients were divided into two study groups.Axillary dissection was performed in the first group by LigaSure and in the second group by linking and electrocautery.

RESULTS

There were a total of thirty three patients with a mean age of 51.4 +- 13.7. In group one, mean age of patients was 54.1 +- 13.2 and 48.68 +- 14.1 in group two. There was no significant statistical difference between the groups regarding age, body mass index, excised tissue weight,tumour size and number of excised lymph nodes. The use of Ligasure reduced drainage amount and duration of drain till removal, but increased operative time.

CONCLUSION

There were no significant differences between study groups regarding the complications. LigaSure electrothermal bipolar vessel sealing system can be safely used in axillary dissection as an alternative to traditional methods.

Laparoscopic versus open appendectomy: where are we now?

PURPOSE

Although the advantages of laparoscopic procedures has been well studied over the last two decade, laparoscopic appendectomy could not to be a standard therapy due to some disadvantages such as longer operative time and higher cost.The objective of our study is to re-evaluate the outcomes of laparoscopic versus open appendectomy with current data.

METHODS

Between January 2012 and July 2012, the data of the patients who had appendectomy were recorded prospectively. Patients' demographics, duration of procedure, length of hospital stay, need of analgesics, postoperative visual analogue scale scores and morbidity were assessed.

RESULTS

Of 241 patients, 120 (49.8%) underwent open and 121(50.2%) laparoscopic appendectomy. The operating time was similar for both groups (p=0.855). The visual analog scale scores of 1st (p=0.001), 6th (p=0.001) and 12th (p=0.028) hours were higher in open the appendectomy group. The total need of analgesics significantly was higher in open group (p=0.001).There was no statistical difference in terms of total morbidity rate between open and laparoscopic appendectomy groups (p=0.617).

CONCLUSION

Two operative techniques are similar in terms of length of hospital stay, operative time, and postoperative complications. Laparoscopic appendectomy reduces the need for analgesics and visual analog scale scores; therefore,it should be considered as the gold standard for surgical treatment of acute appendicitis.

A reliable pancreaticojejunal anastomosis with V-Loc 180 wound closure device for soft pancreatic stump

BACKGROUND/AIMS

Although mortality rates decreased in recent years, pancreaticoduodenectomy is still associated with high morbidity rates. Pancreatic fistula is the leading cause of morbidity after pancreaticojejunal anastomosis and commonly occurs in soft pancreas. The objective of this study is to compare outcomes of conventional modified invaginated end to side pancreaticojejunostomy with a new practical method using V-Loc 'rM 180 wound closure device in soft pancreas.

METHODOLOGY

Between December 2011 and August 2013, a total of 90 pancreaticoduodenectomy procedures were performed in our hospital. 28 of them were defined as soft pancreas according to attending surgeon and included in this study. Patients were divided into two groups consecutively and analysed for postoperative pancreatic fistula (POPF) rate, length of stay, operation time, cost and particular duration of anastomosis. Pancreatic fistulas were classified according to International Study Group on Pancreatic Fistula (ISGPF) definition.

RESULTS

1 grade A and 2 grade B fistulas appeared in V-Loc group (Group 1), whereas 1 grade A, 2 grade B and 1 grade C fistulas appeared in conventional anastomosis group (Group 2).

CONCLUSIONS

Pancreaticojejunostomy with V-Loc suture is a convenient method in soft pancreas and can be performed safely.

Abstract P4-07-08: The predictive and prognostic role of tumoral miRNA expression levels in patients with breast cancer (BC) treated with neoadjuvant chemotherapy (NAC)

Over the last decade, miRNA's have gained considerable interest due to the accumulating evidence regarding their relevant regulatory functions on cancer initiation, proliferation and progression. Furthermore, there are data showing that miRNA's can have a predictive role in response to NAC. The aim of this study is to evaluate the association between miRNA expression profile and response to NAC in patients with BC. 21 patients who received NAC consisting of 4 cycles of antracycline and cyclophosphamide (EC), followed by 4 cycles of docetaxel (T) were included in this study. Tumor core biopsies and blood specimens were collected before initiation, before the 5th cycle and after the completion of NAC for pathologic evaluation, miRNA expression and circulating correlative miRNA levels. The miRNA profile consisted of 9 miRNA's that were previously shown to be related to anthracycline and taxane resistance, as well as those associated with various intracellular functions. Associations with miRNA expression and clinical and pathologic variables, including response were evaluated by the Spearmann Correlation test. Response assessment was carried out every couple of cycles by physical examination, and radiologic evaluation after 4 and 8 cycles, respectively. Clinical response to EC was complete regression in 4.76% (n:1), PR in 66.7% (n:14), minimal response in 23.8% (n:5); and progression in 4.76% (n:1); all patients responded to docetaxel with 1 having CR and 20 PR. Pathologic response evaluation revealed CR in 7 patients (33.3%), good PR (defined as more than 50% regression in the viable tumor cells) in 8 (38.1%) and minimal PR in 6 (28.6%). Baseline levels of miRNA expression before initiation of NAC from the lowest to the highest level were as follows: miR10b (mean relative value (MRV): 0.24), miR-200c, miR34a, miR-11, let7a, miR-200c, miR-21, miR-195 and miR-221 (MRV: 132.5). Although each miRNA tested were in positive correlation with each other (p<0.05), there was no association with any miRNA with known clinic-pathologic variables, such as ER, PR, Her-2/neu or Ki67 levels. All miRNA's showed higher levels in patients presenting with stage 2 disease compared to those with stage 3 disease, which was marginally significant for miR-155 and miR-21 (p:0.05). After 4 cycles of EC miR-21 and miR-195 expression decreased significantly (mean decrease 500 times the initial level) (p<0.05), which was more evident in patients with earlier stage at presentation (stage 2 versus stage 3 disease (p:0.03)). There were no significant correlations seen with any miRNA and response to taxane-based NAC, since all patients showed a response. Furthermore, there was no correlation between pCR and the miRNA's tested. Nevertheless, there was a trend for higher pre-treatment miR-34 levels predictive for a good clinical response to EC, which was defined as more than 50% regression in the largest tumor diameter (p:0.07). In this preliminary study, we have shown that a substantial decrease in miR-155, -21,and -195 expressions after 4 cycles of EC may be associated with clinical response to anthracycline-based NAC. Furthermore, a higher miR-34 expression may predict for athracycline responsiveness.

Citation Information: Cancer Res 2013;73(24 Suppl): Abstract nr P4-07-08.

Male breast cancer: a retrospective study of 15 years

PURPOSE

To retrospectively evaluate the 15-year experience with breast cancer in males at a single institution.

METHODS

The data from 25 male patients who had undergone surgery for breast cancer at a single center were retrospectively analysed. Their medical records were studied for clinical characteristics, therapeutic modalities used and factors associated with disease free (DFS) and overall survival (OS), like local recurrence/distant metastasis.

RESULTS

The median patient age was 67 years (range 38-83). The most frequent presenting symptom was a palpable lump. Eighteen (72%) patients underwent modified radical mastectomy (MRM), while sentinel lymph node biopsy (SLNB) was performed in 14 (56%) cases. Of 25 patients, 21 (84%) underwent axillary lymph node dissection (ALND) and 15 (71.4%) of them had pathological axillary lymph node involvement. Two of 25 (8%) patients with bone and liver metastases underwent toilet mastectomy due to breast ulceration. Estrogen receptor (ER) was positive in 15 (60%) patients, while progesterone receptor (PR) and C-erbB2 (HER-2) were positive in 10 (40%) and 2 (8%) patients, respectively. Ten patients (40%) had both ER(+) and PR(+). The median follow-up period was 19 months (range 3-102). Local recurrence developed in one (4%) patient and distant metastasis in 4 (16%). Five-year OS and DFS were 53 and 49%, respectively. In univariate and multivariate analysis, pathological tumor size (<2 vs. >2 cm), pathological lymph node involvement and preoperative skin involvement over the breast were not associated with breast recurrence. Only in univariate analysis local recurrence/distant metastasis were associated with poor OS.

CONCLUSION

Large cooperative studies are needed using strict clinical and laboratory criteria to advance the understanding of this disease and to identify the most effective treatment approaches.

Trastuzumab use and survival in HER2 (+) nonmetastatic breast cancer among Turkish women

56

Background: HER2 overexpression observed in 10-25% of breast cancers is associated with rapid proliferation. HER2-targeted trastuzumab has been used in metastatic breast cancer, and since 2004 in early breast cancer. However, trastuzumab therapy is expensive and long lasting resulting sometimes in cardiac side effects. In this study we tried to find out whether there was a subgroup of early breast cancer patients trastuzumab could be omitted.

Methods: Records of patients treated for HER2-positive breast cancer in Istanbul Medical School between Jan 2000 and Sept 2009 were retrospectively evaluated. Disease-free survival (DFS) and overall survival (OS) were calculated either from follow-ups, or by calling. Kaplan meier and LogRank tests have been used for comparison (P<0.05, 95% CI).

Results: Follow up period was 32.2±14.9mo for trastuzumab group (TG, n:87) compared to 47.4±20.8mo for non-trastuzumab group (NTG, n:63) (P=0.0001). Groups were similar for age, menopausal status, size (T), histological grade and type, location, hormone responsiveness, presence of lymphovascular invasion, surgery, and use of local/systemic/hormonal therapy. NTG had more N0 cases (44.4% vs. 12.6%, P=0.0001), breast related deaths (15.9% vs. 5.7%, P=.042) and systemic metastases (27% vs. 13.8%, P=.043). Number of local recurrences was similar. Mean DFS and OS were significantly less in TG (P<0.0001). However differences between DFS and OS of groups were not significant despite a considerable increase for both in TG at fifth year (P=0.147, P=0.450). No difference in DFS and OS between TG and NTG was observed when patients who had chemotherapy and/or radiotherapy and/or hormonotherapy were compared to those who did not. OS was not different between TG and NTG for T1, T2, and T3 tumors and for patients ≤35y. But in N2 and N3 tumors, use of trastuzumab increased OS significantly (P=0.007).

Conclusions: Both number of events and systemic relapses were less in TG but we could not find a significant difference in DFS and OS between TG and NTG in Turkish nonmetastatic cancers. Prolonged follow up might be necessary to search for the subgroup who would not benefit, if any, as an incremental benefit in both DFS and OS was observed with trastuzumab use at fifth year.

Results by treatment modalities in multifocal/multicentric breast cancer: Retrospective analysis of 162 patients

266

Background: The prognostic value of multifocal, multicentric breast cancer is still not well known. Although some studies have suggested that it is associated with a worst prognosis some have not suggest. We evaluated the effect of treatment modalities on overall survival and disease-free survival in breast cancer.

Methods: One hundred and sixty two women with multifocal multicentric breast cancer diagnosed at our oncology center between January 2004 and December 2010 were retrospectively evaluated. Multifocality was defined as the presence of 2 or more foci of the tumor clearly separated in the same breast. Multicentricity was defined as the presence of 2 or more foci at different quadrants. Patients received neoadjuvant chemotherapy were excluded.

Results: Median age of 162 women was 48 y ± 13,63 y. Eighty two of 162 patients were treated with breast-conserving surgery and 80 were treated with mastectomy. Radiotherapy was added to adjuvant therapy to patients with 4 or more positive axillary nodes and/or treated with breast conserving surgery. Three (1.8%) patients were excluded because of bilateral cancer and 1 (0.6%) was excluded because of Tx tumor. Eleven of 162 (6.7%) patients were not seen after surgery so data about adjuvant treatment was not known. Fifty of 147 patients were stage III, 68 were stage II and 30 were stage I. 27 (17.2%) patients received anthracycline based chemotherapy, 30 (20.3%) patients received hormonotherapy and 91 (56.1%) patients received taxane based chemotherapy. Trastuzumab added to the treatment at all patients, if HER2 neu-positive. Median follow up was 41 ± 4.1 (72-9 months) months. 30 systemic diseases at 24 patients were seen on follow up. 18 patients were in taxane group, 4 patients were in anthracycline group, 2 patients were in hormonotheraphy group. Nine patients were died in taxane group, 1 died in anthracycline group and 1 died in hormonotherapy group.

Conclusions: Our retrospective analysis showed worst prognosis at taxane group but; patients with positive lymph nodes and perinodal invasion gets taxane based treatments. This retrospective analysis showed that systemic recurrence and survival in multifocal breast cancer are similar with unifocal disease.

Breast conserving surgery in patients with multifocal/multicentric breast cancer

PURPOSE

To retrospectively evaluate the outcome of patients with multifocal (MF) and multicentric (MC) breast cancer treated with conservative surgery.

METHODS

We evaluated 59 patients who had undergone breast conserving surgery (BCS) for MF/MC cancer between 1998-2008. We used sentinel lymph node (SLN) biopsy for all 59 patients and we performed axillary lymph node dissection in those with positive SLN. Local control, overall survival (OS), disease-free survival (DFS) and identification of predictive factors for recurrence were evaluated.

RESULTS

Twenty patients with modified radical mastectomy because of persistent positive margins were excluded from the study. Evaluated were 55 patients with MF (93.2%) and 4 (6.8%) with MC disease. Thirty-four patients (57.6%) had 2, 20 patients (33.9%) had 3 and 5 (8.5%) had 4 or more tumor foci. Median follow up time was 20 months (range 2- 97). The projected 5- and 8-year OS were 95% and 89% respectively, and DFS 92.3%. At multivariate analysis, overexpression of human epidermal growth factor receptor 2 (HER-2) was associated with a higher ipsilateral breast cancer recurrence. Menopausal status, MF/MC disease, number of tumor foci (2 vs. ≥3), histological grade, extracapsular extension (ECE), lymphovascular invasion (LVI), and hormone receptor status were not associated with ipsilateral breast cancer recurrence.

CONCLUSION

Our study demonstrates that in selected patients with MF/MC breast cancer, wide conservative surgery is a safe therapy.

Predictive factor for residual tumor after lumpectomy for close margins

e11538

Background: It is critical to obtain clear margins to minimize local recurrence after breast conserving surgery(BCS). When re-excisions are performed, there is often no residual disease in the new specimen, calling into question the need for re-excision(s) or mastectomy. The aim of the present study was to identify factors predicting a histologically positive re-excision specimen. Methods: Our prospective breast cancer database was queried for all invasive breast cancer patients who underwent a re-excision lumpectomy for either close or positive margins after an attempt at BCS. Close margins are defined as ≤ 2 mm for invasive carcinoma and presence of ductal carcinoma in situ(DCIS). Clinicopathologic features were correlated with the presence of residual disease in the re-excision specimen. Results: Between February 1997 and August 2008, 2054 patients with early breast cancer underwent surgical treatment in our breast unit. 939(45.7%) of them had BCS. In 543 patients(26.4%), re-excision required due to close margins on the permanent section analysis of their initial surgical specimens. 186 patients(34.3%) had previous excisional biopsy in other clinics. Median age of 543 patients was 50 years. In 290 patients(53.4%), mastectomy was performed due to positive surgical margin or poor cosmetic results. There were no residual tumors in re-excision(65.6 %) or mastectomy(42.4%) specimens of patients. The factors associated with tumor positive re-excision specimen were, age ≤50 years(p=0.044), lymphovascular invasion (p=0.029), multifocality(p<0.001), tumor size >2cm(p=0.008), presence of DCIS(p=0.018), focal margin positivity(p<0.001), DCIS at resection margin(p=0.008) and node positivity (p<0.001). Conclusions: Most of our patients with early breast cancer had unnecessary re-excisions or mastectomy to obtain clear surgical margins. In subset group of patients, re-excision or mastectomy may not be required.

No significant financial relationships to disclose.

Prognostic and predictive factors after surgical treatment for locally recurrent rectal cancer: a single institute experience

OBJECTIVE

Resection of locally recurrent rectal cancer (LRRC) after curative resection represents a difficult problem and a surgical challenge. The aim of this study was to evaluate the results of resecting the local recurrence of rectal cancer and to analyze factors that might predict curative resection and those that affect survival.

PATIENTS AND METHODS

A retrospective review was performed in 50 patients who underwent surgical exploration with intent to cure LRRC between April 1998 and April 2005. All of the patients had previously undergone resection of primary rectal adenocarcinoma. Of these patients' charts, operation and pathology reports were reviewed. Primary tumor and treatment details, hospital of initial treatment and TNM stage were registered. The following data were collected concerning the detection of the local recurrence; date of recurrence, symptoms at the time of presentation and diagnostic work-up. Perioperative complication and date of discharge were also gathered. The recurrent tumors were classified as not fixed (F0), fixed at one site (F1) and fixed to two or more sites (F2) according to the preoperative and peroperative findings. Microscopic involvement of surgical margins and localization of recurrence were noted based on pathology reports.

RESULTS

The median time interval between resection of primary tumor and surgery for locally recurrent disease was 24 (4-113) months. In a statistical analysis, initial surgery, complaints of patients, increasing number of sites of the recurrent tumor fixation in the pelvis, location of the recurrent tumor were associated with curative surgery. Curative, negative resection margins were obtained in 24 (48%) of patients; in these patients a median survival of 28 months was achieved, compared to 12 months (p=0.01) in patients with either microscopic or gross residual disease. Primary operation and CEA level at recurrence were also found to be important factors associated with improved survival. There was no operative mortality and, the complication rate was 24%.

CONCLUSIONS

This study demonstrated that many patients with LRRC can be resected with negative margins. The type of primary surgery, symptoms, location, and fixity of recurrent tumor are associated with the increased possibility of carrying out curative resection. Previous surgery and curative surgery are significant predictors of both disease-specific survival and overall survival.

Breast conserving surgery after primary chemotherapy in locally advanced breast cancer

PURPOSE

Primary chemotherapy is being given in the treatment of locally advanced breast cancers (LABC), but a major concern is local recurrence after therapy. The aim of this study was to assess the role of breast conserving surgery (BCS) in patients with locally advanced breast cancer.

MATERIAL AND METHODS

Twenty-eight patients, presenting LABC (T any, N 012, M0) were treated with primary chemotherapy comprising of cyclophosphamide, doxorubicin and fluorouracil and then BCS followed by radiotherapy were examined between the years 1992-2002 retrospectively. Before neoadjuvant chemotherapy, seven patients (25%) were Stage IIB, 19 patients (68%) Stage IIIA and two patients (7%) Stage IIIB. Survival times and curves were established according to the Kaplan-Meier method and compared by means of the log-rank test. The chi-square test and log rank test were performed for univariate statistical analysis of each prognostic factor. P values in multivariate analysis were carried out by the Cox's proportional hazards regression model. All p values were two-sided in tests and p values <0.05 were considered significant.

RESULTS

Clinical down staging was obtained in 25 (89%) of patients. Three (11%) patients had complete clinical response, 22 (78%) patients with partial response and 3 (11%) had stable disease. The primary tumour could not be palpated after chemotherapy in 6 (21%) of 28 patients presenting with palpable mass, therefore needle localization was performed for BCS. Median follow-up was 51.9 months (ranging 10 to 118 months). Local recurrence was detected in 4 (14%) patients. Distant metastasis developed in 5 (18%) patients. Three of the patients died of distant metastases and two of them are alive at 49 months. Five-year survival rate was 66%. Statistically, there were no significant factors in terms of local recurrence. Histological grade and menopause status were significantly associated with overall survival (p = 0.018) and nuclear grade was the one significant factor on distant disease-free survival in univariate analysis (p = 0.006). In multivariate analysis, there were no significant factors in terms of overall and distant disease-free survival

CONCLUSIONS

Negative margin is more important than the clinical and histological parameters, such as pretreatment stage, clinical response rate, ER and PR in terms of local recurrence. BCS can be performed safely by achieving free surgical margin in patients who have small sized tumour and with either N2 axillary involvement or skin invasion.

Comparison of Subdermal and Peritumoral Injection Techniques of Lymphoscintigraphy to Determine the Sentinel Lymph Node in Breast Cancer

PURPOSE

The purpose of this study was to evaluate 2 different injection techniques for lymphoscintigraphy to determine the axillary sentinel lymph node (SLN) in patients with breast cancer.

METHODS

Thirty-six patients with early breast cancer were studied prospectively. Both peritumoral (PT) and subdermal (SD) injections were performed on each patient with Tc-99m rhenium sulfide colloid. PT injections were done 1 to 8 days before surgery and SD injections were done on the day of operation. An intraoperative gamma probe was used to explore the axillary SLNs prior to tumor excision and axillary dissection. All surgical specimens were evaluated histopathologically.

RESULTS

In 19 of 36 patients, the same lymphatic drainage sites were observed with both techniques. Of these, 17 patients showed only axillary, 1 showed axillary and internal mammary (IM), and 1 showed axillary and subclavicular drainage sites. With PT injections 26 of 36 patients (72%), and with SD injections 33 of 36 patients (92%), showed axillary drainage and axillary SLNs. With PT injections 9 patients, and with SD injections only 2 patients, did not show any drainage site. During the operation with a gamma probe, axillary SLNs were excised in 35 patients (success rate, 97%). IM drainage was seen in 8 of 36 patients who underwent PT injections and in 3 of 36 with SD injections.

CONCLUSION

The success rate was found to be higher with the SD injection technique than with PT injections to visualize the axillary SLN. To increase the visualization of both axillary and IM SLNs, it may be useful to perform lymphoscintigraphy with SD and PT injections together.

Laparoscopic treatment of mesenteric cysts

Mesenteric cysts are rare intraabdominal tumors. We review the diagnosis, laparoscopic management, patient's outcome and follow-up of evaluation for three cases of mesenteric cyst that presented to Istanbul University, Istanbul Medical School, Department of Surgery, from 1999 to 2002. All of the patients presented with nonspecific abdominal symptoms such as constipation, abdominal discomfort, and anorexia. Preoperative evaluation for differentiating mesenteric cyst from malignancy is made by abdominal ultrasound and computed tomography. The procedure was completed laparoscopically using three trocars in three patients. In one patient retroperitoneal resection was performed. There were no intraoperative or postoperative complications. The follow-up periods ranged from 6 to 36 months, and there were no recurrences. Currently, the surgical treatment of mesenteric cyst should be performed by laparoscopy, which offers significant advantages in terms of reduced morbidity and hospital stay. For appropriate cases in which cyst arises from mesenterium of colon, the retroperitoneal approach should be applied.

Biological considerations in locally advanced breast cancer treated with anthracycline-based neoadjuvant chemotherapy: thymidine labelling index is an independent indicator of clinical outcome

The present retrospective study aims to determine the clinical value of thymidine labelling index (TLI) together with other established clinical and biological factors in 116 locally advanced breast cancer (LABC) patients treated with anthracycline-based neoadjuvant chemotherapy, surgery, adjuvant chemotherapy and radiotherapy. TLI was determined in 71 LABC patients with a median of 2.62% (0-23.64%) and a mean of 4.71% +/- 5.54. As a result of neoadjuvant chemotherapy, 85 patients (73%) responded to chemotherapy (CT), whereas 31 patients were unresponsive (27%). No relationship has been found between the pretreatment biological variables including TLI, estrogen receptor (ER), progesteron receptor (PgR) status and clinical parameters such as the chemotherapy response rates and axillary lymph node involvement following chemotherapy. Median follow-up was 35 months (18-97 months) and the 3-year overall survival (OS) and disease free survival (DFS) rates were 71.6% and 52.2%, respectively. In univariate analysis, patients with inflammatory breast cancer, high TLI-index (> or = 2.62%), lymph node (LN) positivity or > 3 positive lymph nodes following neoadjuvant chemotherapy and without any response to neoadjuvant chemotherapy were found to have worse DFS and OS-rates and high local and systemic recurrence rates. In multivariate analysis, TLI was estimated as the most powerful independent factor affecting the OS in LABC patients among the other established clinical and biological parameters (p = 0.02). These results suggest that TLI is an important independent indicator of clinical outcome in patients with LABC and these patients with high TLI levels require more effective treatment modalities.

Can preoperative lymphoscintigraphy be used as a guide in treatment planning of breast cancer?

PURPOSE

The purpose of this study was to map the lymphatic drainage patterns of breast cancer with lymphoscintigraphy to evaluate the variability of drainage and to determine whether lymphatic mapping can help to increase the certainty of breast cancer staging.

MATERIALS AND METHODS

Fifty women with breast cancer (mean age, 49 years) were included in the study. Lymphoscintigraphy was performed with 1 mCi Tc-99m rhenium sulfide colloid in a 2-ml volume injected into the four quadrants of the peritumoral area using a 25-gauge needle. Ten-minute dynamic images and 2-hour delayed static images were obtained in the anterior and lateral positions using a gamma camera with a high-resolution collimator. All patients had a modified radical mastectomy and axillary dissection. The results were evaluated with histopathologic findings of the axilla.

RESULTS

Six patients had excision biopsies before surgery. Of 13 patients with centrally located tumors, 84% had axillary lymphatic drainage, whereas 53% drained to internal mammary lymphatics. Of 23 patients with outer quadrant tumors, 4 showed no lymphatic drainage and all of them had metastatic tumor in the axillary lymph nodes. Axillary drainage was seen in 82% of patients and internal mammary lymphatic drainage in 23%. Of eight patients with inner quadrant tumors, one patient with no lymphatic drainage was found to have metastases in the axilla. In this group, 62% had axillary and 50% had internal mammary lymphatic drainage, and one patient had supraclavicular drainage.

CONCLUSIONS

Lymphoscintigraphy indicates that drainage routes may vary, and thus it may play a guiding role in patients with breast cancer who need radiotherapy. In patients with internal mammary lymphatic drainage, the accuracy of radiotherapy planning may increase if internal mammary lymphoscintigraphy is added to the protocol. In patients with internal mammary drainage, obtaining an internal mammary lymphatic biopsy during surgery will also increase the accuracy of staging.

BRCA1 and BRCA2 mutations in Turkish breast/ovarian families and young breast cancer patients

To date, BRCA1 and BRCA2 mutations in breast and/or ovarian patients have not been characterized in the Turkish population. We investigated the presence of BRCA mutations in 53 individuals with a personal and family history of breast and/or ovarian cancer, and 52 individuals with a personal history of breast cancer diagnosed below age 50 without additional family history. We have identified 11 mutations (nine BRCA1 and two BRCA2) using combined techniques involving protein truncation test, direct sequencing and heteroduplex analysis. We found eight out of 53 patients (15.1%) with a family history to carry BRCA gene mutations (seven BRCA1 and one BRCA2). Of these, four were found in 43 families presenting only breast cancer histories, and four were found in families presenting ovarian cancer with or without breast cancer. We also demonstrated two BRCA1 and one BRCA2 mutations in three out of 52 (5.8%) early-onset breast cancer cases without additional family history. Three of nine BRCA1 and both BRCA2 mutations detected in this study were not reported previously. These mutations may be specific to the Turkish population. The BRCA1 5382insC mutation, specific to Ashkenazi and Russian populations, was found twice in our study group, representing a possible founder mutation in the Turkish population.

Vagotomy without gastric drainage laparoscopic or thoracoscopic approach

BACKGROUND/AIMS

This article describes the surgical techniques and preliminary results of a prospective trial of videoendoscopic bilateral truncal vagotomy without a drainage procedure in a series of selected patients with chronic non-obstructive intractible duodenal ulcer.

METHODOLOGY

Video laparoscopic and videothoracoscopic truncal vagotomy of chronic duodenal ulcer in 32 patients has been successfully performed in the Department of Surgery, Istanbul Medical Faculty Hospital. These patients undergoing bilateral truncal vagotomy (BTV) without a drainage procedure were chosen with selective indication regarding the absence of pyloric obstruction and presence of hyperacidity. Endoscopic pyloric balloon dilatation (PBD) was performed at the same stage with vagotomy only for 20 patients as a prospective trial. The results of acid secretory tests and endoscopic control were studied.

RESULTS

All the patients tolerated pure truncal vagotomy well under strict follow-up with semiliquid diet and promotility medication started 24 hours after surgery. The mean decrease in secretory tests for basal acid output (BAO) and peak acid output (PAO) were 70.6% and 79.5%, respectively. Endoscopic controls, 2 months after the operation, showed healing ulcers in patients who were able to be followed-up. One patient who had partial pyloric stenosis and was operated by BTV and PBD, required a drainage procedure in spite of repeated pyloric dilatation. During the mean follow-up period of 26 months (range: 10-46), the only symptom was moderate diarrhea in 4 patients, which became well with medical treatment or spontaneously.

CONCLUSIONS

Videoendoscopic truncal vagotomy seems to be an alternative treatment regimen for the management of chronic duodenal ulcer in a group of selected patients, as a simple, surgeon independent and efficient procedure. Instead of routine addition of a drainage procedure after truncal vagotomy, which may improve the morbidity, observation of the patient after truncal vagotomy with dietary caution supplementary to prokinetic medication may be the chosen method in some patients.