Peri-operative care of elective adult surgical patients with a learning disability

People with a learning disability can experience significant problems in accessing healthcare and this may be partly reflected in worse health outcomes compared with the general population, including a shorter life expectancy. The Equality Act (2010) requires that organisations and individuals make changes to the way services are provided for all disabled people to mitigate, as far as possible, any disadvantage they may face in accessing these services. These changes are termed 'reasonable adjustments'. This article describes the reasonable adjustments that can be made to facilitate the admission of an adult surgical patient with a learning disability, and therefore reduce health inequality. Each stage of a patient's journey through the hospital needs to be anticipated and planned for. Many of these changes are not only applicable to the wider care of people with a learning disability, but also to any person who lacks capacity and who is struggling to access healthcare. Key recommendations include the development of assessment tools, pathways and policies specific to the learning disabled patient; identification of key personnel including a learning disability lead, an acute liaison learning disability nurse, pre-assessment and operating theatre personnel and ward learning disability champions; regular multidisciplinary team meetings for planning and best interest assessments; and establishing an electronic alert on the patient administration system to identify learning disabled patients. The anaesthetist, operating theatre and learning disability teams play a pivotal role in ensuring individualised admission plans are made for patients with a learning disability to reduce these healthcare inequalities and improve peri-operative care.

Abstract ES5-3: Surgical considerations after preoperative therapy for hormone receptor positive breast cancer

Session Title: Multidisciplinary approaches to optimize surgical therapy in hormone receptor positive breast cancer

Talk Title: Surgical considerations after preoperative therapy in hormone receptor positive breast cancer

Abstract:

Preoperative therapy increases rates of breast conservation and decreases the need for axillary lymph node dissection (ALND) in select patients. In hormone receptor positive (HR+) HER2 negative breast cancer patients the choice between neoadjuvant chemotherapy (NAC) and neoadjuvant endocrine therapy (NET) to achieve breast conservation can be challenging and the low rates of axillary pCR with either approach have been associated with higher rates of ALND. For HR+ HER2- patients receiving NAC, available literature supports performing sentinel lymph node biopsy (SLNB) after receipt of therapy with the decision to perform axillary lymph node dissection dictated by the status of the sentinel lymph nodes. For patients receiving NET, there is little data to guide surgical management of the axilla. In a recent review of the NCDB, we assessed axillary management by initial treatment strategy (NET, NAC, or upfront surgery) among a large population of Stage II-III HR+ HER2- breast cancer patients and found that SLNB use after NET in both clinically node negative and clinically node positive patients was similar to SLNB use with upfront surgery. However, among those with pN1 disease, patients who received NET were less likely to undergo ALND. While failure to achieve a nodal pCR after NAC is associated with inferior DFS and OS outcomes; whether or not the same is true after NET remains uncertain. Further, the impact of residual nodal disease after NET on LRR remains an area of ongoing investigation. Understanding the differences in and implications of residual nodal disease after neoadjuvant therapy (NAC vs NET) in HR+ HER2- breast cancer provides the opportunity to develop subtype specific strategies for optimal surgical management of the axilla.

Citation Format: TA King. Surgical considerations after preoperative therapy for hormone receptor positive breast cancer [abstract]. In: Proceedings of the 2019 San Antonio Breast Cancer Symposium; 2019 Dec 10-14; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2020;80(4 Suppl):Abstract nr ES5-3.

Abstract P6-22-03: Tumor phenotype and concordance in synchronous bilateral breast cancer in young women

Background: Synchronous bilateral breast cancer is rare, with reported incidence from 0.3-12%; the incidence and pattern of bilateral breast cancer among younger women is unknown. Here we report the incidence and phenotypes of bilateral breast cancer in women ≤40 years of age enrolled in the Young Women's Study (YWS) cohort.

Methods: The YWS is a multi-center, prospective cohort study that enrolled women with newly diagnosed breast cancer at age ≤40 years from 2006-2016. Those with synchronous bilateral breast cancer (in-situ and/or invasive) formed our study cohort. Disease characteristics and treatment were obtained by medical record review. Central pathology review was performed to capture histologic features and categorize the tumor phenotype as either luminal A (hormone receptor (HR)+, HER2-, grade 1 or 2), luminal B (HR+, HER2+, or HER2- and grade 3), HER2-type (HR-, HER2+), or triple negative (TNC; HR/HER2-). Tumor phenotypes of bilateral breast cancers were compared and evaluated for concordance.

Results: Among 1302 patients enrolled in the YWS, 20 (1.5%) patients presented with bilateral disease, with median age of diagnosis of 38 years (range 18-40). The majority of patients (13 (65%)) presented with unilateral symptoms and contralateral disease was identified on subsequent imaging. 12 (60%) reported a positive family history of breast cancer and 17 (85%) underwent genetic testing; resulting in the identification of 6 mutation carriers (2 BRCA1, 3 BRCA2, 1 TP53). The majority of patients (15 (75%)) underwent bilateral mastectomy, 1 underwent unilateral mastectomy with contralateral lumpectomy, and 4 underwent bilateral lumpectomy. On pathology, 2 patients had bilateral in-situ disease, 5 had unilateral invasive and contralateral in-situ disease, and 13 had bilateral invasive disease. Of those with bilateral invasive disease, all had concordant tumor histology (92% ductal, 8% ductal and lobular), 10 (77%) patients had bilateral luminal tumors and when fully characterized 6 were of the same luminal type. Only one patient had bilateral basal-like breast cancer.

Patient ID ERPRHer2 amplifiedGradePhenotype1Left++-2Luminal A Right++-3Luminal B3Left++-3Luminal B Right++-3Luminal B6Left++-3Luminal B Right++-3Luminal B9Left++-2Luminal A Right++-2Luminal A10Left+++3Luminal B Right++-2Luminal A12Left+--3Luminal B Right+--2Luminal A13Left---NABasal-like Right++-NALuminal A or B14Left+++2Luminal B Right++-3Luminal B15Left++-3Luminal B Right+++3Luminal B16Left+++3Luminal B Right--+NAHEr2-type17Left---3Basal-like Right---3Basal-like19Left++-2Luminal A Right++-3Luminal B20Left++-1Luminal A Right++-2Luminal A

Conclusions: Among a large cohort of young women, only 20 (1.5%) had bilateral disease, and the majority of the invasive tumors were of the luminal phenotype, yet frequently differed by grade or HER2 status; supporting the need for thorough pathologic evaluation of bilateral disease to determine risk and tailor treatment. Overall the low incidence of bilateral disease and preponderance of the luminal phenotype in this population is reassuring.

Citation Format: Pak LM, Rosenberg SM, Ruddy KJ, Tamimi RM, Peppercorn J, Schapira L, Borges VF, Come SE, Warner E, Snow C, Collins L, King TA, Partridge AH. Tumor phenotype and concordance in synchronous bilateral breast cancer in young women [abstract]. In: Proceedings of the 2018 San Antonio Breast Cancer Symposium; 2018 Dec 4-8; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2019;79(4 Suppl):Abstract nr P6-22-03.

Abstract GS6-06: Local therapy and quality of life outcomes in young women with breast cancer

Background: Increasing rates of mastectomy, primarily bilateral mastectomy (BMx), have been most dramatic in young women with breast cancer (BC). Impact on long-term quality of life (QOL) is largely unknown.

Methods: Between 10/2016-11/2017, we administered the BREAST-Q, a validated patient-reported outcomes measure, to women dx with BC at age ≤40 in a large prospective cohort study. Demographic and treatment information was obtained by surveys and chart review. Mean BREAST-Q scores for each domain (breast satisfaction, physical, psychosocial, and sexual) were compared by surgery types; higher BREAST-Q scores (range: 0-100) indicate better QOL. Linear regression was used to identify predictors of BREAST-Q domain scores.

Results: 581 women with stage 0-3 BC completed the BREAST-Q a median of 5.8 years from dx. Median age at dx was 37 (range: 26-40) years; 86% had stage 0, 1 or 2 disease; 28% had breast-conserving surgery (BCS); 72% had mastectomy (Mx), among whom 72% underwent BMx and 89% had reconstruction. Mean BREAST-Q scores (unadjusted) for breast satisfaction, psychosocial, and sexual well-being were lower for patients having unilateral mastectomy (UMx) or BMx compared to BCS; physical function was similar among groups. In multivariate analysis, lower BREAST-Q psychosocial scores were associated with radiation and Mx (UMx or BMx). Lower sexual well-being scores were also associated with Mx. Lower satisfaction with breast scores following radiation were of a clinically significant magnitude (β -8.1 95% CI -11.9- -4.3, p-value 0.03). Lower scores for physical well-being were seen for patients reporting lymphedema and higher for those who had undergone surgery more than 5 years prior. Lower scores across all 4 domains were associated with reported financial distress.

BREAST-Q domain mean scores (SD) BMxUMxBCSp-valueBreast satisfaction60.3 (18.9)59.5 (21.3)65.9 (20.7)0.008Physical well-being78.6 (14.9)79.7 (15.1)78.9 (15.5)0.8Psychosocial well-being68.1 (20.8)70.5 (21.2)76.1 (20.5)<0.001Sexual well-being48.6 (21.3)53.2 (21.7)57.5 (18.7)<0.001SD Standard deviation

Conclusion: Local therapy in young breast cancer survivors may have a persistent impact on their breast satisfaction, psychosocial, and sexual outcomes, with particular effects from UMx or BMx. Socio-economic stressors also appear to play a role. When counseling young women about their surgical decisions, knowledge of potential long-term QOL impact is of critical importance.

Citation Format: Dominici LS, Hu J, King TA, Ruddy KJ, Tamimi RM, Peppercorn J, Schapira L, Borges VF, Come SE, Warner E, Partridge AH, Rosenberg SM. Local therapy and quality of life outcomes in young women with breast cancer [abstract]. In: Proceedings of the 2018 San Antonio Breast Cancer Symposium; 2018 Dec 4-8; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2019;79(4 Suppl):Abstract nr GS6-06.

Abstract PL3: Individualizing Management of the Axillary Nodes

The introduction and widespread adoption of the sentinel lymph node (SLN) biopsy procedure in the mid-1990s, dramatically changed the landscape of axillary nodal staging and management, ultimately leading to the avoidance of axillary node dissection (ALND) and its resultant co-morbidities for thousands of women with node negative breast cancer. For those found to have positive sentinel nodes, the landscape has again changed and many women with limited volume nodal disease, defined as 1 or 2 positive SLN, are now also offered the opportunity to avoid axillary node dissection, largely in favor of observation alone for those undergoing breast conservation therapy (BCT) or in favor of axillary radiation for those undergoing mastectomy. These changes reflect clinical application of the results of several important prospective randomized trials including ACOSOG Z011, IBCSG 23-01, and EORTC 10981-22023 AMAROS, each of which demonstrated equivalence between axillary node dissection and the alternative strategy of interest (observation or axillary radiation).

The increasing use of neoadjuvant therapy, in both high-risk clinically node negative (cN0) disease and in clinically node positive (cN1) disease, represents further opportunities to individualize axillary management; yet decision making must take into account several caveats including the performance characteristics of the SLN procedure after neoadjuvant therapy, the molecular subtype of the primary tumor and the planned breast procedure. For patients with triple negative or HER2+ disease, the use of neoadjuvant therapy is associated with high rates of nodal pCR and therefore a lower likelihood of requiring an axillary node dissection in the cN1 cohort that converts to cN0 and undergoes a successful SLN biopsy procedure; however, in cN0 patients meeting eligibility criteria for avoidance of ALND in the aforementioned trials of upfront surgery, the use of neoadjuvant therapy may not significantly impact rates of ALND. Similarly, for patients with cN0 hormone receptor positive disease, upfront surgery (BCT or mastectomy) likely offers more opportunity for individualized management; whereas for those with cN1 disease, neoadjuvant therapy may result in downstaging of the axilla, although patient selection is critical as many patients with low to intermediate grade, node positive, hormone receptor positive disease are now being offered the opportunity to avoid chemotherapy in the adjuvant setting in favor endocrine therapy alone, and data on management of the axilla after neoadjuvant endocrine therapy are limited.

In aggregate, the evolving literature on management of axilla represents a victory for patients and provides increasing support for the “less is more” approach that has emerged throughout the last decade. In daily clinical practice, the challenge lies in clear communication of the myriad of options and the interplay between tumor biology, systemic therapy and surgical decision making.

Citation Format: King TA. Individualizing Management of the Axillary Nodes [abstract]. In: Proceedings of the 2017 San Antonio Breast Cancer Symposium; 2017 Dec 5-9; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2018;78(4 Suppl):Abstract nr PL3.

Abstract P5-22-01: Evaluating the risk of upgrade to invasive breast cancer and/or DCIS on excision following a diagnosis of non-classic lobular carcinoma in situ

Introduction: Non-classic lobular carcinoma in situ (NC-LCIS) is a rare pathologic entity which encompasses a variety of histologic diagnoses. As such its natural history, including upgrade rates to invasive cancer (IC) or ductal carcinoma in situ (DCIS) on excision, is poorly characterized. We sought to evaluate the risk of upgrade to IC or DCIS when NC-LCIS is diagnosed on core biopsy.

Methods: After obtaining IRB approval, institutional pathology databases were searched for NC-LCIS core biopsy diagnoses (carcinoma in situ (CIS), carcinoma in situ with ductal and lobular features (CIS/DLF), pleomorphic LCIS (P-LCIS), variant LCIS (V-LCIS), LCIS with necrosis). Cases with a NC-LCIS core biopsy diagnosis and with available pathology results from subsequent surgery were included. Cases with known concurrent ipsilateral IC, DCIS and/or atypical ductal hyperplasia were excluded.

Results: 107 cases with NC-LCIS in any pathology report were identified (1998-2016); 44 were excluded due to concurrent ipsilateral IC, the remaining 62 patients with 63 core biopsy diagnoses of NC-LCIS all underwent surgical excision and formed our study cohort. Median age was 56 years (range 43-83); 43 (68%) were postmenopausal. NC-LCIS was diagnosed on core biopsy for mammographic findings in 57 (90%) cases and for MRI findings in 6 (9%). All were BI-RADS 4 lesions; calcifications were the most common biopsy indication (50 (78%)). CIS/DLF was the most common term used for NC-LCIS (28 (44%)), followed by CIS (18 (29%)), V-LCIS (14 (22%)) and P-LCIS (3 (5%)). On core biopsy, 36/44 (82%) of NC-LCIS cases were E-cadherin negative, 38/41 (93%) were ER positive, and 6/34 (18%) were HER2 positive. IC and/or DCIS were diagnosed on subsequent surgery in 22 (33%) of patients, of which 14 (67%) were IC and 8 (18%) had DCIS only.

LesionTotalE-cadherin negativeUpgraded, N (%)Invasive cancer, N (%)DCIS only, N (%)CIS188/10 (80%)3 (16%)2 (67%)1 (33%)CIS/DLF2819/23 (83%)12 (43%)7 (58%)5 (42%)P-LCIS31/1 (100%)3 (100%)2 (67%)1 (33%)V-LCIS148/10 (80%)4 (29%)3 (75%)1 (25%)

Median IC size was 0.2 cm (0.06-1.1 cm). IC histology was ductal in n=4 (29%), lobular in n=7 (50%), and ductal and lobular in n=3 (21%). Among the 14 invasive lesions, 5 (36%) were grade I, 5 (36%) were grade II and 2(13%) were grade III, (grade was not reported for 2 remaining ICs); 12/14 (86%) were ER positive and 1/14 (7%) was HER2 positive; none had LVI or positive nodes.

Among the 42 cases not upgraded, 13 (31%) had mastectomy, 9 (21%) had excision and radiation, 20 had excision only, all had negative margins. At median follow-up of 60 months (1-224 months), 1/20 patients treated with excision only was diagnosed with DCIS, 14 months after surgery for CIS/DLF on core biopsy.

Conclusions: In this large series of NC-LCIS diagnosed on core biopsy, the upgrade rate to carcinoma was 33% supporting the recommendation for routine excision of these lesions. The cancers found at excision were all stage I and the majority were grade I or II. At a median follow-up of 60 months only 1/20 patients with pure NC-LCIS treated with excision alone developed a future ipsilateral cancer. Further study of the natural history of these rare lesions is warranted.

Citation Format: Nakhlis F, Harrison BT, Lester SC, Hughes KS, Coopey SB, King TA. Evaluating the risk of upgrade to invasive breast cancer and/or DCIS on excision following a diagnosis of non-classic lobular carcinoma in situ [abstract]. In: Proceedings of the 2017 San Antonio Breast Cancer Symposium; 2017 Dec 5-9; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2018;78(4 Suppl):Abstract nr P5-22-01.

Abstract P2-01-06: Patterns of axillary evaluation in older patients (pts) with breast cancer and impact on adjuvant therapy

Background:

Axillary lymph node status has traditionally been a key factor in informing adjuvant therapy recommendations for pts with breast cancer. With increased emphasis on tumor biology, this information may be less relevant, particularly in older populations where competing comorbidity frequently influences treatment decisions. We examined patterns of axillary surgery in older breast cancer pts and the impact axillary surgery has on treatment receipt.

Methods:

We identified women aged ≥65 with Stage I-III invasive breast cancer diagnosed during 2012-2013 from the National Cancer Data Base who did not have clinically positive nodes and underwent cancer-directed surgery. Nodal surgery type and receipt of adjuvant therapies were examined. Multivariable logistic regression was used to examine the associations of axillary surgery receipt with pt, clinical and facility factors.

Results:

Among 69,414 eligible women, 40% were aged 65-70, 42% aged 71-80 and 18% aged >80. 91% had axillary surgery (67% sentinel lymph node biopsy, 11% axillary lymph node dissection, 13% unspecified axillary surgery), and 24% of pts had pathologically positive nodes. 10% of pts (stage IIB-III) received adjuvant chemotherapy, 81% (hormone receptor positive) received adjuvant hormonal therapy, 67% (breast conservation or stage III postmastectomy) received radiation. In adjusted analyses, increasing age and neoadjuvant hormonal therapy were strongly associated with lower odds of axillary surgery. Region and mastectomy were strongly associated with higher odds of axillary surgery. The table shows variables associated with axillary surgery.

VariableAdjusted OR (95% CI) for having any axillary surgery*Age (vs. 65-70) 71-75.64 (.58-.71)76-80.34 (.31-.37)>80.08 (.07-.09)Diagnosed in 2013 (vs. 2012)1.08 (1.02-1.15)Stage (vs. II) I1.25 (1.13-1.38)III.73 (.60-.89)Grade (vs. 1) 21.22 (1.14-1.31)31.24 (1.13-1.37)HER2 status (vs. positive) Negative.83 (.73-.93)Tumor size (vs. ≤2 cm) >2-5cm1 (.91-1.11)>5cm.56 (.47-.67)Comorbidity score (vs. 0) 1.85 (.79-.92)>/=2.62 (.56-.68)Region (vs. New England)Range 1.66-2.67 (1.42-3.12)Case volume (vs. high) Low.82 (.73-.93)Medium.98 (.91-1.06)Insurance (vs. private) Uninsured.69 (.44-1.09)Medicaid.67 (.52-.86)Medicare.84 (.77-.93)Median household income ($) (vs. >46K) <30,0001.06 (.95-1.18)30,000-34,9991.11 (1.01-1.21)35,000-45,9991.08 (1.01-1.16)Neoadjuvant hormonal therapy (vs. not).49 (.42-.59)Surgery (vs. BCS) Mastectomy, no recon3.37 (3.09-3.68)Mastectomy, +recon2.76 (2.16-3.51)  *Adjusted for table variables plus race, hormone receptor status, and facility type (none significantly associated with axillary surgery)

Axillary surgery and younger age were significantly associated with receipt of adjuvant chemotherapy, radiation, and hormonal therapy.

Conclusion:

Within the NCDB, 91% of pts age ≥65 with clinically node-negative breast cancer undergo surgical staging of the axilla, and axillary surgery was associated with adjuvant therapy receipt. The impact of routine node assessment on treatment and outcome has been questioned, and further study in this population of pts is warranted.

Citation Format: Dominici LS, Sineshaw H, Jemal A, Lin A, King TA, Freedman RA. Patterns of axillary evaluation in older patients (pts) with breast cancer and impact on adjuvant therapy [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 P2-01-06.

Abstract ES6-2: ES6-2 Surgical considerations in patients receiving neoadjuvant therapy

Early randomized trials of neoadjuvant chemotherapy failed to show an improvement in overall survival compared to adjuvant therapy, yet it reduces the need for mastectomy and axillary lymph node dissection, thus decreasing the morbidity of surgery, without increasing the risk of locoregional recurrence. It is also now increasingly clear that the impact of neoadjuvant chemotherapy varies by molecular subtype; whereby patients with high-grade estrogen receptor negative and/or HER2 positive breast cancers are more likely to experience pathologic complete response to NAC that those with low-grade, estrogen receptor positive cancers. The increasing rates of pCR following neoadjuvant chemotherapy have had a significant impact on local-regional treatment considerations. However, patient selection for this approach remains critical.

Sentinel node biopsy after neoadjuvant chemotherapy accurately stages the axilla and is associated with a low rate of nodal recurrence in patients presenting with a clinically negative axilla. Sentinel node biopsy after neoadjuvant chemotherapy in patients with proven axillary metastases prior to neoadjuvant chemotherapy who become clinically node negative has a false negative rate of less than 10% only when 3 or more sentinel nodes are identified and there are no data on nodal recurrence rates after sentinel node biopsy alone in this population. Hence, strategies to ensure a low false negative rate are critical if sentinel node biopsy is offered to patients with proven axillary metastases prior to neoadjuvant chemotherapy. The relative contribution of pre-treatment stage and post-treatment stage (degree of pathologic response) to local control is also uncertain and tailoring of local therapy based on the degree of response is the subject of ongoing trials.

Citation Format: King TA. ES6-2 Surgical considerations in patients receiving neoadjuvant therapy [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 ES6-2.

Abstract P6-09-23: SETER/PR - A robust 18-gene predictor of sensitivity to endocrine therapy in metastatic breast cancer

Rationale: A robust index for gene expression related to activity of estrogen (ESR1) and progesterone (PGR) receptors could predict sensitivity to endocrine therapy in metastatic breast cancer.

Methods: Transcripts correlated with ESR1 and PGR expression in 389 hormone receptor-positive breast cancer samples (Affymetrix U133A microarrays) were ranked for reliability according to their pre-analytical (intratumoral heterogeneity, biopsy type) and analytical reproducibility. Eighteen target and ten reference genes were selected and summarized as the SETER/PR index. The SETER/PR index was evaluated in a different set of 140 biopsies from distant metastases of hormone receptor-positive and HER2-negative (HR+/HER2-) breast cancer, and in additional pre-analytical and analytical sample cohorts. Thereafter, SETER/PR was translated to a customized format for application to formalin-fixed and paraffin-embedded (FFPE) sections.

Results: Higher SETER/PR in a metastasis was associated with longer progression-free survival (PFS, 9 vs. 2 months) and overall survival (OS, 50 vs. 19 months) following endocrine therapy in the cohort with metastatic breast cancer (MBC) and relapsed disease (n=79), so a cut point was defined in that cohort. SETER/PR was also significantly associated with PFS after adjusting for PR status of the metastasis, presence of visceral metastases, number of previous relapse events, and clinical history of previous sensitivity to endocrine therapy (HR 0.485, 95%CI 0.265 – 0.889, p = 0.019). Technically, SETER/PR was highly reproducible under different pre-analytical and analytical conditions, including host organ contamination. The translated SETER/PR assay used a single 10 µm FFPE tissue section, did not require RNA purification, and represented the microarray results from matched fresh samples with excellent agreement (correlation = 0.980, n = 31).

Conclusion: The SETER/PR index is a new biomarker to predict PFS and OS for patients with HR+/HER2- MBC who receive endocrine therapy. The assay is applicable to FFPE tissue sections from small biopsies of metastases. Additional independent (blinded) validation studies will be necessary to confirm these results.Rationale: A robust index for gene expression related to activity of estrogen (ESR1) and progesterone (PGR) receptors could predict sensitivity to endocrine therapy in metastatic breast cancer.

Methods: Transcripts correlated with ESR1 and PGR expression in 389 hormone receptor-positive breast cancer samples (Affymetrix U133A microarrays) were ranked for reliability according to their pre-analytical (intratumoral heterogeneity, biopsy type) and analytical reproducibility. Eighteen target and ten reference genes were selected and summarized as the SETER/PR index. The SETER/PR index was evaluated in a different set of 140 biopsies from distant metastases of hormone receptor-positive and HER2-negative (HR+/HER2-) breast cancer, and in additional pre-analytical and analytical sample cohorts. Thereafter, SETER/PR was translated to a customized format for application to formalin-fixed and paraffin-embedded (FFPE) sections.

Results: Higher SETER/PR in a metastasis was associated with longer progression-free survival (PFS, 9 vs. 2 months) and overall survival (OS, 50 vs. 19 months) following endocrine therapy in the cohort with metastatic breast cancer (MBC) and relapsed disease (n=79), so a cut point was defined in that cohort. SETER/PR was also significantly associated with PFS after adjusting for PR status of the metastasis, presence of visceral metastases, number of previous relapse events, and clinical history of previous sensitivity to endocrine therapy (HR 0.485, 95%CI 0.265 – 0.889, p = 0.019). Technically, SETER/PR was highly reproducible under different pre-analytical and analytical conditions, including host organ contamination. The translated SETER/PR assay used a single 10 µm FFPE tissue section, did not require RNA purification, and represented the microarray results from matched fresh samples with excellent agreement (correlation = 0.980, n = 31).

Conclusion: The SETER/PR index is a new biomarker to predict PFS and OS for patients with HR+/HER2- MBC who receive endocrine therapy. The assay is applicable to FFPE tissue sections from small biopsies of metastases. Additional independent (blinded) validation studies will be necessary to confirm these results.

Citation Format: Sinn BV, Tsai T-H, Lau R, Fu C, Gould R, Murthy R, King TA, Hatzis C, Kwiatkowski DN, Valero V, Symmans WF. SETER/PR - A robust 18-gene predictor of sensitivity to endocrine therapy in metastatic 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 P6-09-23.

Abstract S4-04: Lobular carcinoma in situ displays intra-lesion genetic heterogeneity and its progression to invasive disease involves clonal selection and variations in mutational processes

Introduction: Lobular carcinoma in situ (LCIS) is considered both a risk factor and non-obligate precursor of invasive breast cancer. We sought to determine the genomic landscape of LCIS and the mutational processes involved in the clonal evolution and progression from LCIS to ductal carcinoma in situ (DCIS) and invasive lobular carcinoma (ILC).

Methods: Patients with a history of LCIS undergoing therapeutic or prophylactic mastectomy were prospectively enrolled in an IRB approved protocol. Frozen tissue blocks were collected, screened for lesions of interest (LCIS, DCIS, ILC, invasive ductal carcinomas (IDC)) and subjected to microdissection and DNA/RNA extraction. Matched germline DNA was available for all cases. Whole exome sequencing was performed on a HiSeq2000 and data were aligned to the reference human genome and processed using GATK. Single nucleotide variants (SNVs) and small insertions/deletions were identified using MuTect and Varscan, respectively. Purity and ploidy estimates were calculated using ABSOLUTE. Clonal frequencies were estimated using Pyclone and the clonal structure of each sample was reconstructed using SubcloneSeeker. Shannon index and Simpson index metrics were used to calculate heterogeneity levels. Mutational signatures were defined according to their mutational trinucleotide context, and the expression levels of APOBEC gene family members were assessed by quantitative reverse transcription (qRT)-PCR.

Results: 30 LCIS, 10 ILCs, 7 DCIS and 5 IDCs from 15 patients qualified for data analysis. CDH1 was the most frequently mutated gene and found to be targeted by mutations in 26 LCIS samples (23 somatic, 3 germline). The repertoire of somatic mutations in LCIS was similar to that of luminal A breast cancers, with the exception of the significantly higher frequency of CDH1 mutations and the lower prevalence of TP53 mutations. ILCs were clonally related to at least one LCIS in 10 patients, and in 3/7 patients, DCIS was clonally related to at least one LCIS. Clonal composition analysis revealed that the presence of a minor clone(s) in LCIS, and the levels of intra-tumor genetic heterogeneity were significantly higher in LCIS clonally related with DCIS/ILC than in LCIS unrelated to DCIS/ILC. In two cases, a minor LCIS subclone constituted the major clone in the associated DCIS/ILC. A comparative analysis of the mutational signatures in the truncal and branch mutations of these cases revealed that whilst the truncal mutations displayed an aging signature, branch mutations were enriched for the APOBEC signature. qRT-PCR analysis demonstrated that cases displaying the APOBEC signature also harbored significantly higher levels of APOBEC3B expression than samples with the aging signature.

Conclusions: LCIS displays intra-lesion genetic heterogeneity, and the progression from LCIS to DCIS or ILC may involve the selection of clones resulting from distinct mutational processes during clonal evolution. Our findings also suggest that cytodine deamination driven by the overexpression of APOBEC3B may drive the progression of LCIS to DCIS/ILC in a subset of cases.

Citation Format: Reis-Filho JS, Schizas M, Piscuoglio S, Sakr RA, Ng CKY, Lim RS, Carniello JVS, Towers R, Martelotto L, Giri DD, de Andrade VP, Viale A, Solit DB, Weigelt B, King TA. Lobular carcinoma in situ displays intra-lesion genetic heterogeneity and its progression to invasive disease involves clonal selection and variations in mutational processes. [abstract]. In: Proceedings of the Thirty-Eighth Annual CTRC-AACR San Antonio Breast Cancer Symposium: 2015 Dec 8-12; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2016;76(4 Suppl):Abstract nr S4-04.

Abstract P6-06-02: Germline CDH1 mutations in lobular carcinoma in situ

BACKGROUND: Germline CDH1 mutations are responsible for the increased risk of both gastric cancer and invasive lobular breast cancer (ILC) in families with hereditary diffuse gastric cancer syndrome; yet germline CDH1 mutations in women with ILC without a family history (FH) of gastric cancer are rare. Lobular carcinoma in situ (LCIS) is both a risk factor and non-obligate precursor of ILC and recent data suggest that germline CDH1 mutations may be present in up to 8% of patients with bilateral LCIS +/- ILC; raising questions about the role of genetic testing in this context. The purpose of this study was to determine the frequency of germline CDH1 mutations in a large prospectively followed cohort of patients with pathologically confirmed bilateral LCIS.

METHODS: Patients with a biopsy proven history of LCIS, entering surveillance or presenting for surgery (prophylactic or therapeutic mastectomy), between 2005 and 2013 were prospectively identified and enrolled in IRB approved protocols at Memorial Sloan-Kettering Cancer Center for the collection of tissue and/or germline DNA (IRB 01-135, 99-030). All biopsies were reviewed to confirm LCIS and mastectomy specimens were subject to extensive sampling of all quadrants. Cases with confirmed bilateral LCIS were chosen for the primary analysis. Cases where bilateral mastectomy tissue sampling confirmed only unilateral LCIS were included for comparison. Germline DNA was anonymized and analyzed for CDH1 mutations using targeted capture sequencing with baits for all exons of CDH1 on HiSeq2000. Germline single nucleotide variants were called using GATK HaplotypeCaller and insertions/deletions by Varscan and Scalpel. Mutations were manually inspected using the Integrative Genomics Viewer (IGV). Clinical data were abstracted prior to anonymization.

RESULTS: Germline DNA was available for 114 patients; 78 underwent bilateral mastectomy for breast cancer (BC), 8 chose prophylactic mastectomy and 28 patients with biopsy proven bilateral LCIS were identified in surveillance. Following mastectomy, tissue sampling confirmed bilateral LCIS in 67/86 (78%) patients, and ruled out bilateral LCIS in 19 patients; yielding 95 patients with bilateral LCIS for the primary analysis. Median age at LCIS diagnosis for bilateral and unilateral cases respectively was 48yrs (range 36-70) and 44 yrs (range 38-63). One patient with bilateral LCIS also reported a FH of gastric cancer. Pathogenic germline CDH1 mutations (D72N (missense) and E35* (nonsense)) were identified in 2/95 (2%) patients with bilateral LCIS, one of whom also had invasive breast cancer (ILC). A germline CDH1 mutation was not identified in the patient with bilateral LCIS and a FH of gastric cancer, nor were CDH1 mutations identified among the 19 patients with unilateral LCIS.

CONCLUSIONS: In this cohort of 95 patients with pathologically documented bilateral LCIS +/- BC, the overall frequency of CDH1 germline mutations was 2%; considerably lower than previously reported. To our knowledge this is the largest series to address this question and these findings do not support germline testing for CDH1 mutations in women with bilateral LCIS.

Citation Format: Reyes SA, Sakr RA, Schizas M, Towers R, Park AY, Ng CKY, Weigelt B, Reis-Filho JS, King TA. Germline CDH1 mutations in lobular carcinoma in situ. [abstract]. In: Proceedings of the Thirty-Eighth Annual CTRC-AACR San Antonio Breast Cancer Symposium: 2015 Dec 8-12; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2016;76(4 Suppl):Abstract nr P6-06-02.

RECK controls breast cancer metastasis by modulating a convergent, STAT3-dependent neoangiogenic switch

Metastasis is the primary cause of cancer-related death in oncology patients. A comprehensive understanding of the molecular mechanisms that cancer cells usurp to promote metastatic dissemination is critical for the development and implementation of novel diagnostic and treatment strategies. Here we show that the membrane protein RECK (Reversion-inducing cysteine-rich protein with kazal motifs) controls breast cancer metastasis by modulating a novel, non-canonical and convergent signal transducer and activator of transcription factor 3 (STAT3)-dependent angiogenic program. Neoangiogenesis and STAT3 hyperactivation are known to be fundamentally important for metastasis, but the root molecular initiators of these phenotypes are poorly understood. Our study identifies loss of RECK as a critical and previously unknown trigger for these hallmarks of metastasis. Using multiple xenograft mouse models, we comprehensively show that RECK inhibits metastasis, concomitant with a suppression of neoangiogenesis at secondary sites, while leaving primary tumor growth unaffected. Further, with functional genomics and biochemical dissection we demonstrate that RECK controls this angiogenic rheostat through a novel complex with cell surface receptors to regulate STAT3 activation, cytokine signaling, and the induction of both vascular endothelial growth factor and urokinase plasminogen activator. In accordance with these findings, inhibition of STAT3 can rescue this phenotype both in vitro and in vivo. Taken together, our study uncovers, for the first time, that RECK is a novel regulator of multiple well-established and robust mediators of metastasis; thus, RECK is a keystone protein that may be exploited in a clinical setting to target metastatic disease from multiple angles.

Abstract P2-06-01: cMethDNA is a quantitative circulating methylated DNA assay for detection of metastatic breast cancer and for monitoring response to therapy

Background- The ability to consistently detect cell-free tumor-specific DNA in peripheral blood of patients with metastatic breast cancer provides the opportunity to detect changes in tumor burden and to monitor response to treatment. Studies of cell-free DNA in the peripheral blood of breast cancer patients suggest that methylated DNA markers in serum or plasma could be used for detection of advanced disease, monitoring of therapeutic response, and for early detection of disease recurrence.

Methods- A genome-wide serum DNA methylome array (Illumina HumanMethylation27 BeadChip) analysis was conducted on cell-free circulating DNA in serum from women with stage IV recurrent breast cancer, and 232 key CpG loci were identified. Methylation for this panel of 10 gene loci was evaluated using our newly developed cMethDNA assay to detect miniscule amounts of methylated DNA in Training and Test sets of sera from a total of 112 women (n = 55 normal, n = 57 metastatic breast cancer). The clinical sensitivity and specificity of the assay, along with technical reproducibility, was determined. To evaluate the concordance of DNA methylation patterns, the 10 gene panel was tested on 22 DNA sets of primary tumor, metastases and serum from the same patient. Finally, the ability of cMethDNA to monitor response to therapy was evaluated in 28 patients with metastatic disease.

Results- A normal laboratory threshold of 7 cumulative methylation units was set and assay parameters were locked, based on Receiver Operating Characteristic (ROC) analyses of DNA from 300 ul of patient sera in the Training set (normal, n = 28; cancer, n = 24; 92% sensitivity, 96% specificity, and AUC = 0.950). Evaluation of the Test set of patient sera (normal, n = 27; cancer n = 33) resulted in detection of metastatic breast cancer with 91% sensitivity, 100% specificity, and AUC = 0.994 (0.984-1.005, p<0.0001). Reproducibility of the cMethDNA assay increased with copy number; with the highest variation at 50 copies (CV = 29.1%) and the lowest at 3,200 copies (CV = 2.5%) of methylated DNA. The test was shown to be operator independent (ICC = 0.99). Evaluation of concordance between primary and disseminated tumor methylation showed that the methylation pattern from any given individual is highly conserved between serum, primary tissue and their metastases, and poorly conserved between different individuals. cMethDNA analysis of 28 patients before and after initiation of therapy showed a decrease in cumulative methylation in women with stable/responsive disease and a correlation with disease progression free survival (p<0.0001).

Conclusion- Together, our data suggest that the cMethDNA test 1) can detect tumor DNA shed into blood, 2) reflect the methylation alterations typical of the primary tumor and its metastatic lesions, and 3) reflect response to treatment after chemotherapy. Next, we will test the clinical utility of cMethDNA in independent clinical trial sample sets where it's complementary and independent roles will be examined against CA15.3 and CTC assays.

Citation Information: Cancer Res 2013;73(24 Suppl): Abstract nr P2-06-01.

Abstract PD05-02: Novel mutations in lobular carcinoma in situ (LCIS) as uncovered by targeted parallel sequencing

Background: LCIS has traditionally been recognized as a marker of increased risk for the subsequent development of breast cancer, of either the lobular or ductal phenotype, yet due to the incidental nature of LCIS little is known about its underlying biology. Here we describe the first report of novel mutations in LCIS using targeted exome sequencing of fresh frozen tissue samples.

Methods: Fresh frozen tissue samples from patients with a prior history of LCIS undergoing therapeutic or risk-reducing mastectomy from 2003–08 were harvested and systematically reviewed to identify LCIS. Cells from individual LCIS lesions +/− associated cancers were collected by laser capture microdissection. For the purposes of this study, germline DNA (blood) and DNA from 12 unique LCIS lesions were subject to targeted parallel sequencing of exons corresponding to 230 cancer genes using the Illumina HiSeq 2000 platform. DNA from an associated ductal carcinoma in situ (DCIS) and/or an invasive ductal (IDC) or lobular (ILC) lesion was also available for 7 of these cases resulting in 41 samples from 12 pts for mutational analysis. Normalized (RMA) Affymetrix U133A gene expression data were also available.

Results: DNA profiling reliably identified 7 somatic mutations in 5/12 LCIS samples (41.7%). Of these, 4/7 mutations were base substitutions (missense mutations); and the others included: 1 deletion; 1 silent and 1 splice-site mutation. Mutations in LCIS were identified in 5/230 cancer genes analyzed, including: PIK3CA, CDH1, NOTCH4, PREX2 and ARAF. PIK3CA and CDH1 mutations were each identified in two samples, representing 4/7 (57.1%) mutations. Specific mutations found in LCIS and their frequencies are listed (table). Among 3 LCIS-ILC pairs, one shared the G914R mutation in PIK3CA, and 1/3 LCIS-IDC pairs exhibited an identical point mutation (R373W) in the NOTCH4 gene. No shared mutations were observed in 3 LCIS-DCIS pairs. Both CDH1 mutated cases were associated with decreased e-cadherin mRNA levels when compared to non-mutated cases (mean 9.88 vs 11.01), as was the NOTCH4 mutation (mean 6.02 vs 6.47). Mutations in ARAF and PREX2 were associated with increased mRNA levels, mean 7.07 vs 6.52 and 4.82 vs 4.22, respectively. The hotspot PIK3CA mutation (E545K) was also associated with increased gene expression (mean 5.15 vs 4.64) whereas the G914R mutant was associated with decreased expression (mean 4.13 vs 4.64).

MS1-2: Tumor Entrained Neutrophils Inhibit Seeding in the Pre-Metastatic Lung

Primary tumors have been shown to prepare distal organs for later colonization of metastatic cells by stimulating organ-specific infiltration of bone marrow derived cells. We have recently demonstrated that neutrophils are mobilized by the primary tumor and accumulate in the lung prior to the arrival of metastatic cells in mouse models of breast cancer. Tumor-entrained neutrophils (TENs) inhibit metastatic seeding in the lungs by generating H2O2 and tumor secreted CCL2 is both required and sufficient for optimal anti-metastatic entrainment of G-CSF-mobilized neutrophils. TENs are present in the peripheral blood of breast cancer patients prior to surgical resection but not in healthy individuals. Thus, while tumor-secreted factors contribute to tumor progression at the primary site, they concomitantly induce a neutrophil-mediated inhibitory process at the metastatic site.

Citation Information: Cancer Res 2011;71(24 Suppl):Abstract nr MS1-2.

P5-14-13: Favorable Prognosis in Patients with T1a,b Node-Negative Triple Negative Breast Cancers Treated with Multimodality Therapy

Purpose: To evaluate the clinical characteristics, natural history and outcomes in patients with ≤1cm, node-negative triple negative breast cancer (TNBC).

Materials and Methods: After excluding patients who received neoadjuvant therapy, 1,022 TNBC patients who received definitive breast surgery from 1999 to 2006 were identified from an institutional database. Among these, 194 patients had node-negative tumors ≤1cm and comprise the study population. Clinical data was abstracted and survival outcomes were analyzed.

Results: Median follow-up time was 71 months (range 2–143). Median age at diagnosis was 55.5 years (range 27–84). T stage was T1mic in 16 (8.2%), T1a in 49 (25.3%), T1b in 129 (66.5%). The majority of tumors were poorly differentiated (N= 142, 73%), lacked lymphovascular invasion (N= 170, 87.6%) and were screening-detected (69%, N=134). Breast-conserving surgery (BCS) was employed in 129 (66.5%) and mastectomy in 65 (33.5%) patients. 113 (58%) patients received adjuvant chemotherapy and 123 (63%) received whole breast radiation. Patients who received chemotherapy tended to have more adverse clinical and disease features (younger age,T1b, poor tumor grade; all p<0.05). For the entire group, 5 year local recurrence-free survival was 96% and distant metastasis-free survival was 95%, with no difference in distant relapse rates between T1mic/T1a vs. T1b patients (94.5% vs 95.5%, p=0.81 )or by receipt of chemotherapy (95.9% vs 94.5%, p=0.63).

Conclusion: Excellent 5-year locoregional and distant control rates were achievable in patients with TNBC tumors ≤ 1.0 cm, 58% of whom received chemotherapy. These results identify a group of TNBC patients with favorable outcomes following early detection and multimodality treatment.

Citation Information: Cancer Res 2011;71(24 Suppl):Abstract nr P5-14-13.

Patient characteristics associated with the decision to undergo bilateral prophylactic mastectomy for lobular carcinoma in situ

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Background: Women at increased risk for breast cancer due to a diagnosis of lobular carcinoma in situ (LCIS) have three management options: high risk surveillance +/- chemoprevention (CP) or bilateral prophylactic mastectomy (BPM). Among a large cohort of women with LCIS, we previously reported there were no differences between women choosing CP compared to those choosing surveillance alone. The purpose of this study was to identify patient factors associated with the decision to pursue BPM for LCIS.

Methods: We reviewed our prospectively maintained LCIS database to identify women choosing BPM (1995-2009). Comparisons were made between patients who chose BPM versus those who chose high risk surveillance +/- CP.

Results: Among 995 pts with LCIS, 795 (80%) chose surveillance alone, 149 (15%) chose CP and 51 (5%) chose BPM. Compared to patients electing surveillance +/- CP patients who pursued BPM were younger at age of LCIS diagnosis (48 vs. 52 yrs, p < 0.001), more likely to have bilateral biopsies with LCIS (14% vs. 3%, p = 0.002) and more likely to be premenopausal (82% vs. 57%, p < 0.001). Patients choosing BPM were also more likely to have additional risk factors for breast cancer including: stronger family histories and extremely dense breasts (Table). Occult breast cancer was found in 4 (8%) BPM patients. At a median follow-up of 54 months (range 0-190 mos), 120/944 (13%) patients in the surveillance +/- CP group developed breast cancer.

Conclusions: High-risk surveillance alone is the preferred management option for women with LCIS at our institution. Patients electing BPM are younger and more likely to have other associated risk factors for developing breast cancer. Further research to define how the increased risk imparted by LCIS is augmented by these factors may allow for better risk stratification and more informed discussions with patients.

[Table: see text]

Experimental infections of the monogenean Gyrodactylus turnbulli indicate that it is not a strict specialist

Parasites represent a threat to endangered fish species, particularly when the parasite can host switch and the new host is vulnerable. If the parasite is highly host specific then successful host switching should be a rare occurrence; however, the host range of many parasites which are assumed to be specialists has never been tested. This includes the monogenean Gyrodactylus turnbulli, a well-studied ectoparasite found caudally on its known host, the guppy, Poecilia reticulata. In this study, we monitored parasite establishment and reproduction on a range of poeciliids and more distantly related fish. Individually maintained fish were experimentally infected with a single parasite and monitored daily to establish whether G. turnbulli could survive and reproduce on other fish species. Gyrodactylus turnbulli can infect a wider range of hosts than previously considered, highlighting the fact that host specificity can never be assumed unless experimentally tested. Our findings also have significant implications for parasite transmission to novel hosts and provide further insight into the evolutionary origins of this ubiquitous group of fish pathogens. Previous molecular evidence indicates that host switching is the key mechanism for speciation within the genus Gyrodactylus. Until recently, most Gyrodactylus spp. were assumed to be narrowly host specific. However, our findings suggest that even so-called specialist species, such as G. turnbulli, may represent a threat to vulnerable fish stocks. In view of the potential importance of host switching under artificial conditions, we propose to describe this as 'artificial ecological transfer' as opposed to 'natural ecological transfer', host switching under natural conditions.

Abnormal microvascular response is localized to the digits in patients with systemic sclerosis

OBJECTIVE

To investigate the hypothesis that cutaneous microvascular perfusion of the dorsum of the hand (in response to local heating) and distal phalanx (in response to occlusion) is impaired in patients with systemic sclerosis (SSc) compared with healthy controls.

METHODS

Twenty-nine patients with SSc and 29 control subjects were recruited. Perfusion was monitored using novel dual-wavelength laser Doppler imaging, allowing measurement of both smaller (capillaries) and larger (thermoregulatory) vessels. Postacclimatization, a baseline dorsum scan (red or green wavelength) was performed. A heating pad was placed on the dorsum (total stimulus time 6 minutes at 34-40 degrees C), and following removal of the pad, baseline wavelength scans were performed until perfusion returned to baseline values. This was then repeated for the second wavelength. The maximum perfusion increase due to heating (PEAK1) and area under the perfusion-time curve (AUC) were determined. In addition, scans (both wavelengths) of the index finger were performed prior to and during 2 minutes of suprasystolic occlusion, and the response upon occlusion release was monitored with single-point laser Doppler. The decrease in perfusion due to occlusion (from preocclusion baseline values) (%DECREASE) and the maximum increase (from baseline perfusion values under occlusion) in hyperemic perfusion upon removal of occlusion (PEAK/OCC) were calculated.

RESULTS

PEAK1 and AUC values were not significantly different between patients and controls, as assessed with either wavelength. A significant difference between groups was found in the %DECREASE values with the green, but not the red, wavelength. A significant between-group difference was also found in PEAK/OCC values, using both wavelengths.

CONCLUSION

This study suggests that SSc has no effect on microvascular perfusion in the dorsum of the hand, and that the abnormal microvascular response is localized to the digits, affecting both smaller and larger vessels.

Dual wavelength (532 and 633 nm) laser Doppler imaging of plaque psoriasis

BACKGROUND

Increased blood flow occurs in plaques of psoriasis, and an increase in blood flow has been shown to occur in uninvolved skin adjacent to the active edge.

OBJECTIVES

In order to gain more insight into the pathophysiology of the active edges of plaques of psoriasis, we investigated different components of the microcirculation in the lesional and nonlesional skin of patients with psoriasis, using dual wavelength laser Doppler imaging (LDI).

METHODS

The cutaneous blood flow in 23 plaques on the forearms of 20 patients with chronic plaque psoriasis was recorded using dual wavelength LDI. Perfusion was determined within the plaque (P), in uninvolved skin adjacent to the plaque (A) and in nonadjacent skin (U).

RESULTS

Perfusion in plaques was increased as imaged by either 633 nm (red wavelength) or 532 nm (green wavelength) compared with both adjacent and nonadjacent uninvolved skin: median (interquartile range) P/A(RED) = 3.7 (2.5-4.9), P/A(GREEN) = 1.3 (1.2-1.6), P/U(RED) = 4.2 (2.7-6.1), P/U(GREEN) = 1.5 (1.3-1.9).

CONCLUSIONS

Vascular perfusion is increased within plaques of psoriasis compared with adjacent and nonadjacent uninvolved skin. The results suggest an area of increased perfusion in skin adjacent to plaques, when compared with nonadjacent skin, for both deeper (large) and superficial (small) vessels (imaged by 633 and 532 nm, respectively). We believe that this dual wavelength tool may be a suitable and useful way of assessing pathophysiology and treatment response in psoriasis.

Thermal effects of the Er:YAG laser on a simulated dental pulp: a quantitative evaluation of the effects of a water spray

OBJECTIVES

To quantify the temperature increments in a simulated dental pulp following irradiation with an Er:YAG laser, and to compare those increments when the laser is applied with and without water spray.

METHODS

Two cavities were prepared on either the buccal or lingual aspect of sound extracted teeth using the laser. One cavity was prepared with water spray, the other without and the order of preparation randomised. Identical preparation parameters were used for both cavities. Temperature increments were measured in the pulp chamber using a calibrated thermocouple and a novel pulp simulant.

RESULTS

Maximum increments were 4.0 degrees C (water) and 24.7 degrees C (no water). Water was shown to be highly significant in reducing the overall temperature increments in all cases (p<0.001; paired t-test). None of the samples prepared up to a maximum of 135 J cumulative energy prepared with water spray exceeded that threshold at which pulpal damage can be considered to occur. Only 25% of those prepared without water spray remained below this threshold.

DISCUSSION

Extrapolation of the figures suggests probably tolerable limits of continuous laser irradiation with water in excess to 160 J. With the incorporation of small breaks in the continuity of laser irradiation that occur in the in vivo situation, the cumulative energy dose tolerated by the pulp should far exceed these figures.

CONCLUSIONS

The Er:YAG laser must be used in conjunction with water during cavity preparation. As such it should be considered as an effective tool for clinical use based on predicted pulpal responses to thermal stimuli.

Soft and hard tissue ablation with short-pulse high peak power and continuous thulium-silica fibre lasers

Thulium lasers operating near approximately 2 microm are the subject of interest for various medical applications. The newly developed Tm3+ silica fibre laser in Q-switched and CW operation was investigated to determine its efficiency in the interaction with soft and hard tissues. The interaction was investigated using a free-running continuous (CW) Tm(3+)-doped fibre laser (wavelength 1.99 microm, with self-pulsation ranging over 1 to few tens of microseconds) and for novel Q-switched operation of the same fibre laser (pulse durations from 150 to 900 ns and pulse repetition rates from 100 Hz to 17 kHz). Residual damage and affected zones using the Q-switched laser were nearly six times smaller than using the CW fibre laser for about 50 s of exposure time, and increased with pulse repetition rate. The energy required to ablate tissue with the Q-switched fibre laser ranged from 0.2 to 0.6 kJ/cm3 and was significantly smaller than that for the CW fibre laser of 153 to 334 kJ/cm3. Under both high-resolution reflected optical microscopy and histological examination, tissue crater depths were observed as cleanly cut with smooth walls and minimal charring in the case of Q-switched operation of the fibre laser. This study is the first direct comparison of tissue interaction of short-pulse (Q-switched) and CW Tm(3+)-doped silica fibre lasers on crater depth, heat of ablation and collateral damage. The Q-switched Tm(3+)-doped silica fibre laser effectively ablates tissue with little secondary damage.

Digital vascular response to topical glyceryl trinitrate, as measured by laser Doppler imaging, in primary Raynaud's phenomenon and systemic sclerosis

OBJECTIVE

To investigate digital microvascular responses to topical glyceryl trinitrate (GTN) in patients with primary Raynaud's phenomenon (PRP), limited cutaneous systemic sclerosis (LCSSc) and healthy control subjects, using laser Doppler imaging.

METHODS

Ten patients with PRP, 13 with LCSSc and 10 control subjects were studied. Baseline skin microvascular blood flow of the dorsum of the index, middle and ring fingers of the non-dominant hand was measured using scanning laser Doppler imaging. After the initial image, 2% GTN ointment was rubbed on the dorsum of one finger for 1 min; placebo ointment was rubbed on the dorsum of a second finger for 1 min, and the third finger remained untreated. Further laser Doppler scanning of these three fingers was conducted immediately, 10 and 20 min after ointment application.

RESULTS

There was increased blood flow response to placebo compared with no treatment (P<0.001) and to GTN compared with placebo (P=0.004). The change in blood flow over time differed significantly between placebo and GTN (P<0.001), but not between placebo and no ointment application: blood flow increased with GTN and decreased with placebo/no treatment at 10 and 20 min. There were no differences in initial baseline blood flow or response between the subject groups.

CONCLUSIONS

An exogenous supply of nitric oxide by topical GTN ointment causes local endothelial-independent vasodilatory responses in PRP, LCSSc patients and control subjects. As well as demonstrating the effectiveness of topical GTN in patients with PRP and LCSSc, this study illustrates the ability of laser Doppler imaging to quantify local vasodilatory effects.

A mass on breast imaging predicts coexisting invasive carcinoma in patients with a core biopsy diagnosis of ductal carcinoma in situ

An image-guided core-needle breast biopsy (IGCNBB) diagnosis of ductal carcinoma in situ (DCIS) is often upgraded to invasive carcinoma (IC) after complete excision. When IC is identified after excision patients must be returned to the operating room for evaluation of their axillary nodes. We performed this study to identify histologic or mammographic features that would predict the presence of invasion when DCIS is documented by IGCNBB. Patients with an IGCNBB diagnosis of DCIS were identified from a prospective database. Imaging abnormalities were classified as either calcification only or mass with or without calcifications. IGCNBB specimens were reviewed to document nuclear grade and the presence of comedo-type necrosis, periductal fibrosis, and periductal inflammation. Patients were divided into two groups, DCIS and IC, on the basis of the final diagnosis after complete excision. From July 1993 through May 2000, 148 of 2995 (4.9%) IGCNBBs demonstrated DCIS; eight were excluded after pathologic review. Of the remaining 140 patients 36 (26%) demonstrated IC after complete excision. The presence of a mass on breast imaging was the only significant predictor of IC (P = 0.04). On the basis of the results of this study we now perform sentinel lymph node mapping and biopsy at the initial surgical procedure for patients with an IGCNBB diagnosis of DCIS and an associated mass on breast imaging.

Biopsy technique has no impact on local recurrence after breast-conserving therapy

Image-guided core needle breast biopsy (IGCNBB) is an incisional biopsy technique that has been associated with tumor cell displacement. Theoretically tumor cell displacement may affect local recurrence rates in patients treated with breast-conserving therapy (BCT). We performed a study to determine if the biopsy method impacted local control rates following BCT. Patients with nonpalpable breast cancer (invasive and intraductal) diagnosed at our institution and treated with BCT between July 1993 and July 1996 were selected to provide a follow-up period in which the majority of local recurrences should be detected. Patients were divided into two groups based on their method of diagnosis. Group I patients were diagnosed by IGCNBB and group II patients were diagnosed by wire localized excisional breast biopsy (WLEBB). Factors potentially affecting local recurrence rates were retrospectively reviewed. Two hundred eleven patients were treated with BCT, 132 were diagnosed by IGCNBB and 79 by WLEBB. The two patient groups were similar when compared for prognostic factors and treatment. All patients' BCT included histologically negative margins. There were 4 (3.0%) local recurrences in Group I at a median follow-up of 44.4 months and 2 (2.5%) local recurrences in group II at a median follow-up of 50.1 months. This difference was not significant. Breast cancer patients diagnosed by IGCNBB can be treated by BCT with acceptable local control rates. Additional surveillance of our institutional experience and others' is mandatory to validate IGCNBB as the preferred biopsy method for nonpalpable mammographic abnormalities.

Developing an infection control for anaesthetic equipment

Hospital risk management demands the development of broad and inclusive infection control policies. This is particularly true for anaesthetic equipment where appropriate recommendations on decontamination measures remains a difficult subject for infection control teams since there are no national guidelines. It is a topic which has perhaps been neglected in hospital infection control policies despite the widespread use of anaesthetic equipment in many clinical areas outside the theatre complex. This article offers practical guidance when preparing an infection control policy for anaesthetic equipment. The cost effectiveness of single patient use items versus reprocessing equipment is discussed. The importance of a multi-disciplinary approach, especially where the evidence base is weak, is highlighted.

Image-guided breast biopsy

Image-guided breast biopsy has become an attractive alternative to wire-localized excisional biopsy to evaluate women with nonpalpable abnormalities detected by breast imaging. We have organized a database from our institution that includes over 3,500 procedures. We have reviewed our institutional results and the literature pertaining to image-guided breast biopsy. Discussed in this review are the indications and contraindications for image-guided biopsy, common techniques employed, accuracy based on pathology, reimbursement issues, and the multidisciplinary approach used at our institution. The results of our review affirm our position that image-guided breast biopsy is the preferred technique to evaluate women with nonpalpable breast imaging abnormalities.