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.

Complications of local/regional treatment of breast cancer and quality of life

e11597

The aim of this prospective clinical study was to evaluate early and late complications of different surgical procedures, and compare conservative surgical treatments (breast conserving surgery, sentinel lymph node biopsy) to more radical ones (mastectomy, axillary lymph node dissection), and find factors that were related to these complications. 218 early stage breast cancer patients (stage I and II) were enrolled in this study. Physical complications (restrictions in shoulder motions, shoulder functional capacity, pain, lymphedema and sensory loss), psychological complications and the factors related to these complications were studied in patients after breast cancer surgery and/or radiotherapy at first week, at 9th-12th months and at mean follow up time of 34 months. Lymphedema rates after surgery were 14.7 %, 24.8% and 17.0% at first week, 9th-12th months, and long term respectively. In early postoperative period, pain and functional capacity of the effected shoulder were worse than preoperatively measured values and all axis of motion of shoulder joint were effected significantly. On the other hand, at 9th-12th months, only internal flexion was still affected. At the long term period, all axis of motion of shoulder joint, pain and functional capacity were in normal range as before treatment. The factors related to lymphedema were axillary lymph node dissection (p=0.002), radiation therapy to axillae (p<0.001). The patients who had both axillary lymph node dissection and axillary radiotherapy had more lymphedema than the patients who only had axillary lymph node dissection or sentinel lymph node biopsy (p=0.004). The factors related to postoperative depression at early period were cigarette smoking (p=0.008), axillary lymph node dissection (p=0.045) and arm lymphedema (p=0.005). At long term period they were axillary lymph node dissection (p=0.021), mastectomy (p=0.036), drain usage (p=0.028) and sensory loss (p=0.027). The patients who had sentinel lymph node biopsy, axillary dissection without axillary radiotherapy had better quality of life. The patients with cigarette smoking, axillary lymph node dissection, mastectomy, drain, lymphedema and sensory loss had increased incidence of depression than others, these results were statistically significant.

No significant financial relationships to disclose.

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.

Is the sentinel lymph node biopsy accurate for patients with initially clinically axilla-positive locally advanced breast cancer after neoadjuvant chemotherapy?

Abstract #5123

Background: Approximately one third of patients with locally advanced breast cancer (LABC) have no axillary metastatic lymph node(s) after neoadjuvant chemotherapy (NAC). Axillary dissection could be omitted in these patients if SLNB is negative. The aim of this study is to evaluate the accuracy of sentinel lymph node biopsy (SLNB) after NAC for LABC.&#x2028; Materials and Methods: Between January 1992 to May 2008, a total of 69 patients with clinical or radiological positive axilla (N1 or N2) in LABC were enrolled in this study. After NAC, all patients underwent SLNB followed by complete axillary lymph node dissection. SLNB was performed with either a combined detection using blue dye and radiocolloid or blue dye alone. All the sentinel lymph nodes were examined by multisection hematoxylin eosin staining and cytokeratin- immunohistochemistry, whereas the non-sentinel nodes were examined by routine histology.&#x2028; Results: Sentinel lymph nodes were successfully identified in 58 patients among 69 patients (85%). The median age was 46 (range 25 to 76). The clinical stages before chemotherapy were as follows: IIB:46%, IIIA: 22%, and IIIB: 32%, respectively. All of 58 patients had either clinically or radiologically suspicious node-positive disease based on ultrasound findings before neoadjuvant chemotherapy. Pathologic complete response were obtained in 5 patients (9%). The false negative rate was found to be 17.4 % (8/46), whereas the accuracy rate was 86.2% (50/58) among patients with succesful lymphatic mapping.&#x2028; Conclusion: The accuracy of the SLNB procedure seems to be not reliable in patients with locally advanced disease with a positive axilla before NAC therapy due to its high false negative rates. Therefore, complete axillary dissection is still required in patients with a positive-axilla before chemotherapy.

Citation Information: Cancer Res 2009;69(2 Suppl):Abstract nr 5123.

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.

Glucagon-induced hypocalcemia in the rat: effects of maturation and insulin

In adults of several species including man, a small transient decrease in serum calcium concentration follows glucagon administration in doses of 1 to 10 mg/kg. The effects of maturation and insulin on this phenomenon were assessed by comparing the response of newborn and adult rats to equivalent doses of glucagon with and without prior insulin administration. After injection of 1 microgram/g of glucagon, the decrease in serum calcium concentration at 60 min was significant in the newborn rats (-1.75 mg/dl; P less than 0.001) and not significant in the intact adults (-0.07 mg/dl; P greater than 0.1). In pancreatomized adults, the decrease in serum calcium after the same dose of glucagon became significant (-1.23 mg/dl; P less than or equal to 0.01). This hypocalcemic effect was prevented in the pancreatectomized adult rat if insulin in a dose of 0.01 micron/g was given 15 min before glucagon. In the newborn rats, the same dose of insulin decreased the hypocalcemic effect, but the change was still significant (-0.74 mg/dl; P less than 0.01). Glucagon decreased serum calcium at one hr in newborn rats but not in adults. After pancreatectomy, the adult response to glucagon was significant and similar to that of the newborn. Insulin cancelled this effect of glucagon in the pancreatectomized adults and reduced it in the newborns.