Sentinel lymph node mapping with patent blue dye in patients with breast cancer: a retrospective single institution study

Background

Since the end of the last century, sentinel lymph node biopsy (SLNB) has replaced axillary lymph node dissection (ALND) as standard of care for axillary staging in early breast cancer in patients without any clinical sign of axillary lymph node infiltration. The worldwide most frequently used mapping method consists in the injection of radioactive technetium-99 isotope alone or in combination with blue dye. As a specific infrastructure and dedicated personnel are needed for the use of a radioactive tracer, the CHC in Liege (Belgium) decided to test the use of patent blue dye alone to detect sentinel lymph nodes in a large consecutive cohort of patients and compared the results with radioactive mapping methods and guidelines recommendations.

Methods

Patent blue dye was used in 456 consecutive patients with early breast cancer who underwent conservative breast cancer surgery or radical mastectomy between 1/1/2000 and 31/12/2007 in a community hospital (CHC Liège, Belgium). After SLNB, an ALND was performed in each patient.

Results

Sentinel lymph nodes were identified in 444 patients among the 456 patients evaluated by this mapping method during this time period, which represents a detection rate of 97.4%. Infiltrated lymph nodes were detected in 32.7% of patients (149/456) while in the 444 patients with sentinel lymph nodes identified and resected, 137 patients have at last one positive lymph node (30.9%). The false negative rate was 4.9% and the predictive negative value was 97.7% with the blue dye mapping method.

Conclusions

In addition of the simplicity of the method and the large economic advantage, SNLB using blue dye alone showed a quite acceptable performance in our retrospective analysis concerning its ability to find the SLN as well as its reliability to remove the good ones.

From modified radical mastectomy to infra-radical mastectomy: a phase I study for surgical de-escalation focusing on pathological analyses

Background

Despite that breast conservative therapy became the standard of care in breast cancer, modified radical mastectomy, a large mutilating surgery, is still required for an important number of patients. In order to improve the quality of life and the psychological aspects of a surgery involving the femininity of woman, we developed a new less invasive procedure called infra-radical mastectomy. It aims to save the neckline of patients by the maintenance of the peripheral skin-fatty flap that constitutes the base for implantation of the breast. This phase I study analyzed the feasibility of this procedure using outcome of anatomo-pathological analyses as primary endpoint.

Methods

Between March 2015 and July 2017, all women with operable breast cancer without signs of lymph node invasion were invited to participate in the study in the 2 participating institutions. After a water-assisted dissection of the peri-glandular space, an enucleation of the breast was performed by a cold knife which represents the infra-radical mastectomy. A peri-glandular re-excision (PGR) of the skin and the fat tissue surrounding the gland was then achieved to obtain an MRM. This PGR underwent a careful pathological examination (10 samples per patient). Moreover, the tissue volume and the skin surface of the PGR were quantified.

Results

A total of 53 patients (median age: 60 years) were prospectively recruited. The pathological analysis of peri-glandular biopsies revealed none residual invasive carcinoma, 1% of biopsies contained focal ductal carcinoma in situ (DCIS) and 0.4% atypical hyperplasia corresponding to 4 and 2 patients respectively. These 4 patients with residual DCIS were preoperatively diagnosed with extensive DCIS. On average after an infra-radical mastectomy, 37% of the volume and 53% of the skin surface of a complete modified radical mastectomy were sparred.

Conclusions

The evaluation of biopsies from peri-glandular tissue suggests that infra-radical mastectomy should be further evaluated except for patients diagnosed with extensive DCIS which must be excluded of this infra-radical approach. Additional work is needed to evaluate cosmetic outcome and impact on quality of life, the need of radiotherapy and the oncological long-term outcome.

Abstract P3-13-22: Should modified radical mastectomy be modified? A phase 1 study to evaluate infraradical mastectomy for invasive breast cancer

Background: Surgical procedures in breast cancer have become less aggressive. However, around one in three patients must undergo modified radical mastectomy (MRM). We evaluated if infraradical mastectomy (IFM), which preserves the skin and fat tissues surrounding the breast, is safe. IFM has the potential to preserve neck opening and by the way femininity of patients. Aesthetic results obtained after breast reconstruction are also expected to be improved.

Objective: The primary objective of this phase 1 trial is to evaluate the feasibility and safety of IFM.

Methods: Patients were recruited in two specialized breast clinics. We performed enucleation with a cold knife to the mammary gland after a water-assisted dissection of the periglandular space using a dedicated tool. In a second step we removed the peripheral skin and fat tissue which surrounded the gland to obtain a classical MRM. Fat tissue removed in the second step underwent a careful pathological examination (10 biopsies) in order to evaluate residual invasive or in situ breast cancer and atypical hyperplasia. We also evaluated which is the percentage of tissue and skin removed in the second step with regard to the global surgical specimen because that could be left in the future if the procedure is declared safe.

Results: A total of 35 patients (43 to 80 years old) were prospectively recruited from March 2015 to March 2016. The distribution of tumor type was: pTis 2.9%, pT1 45.7%, pT2 45.7% and pT3 5.7%. Pathological analysis of the periglandular tissue removed in the second step revealed: 0% invasive carcinoma, 1% focal ductal carcinoma in situ (DCIS), and 0% atypical hyperplasia. On average, the weight of an IFM was 37% lower compared to the weight of a MRM. Skin resection was reduced by 48% with IFM. No serious adverse event was observed.

Conclusions: Preliminary results are promising. Our phase 1 trial suggests that the procedure is safe concerning premalignant or malignant disease left after IFM. Moreover, a high quantity of skin and fat tissue is saved by IFM. We are now recruiting a second cohort of patients in order to confirm these results. In addition, we will also quantify the amount of mammary glands left around IFM compared to MRM by performing additional biopsies and quantitative evaluation by pathologists.

Presurgical selection criteria have been modified for the second cohort in order to avoid residual DCIS left after IFM. After this second cohort, we plan to begin a large prospective randomized phase 3 trial with long-term disease-free survival and aesthetic results as the primary endpoints.

Citation Format: Coibion M, Lifrange E, Jossa V, Mutijima E, Crevecoeur A, Olivier F, Di Bella J, Jerusalem G. Should modified radical mastectomy be modified? A phase 1 study to evaluate infraradical mastectomy for invasive breast cancer [abstract]. In: Proceedings of the 2016 San Antonio Breast Cancer Symposium; 2016 Dec 6-10; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2017;77(4 Suppl):Abstract nr P3-13-22.

Genomic Grade Index (GGI): feasibility in routine practice and impact on treatment decisions in early breast cancer

Purpose

Genomic Grade Index (GGI) is a 97-gene signature that improves histologic grade (HG) classification in invasive breast carcinoma. In this prospective study we sought to evaluate the feasibility of performing GGI in routine clinical practice and its impact on treatment recommendations.

Methods

Patients with pT1pT2 or operable pT3, N0-3 invasive breast carcinoma were recruited from 8 centers in Belgium. Fresh surgical samples were sent at room temperature in the MapQuant Dx™ PathKit for centralized genomic analysis. Genomic profiles were determined using Affymetrix U133 Plus 2.0 and GGI calculated using the MapQuant Dx® protocol, which defines tumors as low or high Genomic Grade (GG-1 and GG-3 respectively).

Results

180 pts were recruited and 155 were eligible. The MapQuant test was performed in 142 cases and GGI was obtained in 78% of cases (n=111). Reasons for failures were 15 samples with <30% of invasive tumor cells (11%), 15 with insufficient RNA quality (10%), and 1 failed hybridization (<1%). For tumors with an available representative sample (≥ 30% inv. tumor cells) (n=127), the success rate was 87.5%. GGI reclassified 69% of the 54 HG2 tumors as GG-1 (54%) or GG-3 (46%). Changes in treatment recommendations occurred mainly in the subset of HG2 tumors reclassified into GG-3, with increased use of chemotherapy in this subset.

Conclusion

The use of GGI is feasible in routine clinical practice and impacts treatment decisions in early-stage breast cancer.

Trial Registration

ClinicalTrials.gov NCT01916837, http://clinicaltrials.gov/ct2/show/NCT01916837

In vitro influence of estradiol or progesterone on the thymidine labeling indices of human benign breast tumors

Using an in vitro tritiated thymidine (3H-dThd) nuclear labeling followed by autoradiography, the effects of 17-beta-estradiol (E2) or progesterone (Pg) on cell proliferation were studied in 22 human benign breast tumors, i.e. 7 fibroadenomas 8 fibrocystic dysplasias 4 gynecomastias and 3 phyllodas. Small tumor fragments were incubated in a chemically-defined medium without serum and were hormonally stimulated in vitro. The procedure used allowed discrimination between weak labeling, suggestive of DNA repair mechanism, and strong labelling, suggesting a true DNA synthesis (S phase). Taking this into account, our results have shown that both estradiol and progesterone can induce in vitro cell replication of both ER+PgR+ and ER-PgR- human breast fibroadenoma, without affecting those of fibrocystic dysplasia, gynecomastia and phylloda. Progesterone, but not estradiol, might significantly decrease DNA repair mechanism in fibrocystic dysplasia, according to the Pg-induced decrease of nuclear incorporation of small amounts of 3H-dThd. We have thus characterized a dynamic test of hormone dependence which permits in vitro study of the hormonal sensitivity of human benign breast tumors, as well as that of any other human neoplasm. This test could be of great value to help clinicians to diagnose and treat hormone-dependent neoplasms properly. Its clinical relevance is now under study.

Influences of dihydrotestosterone, testosterone, estradiol, progesterone, or prolactin on the cell kinetics of human hyperplastic prostatic tissue in organ culture

In an effort to characterize the hormone sensitivity of human benign prostatic hyperplasia (BPH) maintained in organ cultures for 12-72 h, the influence of 5-alpha-dihydrotestosterone (DHT), testosterone (T), 17-beta-estradiol (E2), progesterone (Pg), or prolactin (PRL) was assessed on the cell proliferation rate of 25 BPH specimens by the use of tritiated thymidine incorporation followed by autoradiography. Significant increases in the thymidine-labeling index (TLI: percentage of labeled nuclei) were observed in glandular tissue after a 36-h incubation period in presence of DHT, E2, Pg, or PRL in 52%, 44%, 28%, and 60% of BPH cases, respectively. Nonparametric statistics (Spearman and Kendall rank correlation tests) have shown that 1) the steroid-induced TLI increases are dependent on the basal rate of cell proliferation, while the PRL-induced effect is independent of it, and 2) all the steroid-mediated effects on BPH TLI are correlated together, whereas they seem to be independent of the PRL-induced TLI increase. When T was compared with DHT on nine BPH specimens, three were found to be sensitive to both hormones, and two responded to DHT only. We propose that our study methods are suitable as a means to assess the hormone sensitivity of individual cases of BPH and possibly prostatic tumors.