A Multidisciplinary Team Approach Minimizes Risk-Reducing MasZtectomy Rates

Guido Libondi1, Daniel R Leff2, Lucy Side3, Venkat Ramakrishnan1

1Department of Plastic Surgery, St Andrews Centre for Plastic Surgery, Broomfield, Chelmsford, Essex, UK; 2The Breast Unit, Broomfield Hospital, Broomfield, Chelmsford, Essex, UK; 3Institute for Womens Health, University College Hospitals, London, UK

Background: Risk-reducing mastectomy (RRM) has become increasingly common but is not without complications especially if accompanied by reconstructive surgery. In patients with sporadic unilateral breast cancer, contralateral RRM offers no survival advantage.  Multidisciplinary team (MDT) communication and interaction may facilitate shared decision-making and curtail RRM rates.

Objective: The aim of this study was investigate the effect of a regional MDT meeting on RRM decision-making.

Methods: We conducted an observational study involving retrospective review of prospectively recorded MDT meeting records for a 151 patient requests for RRM from 2011 to 2014. Final MDT decisions were recorded as RRM accepted, declined or pending. For MDT sanctioned requests, the factors justifying RRM were recorded. Where RRM was declined, justification for MDT refusal was sought and recorded.

Results: Approximately half of all requests for RRM have been upheld (53.0%) and 1/3 of requests have been declined (32.5%). Of those declined, low risk of contralateral breast cancer versus relatively high risk of systemic relapse were commonly cited as justification for RRM refusal (45.7%). A proportion of patients who initiated RRM discussion subsequently changed their minds (19.6%), or failed to attend clinic appointments (6.5%). Some patients were deemed medically unfit for complex reconstructive surgery (13%), or were declined on the basis of an apparent cosmetic drive for surgery (6.5%), concerns regarding depression or anxiety (2.2%) and/or if family history could not be substantiated (6.5%)

Conclusion: MDT meetings facilitate cross-specialty interrogation of requests for PM, minimize unnecessary surgery and restrict PM to those likely to derive maximum benefit.

Benefits of Nationwide Mammography Screening Program in Latvia

Krista Arcimovica1,2, Toms Arcimovics3, Peteris Loza1,2, Egils Purmalis2, Mihails Timofejevs2, Andrejs Srebnijs2, Kristaps Eglitis4, Janis Eglitis2

1Resident in General Surgery, University of Latvia, Latvia; 2Department of Breast Surgery, Riga East University Hospital, Oncology Center of Latvia, Latvia; 3Faculty of Medicine, Riga Stradins University, Latvia; 4Faculty of Medicine, University of Latvia, Latvia

Background: Breast cancer (BC) is the most common cancer type and the most common cause of cancer related women deaths worldwide, also in Latvia. Since 2009 nationwide mammography screening program (NMSP) has started in Latvia, where women once in two years in age from 50 until 69 are included. Female BC patients from Latvia also were included in multinational analysis Delays in diagnosis and treatment of breast cancer in 2013.

Objective: Determine impact of NMSP on changes in diagnostics of BC in Latvia. Analyze reasons and features of patient delay time in Latvian population.

Methods: Statistics of BC incidence in Latvia were provided from CDPC. Statistical analysis was performed by T- test. NMSP attendance data was provided from NHS. Data from multinational analysis were explored and adapted to statistics of BC incidence and attendance of NMSP in Latvia.

Results: Incidence of BC in Latvia in 2014 is 108,6 per 100 000 women. Attendance of NMSP is increasing: in 2009 – 21.1%, in 2014 - 35,9%. Since 2009 0 stage and I stage BC are diagnosed statistically significant more frequently compared to the period from 2002 - 2008 (p=0.001, p=0.02). Multinational analysis showed the longest patient delay time in Latvia (6,2 weeks) compare to other countries. The reasons are disregard of discovered symptoms, distrust in medical system and success of therapy.

Conclusion: The delay in diagnosis of BC remains a problem even after initiation of NMSP in Latvia. Despite the fact that attendance of NMSP is increasing, the attendance is still insufficient. Increasing quality of NMSP process could reduce distrust in medical system, thereby also decreasing patient delay time.

Access to Care for Breast Cancer in Middle-Income Country: Example of Morocco

Errihani Hassan, Akkar Othman, Errihani Hassan, Akkar Othman, Ettahiri Hamza, Berrada Narjiss

Medical Oncology, National Institute of Oncology, Morocco

Background: Breast cancer is a real public health problem in middle- income countries. Disease is often diagnosed at late stage and survival is worse. In addition, these countries had limit resource to face to this expensive and complex long term disease as well as their public health care is not adapted to the needs generated by this escalating disease. The purpose of this work was to describe the current situation in the management of advanced breast cancer and to identify the main challenges in Morocco.

Materials and Methods: We first realized a review of data available in: our two registries (Casablanca the biggest and Rabat), PubMed or presented in local meeting then we realized a survey among 25 medical oncologists working in different centers about their practices.

Results: There are approximately 7000 new cases per years. According to Registries, advanced stage at first diagnosis represent 7 to 14%. Median age is 48 years old. 33.5% of patients have insurance; the others have government insurance or must pay for them self. The management of BC is done by different actors both in the private and public sectors. There are 12 private clinics and 8 public hospitals. The National Institute of Oncology is the first and the biggest center of the kingdom. The Princess Lalla Salma Foundation is currently building new centers. Interdisciplinary team meetings are available in 83% of centers. The Princess Foundation and made important drug donations for the public hospital. Chemotherapies are available in all the hospital. New endocrine therapy and target therapy are available only in few centers. The estimation of the cost of treatment is 35.058 Euro per patient at public hospital. No data are available from patient treated at private clinics. 75% of oncologists follow international guidelines (55% to NCCN guidelines, 37% to ABC consensus). 35% of oncologists remain informed by internet.

Conclusion: The management of advanced breast cancer in Morocco has evolved in recent years. The main challenge in the future will be the continuous formation of oncologists and the availability of news target therapies.

Probability of Tumor Induction in the Dutch Breast Cancer Screening Program: Effect of Lowering the Starting Age

Marcel Greuter1, Rositsa Koleva-Kolarova2, Chris de Jonge2, Alicja Daszczuk2,3, Geertruida de Bock2

1Radiology, Universitair Medisch Centrum Groningen, Netherlands; 2Epidemiology, Universitair Medisch Centrum Groningen, Netherlands; 3Radiology, Universitair Ziekenhuis Brussel, Vrije Universiteit Brussel, Belgium

Background: Breast cancer is the leading cause of cancer deaths in women, accounting for 29% of all cancers and 17% of all cancer deaths in Europe. In the Netherlands, the breast cancer incidence and mortality is among the highest in Europe. As life expectancy of breast cancer patients decreases with advanced tumour stage, population-based breast cancer screening using mammographic x-rays is used in many countries worldwide. However, the probability of tumor induction in breast cancer screening programs is largely unknown.

Objective: The aim of this study was to assess the probability of tumor induction in the Dutch breast cancer screening program.

Methods: A previously validated micro simulation model SiMRiSc was used. A biannual screening program from 50 to 75 years was simulated, as well as two alternative scenarios: biannual screening from 48 to 75 years and from 46 to 75 years. Women were simulated during their lifetime taking into account life expectancy, chance of developing a tumor, tumor growth and survival, breast density, mammographic sensitivity, and tumor induction due to diagnostic x-rays. Mammography dose was set at 3 mSv.

Results: In the current screening program approximately 28 tumors were induced during lifetime in a screening cohort of 10.000 women, which is approximately 5.1% of the number of detected tumors. However, when the starting age was decreased to 48 and 46 years, the number of tumors induced increased to 5.6% and 6.1%, respectively.

Conclusion: The contribution of tumor induction in the Dutch breast cancer screening program is relatively small but increases at decreasing starting age.

Can Breast Tomosynthesis Beat Mammography and Breast MRI?

Dragana Djilas1, Dragana Roganovic2, Natasa Prvulovic-Bunovic1, Tatjana Kapicl1

1Diagnostic imaging department, Oncology Institute of Vojvodina, Serbia; 2Radiology, Dom zdravlja Banjaluka, Bosnia and Herzegovina

Early breast cancer detection is a necessity. Depending on breast density and tumor growth pattern, the false-negative rate of mammography ranges from 8% to 66% in symptomatic women. Ultrasound, digital breast tomosynthesis and breast MRI are often used to exceed relatively low sensitivity of mammography. The aim of this study was to investigate the sensitivity and specificity of three methods for early detection of breast cancer: breast magnetic resonance imaging (MRI), digital mammography (DM), and digital breast tomosynthesis (DBT) in comparison to histopathology, as well as to investigate the intraindividual variability between these modalities.

We included 57 breast lesions, each detected by three diagnostic modalities: DM, breast MRI, and DBT, and subsequently confirmed by histopathology. Morphologic characteristics of all detected lesions were analyzed in all three diagnostic modalities, and their kinetic characteristics (enhancement curves and peak enhancement) were analyzed on breast MRI. Breast Imaging-Reporting and Data System (BI-RADS) was used for characterizing the lesions. Experienced radiologist interpreted all three diagnostic modalities.

Twenty-nine of the breast lesions were malignant while 28 were benign. The sensitivity for digital mammography, breast MRI, and breast tomosynthesis, was 72.4%, 93.1%, and 100%, respectively; while the specificity was 46.4%, 60.7%, and 75%, respectively. Receiver operating characteristics (ROC) curve analysis showed an overall diagnostic advantage of DBT over both breast MRI and DM.

Our study shows that digital breast tomosynthesis performs better in detection and characterization of breast lesions compared to digital mammography and breast MRI.

Social Influence on 5-Year Survival in a Longitudinal Chemotherapy Ward Co-Presence Network

Jeffrey Likenert1,2, Chris Marcum1, John Finney3, Felix Reed-Tsochas2,4,5, Laura Koehly

1National Human Genome Research Institute, National Institutes of Health, USA; 2Said Business School, University of Oxford, UK; 3OUS, NHS, UK; 4Sociology, University of Oxford, UK; 5Oxford Matrin School, University of Oxford, UK

Chemotherapy is often administered in openly-designed hospital wards, where there may be a possibility of social influence effects between patients. Previous research has found evidence that cancer patients are influenced at home and in cancer support groups through the receipt of social support resources; however, social influence between patients has not been examined in the setting of the chemotherapy ward. Using data on 4,691 chemotherapy patients in Oxfordshire, UK, we connect patients who spend significantly more time together than would be expected based on appropriately randomized patient schedules (p<0.01). On average, patients are 60 years of age (SD=13), of whom 2,094 (45%) are male. The co-presence network, which formalizes overlap between patients, is comprised of 13,459 edges, with a density of 0.0012. We count both the number of times that a focal patients immediate neighbors or those two nodes away finish their chemotherapy cycle and either survive 5 years or die within 5 years. The influence of neighbors survival and death outcomes on focal patients likelihood of dying within 5 years was evaluated based on a series of Generalized Estimating Equations, which model the likelihood of 5-year survival for a focal patient to estimate the social influence on health. Being an isolate increases the log-likelihood of death (0.402 CI: 0.247,0.558). Each patient previously finishing chemotherapy and surviving 5 years, who is directly connected to the focal patient, changes the focal patients log-likelihood of death by -0.095 (CI: -0.145,-0.045), while those dying within 5 years changes the focal patients log-likelihood of death by 0.067 (CI: 0.034,0.100). Our results suggest that social influence occurs in chemotherapy wards taking on both positive and negative effects, which may need to be taken into account when designing how and when chemotherapy is delivered.

Surgical Resection of the Primary Tumor is Associated with Increased Long-term Survival in Patients with Stage IV Breast Cancer

Anna Sukhotko, Aziz ZIKIRYAHODJAEV, Larisa Bolotina

Department of Oncology and Breast Reconstructive Surgery, P.A. Herzen Moscow Oncology Research Institute, Ministry of Health of Russia, Moscow, Russia

Purpose: To evaluate the expediency and timeliness of performance of surgical treatment as a component of multi-therapy treatment of patients with stage IV breast cancers.

Materials and Methods: This investigation comparatively analyzed the results of complex treatment with or without surgery in patients with metastatic breast cancer. We analyzed retrospectively treatment experience of 196 patients with generalized breast cancer in the department of oncology and breast reconstructive surgery of P.A. Herzen Moscow Cancer Research Institute from 2000 to 2015. Average age was (581,1) years. Invasive ductul carcinoma was verified in128 patients (65,3%), invasive lobular carcinoma - 33 (16,8%), complex form - 19 (9,7%). Complex palliative care involving drug and radiation therapies was performed in two patient groups. The first group includes 124 patients who underwent surgical intervention as complex treatment, the second group includes 72 patients with only medical therapy. Standard systemic therapy was given to all patients.

Results: Overall, 3-and 5-year survival in fist group was 43,8 and 21%, in second - 15,1 and 9,3% respectively [p=0,00002 log-rank]. Median survival in patients with surgical treatment composed 32 months, in patients with only systemic therapy - 21. The factors having influencing an influence on the prognosis and the quality of life outcomes for of patients with generalized breast cancer were are also studied: hormone-dependent tumor, Her2/neu hyper-expression, reproductive function status (age, menopause existence).

Conclusion: Removing primary breast tumor in patients with generalized breast cancer improve long-term outcomes. Three- and five-year survival increased by 28,7 and 16,3% respectively, and median survival – for 11 months. These patients may benefit from resection of the breast tumor. One explanation for the effect of this resection is that reducing the tumor load influences metastatic growth. Key words: breast cancer, combination therapy, factors of prognosis.

Breast Conserving Treatment for DCIS: Impact of Boost and Tamoxifen on Local Recurrences

Bruno Cutuli1, Nadia Wiezzane2, Isabella Palumbo3, Paola Barbieri4, Marina Guenzi5, Alessandra Huscher6, Simona Borghesi7, Catherine Delva8, Tiziana Iannone9, Elena Vianello10, Maria-Elena Rosetto11, Cynthia Aristei3

1Radiation Oncology, Institut du Cancer Courlancy, France; 2Radiation Oncology, Centre Georges-Franois Leclerc, France; 3Radiation Oncology, University of Perugia, Italy; 4Radiation Oncology, Policlinico di Modena, Italy; 5Radiation Oncology, Azienda Ospedaliera Universitaria, Italy; 6Radiation Oncology, Fondazione Poliambulanza, Italy; 7Radiation Oncology, Ospedale San Donato, Italy; 8Statistics, Sylia-Stat, France; 9Radiation Oncology, Ospedale San Martino, Italy; 10Radiology, Ospedale San Giovanni, Italy; 11Radiation Oncology, Ospedale Belcolle, Italy

Background: DCIS represents 15-20% of all BC. Breast-conserving surgery (BCS) and whole breast irradiation (WBI) was performed in about 60% of the cases. This study reports local recurrence (LR) rates in DCIS patients treated with or without boost and/or tamoxifen (TAM). We also compared different therapeutic options in two European countries.

Materials and methods: Between 1998 and 2007, 819 patients with pure DCIS were collected both in France (266) and Italy (553). Median age was 56. All underwent BCS+WBI; 391 (48%) received a boost (55% in France and 45% in Italy, p= 0.017) and 173 (22.5%) Tamoxifen (4.5% in France and 32% in Italy, p0.0001).

Results: With a 90-month median follow-up, 51 (6.2%) LR occurred; 27 (53%) were invasive. The 5- and 10-year LR probabilities were 4% and 8.6%. Two patients had axillary recurrence; 12 (1.5%) developed metastases (7 after invasive LR); 41 (5%) patients had contralateral BC. In multivariate analysis, high nuclear grade and absence of TAM are the most powerful predictors of LR with 2.6 (95% CI: 1.74-3.89, p=0.0012) and 2.85 (95% CI 1.42-5.72, p=0.04) OR estimates, respectively. Age, margin status and boost did not influence LR rates.

Conclusions: This study confirms the treatment heterogeneity in DCIS among countries and the unfavourable prognostic role of nuclear grade. Tamoxifen reduces LR rates and might be considered for some subgroups of patients, but further confirmation is required. The boost usefulness still remains unclear.

Cryoablation of Breast Cancer in Metastatic Patients. Preliminary Experience.

Claudio Pusceddu, Luca Melis, Gianni Amucano, Nicola Ballicu, Barbara Sotgia, Alessandro Fancellu

Interventional Radiology, AOBrotzu, Italy

Background: metastatic breast cancer is considered an incurable disease, and the main treatment goal is palliation, with the aim of maintaining or improving the quality of life and possibly improving survival.

Objectives: to evaluate the safety and efficacy of breast cryoablation (CRA) as local therapy for patient with metastatic breast cancer.

Methods: thirty-nine breast lesions, mean size 2,1 (range 1 - 6,7 cm) in twenty-nine consecutive patients, mean age 51 (36-81) with core-needle biopsy-proven breast carcinoma and metastases were included in this study. Twenty-three patients had one lesion, 4 patients two lesions, 1 patient three lesions and 1 patient five lesions. Under local anaesthesia and mild conscious sedation, the tumour and surrounding breast tissue were ablated with percutaneous CT-guided CRA. Cryoablation consisted of 2 cycles each of 10 minutes of freezing followed by a 4-min active and 4-min passive thawing phase for each one. Twenty-four patients underwent one CRA session, four patients 2 CRA sessions and one patient underwent 3 CRA sessions.

Results: all CRA sessions were successfully completed and all breast tumours were ablated. Morbidity consisted in transient and mild ecchymotic changes and post-procedural oedema seen in ten cases. The therapeutic outcomes were evaluated by contrast-enhanced TC or MRI at 2-, 6-, 12-, and 18-month intervals. The absence of tumour enhancement TC or MR image was considered as indicating complete tumour necrosis. During the mean follow-up of 15 months (6- 28 months) 26 patients had shown complete response to the treatment. Only 3 patients out 29 (10%) showed relapse close to the treated lesion. These patients were treated with a second CRA procedure.

Conclusions: CRA of metastatic breast cancer is a safe and effective method which allows local control of the disease.

A Comparison of Dosimetric Variance of Target and Organ at Risk during External-Beam Partial Breast Irradiation Using 4DCT

Bing Guo, Jianbin Li, Wei Wang, Yankang Li

Radiation Oncology, Shandong Cancer Hospital & Institute, China

Purpose: This study sought to evaluate the correlation between the respiration-induced target motion and volume variation with the dosimetric variation for target and organ at risk (OAR) during free breathing.

Methods and Materials: 4DCT scan sets were acquired for 20 patients who underwent external-beam partial breast irradiation (EB-PBI). The volume of the tumour bed (TB) was determined based on seroma and surgical clips on the ten sets of 4DCT images. For each patient a conventional 3D conformal plan (3D-CRT) was generated based on the 4DCT end inhalation phase images, then copied and applied to the other phases.

Results: During free breathing, the median of TB centroid motion was 0.90 mm, 0.75 mm and 0.80 mm in the lateral, anteroposterior and superoinferior directions, respectively. The spatial motion vector was 0.95 mm. In the superoinferior direction, the correlation between the TB motion and dosimetric parameters of the PTV and the ipsilateral normal breast revealed statistical significance (p < 0.05). In the motion vector, the dosimetric parameters of the ipsilateral lung all correlated well with the TB motion (p < 0.05). The lung volume variation and lung high dose volume all correlated reasonably well (p < 0.05), and a correlation also existed between heart volume variation and heart dose volume (p < 0.05).

Conclusions: Although respiratory motion can cause a small TB motion during free breathing, this small TB motion still results in dosimetric variation of the target with a possibility of dosimetric off-target or suboptimal dose coverage for EB-PBI. The impact of the respiratory motion on the heart dose may be limited. However, the doses received by the lung during free breathing are relatively sensitive to TB motion and thorax expansion.

The Breast-Q Assessment: Santandrea Experience

Valeria Vitale, Augusto Lombardi, Stefano Maggi, Gianluca Stanzani, Camilla Romano, Ivan Gentili, Maria Sole Mattei, Emiliano Nuccetelli, Claudio Amanti

Breast Surgery, SantAndrea Hospital, La Sapienza University of Rome, Italy

Mastectomy is still indicated in approximately 30% of cases, for large invasive carcinoma, but also for multicentric tumors and intraductal diffuse carcinomas or prophylactic. We achieved a significant improvement of the aesthetic result performing Nipple sparing mastectomy (NSM), joined with reconstruction techniques.

This approach has a positive impact on psychology and quality of life (QOL) of breast cancer patients. To evaluate these important aspects, we retrospectively applied the BREAST-Q questioner to 101 patients underwent a NSM.

BREAST-Q is an instrument designed by the Evelyn H. Lauder Breast Center, MSKCC (NY), to assess outcomes among women undergoing different types of breast surgery: we chose reconstruction module that is comprised of two domains: patient satisfaction and QOL. There are six subthemes (physical, psychosocial and sexual well-being patient, satisfaction with breast, satisfaction with overall outcomes and satisfaction with care).

We performed 157 NSMs with immediate breast reconstruction on a court of 117 patients. Selection criteria included women with tumor at least 1 cm from nipple-areola complex (NAC) without nipple discharge or NAC retraction. The median follow-up was 40 months with an age range between 19 and 72 y. We recorded 2 deaths for breast cancer, with a overall survival of 97% and a rate of local recurrence of 8.5% (10 cases).

Our follow-up program included medical interview, examination of routine clinical and imaging findings, and collecting information by the BREAST-Q survey. 101 patients agreed the questioner.

Our results confirm that BREAST-Q is an useful to evaluate QOL and obtain a more tailored surgery.

Imaging Features of Triple Negative Breast Cancers – Mammography, Ultrasound and Magnetic Resonance

Gordana Ivanac, Martina Dzoic Dominkovic, Boris Brkljacic

Department of Diagnostic and Interventional Radiology, University Hospital Dubrava, Croatia

Background: Triple-negative breast cancer (TNBC) is a distinctive sub-group of breast cancers that do not express estrogen receptor (ER), progesterone receptor (PR) and human epidermal growth factor receptor 2 (HER2). This phenotype of breast cancer demonstrates poor prognosis because of aggressive tumor biology.

Objective: To evaluate imaging features of TNBC comparing them to non TNBC.

Methods: We reviewed images of 23 patients who had been diagnosed as having TNBC and 30 patients with non TNBC (control group) using criteria described for mammography, sonography and magnetic resonance imaging (MRI) in Breast Imaging-Reporting and Data System (BI-RADS) lexicon for image interpretation. Age of patients, size of tumor, multifocality, tumor histological type, tumor grade and status of lymph nodes were reviewed.

Results: On mammography and ultrasound TNBC mostly appeared as unifocal mass with regular shape and distinct borders. TNBC were hypoechogenic masses with no back acoustic features and with visible blood flow. On MRI TNBC presented as a mass type of enhancement mostly having rim type of enhancement and plateau type of curve. Most frequent category reported after ultrasound and mammography was BI RADS 4. 20% TNBC presented as BI RADS 3 after MRI, 40% as BI RADS 4 and 40% as BI RADS 5.

Conclusion: TNBC are most often presented as a mass on mammography and sonography but also in significant number of cases they remained unrecognized, one of the reasons having benign imaging features of TNBC. All cases are recognized on MRI where they appear as mass type of enhancement and less likely have wash out type of curve.

Management of Radial Scars as High Risk Suspicious Lesions of the Breast

Zeliha Turkyilmaz1, Elif Sarşk, Enver Ozkurt2, Semen nder3, Mustafa Tkenmez2, Mahmut Mslmanoğlu2, Abdullah İğci2, Vahit zmen2, Ahmet Dinağ2, Neslihan Cabioğlu2

1Department of Surgery, Edirne 1. Murat State Hospital, Turkey; 2Department of Surgery, Istanbul University, Istanbul Medical Faculty, Turkey; 3Department of Pathology, Istanbul University, Istanbul Medical Faculty, Turkey

Background: Radial scars are benign lesions of the breast that could radiologically mimic malignancy.

Objective: The aim of the study was to determine the distinguishing radiological features on imaging methods to outline the management strategies.

Methods: Between 1995-2015, 1370 patients were retrospectively analyzed who underwent an excisional biopsy with a diagnosis of benign breast lesion at the Department of Surgery, Istanbul University Istanbul Faculty of Medicine. Of those, 46 cases were found to have radial scar or complex sclerosing lesion (RS/CSL), and their demographic and pathological features were reviewed.

Results: The median age was 45 (range, 22-61). Of 46 patients, 31 (67.4%) were premenopausal whereas 15 were postmenopausal (32.6%). Seven patients (15.2%) had a family history of breast cancer. In physical exam, 14 patients (%30.4) presented with a palpable mass. Radial scars were detected as as spiculated lesions on mammography.in 16 cases (34.8%) as BIRADS IV and BIRADS V lesions (n=6, 23%). Six patients (23.1%) were found to have BIRADS III lesions whereas 14 patients (54%) had BIRADS IV lesions (53.8%). The majority of patients (n=32, 70%) with non-palpable lesions underwent wire localized excisional biopsy (n=31) or excisional biopsy with Radioguided occult lesion localisation (ROLL) (n=1). The mean size of RS/CSL was 10.8 mm (range, 0.2-30 mm). In definitive pathology, 18 cases (39.1%) were found to have adenosis, whereas intraductal papilloma (IDP) and atypical epithelial hyperplasia (AEH) associated with RS/CSL were found in 16 (%35), and 15 patients (33%) respectively. No significant correlation could be found between the size of RS/CSL and presence of AEH.

Conclusion: RS/CSL was considered benign lesion that present with other high risk benign breast lesions. Radiologically, they mostly present as suspicious lesions that should be distinguished from malignancy, and therefore warranting core biopsy and/or excisional biopsy for definitive histopathological diagnosis as an important management strategy.

A Comparison of Methods to Determine Gross Tumor Volume for Radiotherapy after Breast-Conserving Surgery

Aiping Zhang

Department of Radiation Oncology, Shandong Cancer Hospital & Institute, China; Medicine and Life Sciences College, Medicine and Life Sciences College of Shandong Academy of Medical Sciences, China

Background: Preoperative magnetic resonance imaging (MRI) can detect occult tumors and provide additional information about the original tumor location during breast-conserving surgery (BCS).

Objective: The aim of the study was to compare preoperative MRI, postoperative pathology, excised specimen size, and tumor bed delineation as methods for determining gross tumor volume (GTV) for radiotherapy after BCS.

Methods: Fifty patients who underwent preoperative MRI and radiotherapy after BCS were enrolled. The GTVs determined by MRI, pathology, and the excised specimen were defined as GTVMRI, GTVPAT, and GTVES, respectively. GTVMRI+1 was defined as extending 1.0-cm margin around GTVMRI. The radiation oncologist delineated GTV of the tumor bed (GTVTB) using planning computed tomography according to surgical clips placed in the lumpectomy cavity. Potential factors such as interval from surgery to radiotherapy, number of clips, locations of primary tumors that may affect the coincidence degree between GTVES and GTVTB were analyzed.

Results: The median GTVMRI, GTVMRI+1, GTVPAT, GTVES, and GTVTB were 0.97 cm3 (range, 0.01–6.88), 12.58 cm3 (range, 3.90–34.13), 0.97 cm3 (range, 0.01–6.36), 15.46 cm3 (range, 1.15–70.69), and 19.24 cm3 (range, 4.72–54.33), respectively. There were no significant differences between GTVMRI and GTVPAT, GTVMRI+1 and GTVES, GTVES and GTVTB (p = 0.188, 0.070, 0.264, respectively). Neither GTVES nor GTVTB correlated with GTVMRI (p = 0.071, 0.378, respectively). Furthermore, neither GTVES nor GTVTB correlated with GTVMRI+1 (p = 0.068, 0.375, respectively). And the factors we analyzed had no impact on the coincidence degree between GTVES and GTVTB (p > 0.05).

Conclusion: When 5 surgical clips were placed in the lumpectomy cavity for BCS, GTVTB was consistent with GTVES. If the boundary of the resected tumor was not pre-or intraoperatively marked by image guidance, neither GTVTB nor GTVES  correlated significantly with the volume of tumor defined by preoperative MRI.

Skin-Sparing Goldilocks-Mastectomy – Safe Alternative for Reconstruction. Single Institution Experience

Andrii Zhygulin, Valentin Palytsia, Oleg Dmytrenko

Breast Unit, LISOD Israeli Cancer Care hospital, Ukraine

Background: High quality of life along with life expectancy are fundamental principles of breast cancer treatment. Aesthetic and functional results of breast cancer surgery are very important even if the patient needs mastectomy. When the patient refuse breast reconstruction - goldilocks-mastectomy can be the way out. Surgery was proposed by G.Ma and H.Richardson in 2011 as intermediate option between Madden mastectomy and breast reconstruction with implants and flaps.

Methods: All the patients discussed on the multidisciplinary tumor board according to the international guidelines. The surgery technique includes Wise pattern skin-reducing subcutaneous mastectomy and using deepidermized breast skin of the lower flap for filling defect after parenchyma  erformed at all treatment stages.

Results: 21 skin-sparing goldilocks-mastectomies were performed from 2012 to 12.2015 in our hospital, which amounts 21,6% of the total number of ablative mastectomy (without immediate reconstruction). The average age was 59(34-76)y.o. ALND were performed in 12(57,1%) cases, SLNB in 8(38,1%). The average weight of specimen was 627g(336-1390). 10 cases of complications were observed – 4 seromas, 3 cellulitis, 3 margin necrosis. We followed up 17(80,9%) patients during 28,2(4-45) months. No local recurrences were found. We found 3 systemic recurrences and 1 patient died due to metastasis. 1 patient had immediate and 1 – delayed lipografting sessions.

Conclusions: Goldilocks-mastectomy is technically easy and safe surgery, allows significantly improving life quality of breast cancer patients who refuse from immediate reconstruction. The creation of additional skin flap can be used in delayed reconstruction.

Oncoplastic Breast Conserving Surgery. Single Institution Experience from the First Breast Unit in Ukraine, Organized in Accordance with EUSOMA Criteria

Andrii Zhygulin, Valentin Palytsia, Oleg Dmytrenko, Daria Vinnytska, Valerii Bondarenko

Breast Unit, LISOD Israeli Cancer Care hospital, Ukraine

Introduction: Aesthetic results of breast cancer surgery are very important due to the quality of life of the patients. Oncoplastic surgery is modern and effective method which is interesting for the surgeons and beneficial for the patients.

Methods: We present our 9-year experience. All the patients have been discussed on the multidisciplinary meeting. All surgical approaches and parenchymal resections have been planned according to principles of mastopexy/reduction mammoplasty. Displaced flaps were used if more than 25% of the breast had been removed. The lateral thoracic, rotation advancement, LD, epigastric and LICAP flaps were commonly performed. Preoperative planning and photos of all patients were performed.

Results: In total, 352 oncoplastic BCS were performed in 345 patients from 2007 till 12.2015. The average age was 53(22-85) y.o., average specimen weight was 107,8g (5-1034). Level 1 techniques were performed in 116(32,9%), advanced parenchymal rotations – in 36(10,2%), reduction mammoplasty – 92(26,1%), mastopexy – 23 (6,5%) displaced local flaps – in 85(24,1%) patients. 229(65,1%) patients had SLNB, 150(42,6%) – ALND. For patients with non-palpable lesions we used US-localization (in 26(7,4%) cases), Fine Needle Localization (FNL) – in 52(14,8%) patients and Radioactive Occult Lesion Localization (ROLL) technique in 19(5,4%) cases. Postoperative complications were observed in 86(24,4%) patients. Positive resection margins were found in 14(3,9%) patients. We followed up 291(84,3%) patients during 35,2(5-103) months. Local recurrence occurred in 7(1,9%), metastases - in 32(9,2%) and 18(5,2%) patients died.

Conclusions: We evaluated our experience with introducing of oncoplastic surgery in a dedicated BU that would allow radical treatment with good outcomes. Introduction of the different oncoplastic techniques allows achieving not only good oncological, but also good aesthetic results.

Resection of the Primary Tumor Neither Increases 30-Day Mortality nor Delays Systemic Treatment in de Novo Stage IV Breast Cancer; The Turkish Study Protocol MF07-01

Atilla Soran1,2, Vahit Ozmen1,2, Serdar Ozbas1, Hasan Karanlik1,2, Mahmut Muslumanoglu1,2, Abdullah Igci1,2, Zafer Canturk1,2, Zafer Utkan1,2, Cihangir Ozaslan1,2, Turkkan Evrensel2, Cihan Uras1,2, Erol Aksaz1,2, Aykut Soyder1,2, Umit Ugurlu1,2, Cavit Col1,2, Neslihan Cabioglu1,2, Betul Bozkurt1,2, Temel Dagoglu2, Ali Uzunkoy1,2, Mustafa Dulger1,2, Neset Koksal1,2, Omer Cengiz1,2, Bahadir Gulluoglu1,2, Bulent Unal1,2, Can Atalay1,2, Emin Yildirim1,2, Ergun Erdem1,2, Semra Salimoglu1,2, Atakan Sezer1,2, Ayhan Koyuncu1,2, Gunay Gurleyik1,2, Haluk Alagol1,2, Nalan Ulufi1,2, Ugur Berberoglu1,2, Ronald Johnson1,2, Barry Lembersky1,2

1Department of Surgery and Oncology, Turkish Federation of Breast Diseases Associations, Turkey; 2Department of Surgery and Oncology, Turkish Federation of Breast Diseases Associations, Turkey

Objective: The MF07-01 trial is a phase-III randomized controlled trial of BC women with distant metastases at presentation that receive loco-regional (LR) treatment for intact primary tumor compared with those who do not receive such treatment (ST group). The purpose of the current analysis was to compare the 30-day mortality rate associated with breast surgery in the metastatic setting and evaluate the impact of surgery on delaying ST.

Methods: We performed subgroup analysis of the participant files of the MF07-01 randomized trial, for 30-day inpatient and outpatient mortality, and time between surgery to ST. Loco-regional treatments consisted of either mastectomy or breast conserving surgery (BCS) with level I-II axillary clearance in clinically or sentinel lymph node positive patients.

Results: There were 138 women in the surgery group and 136 in the ST group. The mean age was 51.8 13.5 years, and the groups were comparable regarding, age, BMI, ER/PR and HER-2 status, tumor type and size between the groups (all p>0.05). BCS was performed in 36 (26%) patients and 128 (93%) of the patients underwent full axillary lymph node dissection in the surgery group. The overall 30-day mortality rate was not different in the surgery group from ST group (2 patients [1.4%] in surgery, 2 patients [1.5%] in ST group, p=0.98). Mortality was seen in patients with multiple bone metastasis (n=1), one visceral metastasis without bone metastasis (n=2), and multiple visceral metastasis (n=1). The mean time between surgery and ST was 27.1+9.9 days (range 7-55 days).

Conclusion: We found that the 30-day mortality rates following breast surgery in the metastatic setting was not significantly different than in the non-operative group, and primary surgery on this group of patients doesnt delay institution of ST. Visceral and disseminated bone metastasis can be related with early term mortality rates independently from surgical intervention.

SPAIR Technique in Oncoplastic Breast Surgery: The First Case Series

Rosa Di Micco, Rachel OConnell, Jennifer Rusby, Peter Barry

Breast Surgery, Royal Marsden NHS Trust, UK

Introduction: Therapeutic mammoplasty combines plastic surgical techniques with oncological breast cancer resection to obtain optimal margins and acceptable aesthetic outcomes despite larger tumour-to-breast volume ratios. The Short scar Periareolar Inferior Pedicle Reduction(SPAIR) technique was described by Hammond in 1998. It combines avoidance of T junction scarring with a secure inferior pedicle.

Objective: This is the first series reporting its application in oncoplastic breast surgery. We report our experience to show the safety and feasibility of this technique in breast cancer surgery.

Methods: A consecutive, single surgeon series of prospective data on patients undergoing SPAIR mammoplasty for malignancy from February 2012 to November 2015 was collected. Data includes clinico-pathological factors and outcomes. PROMs data are being collected.

Results: Thirty-two procedures (18 unilateral therapeutic, 7 bilateral, of which 5 were synchronous and 7 symmetrizing only) were performed. The median follow-up was 20(5.75-23) months. All breasts presented at least grade 1 ptosis and a range of cup size from B to J. The mean reduction specimen weight was 294178.6g. In the therapeutic SPAIR series all tumours were located in the upper quadrants with an average cancer size of 36.415.6mm on preoperative imaging, 42.115.6mm at pathology. Two cases of margin involvement were treated by simple re-excision. There were only minor complications, all treated conservatively: 5(15.6%) cases of superficial dehiscence, 4(12.5%) of delayed wound healing, 5(15.6%) superficial infections, 3(9.3%) seromas. No breast recurrence has been reported.

Conclusions: SPAIR mammoplasty is a feasible and safe technique, which is applicable to ptotic breasts of all sizes to treat upper and\or multifocal tumours. Our experience suggests that this technique is a useful addition to the oncoplastic repertoire.

Genetic and Epigenetic Signatures at the BRCA1 Promoter in Women with Familial Breast and/or Ovarian Cancer and with Reported Maternal History of the Disease

Beata Bielinska1, Dorota Nowakowska2, Elzbieta Skasko2, Janusz Aleksander Siedlecki1

1Molecular and Translational Oncology, Maria Sklodowska-Curie Memorial Cancer Center and Institute of Oncology, Poland; 2Genetic Counseling Unit, Maria Sklodowska-Curie Memorial Cancer Center and Institute of Oncology, Poland

Background: Association of the minor variants of the SNP (rs11655505;c.2265CT) at the BRCA1 promoter/enhancer region with the risk of familial breast and ovarian cancer (FBOC) in women over 50 years of age and with maternal history of the disease has been reported. In its genomic context the SNP rs1165505 is located near binding site of architectural protein CTCF, which affect genomic and epigenomic stability. At the BRCA1 promoter, this CTCF1 binding site have been proposed to function as a putative methylation boundary, which flanks unmethylated region of the BRCA1 promoter. Mutations at CTCF binding sites are frequently observed in cancer.

Objective: We aimed to further characterize genetic and epigenetic signature of the BRCA1 promoter in proximity to the SNP rs11655505.

Methods: The occurrence of the germline alternation within BRCA1 promoter region was determined by direct sequencing in peripheral blood cells (PBC) of FBOC cases (84) from the (Central Poland) (age range: 29-67; median age: 48), non-carriers of BRCA1 mutations, with a history of reporting at least two first-degree relatives affected by FBOC on the maternal side of the family. DNA methylation of the BRCA1 promoter was examined by sequence-based quantitative methylation analysis, cloning and sequencing in PBC of a subgroup (20) of FBOC cases with reported maternal history (age range: 39-64; median age: 48) and age-matched controls (12).

Results: Any mutations at CTCF binding sites were not observed. An inter-individual differences (range 31–60 %) between methylation levels of 11 CpGs, including those falling into CTCF1 binding site at the BRCA1 promoter were detected.

Conclusion: The observation may indicate an occurrence of inter-individual variations of CpGs methylation within CTCF binding site at the BRCA1 promoter/enhancer regulatory element. This in turn may suggest a novel CpGs-driven candidate for epimutation transmited across generation through maternal lineage.

Attempts to Determine the Status of HER2 in Breast Cancer by FISH in Equivocal Cases, using Alternative DNA Probes

Barbara Pienkowska-Grela, Aneta Wojnowska, Katarzyna Olszewska, Magdalena Grabowska-Kieryl, Julia Doerr

Cancer Genetics Laboratory, Department of Pathology and Diagnostic Laboratory, Maria Sklodowska-Curie Cancer Center, Poland

Background: The correct identification of HER2 amplification on breast cancer has important clinical significance. FISH test classifies patients as HER2+ (with amplification) and HER2- (without amplification). Last ASCO-CAP recomendations resulted in increased equivocal cases, with undefined HER2 status. Therefore, additional procedures with alternative DNA probe(s) should be performed.

Objective: Determining HER2 gene status in a group of equivocal cases, using complementary FISH test.

Methods: The study included 80 of 108 equivocal cases, obtained in routine FISH testing using PATHVISION HER-2 DNA Probe Kit II, Abbott (CE-IVD). The subsequent procedure was performed to designate the copy number of the short arm of chromosome 17 using TP53 Vysis FISH Probe Kit, Abbott (CE-IVD). The results were compared with the number of copies of centromere 17 (CEN17) and HER2 gene.

Results: In the group of 108 equivocal cases about 75 % of the patients showed an unusual signal pattern, corresponding to an amplified number of chromosome 17 copies or simultaneous amplification of CEN17 and HER2. Among these 80 cases, the average number of HER2 signals varied in the range 4.0-6.0, and the average CEN17 number was 3.0 or more. RATIO I (HER2/CEN17 2.0) and  HER2 copy number (4.0 6.0) did not indicate HER2 amplification. This corresponds to both: the polysomy 17 and co-amplification CEN17 and HER2. In 15% of cases no informative labeling was obtained. In 30 % of cases the number of TP53 signals does not exceed 3.0, excluding complete duplication of chromosome 17. In these cases RATIO II (HER2 /TP53), exceeded the value of 2.0, indicating co-amplification CEN17 and HER2 gene.

Conclusion: Complementary FISH test determined HER2+ status in 30% equivocal group. In other 70%, HER2 gene amplification was not confirmed. An increasing HER2 copy number could be influenced by poliploidisation of tumor cells. Ploidy status evaluation requires further research.

Novel, Safe Techniques in Immediate Breast Reconstruction, Locally Advanced Breast Cancer

Marisse Venter, Carol Anne Benn

Plastic Surgery, Netcare Breast Care, South Africa

Background: Locally advanced breast cancer poses unique surgical dilemmas. Studies involving reconstruction are few, most units do not reconstruct immediately if local surgery is performed. In our unit we perform a two part surgery apart in order to facilitate immediate reconstruction in these patients.

Objective: To demonstrate that breast reconstruction is possible in advanced breast cancer.

Methods: A prospective study of patients with locally advanced breast cancer treated in our unit from October 2013 to January 2016. Patients with inflammatory breast cancer, extensive DCIS with invasion and nodal disease, unknown primary disease were included in the study. Standard oncological protocol for locally advanced breast cancer (primary chemotherapy) was observed. We evaluated the patient demographics, histological features, tumor biology, oncological and reconstructive procedures.

Results: 101 patients were referred to a single reconstructive surgeon during this period; 2 patients had bilateral breast cancer, 21% inflammatory cancers, 8% unknown primary, 37% multi-centric disease, 17% extensive DCIS , with invasive and nodal disease and 17% large tumors post primary chemotherapy. The average patient age was 47 years. All patients received radiation post-surgery. Chemotherapy protocols were initially decided in the MDM. The majority of patients underwent reconstruction to the affected breast with an opposite side matching procedure. The average duration of the first procedure was 25 min and the reconstructive procedure was 133 min. Surgery and reconstructive outcomes were evaluated photographically. More than 50% of patients had a complete histological response.

Conclusion: Breast reconstruction is possible in locally advanced breast cancer. The procedure allows for adequate histological assessment and clear margins prior to immediate reconstruction and facilitates a better cosmetic result. Advances in chemotherapeutic regimes have improved the survival of these patients and breast reconstruction improves their quality of life.

Italian Trial Sinodar One: Axillary Dissection or Not in Sentinel Node Macrometastasis of Breast Cancer

Corrado Tinterri, Emilia Marrazzo, Wolfgang Gatzemeier, Andrea Sagona, Erika Barbieri, Arianna Rubino, Marco Eboli, Carlo Rossetti, Giuseppe Canavese

Oncological Department, Humanitas Research Hospital, Italy

Introduction: International guidelines keep recommending axillary lymph node dissection (ALND) in the presence of positive(+)sentinel lymph node (SLN).However SLN is the only site of axillary metastasis(MTS)in many cases(60%).Retrospective studies have also shown a low risk of locoregional relapse in patients with SLN+ not receiving ALND.The aim of this trial is to confirm that performing only SLNB does not affect survival or relapse risk in patients with 1-2 SLNs+.This procedure could reasonably be introduced in the clinical management of this patient subgroup, providing them also with a better quality of life due to a reduction of morbidities associated to ALND.

Materials and Methods: The multicenter clinical trial randomize 2,000 patients distributed in two arms: standard treatment of axillary dissection in patients with metastatic SLN vs no axillary dissection. The study will close in 3 years. Eligibility criteria are: age 40-75 years; primary invasive T1-T2 tumor; axillary nodes clinically N0;no more than 2 SLNs within macro MTS at intraoperative or definitive histological evaluation; no distant MTS; no neoadjuvant therapy; no previous invasive BC; signed informed consent. Exclusion criteria are: DCIS; inflammatory; contralateral BC; presence of only microMTS in the SLN ;pregnancy or breast feeding; comorbidity impeding adjuvant therapy. Follow-up controls foresee: clinical examination every 6 months for 5 years and yearly thereafter; annual mammography and breast echography; annual axillary echography for patients in the SLNB arm; additional laboratory and instrumental surveys in case of suspected onset of distant MTS

Conclusion: The result of this trial will confirm that the only SLNB introduction into clinical practice would be determine a significant reduction in ALND complications, improving the quality of life without compromising survival or the risk of locoregional recurrence.


SIS Journal is the Electronic Journal of the Senologic International Society, the World Society of Breast Diseases. ISSN: 1688-8170