- Email: [email protected]
Analysis of Lymph Node Positivity in DCIS Patients Undergoing Total Mastectomy
BREAST Mohamad E Sebai, MBBS, Ricardo J Bello, MD, MPH, Chris Devulapalli, MD, Carisa M Cooney, MPH, Gedge D Rosson, MD Johns Hopkins University School of Medicine, Baltimore, MD
Analysis of Lymph Node Positivity in DCIS Patients Undergoing Total Mastectomy Valentina Bonev, MD, Carlos E Chavez de Paz, MD, Naveenraj L Solomon, MD, FACS, Mark E Reeves, MD, PhD, FACS, Maheswari Senthil, MBBS, FACS, Carlos A Garberoglio, MD, FACS, Sharon S Lum, MD, FACS Loma Linda University Medical Center, Loma Linda, CA
INTRODUCTION: Despite well-characterized clinical benefits, staged breast reconstruction (SBR) with tissue expanders may cause patient dissatisfaction and affect patient-reported outcomes by delaying the reconstruction process. This study aimed to evaluate the association between quality of life (QoL) and the time interval between tissue expander insertion after mastectomy until final breast reconstruction (TE-to-BR) in staged reconstructions.
INTRODUCTION: Sentinel lymph node dissection (SLND) is recommended for patients diagnosed with DCIS undergoing total mastectomy (TM) due to technical difficulty in performing SLND after the breast is removed. Historically, positive axillary lymph nodes (LN) have been reported in 10% of patients with ductal carcinoma in situ (DCIS).
METHODS: We prospectively followed all patients undergoing SBR at our institution between 2010 and 2013. We tracked Breast-Q scores preoperatively, after tissue expander placement, and at 6 and 12 months after final reconstruction. After dividing TE-to-BR interval into tertiles, linear regression was used to assess the association between the TE-to-BR interval and changes in QoL.
METHODS: We evaluated LN status, patient and tumor characteristics, and overall survival of women with a clinical diagnosis of DCIS (cTisN0M0), who underwent TM from 1998 to 2012 in the National Cancer Data Base.
RESULTS: One hundred forty-four patients underwent SBR. Median TE-to-BR interval was 200 days (interquartile range: 130-320 days). TE-to-BR interval tertiles were defined as <144, 144-266, and >266 days. Receipt of chemotherapy, radiotherapy, autologous reconstruction, and axillary dissection were significantly associated with longer TE-to-BR interval. Unadjusted analysis demonstrated an association between longer TE-to-BR interval and decreased satisfaction with breast (p¼0.014), psychosocial well-being (p¼0.002), and sexual wellbeing (p¼0.004). However, these associations were no longer significant after adjusting for age, BMI, type of reconstruction, chemotherapy, and radiotherapy (p¼0.840, p¼0.118, p¼0.942, respectively).
RESULTS: We identified 37,185 women with clinical DCIS who underwent TM. Mean age was 55.3 years (SD 12.6 years); 79.8% of patient were non-Hispanic white; 1.8% lacked insurance; and 28.8% were treated at academic centers. Tumor grade was poorly/undifferentiated in 46.2% of patients, extent of DCIS was >2 cm in 25.2%, and the estrogen and progesterone receptors were negative in 22.9% and 35.0% of patients, respectively. Overall, axillary LN were positive in 5.5% of patients. Pathologically positive LN were significantly associated with age <75 years, nonwhite race/ethnicity, grade, lack of insurance, academic hospital, hormone receptor negativity, extent of DCIS, and the number of axillary LN removed. Median overall survival for pN+ patients was 44 months (range 0-189 months) and for pN0, 53 months (range 0-191 months) (p<0.0001) (Table).
CONCLUSIONS: These findings suggest that longer TE-to-BR intervals may not be associated with patient-reported changes in QoL after SBR. Rather, negative effects on QoL seem to be associated with chemotherapy and radiotherapy. This may help physicians in counseling patients undergoing SBR about its impact on their QoL.
Table. Lymph Node Status and Overall Survival* Number of LN removed (n ¼ 36, 572)
0 (n¼5670) 1-3 (n¼18,410) 4-6 (n¼6,146) 7-9 (n¼2,403) >10 (nand ¼3,943)
Positive LN, n(%) (n ¼ 2,005)
14 547 305 196 943
(0.2) (3.0) (5.0) (8.2) (23.9)
Hazard ratio (95% CI)
Reference 0.76 (0.69-0.84) 0.79 (0.70-0.89) 1.16 (1.01-1.34) 1.26 (1.11-1.42)
Phase Ib Trial Comparing Different Doses and Schedules of a Folate-Binding Protein-Derived Peptide Vaccine, E39, and its Attenuated Version, E39’, to Induce Long-Term FolateBinding Protein-Specific Immunity in DiseaseFree Cancer Patients Doreen O Jackson, MD*, Timothy Vreeland, MD, Diane F Hale, MD, Julia M Greene, MD, John S Berry IV, MD, Alfred F Trappey, Mark O Hardin, MD, Guy T Clifton, MD, FACS, George E Peoples, Jr, MD, FACS, Elizabeth A Mittendorf, MD, PhD, FACS San Antonio Military Medical Center, San Antonio, TX, Cancer Vaccine Development Program, San Antonio, TX, MD Anderson Cancer Center, Houston, TX
*Multivariate Cox proportional hazards regression with propensity score matching adjusted for pathologic nodal status, age, race/ethnicity, insurance status, comorbidity score, education, income, and estrogen receptor.
CONCLUSIONS: While the overall risk of nodal positivity in patients with DCIS undergoing TM is lower than in previous reports, the number of LN removed with surgical axillary staging is independently associated with survival. Further investigation is required to determine if these findings reflect access to standard of care vs stage migration.
INTRODUCTION: E39(FBP191-199,GALE-301,EIWTHSYKV) is a folate-binding protein (FBP)-derived peptide vaccine shown to be safe and immunogenic, with early clinical efficacy in a phase I/IIa trial. Due to concerns of overstimulation and loss of peptide-specific
Impact of Tissue Expander to Final Breast Reconstruction Time Interval on Postoperative Quality of Life: A Cohort Study of 144 Breast Reconstruction Patients using Breast-Q
S20
http://dx.doi.org/10.1016/j.jamcollsurg.2016.06.052 ISSN 1072-7515/16
Analysis of Lymph Node Positivity in DCIS Patients Undergoing Total Mastectomy Valentina Bonev, MD, Carlos E Chavez de Paz, MD, Naveenraj L Solomon, MD, FACS, Mark E Reeves, MD, PhD, FACS, Maheswari Senthil, MBBS, FACS, Carlos A Garberoglio, MD, FACS, Sharon S Lum, MD, FACS Loma Linda University Medical Center, Loma Linda, CA
INTRODUCTION: Despite well-characterized clinical benefits, staged breast reconstruction (SBR) with tissue expanders may cause patient dissatisfaction and affect patient-reported outcomes by delaying the reconstruction process. This study aimed to evaluate the association between quality of life (QoL) and the time interval between tissue expander insertion after mastectomy until final breast reconstruction (TE-to-BR) in staged reconstructions.
INTRODUCTION: Sentinel lymph node dissection (SLND) is recommended for patients diagnosed with DCIS undergoing total mastectomy (TM) due to technical difficulty in performing SLND after the breast is removed. Historically, positive axillary lymph nodes (LN) have been reported in 10% of patients with ductal carcinoma in situ (DCIS).
METHODS: We prospectively followed all patients undergoing SBR at our institution between 2010 and 2013. We tracked Breast-Q scores preoperatively, after tissue expander placement, and at 6 and 12 months after final reconstruction. After dividing TE-to-BR interval into tertiles, linear regression was used to assess the association between the TE-to-BR interval and changes in QoL.
METHODS: We evaluated LN status, patient and tumor characteristics, and overall survival of women with a clinical diagnosis of DCIS (cTisN0M0), who underwent TM from 1998 to 2012 in the National Cancer Data Base.
RESULTS: One hundred forty-four patients underwent SBR. Median TE-to-BR interval was 200 days (interquartile range: 130-320 days). TE-to-BR interval tertiles were defined as <144, 144-266, and >266 days. Receipt of chemotherapy, radiotherapy, autologous reconstruction, and axillary dissection were significantly associated with longer TE-to-BR interval. Unadjusted analysis demonstrated an association between longer TE-to-BR interval and decreased satisfaction with breast (p¼0.014), psychosocial well-being (p¼0.002), and sexual wellbeing (p¼0.004). However, these associations were no longer significant after adjusting for age, BMI, type of reconstruction, chemotherapy, and radiotherapy (p¼0.840, p¼0.118, p¼0.942, respectively).
RESULTS: We identified 37,185 women with clinical DCIS who underwent TM. Mean age was 55.3 years (SD 12.6 years); 79.8% of patient were non-Hispanic white; 1.8% lacked insurance; and 28.8% were treated at academic centers. Tumor grade was poorly/undifferentiated in 46.2% of patients, extent of DCIS was >2 cm in 25.2%, and the estrogen and progesterone receptors were negative in 22.9% and 35.0% of patients, respectively. Overall, axillary LN were positive in 5.5% of patients. Pathologically positive LN were significantly associated with age <75 years, nonwhite race/ethnicity, grade, lack of insurance, academic hospital, hormone receptor negativity, extent of DCIS, and the number of axillary LN removed. Median overall survival for pN+ patients was 44 months (range 0-189 months) and for pN0, 53 months (range 0-191 months) (p<0.0001) (Table).
CONCLUSIONS: These findings suggest that longer TE-to-BR intervals may not be associated with patient-reported changes in QoL after SBR. Rather, negative effects on QoL seem to be associated with chemotherapy and radiotherapy. This may help physicians in counseling patients undergoing SBR about its impact on their QoL.
Table. Lymph Node Status and Overall Survival* Number of LN removed (n ¼ 36, 572)
0 (n¼5670) 1-3 (n¼18,410) 4-6 (n¼6,146) 7-9 (n¼2,403) >10 (nand ¼3,943)
Positive LN, n(%) (n ¼ 2,005)
14 547 305 196 943
(0.2) (3.0) (5.0) (8.2) (23.9)
Hazard ratio (95% CI)
Reference 0.76 (0.69-0.84) 0.79 (0.70-0.89) 1.16 (1.01-1.34) 1.26 (1.11-1.42)
Phase Ib Trial Comparing Different Doses and Schedules of a Folate-Binding Protein-Derived Peptide Vaccine, E39, and its Attenuated Version, E39’, to Induce Long-Term FolateBinding Protein-Specific Immunity in DiseaseFree Cancer Patients Doreen O Jackson, MD*, Timothy Vreeland, MD, Diane F Hale, MD, Julia M Greene, MD, John S Berry IV, MD, Alfred F Trappey, Mark O Hardin, MD, Guy T Clifton, MD, FACS, George E Peoples, Jr, MD, FACS, Elizabeth A Mittendorf, MD, PhD, FACS San Antonio Military Medical Center, San Antonio, TX, Cancer Vaccine Development Program, San Antonio, TX, MD Anderson Cancer Center, Houston, TX
*Multivariate Cox proportional hazards regression with propensity score matching adjusted for pathologic nodal status, age, race/ethnicity, insurance status, comorbidity score, education, income, and estrogen receptor.
CONCLUSIONS: While the overall risk of nodal positivity in patients with DCIS undergoing TM is lower than in previous reports, the number of LN removed with surgical axillary staging is independently associated with survival. Further investigation is required to determine if these findings reflect access to standard of care vs stage migration.
INTRODUCTION: E39(FBP191-199,GALE-301,EIWTHSYKV) is a folate-binding protein (FBP)-derived peptide vaccine shown to be safe and immunogenic, with early clinical efficacy in a phase I/IIa trial. Due to concerns of overstimulation and loss of peptide-specific
Impact of Tissue Expander to Final Breast Reconstruction Time Interval on Postoperative Quality of Life: A Cohort Study of 144 Breast Reconstruction Patients using Breast-Q
S20
http://dx.doi.org/10.1016/j.jamcollsurg.2016.06.052 ISSN 1072-7515/16