- Email: [email protected]
28 ORAL Validation and limitations of use of a Breast Cancer Nomogram predicting the likelihood of non-sentinel node involvement after positive sentinel node biopsy
S10
Proffered papers: Cytoreductive surgery
Conclusion: The SLNB is associated with reduced arm morbidity. There is no evidence of a negative impact of the procedure on psychological well being. While waiting for long-term efficacy results of the ongoing randomized clinical trials, the SNP may be proposed to early stage breast cancer patients after adequate information on the expected advantages and the possible risks. 27
ORAL
Sentinel lymph node biopsy using a blue dye directed technique alone leads to a high false negative rate O.J. Greene, K.J. Whannel, W.D. George, C.R. Wilson, J.C. Doughty. Western Infirmary, Department of Surgery, Glasgow, United Kingdom Introduction: Axillary sampling techniques have evolved over time to provide a more conservative assessment of metastatic axillary disease in breast cancer by identification of the sentinel lymph node (SLN), thus minimising morbidity associated with axillary surgery. The aim of this study was to determine the identification and false negative rates of Blue Dye Directed Sample (BDDS) when used as an isolated technique for SLN biopsy in Breast Cancer. BDDS involves injecting Patent Blue dye into the periareolar region of the breast prior to axillary dissection. All blue nodes are excised together with any palpable non-blue nodes, to obtain a sample comprising at least four nodes. Method: This technique of BDDS was audited sequentially in 207 patients presenting to the Western Infirmary with conservable breast cancers between March 2003 and April 2006. Results: Median sample size was 4 nodes (range 1-7). Median number of blue nodes was 2 (range 1-6) and non-blue nodes 3 (range 0-6). Our results (table 1) showed an identification rate of sentinel lymph node of 96.1%. A total of 30 patients had metastatic axillary disease, however 8 of these had no disease detected in their blue nodes, giving a false negative rate of 26.6%. Table 1 Blue nodes Negative Negative Positive Positive
Non-blue nodes
Total cases
Negative Positive Negative Positive
177 (85%) 8 (3.9%) 16 (7.7%) 6 (2.9%)
Conclusion: BDDS produces an identification rate greater than the recommended rate of 95%. However, BDDS with excision of blue nodes only gives an unacceptably high false negative rate compared with dual technique combining BDDS with Isotope Radionucleotide Scanning. It also questions the benefit of using BDDS in place of axillary sampling alone with morbidity associated with BDDS. Our results suggest that the use of BDDS in isolation cannot be advocated. 28
ORAL
Validation and limitations of use of a Breast Cancer Nomogram predicting the likelihood of non-sentinel node involvement after positive sentinel node biopsy S. Alran 1 , Y. De Rycke 2 , V. Fourchotte 1 , H. Charitansky 1 , M. Falcou 2 , P. Freneaux 3 , M. Benamor 4 , B. Sigal Zafrany 3 , R. Salmon 1 . 1 Curie, Surgery, Paris, France; 2 Curie, Biostatistics, Paris, France; 3 Curie, Pathology, Paris, France; 4 Curie, Nuclear Medicine, Paris, France Background: Axillary lymph node dissection (ALND) for patients with positive sentinel lymph nodes (SLN) is currently under discussion in the literature. The breast cancer nomogram (BCN), an online tool developed by Memorial Sloan-Kettering Cancer Center (MSKCC), aims to predict the risk of positive non-sentinel node in SLN positive patients. The purpose of this study was to test the accuracy of the nomogram on patients with metastatic (>2mm) and minimal lymph node involvement [pN1mi (≤2mm) or pN0i+ (immunohistochemistry+)] on SLN biopsies. Methods: Patient characteristics, tumor pathology and positive SLN characteristics were collected on 588 consecutive patients who underwent completion ALND. The MSKCC BCN tool was used to calculate risk of metastases; for all 588 cases which included a subgroup of the 213 patients with minimal sentinel lymph node involvement. The BCN was performed for positive
SLN biopsies regardless of the method of metastasis detection. Evaluation of the BCN was performed using the area under the curve (AUC) method. Results: The BCN applied to all 588 patients achieved an area under the receiver operating characteristic curve (ROC) of 0.724([0.677-0.771)] compared to 0.76 in the MSKCC study. When the tool was applied solely to the 213 patients with minimal sentinel lymph node involvement, the area under the ROC was 0.538([0.423-0.653]). Conclusions: The MSKCC nomogram has been validated for all the patients having a metastatic SLN at the Institut Curie. However, this model was not reliably predictive for positive non-sentinel nodes in cases with minimal lymph node involvement.
PROFFERED PAPERS
Cytoreductive surgery 29
ORAL
Radioimmunotherapy is an effective adjuvant therapy to cytoreductive surgery for peritoneal carcinomatosis of Colonic Origin F. Aarts 1 , M.J. Koppe 1 , T. Hendriks 1 , W.J.G. Oyen 2 , O.C. Boerman 2 , R.P. Bleichrodt 1 . 1 Radboud University Nijmegen Medical Centre, Surgery, Nijmegen, The Netherlands; 2 Radboud University Nijmegen Medical Centre, Nuclear Medicine, Nijmegen, The Netherlands Introduction: Radioimmunotherapy (RIT) is an effective treatment modality for small volume disease, and therefore holds promise as adjuvant therapy after cytoreductive surgery (CS) of peritoneal carcinomatosis (PC). In the present study, we investigated its potential and optimal timing to CS in a rat model. Materials and methods: PC was induced in male Wag/Rij rats by intraperitoneal injection of 2 × 106 the syngeneic coloncarcinoma cell line CC531. Seven days after tumour induction, the animals underwent a surgical cytoreduction. Rats were subjected to exploratory laparotomy (EL) only, CS only, EL + RIT, or CS + RIT ranging from directly (RIT 0), 4 days after surgery (RIT 4) to 14 days following surgery (RIT 14). RIT consisted of i.p injected 177 Lu-labeled anti-CC531 monoclonal antibody, administered directly after CS, (RIT T=0), four days after CS (RIT T=4) or 14 days after CS (RIT T=14). Survival was the primary outcome parameter. Results: In all rats cytoreductive surgery resulted in removal of all macroscopic disease. Median survival for EL was only 41 days. Median survival of the rats treated with CS only, EL + RIT, or CS + RIT was 51 days (P=0.05), 61.5 days (P=0.03) and 88 days (P=0.0001), respectively. Median survival for CS + RIT 0, or RIT 4 and RIT 14 was 77 days (P<0.0001), 52 days (P<0.0001) and 45 days (P<0.0001), respectively. Moreover, there was a significant difference in survival between CS + RIT groups; RIT 0 vs RIT 14 (P<0.02). Conclusion: RIT is an effective adjuvant therapy in combination with CS of PC of colonic origin. Moreover, this study shows that the efficacy of adjuvant RIT after CS for the treatment of PC of colonic origin decreases when the administration of the radiolabeled MAbs is postponed. This study indicates that adjuvant RIT should be given as early after surgery as possible. 30
ORAL
Radioimmunotherapy as adjuvant treatment of peritoneal carcinomatosis of colonic origin is at least as effective as HIPEC F. Aarts 1 , T. Hendriks 1 , J. Eerd-Vismale van 2 , W.J.G. Oyen 2 , O.C. Boerman 2 , R.P. Bleichrodt 1 . 1 Radboud University Nijmegen Medical Centre, Surgery, Nijmegen, The Netherlands; 2 Radboud University Nijmegen Medical Centre, Nuclear Medicine, Nijmegen, The Netherlands The purpose of our study was to compare the efficacy and toxicity of combined cytoreductive surgery (CS) and radioimmunotherapy (RIT) for treatment of peritoneal carcinomatosis (PC) of colonic origin to the standard of care in current clinical practice, CS and hyperthermic intraperitoneal chemotherapy (HIPEC). Introduction: Cytoreductive surgery in combination with HIPEC is the current standard therapy for peritoneal carcinomatosis of colorectal origin. The median 2-year survival in these patients is 19%-27%. Morbidity after
Proffered papers: Cytoreductive surgery
Conclusion: The SLNB is associated with reduced arm morbidity. There is no evidence of a negative impact of the procedure on psychological well being. While waiting for long-term efficacy results of the ongoing randomized clinical trials, the SNP may be proposed to early stage breast cancer patients after adequate information on the expected advantages and the possible risks. 27
ORAL
Sentinel lymph node biopsy using a blue dye directed technique alone leads to a high false negative rate O.J. Greene, K.J. Whannel, W.D. George, C.R. Wilson, J.C. Doughty. Western Infirmary, Department of Surgery, Glasgow, United Kingdom Introduction: Axillary sampling techniques have evolved over time to provide a more conservative assessment of metastatic axillary disease in breast cancer by identification of the sentinel lymph node (SLN), thus minimising morbidity associated with axillary surgery. The aim of this study was to determine the identification and false negative rates of Blue Dye Directed Sample (BDDS) when used as an isolated technique for SLN biopsy in Breast Cancer. BDDS involves injecting Patent Blue dye into the periareolar region of the breast prior to axillary dissection. All blue nodes are excised together with any palpable non-blue nodes, to obtain a sample comprising at least four nodes. Method: This technique of BDDS was audited sequentially in 207 patients presenting to the Western Infirmary with conservable breast cancers between March 2003 and April 2006. Results: Median sample size was 4 nodes (range 1-7). Median number of blue nodes was 2 (range 1-6) and non-blue nodes 3 (range 0-6). Our results (table 1) showed an identification rate of sentinel lymph node of 96.1%. A total of 30 patients had metastatic axillary disease, however 8 of these had no disease detected in their blue nodes, giving a false negative rate of 26.6%. Table 1 Blue nodes Negative Negative Positive Positive
Non-blue nodes
Total cases
Negative Positive Negative Positive
177 (85%) 8 (3.9%) 16 (7.7%) 6 (2.9%)
Conclusion: BDDS produces an identification rate greater than the recommended rate of 95%. However, BDDS with excision of blue nodes only gives an unacceptably high false negative rate compared with dual technique combining BDDS with Isotope Radionucleotide Scanning. It also questions the benefit of using BDDS in place of axillary sampling alone with morbidity associated with BDDS. Our results suggest that the use of BDDS in isolation cannot be advocated. 28
ORAL
Validation and limitations of use of a Breast Cancer Nomogram predicting the likelihood of non-sentinel node involvement after positive sentinel node biopsy S. Alran 1 , Y. De Rycke 2 , V. Fourchotte 1 , H. Charitansky 1 , M. Falcou 2 , P. Freneaux 3 , M. Benamor 4 , B. Sigal Zafrany 3 , R. Salmon 1 . 1 Curie, Surgery, Paris, France; 2 Curie, Biostatistics, Paris, France; 3 Curie, Pathology, Paris, France; 4 Curie, Nuclear Medicine, Paris, France Background: Axillary lymph node dissection (ALND) for patients with positive sentinel lymph nodes (SLN) is currently under discussion in the literature. The breast cancer nomogram (BCN), an online tool developed by Memorial Sloan-Kettering Cancer Center (MSKCC), aims to predict the risk of positive non-sentinel node in SLN positive patients. The purpose of this study was to test the accuracy of the nomogram on patients with metastatic (>2mm) and minimal lymph node involvement [pN1mi (≤2mm) or pN0i+ (immunohistochemistry+)] on SLN biopsies. Methods: Patient characteristics, tumor pathology and positive SLN characteristics were collected on 588 consecutive patients who underwent completion ALND. The MSKCC BCN tool was used to calculate risk of metastases; for all 588 cases which included a subgroup of the 213 patients with minimal sentinel lymph node involvement. The BCN was performed for positive
SLN biopsies regardless of the method of metastasis detection. Evaluation of the BCN was performed using the area under the curve (AUC) method. Results: The BCN applied to all 588 patients achieved an area under the receiver operating characteristic curve (ROC) of 0.724([0.677-0.771)] compared to 0.76 in the MSKCC study. When the tool was applied solely to the 213 patients with minimal sentinel lymph node involvement, the area under the ROC was 0.538([0.423-0.653]). Conclusions: The MSKCC nomogram has been validated for all the patients having a metastatic SLN at the Institut Curie. However, this model was not reliably predictive for positive non-sentinel nodes in cases with minimal lymph node involvement.
PROFFERED PAPERS
Cytoreductive surgery 29
ORAL
Radioimmunotherapy is an effective adjuvant therapy to cytoreductive surgery for peritoneal carcinomatosis of Colonic Origin F. Aarts 1 , M.J. Koppe 1 , T. Hendriks 1 , W.J.G. Oyen 2 , O.C. Boerman 2 , R.P. Bleichrodt 1 . 1 Radboud University Nijmegen Medical Centre, Surgery, Nijmegen, The Netherlands; 2 Radboud University Nijmegen Medical Centre, Nuclear Medicine, Nijmegen, The Netherlands Introduction: Radioimmunotherapy (RIT) is an effective treatment modality for small volume disease, and therefore holds promise as adjuvant therapy after cytoreductive surgery (CS) of peritoneal carcinomatosis (PC). In the present study, we investigated its potential and optimal timing to CS in a rat model. Materials and methods: PC was induced in male Wag/Rij rats by intraperitoneal injection of 2 × 106 the syngeneic coloncarcinoma cell line CC531. Seven days after tumour induction, the animals underwent a surgical cytoreduction. Rats were subjected to exploratory laparotomy (EL) only, CS only, EL + RIT, or CS + RIT ranging from directly (RIT 0), 4 days after surgery (RIT 4) to 14 days following surgery (RIT 14). RIT consisted of i.p injected 177 Lu-labeled anti-CC531 monoclonal antibody, administered directly after CS, (RIT T=0), four days after CS (RIT T=4) or 14 days after CS (RIT T=14). Survival was the primary outcome parameter. Results: In all rats cytoreductive surgery resulted in removal of all macroscopic disease. Median survival for EL was only 41 days. Median survival of the rats treated with CS only, EL + RIT, or CS + RIT was 51 days (P=0.05), 61.5 days (P=0.03) and 88 days (P=0.0001), respectively. Median survival for CS + RIT 0, or RIT 4 and RIT 14 was 77 days (P<0.0001), 52 days (P<0.0001) and 45 days (P<0.0001), respectively. Moreover, there was a significant difference in survival between CS + RIT groups; RIT 0 vs RIT 14 (P<0.02). Conclusion: RIT is an effective adjuvant therapy in combination with CS of PC of colonic origin. Moreover, this study shows that the efficacy of adjuvant RIT after CS for the treatment of PC of colonic origin decreases when the administration of the radiolabeled MAbs is postponed. This study indicates that adjuvant RIT should be given as early after surgery as possible. 30
ORAL
Radioimmunotherapy as adjuvant treatment of peritoneal carcinomatosis of colonic origin is at least as effective as HIPEC F. Aarts 1 , T. Hendriks 1 , J. Eerd-Vismale van 2 , W.J.G. Oyen 2 , O.C. Boerman 2 , R.P. Bleichrodt 1 . 1 Radboud University Nijmegen Medical Centre, Surgery, Nijmegen, The Netherlands; 2 Radboud University Nijmegen Medical Centre, Nuclear Medicine, Nijmegen, The Netherlands The purpose of our study was to compare the efficacy and toxicity of combined cytoreductive surgery (CS) and radioimmunotherapy (RIT) for treatment of peritoneal carcinomatosis (PC) of colonic origin to the standard of care in current clinical practice, CS and hyperthermic intraperitoneal chemotherapy (HIPEC). Introduction: Cytoreductive surgery in combination with HIPEC is the current standard therapy for peritoneal carcinomatosis of colorectal origin. The median 2-year survival in these patients is 19%-27%. Morbidity after