Association between breast cancer-related lymphoedema and lower limb lymphatic dysfunction

ABSTRACTS

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Results: 78 relevant patients were identified, 37 with SBCs and 41 with MBCs. Of tumours for which data was available:

Histological concordance ER Status concordance PR Status concordance

Synchronous tumours

Metachronous tumours

Random tumour pair

65% (20/31) 85% (23/27) 79% (19/24)

57% (20/37) 52% (11/21) 47% (7/15)

61% 62% 52%

Conclusion: SBCs arise under identical genetic and environmental conditions, so could be expected to show similar characteristics more frequently than MBCs which may develop under different environmental conditions. 65% of SBCs had concordant histological types, MBCs 57%. The distribution of types was similar and as expected for non-bilateral cancers. The probability of two random tumours having the same ER status is 62%. Concordance for ER status in SBCs is higher (85%) and that of MBCs lower (52%). The probability of random tumours having the same PR status is 52%. There is a higher concordance rate for SBCs (79%); that for MBCs (47%) is similar to that predicted by chance. Concordance rates for type are close to the 61% expected by chance, suggesting type develops at random. Receptor status seems to be more dependent on environmental factors. http://dx.doi.org/10.1016/j.ejso.2013.07.206 Extramural venous invasion confers an increased risk of disease recurrence in stage II rectal cancer Manish Chand1,2, Aneel Bhangu1,2, Jessica Evans1, Ian Swift3, Paris Tekkis1,2, Gina Brown1,2 1 Royal Marsden Hospital, London, UK 2 Imperial College, London, UK 3 Croydon University Hospital, London, UK Introduction: Unlike in Stage III disease, patients with Stage II or node-negative rectal cancer are not routinely offered adjuvant chemotherapy due to the limited benefit in terms of survival. This observation does not account for more recent markers of poor prognosis such as extramural venous invasion (EMVI). EMVI is identified on MRI and may be more accurate than routine histopathological analysis. This study examined the recurrence rates and DFS in patients with Stage II rectal cancer in relation to EMVI status. Methods: A retrospective analysis was conducted of consecutive patients presenting with Stage II and III rectal cancer on final pathology. All patients had undergone neoadjuvant chemoradiotherapy and curative surgery. MRI scans were reviewed for tumour characteristics, specifically nodal and EMVI status. The post-treatment MRI was used to group patients into mrEMVI negative and positive. Kaplan Meier curves were used to demonstrate survival and comparison was made with Mantel-Cox log-rank test. Results: 66 patients with Stage II disease were included. In the mrEMVI-negative patients there were 8 recurrences (4 local, 4 distant) out of 57. In the mrEMVI-positive patients, there were 4 recurrences from 9 (all distant). 5-year DFS was 67% versus 47% (p¼0.02). A further group of 105 Stage III patients were classified into mrEMVI negative or positive; 5-year DFS was 47% versus 45%, respectively (p>0.05). Conclusion: EMVI status has a prognostic effect on disease-free survival in Stage II rectal cancer and should be a consideration for adjuvant chemotherapy. This effect is not seen in Stage III patients. http://dx.doi.org/10.1016/j.ejso.2013.07.207 Axillary sentinel lymph node (SLN) biopsy using radioisotope alone: A local audit Elena Popa, Natasha Jiwa, Frances Hanlon, Steven Goh Breast Unit, Peterborough City Hospital, Peterborough, UK

Introduction: NICE recommends performing SLN biopsy using a dual technique with blue dye and isotope. Following 2 successive cases of anaphylactic reactions, our unit has stopped using blue dye for SLN identification. We evaluated our practice in this audit. Methods: A retrospective review was conducted on all SLN biopsies performed between April 2010 and March 2013. Cancer registry, case-notes and histopathological reports were cross-referenced for data collection. Results: 398 from 486 SLN biopsies with completed data were included. All patients received technetium (Tc99)-labelled nanocolloid. A mean number of 1.73 SLN were excised and the SLN metastasis rate was 23.4%. In 224 cases SLN only were removed during surgery. SLN and non-SLN were removed in 161 cases. These were subdivided into:

SLN SLN SLN SLN

negative, Non SLN negative positive, Non-SLN negative positive, Non-SLN positive negative, Non-SLN positive

n

Mean number of SLN

115 22 17 7

1.60 2.09 1.82 1.14

(1e7) (1e4) (1e4) (1e2)

Radioisotope localisation failed in 13 cases. 11 of these underwent blue dye-assisted sampling and 2 were converted to axillary dissection (ALND). 28 of the 74 patients who underwent ALND following SLN biopsies had further nodal metastases. Conclusions: Radioisotope alone successfully identified SLN in 96.7% of our patients. However, 7 patients were found to have metastases in nonSLN when their SLN was negative. This cohort appeared to have a lower number of SLN excised. Longer term follow up is needed to determine the incidence of local axillary recurrence. Further studies should also be conducted to evaluate the practice of removing non-SLN. http://dx.doi.org/10.1016/j.ejso.2013.07.208

Association between breast cancer-related lymphoedema and lower limb lymphatic dysfunction Salena Bains1,2, Charles Zammit3, Peter Mortimer4, Adrien Peters3, Arnie Purushotham1,2 1 King’s College London, London, UK 2 Guy’s and St Thomas’ NHS Foundation Trust, London, UK 3 Brighton and Sussex University Hospitals NHS Trust, Brighton, UK 4 St George’s, University of London, London, UK Introduction: Previous studies have suggested that some women are more susceptible to developing breast cancer-related lymphoedema (BCRL). Our aim was to investigate the hypothesis that there is a constitutional predisposition to BCRL and that this is reflected in abnormal lower limb lymphatic function. Methods: Following Local Research Ethics Committee approval, two groups of patients with and without BCRL, who had undergone axillary surgery for breast cancer at least 3 years previously, were recruited. None of the patients had any clinically demonstrable lower limb abnormality. Following subcutaneous injection of 99mTc-labelled nanocolloid into the first web-space of each foot, lower limb lymphoscintigraphy was performed. Images were obtained from the upper abdomen to the toes with a gamma camera at 5, 45 and 150 min after injection. Lymphoscintigraphy was classified as normal or abnormal using conventional criteria and read blinded (AMP). Results: The mean number of lymph nodes removed was 16.18.7 (S.D) in the BCRL group and 17.84.7 in the non-BCRL group. Of 13 patients studied thus far, nine have BCRL. Seven of these 9 patients with BCRL were found to have abnormal lower limb imaging on lymphoscintigraphy compared to 1 of 4 without BCRL (proportion analysis: p ¼ 0.07). Conclusion: These preliminary results are consistent with the hypothesis that there may be a constitutional disturbance in lymphatic function in patients

S70 who have BCRL, suggesting an inherent predisposition. This could have a potential impact on the future management of patients who are subjected to surgical intervention that might increase their risk of lymphoedema. http://dx.doi.org/10.1016/j.ejso.2013.07.209 Cancer charity collaborations with NHS services e Do they improve patient care? Laura Johnson, Alex Photiou, Elizabeth Sharp Queen Elizabeth the Queen Mother Hospital, Margate, UK Introduction: In November 2011, we launched a collaborative project with the cancer charity Break Through Breast Cancer. Following meetings with local patients and after receiving feedback from clinicians, a ‘breast service pledge’ was created. Methods: Standards published in the ‘Breast service pledge’ booklet were compared with current practice one year after its launch. Results: Despite fulfilling our pledge in several aspects, certain areas were identified in which we fell short. The most notable of these included:  ‘Patients should be offered a choice of appointment’ e An inflexible approach to appointments existed. An automated service now gives patients greater choice.  ‘A breast care nurse should be available in every clinic’ e There were insufficient staff to fulfil this pledge, but funding for an additional specialist nurse was subsequently aided by the pledge.  Patients to receive copies of their clinic letters’ e 52% were offered copies of their clinic letters, although some declined the offer. The patient’s preference is now noted at appointment check in.  ‘There is space for a friend or relative’ e Our consulting rooms were poorly laid out making this difficult. A more comfortable environment now exists. Conclusion: The ‘breast service pledge’ identified markers of care for breast patients beyond those traditionally used to judge a department’s ‘success’. Collaboration with a charity gave our patients a voice to identify non-clinical aspects of care they thought would improve the breast clinic experience. Such local-level collaborations should be encouraged nationwide to recognise the specific holistic needs of patients attending their local breast clinic.

ABSTRACTS difference in excised specimen volume, favouring WGL (MD, 6.79; 95% CI, 0.03, 13.56). The MD for specimen weight of -3.00 (95% CI, -15.15, 9.15), showed no significant difference between RGL and WGL. Conclusions: RGL reduced operating time but required larger volume excisions compared to WGL. There is insufficient evidence to support the uptake of RGL over WGL and adequately powered RCTs are required. http://dx.doi.org/10.1016/j.ejso.2013.07.211

A systematic review and meta-analysis of intra-operative ultrasound versus wire-guided localization in the surgical management of nonpalpable breast cancers Muneer Ahmed, Michael Douek King’s College London, London, UK Background: Non-palpable breast cancers represent one-third of all breast cancers and provide a significant burden on health care systems. The current standard of treatment for non-palpable breast cancers is wire-guided localization (WGL). WGL has its drawbacks and alternatives such as radio-guided surgery (RGL) and intra-operative ultrasound (IOUS) have been developed. The clinical effectiveness of all forms of RGL has been assessed against WGL in previous systematic reviews and meta-analyses. We performed the first systematic review and meta-analysis of IOUS in the management of non-palpable breast cancers. Methods: Studies were included if they; 1) assessed the role of surgeon performed IOUS for the treatment of non-palpable breast cancers and ductal carcinoma in-situ (DCIS) 2) specified surgical margin excision status. Those studies, which were randomized controlled trials (RCTs) or cohort studies with comparison WGL groups were included in the meta-analysis. For those studies included in the meta-analysis, pooled odds ratios (ORs) and 95% confidence intervals were estimated using fixed-effects analyses and random-effects analyses in case of statistically significant heterogeneity (p<0.05). Results: A total of 18 studies reported data on IOUS in 1328 patients with non-palpable breast cancer and DCIS. Nine cohort studies with control WGL groups and one RCT were included in the meta-analysis. Successful localization rates varied between 95 to 100 per cent in all studies and there was a statistically significant difference in the rates of involved surgical margins in favour of IOUS with pooled OR 0.52 (95% CI, 0.38e0.71). Conclusion: Compared to WGL, IOUS reduces involved surgical margin rates. Adequately powered RCTs are required to validate these findings.

http://dx.doi.org/10.1016/j.ejso.2013.07.210 http://dx.doi.org/10.1016/j.ejso.2013.07.212 Systematic review and meta-analysis of radio-guided versus wireguided localization in the treatment of non-palpable breast cancers Muneer Ahmed, Mieke Van Hemelrijck, Michael Douek King’s College London, London, UK Background: One-third of breast cancers present as non-palpable lesions. The current gold standard surgical treatment for these cancers is wide local excision using wire-guided localization (WGL). WGL has drawbacks including technical and scheduling issues, which resulted in the development of alternative radio-guided techniques (RGL). Methods: A systematic review was performed to identify studies comparing RGL and WGL. The outcomes of surgical margin status, reoperation rates, surgical operative time, volume and excised specimen weight and successful sentinel lymph node biopsy (SLNB) rates, were evaluated. Pooled odds ratios (ORs) and 95% confidence intervals were estimated using fixed-effects analyses and random-effects analyses in case of statistically significant heterogeneity (p<0.05). Results: Seven randomized controlled trials (RCTs) matching the inclusion criteria were identified. The pooled OR for involved surgical margin status of 0.78 (95% CI, 0.52e1.17); for re-operation of 0.74 (95% CI, 0.49e1.11) and for successful SLNB of 1.29 (95% CI, 0.66e2.53). There was a significant difference in surgical operating time in favour of RGL (mean difference (MD), -2.95; 95% CI, -4.43, -1.47) and a significant

The impact of oncoplastic techniques on re-operation rate following breast conserving surgery Jane McClements, David Neely, Brendan McFall, Peter Mallon Breast Surgery Unit, Craigavon Area Hospital, Craigavon, Northern Ireland, UK Introduction: The European Society of Breast Cancer Specialists (EUSOMA) quality guidelines state that the minimum target re-operation rate for breast conserving surgery (BCS) is 20%. Many factors affect re-operation rate (accepted margin clearance, tumour size). There is evidence to suggest that oncoplastic BCS can reduce re-operation rates. A comparative audit was conducted to determine if increasing the proportion of oncoplastic BCS procedures impacts on re-operation rates within a district general hospital breast unit. Methods: Charts and pathology reports were retrieved on patients who had BCS from 05/01/12e20/09/12 (Group 1) and 3/1/2013e24/5/2013 (Group 2). The accepted margin clearance was 2 mm. Cavity shaves at first operation were not routinely performed. Data on operation type, re-operation rate, tumour size, and incidence of DCIS was recorded. Statistical analysis was performed using Graphpad software. Fisher’s exact test was used to compare the re-operation rates and proportion of DCIS, with ttest for comparison of mean tumour size. Statistical significance was p <0.05.