- Email: [email protected]
Can we predict further axillary nodal disease in patients with sentinel node macro metastases by OSNA in early breast cancer?
ABSTRACTS the combination of the pectoral muscle and either a dermal sling or mesh. However, prepectoral implant reconstructions have become increasingly popular and have been shown to result in equally good outcomes. Methods: We performed a retrospective audit comparing the length of hospital stay, use of analgesia and complication rate (delayed healing, infection, implant loss, return to theatre) in patients who had prepectoral and subpectoral implant based reconstruction over the last year. Results: A total of 44 patients were included in this study with 22 patients in each group. There was no significant difference in the patients’ age, smoking history or indication for mastectomy (DCIS or cancer). However, patients who had prepectoral implants had significantly shorter hospital stay (p ¼ 0.047). No difference was seen in analgesia requirements. There was also no difference in the rate of complications between the two groups. Conclusions: Prepectoral implant reconstruction achieves comparable outcomes to the placement of subpectoral implants. With less intraoperative dissection, patients need less time to recover. Further prospective studies are needed to look at the long-term outcomes of prepectoral implant reconstruction. http://dx.doi.org/10.1016/j.ejso.2017.01.101
P050. BRCA ‘variants of unknown significance’ need regular review to facilitate optimal patient management Gareth Irwin1, Cassandra Freitas2, Stuart McIntosh1,2, Kienan Savage2 1 Belfast City Hospital, Belfast, UK 2 Queen’s University, Belfast, UK Introduction: Most BRCA1 and 2 mutations are known to either be pathogenic or benign but for some their clinical significance is unknown, leading to uncertainty regarding management. Periodically, these ‘variants of unknown significance’ are reclassified by ClinVar, IARC or AlignGVGD, gene classification databases, potentially leading to a change in optimal management. Methods: All VUS of BRCA1 and 2 were identified from the Northern Ireland BRCA database and reanalysed by updated review of ClinVar, IARC, BRCA1 Circos or Align-GVGD to evaluate whether or not they had been reclassified, and if this reclassification may have an impact on clinical management. Results: 170 VUS were identified: 67 in BRCA1 and 103 in BRCA2. Of these 4 BRCA1 and 5 BRCA2 VUS were reclassified as either definitely or probably pathogenic. 78% of BRCA1 and 71% of BRCA2 VUSs were reclassified as either benign, probably benign or of little impact. 21% of all the VUSs remained unable to be classified. Conclusions: As more information is gleaned about VUS the frequency of their reclassification is increasing. This study highlights the need to revisit VUSs as their reclassification may have clinical implications, with 5% of patients in this study now being diagnosed as either definitely or probably pathogenic. In addition, up to 78% could be reassured by an unknown variant being reclassified as benign. This has implications for consent to undertake genetic testing and the need to update patients as more information becomes available. http://dx.doi.org/10.1016/j.ejso.2017.01.103
P051. Exploiting the potential of publically available gene expression repositories to develop a better understanding of differential gene expression in breast cancer tissue Mary McCumiskey1,2, Conor Judge3, John Hogan4, Bridget Anne Merrigan2, Shona Tormey2, Ashish Lal2, Aoife Lowery2,5,7, Calvin Coffey2,5,7, Tara Dalton1, Patrick Kiely5,6,7 1 Stokes Laboratories, Bernal Institute, University of Limerick, Limerick, Ireland 2 Department of Surgery, University Hospital Limerick, Limerick, Ireland 3 Department of Medicine, University Hospital Galway, Galway, Ireland 4 Department of Cardiothoracics, University Hospital Wales, Cardiff, UK
S25 5
Graduate Entry Medical School (GEMS), University of Limerick, Limerick, Ireland 6 Health Research Institute, University of Limerick, Limerick, Ireland 7 4i Centre for interventions in Infection, Inflammation and Immunity, GEMS, University of Limerick, Limerick, Ireland Introduction: There are large volumes of data available within public gene expression repositories (PGER). However it is not possible to search through these using relevant clinical terms. Previous research at the University of Limerick has led to the development of software tools (Rover) that permit clinically relevant searches, allowing for the analysis of datasets based upon specific clinical parameters. In breast cancer they can be challenged by asking specific questions about how normal tissue compares with cancer tissue and with respect to Oestrogen Receptor status, Progesterone Receptor Status, Lymph node status, HER2 status and reoccurrence compared to non-reoccurring breast cancer. The aim of this study is to exploit the potential of the data available from publicly available gene expression repositories to develop a potential gene expression profile to help differentiate between normal tissue and breast cancer. Methods: A University of Limerick Breast Cancer Archive was established based on datasets derived from Gene Expression Omnibus (GEO) and ArrayExpress which were searched using the phrase, “breast.” The datasets were subsequently reviewed and only those which obtained a 5* in Minimum Information About a Microarray Experiment (MIAME) compliance score within ArrayExpress and imported into Chipster for further analysis. Results: This search yielded 29 datasets which obtained a 5* MIAME compliance score within ArrayExpress, 6 of these datasets GSE 42568, GSE 42568, GSE 50428, GSE 50567, GSE 57297 and GSE 59246 compared the microarray expression between normal and breast cancer tissue. Further analysis of which further identified the following genes as being the most dysregulated throughout all the datasets: FABP4, MMP1, AdipoQ, C2orf40, CD36, CYP2B6, KRT5 AND S100P. Conclusions: This demonstrates that it is possible to use the microarray expression data available within public gene expression repositories in relation to breast cancer to generate consensus profiles which can potentially be further assessed to provide diagnostic and prognostic information. http://dx.doi.org/10.1016/j.ejso.2017.01.104
P052. Can we predict further axillary nodal disease in patients with sentinel node macro metastases by OSNA in early breast cancer? Uma Sridharan, Anita Hargreaves, Adrian McKenna, Shelley Potter, Hannah Lennon, Catherine Eley, Chris Holcombe, Geraldine Mitchell Royal Liverpool University Hospital, Liverpool, UK Introduction: OSNA (One step nucleic Acid Amplification) is an intra-operative assessment which enables axillary node clearance in the presence of macro metastases. More than 50% of women who have axillary clearance do not have any further nodal involvement. We aimed to identify factors which can help to predict further axillary disease in the patients who have macro metastases to avoid unnecessary axillary clearance. Method: A retrospective analysis of 995 consecutive patients with invasive breast carcinoma in a single centre from November 2012 to October 2016 was performed. All patients were clinically node negative pre-operatively, and underwent OSNA. Demographics, histopathological data and details of axillary management were analysed. Results: Among 995 patients, 433 (43.5%) patients were node positive. 274 (27.5%) patients had micro metastases and 159 (16%) had macro metastases. In the cohort with macro metastases, 118 (76%) patients proceeded to axillary node clearance. Of these, 58 patients had further axillary disease. Tumour size, presence of LVI, high KI-67 and high CK19 predicted for further axillary disease.
S26
Age (Median) Surgery Mastectomy WLE Histology IDC ILC Size (Mean) LVI Ki 67 > 15% CK 19 copy No. <50,000 ➢50,000
ABSTRACTS
No further axillary disease N ¼ 60
Further axillary disease N ¼ 58
60 28 32 56 4 30.4 mm 56.7% 25% 58.3 % 41.7%
58 39 19 39 19 47.3 mm 63.7% 39.7% 29% 71%
Conclusion: The tumour size, presence of LVI, high KI-67 and high ck19 predict further axillary disease.
Method: The study used a qualitative phenomenological approach to elicit these experiences, from five women diagnosed with breast cancer who choose to have CPM at their initial breast cancer diagnosis. Data was collected using audio-recorded, semi structures interviews and analysed using Colaizzi’s (1978) framework for data analysis. Findings: Three overarching themes emerged: Theme 1: Factors contributing to constructing the decision Theme 2: The process of the decision Theme 3: No regret Conclusion: There needs to be a balance between speed of treatment and making sure women have sufficient time to think about their decision. Service provision for these women needs to be considered as well as the quality and the way information is delivered and the nature of communication with health care professionals. A decision making support tool generated from this study could be used to facilitate with the decision making process to assist specialist nurses when counselling, this tool could be trialled in clinical practice. http://dx.doi.org/10.1016/j.ejso.2017.01.107
http://dx.doi.org/10.1016/j.ejso.2017.01.105
P053. Unplanned revisional surgery for cosmesis following immediate implant based reconstruction Richard Clough1, Lynn Darragh2, Joe O’Donoghue3 1 Newcastle University, Newcastle Upon Tyne, UK 2 General Surgery Department, Ulster Hospital, Dundonald, UK 3 Plastic Surgery Department, Royal Victoria Infirmary, Newcastle Upon Tyne, UK Introduction: Increasingly reconstruction following mastectomy is carried out as an immediate procedure. Reconstruction options are varied and a collaborative approach between clinicians and patients is required. Patients are generally advised that implant based reconstructions may require maintenance surgery in the future. This study aimed to quantify how many patients required unplanned surgery to improve cosmesis, following successful immediate implant based reconstruction in the short term. Methods: A retrospective audit of patients who had successful (i.e. no implant loss at 3 months) fixed volume implant based reconstruction between June 2012 and June 2013 was carried out. Unplanned procedures to improve cosmesis were recorded. Nipple reconstruction and contralateral procedures were excluded. Results: 88 implants (69 patients) were included with an average of 38.6 months follow up. 39 implants (44%) required a mean of 1.36 (range 1e5) revisional surgeries. Lipomodelling accounted for 34%, implant exchange 30%, implant removal 21% and other procedures 15%. There was a significantly higher rate of revisional surgery in patients who had an early complication following the initial procedure (14/21 vs 25/67; p ¼ 0.018). Conclusion: The potential requirement for revisional surgery to obtain satisfactory cosmesis in the first 3 years following immediate implant based reconstruction should be communicated to patients in a collaborative decision making process.
P055. NHSBSP Guidelines and use of VAE for B3 pathology saves money and reduces patient pathway Blossom Lake, Susan Williams, Tamoor Usman, Cerys Burrows Shrewsbury & Telford NHS Trust, Telford, UK Introduction: B3 or indeterminate breast pathology combines a variety of heterogeneous pathological entities, with varying malignant potential and often cause a treatment dilemma. Recent NHSBSP guidelines help to delineate the treatment pathway following B3 diagnosis. Recommendations include for certain B3 pathology the use of second line Vacuum Assisted Excision(VAE), which decreases the need for open surgical biopsy. The aim of this audit was to assess current practice compared to guidelines and the potential cost saving from implementation. Method: A 5 year audit of all B3 pathologies at Shrewsbury and Telford NHS Trust was performed from 2010 to 2015. Data was recorded from the Clinical Portal and included initial pathology, subsequent procedures, subsequent pathology, upgrade and downgrade rates. Cost saving analysis was performed to see how much would have been saved if the new NHSBSP guidelines had been followed. Results: 297 B3 pathologies were identified; repeat B3 biopsy and B4 pathology were excluded. Commonest initial B3 pathology was Papilloma or Papillary lesion without atypia 24%. 140 patients (47%) had excision as second line procedure. Upgrade rate was 22% and downgrade rate was 29%. Cost saving analysis showed that if VAE was available as a second line procedure, 115 patients (39%) could have had this instead of excision saving £80,960. In addition 10% of patients would have had reduced clinical pathway. Conclusion: New guidelines recommend for selected B3 pathology the use of VAE. This audit demonstrates not only does this save money but also reduces the steps in the patient’s pathway. http://dx.doi.org/10.1016/j.ejso.2017.01.108
http://dx.doi.org/10.1016/j.ejso.2017.01.106
P054. What are the experiences and motivating factors of women who choose contralateral prophylactic mastectomy at initial breast cancer diagnosis in the absence of a strong family history? Rosemary Buck Portsmouth Hospital NHS Trust, Portsmouth, UK Introduction: To explore the experience, motivational factors and decision making strategies of women who choose contralateral prophylactic mastectomy (CPM) in the absence of a strong family history of breast cancer at the initial breast cancer diagnosis.
P056. Mammographic surveillance in family history patients: Do low cancer detection rates justify the high numbers of breast cancers detected? Christopher Madden-McKee1,2, Grainne Culleton1,2, Gwyneth Hinds3, Stuart McIntosh1,2 1 Centre for Cancer Research and Cell Biology, Belfast, UK 2 Queen’s University Belfast, Belfast, UK 3 Breast Surgery Department, Belfast City Hospital, Belfast, UK Introduction: NICE recommends that women at increased risk of breast cancer due to family history (FH) should undergo enhanced mammographic screening. We examined the performance of the Belfast
P050. BRCA ‘variants of unknown significance’ need regular review to facilitate optimal patient management Gareth Irwin1, Cassandra Freitas2, Stuart McIntosh1,2, Kienan Savage2 1 Belfast City Hospital, Belfast, UK 2 Queen’s University, Belfast, UK Introduction: Most BRCA1 and 2 mutations are known to either be pathogenic or benign but for some their clinical significance is unknown, leading to uncertainty regarding management. Periodically, these ‘variants of unknown significance’ are reclassified by ClinVar, IARC or AlignGVGD, gene classification databases, potentially leading to a change in optimal management. Methods: All VUS of BRCA1 and 2 were identified from the Northern Ireland BRCA database and reanalysed by updated review of ClinVar, IARC, BRCA1 Circos or Align-GVGD to evaluate whether or not they had been reclassified, and if this reclassification may have an impact on clinical management. Results: 170 VUS were identified: 67 in BRCA1 and 103 in BRCA2. Of these 4 BRCA1 and 5 BRCA2 VUS were reclassified as either definitely or probably pathogenic. 78% of BRCA1 and 71% of BRCA2 VUSs were reclassified as either benign, probably benign or of little impact. 21% of all the VUSs remained unable to be classified. Conclusions: As more information is gleaned about VUS the frequency of their reclassification is increasing. This study highlights the need to revisit VUSs as their reclassification may have clinical implications, with 5% of patients in this study now being diagnosed as either definitely or probably pathogenic. In addition, up to 78% could be reassured by an unknown variant being reclassified as benign. This has implications for consent to undertake genetic testing and the need to update patients as more information becomes available. http://dx.doi.org/10.1016/j.ejso.2017.01.103
P051. Exploiting the potential of publically available gene expression repositories to develop a better understanding of differential gene expression in breast cancer tissue Mary McCumiskey1,2, Conor Judge3, John Hogan4, Bridget Anne Merrigan2, Shona Tormey2, Ashish Lal2, Aoife Lowery2,5,7, Calvin Coffey2,5,7, Tara Dalton1, Patrick Kiely5,6,7 1 Stokes Laboratories, Bernal Institute, University of Limerick, Limerick, Ireland 2 Department of Surgery, University Hospital Limerick, Limerick, Ireland 3 Department of Medicine, University Hospital Galway, Galway, Ireland 4 Department of Cardiothoracics, University Hospital Wales, Cardiff, UK
S25 5
Graduate Entry Medical School (GEMS), University of Limerick, Limerick, Ireland 6 Health Research Institute, University of Limerick, Limerick, Ireland 7 4i Centre for interventions in Infection, Inflammation and Immunity, GEMS, University of Limerick, Limerick, Ireland Introduction: There are large volumes of data available within public gene expression repositories (PGER). However it is not possible to search through these using relevant clinical terms. Previous research at the University of Limerick has led to the development of software tools (Rover) that permit clinically relevant searches, allowing for the analysis of datasets based upon specific clinical parameters. In breast cancer they can be challenged by asking specific questions about how normal tissue compares with cancer tissue and with respect to Oestrogen Receptor status, Progesterone Receptor Status, Lymph node status, HER2 status and reoccurrence compared to non-reoccurring breast cancer. The aim of this study is to exploit the potential of the data available from publicly available gene expression repositories to develop a potential gene expression profile to help differentiate between normal tissue and breast cancer. Methods: A University of Limerick Breast Cancer Archive was established based on datasets derived from Gene Expression Omnibus (GEO) and ArrayExpress which were searched using the phrase, “breast.” The datasets were subsequently reviewed and only those which obtained a 5* in Minimum Information About a Microarray Experiment (MIAME) compliance score within ArrayExpress and imported into Chipster for further analysis. Results: This search yielded 29 datasets which obtained a 5* MIAME compliance score within ArrayExpress, 6 of these datasets GSE 42568, GSE 42568, GSE 50428, GSE 50567, GSE 57297 and GSE 59246 compared the microarray expression between normal and breast cancer tissue. Further analysis of which further identified the following genes as being the most dysregulated throughout all the datasets: FABP4, MMP1, AdipoQ, C2orf40, CD36, CYP2B6, KRT5 AND S100P. Conclusions: This demonstrates that it is possible to use the microarray expression data available within public gene expression repositories in relation to breast cancer to generate consensus profiles which can potentially be further assessed to provide diagnostic and prognostic information. http://dx.doi.org/10.1016/j.ejso.2017.01.104
P052. Can we predict further axillary nodal disease in patients with sentinel node macro metastases by OSNA in early breast cancer? Uma Sridharan, Anita Hargreaves, Adrian McKenna, Shelley Potter, Hannah Lennon, Catherine Eley, Chris Holcombe, Geraldine Mitchell Royal Liverpool University Hospital, Liverpool, UK Introduction: OSNA (One step nucleic Acid Amplification) is an intra-operative assessment which enables axillary node clearance in the presence of macro metastases. More than 50% of women who have axillary clearance do not have any further nodal involvement. We aimed to identify factors which can help to predict further axillary disease in the patients who have macro metastases to avoid unnecessary axillary clearance. Method: A retrospective analysis of 995 consecutive patients with invasive breast carcinoma in a single centre from November 2012 to October 2016 was performed. All patients were clinically node negative pre-operatively, and underwent OSNA. Demographics, histopathological data and details of axillary management were analysed. Results: Among 995 patients, 433 (43.5%) patients were node positive. 274 (27.5%) patients had micro metastases and 159 (16%) had macro metastases. In the cohort with macro metastases, 118 (76%) patients proceeded to axillary node clearance. Of these, 58 patients had further axillary disease. Tumour size, presence of LVI, high KI-67 and high CK19 predicted for further axillary disease.
S26
Age (Median) Surgery Mastectomy WLE Histology IDC ILC Size (Mean) LVI Ki 67 > 15% CK 19 copy No. <50,000 ➢50,000
ABSTRACTS
No further axillary disease N ¼ 60
Further axillary disease N ¼ 58
60 28 32 56 4 30.4 mm 56.7% 25% 58.3 % 41.7%
58 39 19 39 19 47.3 mm 63.7% 39.7% 29% 71%
Conclusion: The tumour size, presence of LVI, high KI-67 and high ck19 predict further axillary disease.
Method: The study used a qualitative phenomenological approach to elicit these experiences, from five women diagnosed with breast cancer who choose to have CPM at their initial breast cancer diagnosis. Data was collected using audio-recorded, semi structures interviews and analysed using Colaizzi’s (1978) framework for data analysis. Findings: Three overarching themes emerged: Theme 1: Factors contributing to constructing the decision Theme 2: The process of the decision Theme 3: No regret Conclusion: There needs to be a balance between speed of treatment and making sure women have sufficient time to think about their decision. Service provision for these women needs to be considered as well as the quality and the way information is delivered and the nature of communication with health care professionals. A decision making support tool generated from this study could be used to facilitate with the decision making process to assist specialist nurses when counselling, this tool could be trialled in clinical practice. http://dx.doi.org/10.1016/j.ejso.2017.01.107
http://dx.doi.org/10.1016/j.ejso.2017.01.105
P053. Unplanned revisional surgery for cosmesis following immediate implant based reconstruction Richard Clough1, Lynn Darragh2, Joe O’Donoghue3 1 Newcastle University, Newcastle Upon Tyne, UK 2 General Surgery Department, Ulster Hospital, Dundonald, UK 3 Plastic Surgery Department, Royal Victoria Infirmary, Newcastle Upon Tyne, UK Introduction: Increasingly reconstruction following mastectomy is carried out as an immediate procedure. Reconstruction options are varied and a collaborative approach between clinicians and patients is required. Patients are generally advised that implant based reconstructions may require maintenance surgery in the future. This study aimed to quantify how many patients required unplanned surgery to improve cosmesis, following successful immediate implant based reconstruction in the short term. Methods: A retrospective audit of patients who had successful (i.e. no implant loss at 3 months) fixed volume implant based reconstruction between June 2012 and June 2013 was carried out. Unplanned procedures to improve cosmesis were recorded. Nipple reconstruction and contralateral procedures were excluded. Results: 88 implants (69 patients) were included with an average of 38.6 months follow up. 39 implants (44%) required a mean of 1.36 (range 1e5) revisional surgeries. Lipomodelling accounted for 34%, implant exchange 30%, implant removal 21% and other procedures 15%. There was a significantly higher rate of revisional surgery in patients who had an early complication following the initial procedure (14/21 vs 25/67; p ¼ 0.018). Conclusion: The potential requirement for revisional surgery to obtain satisfactory cosmesis in the first 3 years following immediate implant based reconstruction should be communicated to patients in a collaborative decision making process.
P055. NHSBSP Guidelines and use of VAE for B3 pathology saves money and reduces patient pathway Blossom Lake, Susan Williams, Tamoor Usman, Cerys Burrows Shrewsbury & Telford NHS Trust, Telford, UK Introduction: B3 or indeterminate breast pathology combines a variety of heterogeneous pathological entities, with varying malignant potential and often cause a treatment dilemma. Recent NHSBSP guidelines help to delineate the treatment pathway following B3 diagnosis. Recommendations include for certain B3 pathology the use of second line Vacuum Assisted Excision(VAE), which decreases the need for open surgical biopsy. The aim of this audit was to assess current practice compared to guidelines and the potential cost saving from implementation. Method: A 5 year audit of all B3 pathologies at Shrewsbury and Telford NHS Trust was performed from 2010 to 2015. Data was recorded from the Clinical Portal and included initial pathology, subsequent procedures, subsequent pathology, upgrade and downgrade rates. Cost saving analysis was performed to see how much would have been saved if the new NHSBSP guidelines had been followed. Results: 297 B3 pathologies were identified; repeat B3 biopsy and B4 pathology were excluded. Commonest initial B3 pathology was Papilloma or Papillary lesion without atypia 24%. 140 patients (47%) had excision as second line procedure. Upgrade rate was 22% and downgrade rate was 29%. Cost saving analysis showed that if VAE was available as a second line procedure, 115 patients (39%) could have had this instead of excision saving £80,960. In addition 10% of patients would have had reduced clinical pathway. Conclusion: New guidelines recommend for selected B3 pathology the use of VAE. This audit demonstrates not only does this save money but also reduces the steps in the patient’s pathway. http://dx.doi.org/10.1016/j.ejso.2017.01.108
http://dx.doi.org/10.1016/j.ejso.2017.01.106
P054. What are the experiences and motivating factors of women who choose contralateral prophylactic mastectomy at initial breast cancer diagnosis in the absence of a strong family history? Rosemary Buck Portsmouth Hospital NHS Trust, Portsmouth, UK Introduction: To explore the experience, motivational factors and decision making strategies of women who choose contralateral prophylactic mastectomy (CPM) in the absence of a strong family history of breast cancer at the initial breast cancer diagnosis.
P056. Mammographic surveillance in family history patients: Do low cancer detection rates justify the high numbers of breast cancers detected? Christopher Madden-McKee1,2, Grainne Culleton1,2, Gwyneth Hinds3, Stuart McIntosh1,2 1 Centre for Cancer Research and Cell Biology, Belfast, UK 2 Queen’s University Belfast, Belfast, UK 3 Breast Surgery Department, Belfast City Hospital, Belfast, UK Introduction: NICE recommends that women at increased risk of breast cancer due to family history (FH) should undergo enhanced mammographic screening. We examined the performance of the Belfast