Dukes C colorectal cancer; is the negative lymph node count important?

ABSTRACTS P10. Review of family history taking in women aged under fifty years presenting with colorectal cancer Ruth Copeland, W. Chorley, N. Hurst Derby City General Hospital, Uttoxeter Road, Derby, DE22 3NE Introduction: Colorectal Cancer is a leading cause of mortality in the UK, with an average age of diagnosis of 64 years. HNPCC is a genetic condition caused by germline mutations in DNA mismatch repair gene, manifesting as an 80% lifetime risk of developing colorectal cancer with an average age of diagnosis of 44 years. HNPCC also signifies an increased risk of other cancers including endometrial, ovarian, small bowel, ureter and stomach. It is therefore relevant for a comprehensive family history to be elicited in women <50 years presenting with colorectal cancer. Methods: The audit reviewed the medical notes of nine women aged between 34 and 49 who were diagnosed with colorectal cancer (adenocarcinoma or squamous cell carcinoma of the anus) between 2006 and 2008 in Derby Hospitals Foundation Trust. All documented family histories were reviewed. Results: Results showed a multidisciplinary input into family history taking and a family history was taken at least once in every case. Six patient notes contained references to a family history of colorectal pathology, suggesting a tendency for professionals to enquire about relatives with similar presenting complaints. A family history of a non-HNPCC related tumour was documented in two cases. ‘None relevant’ or a similar phrase was recorded in four patient notes. Conclusions: Healthcare professionals are successful eliciting a family history at a number of levels in the patient care pathway. However, the documented notes vary in both depth and focus. A short, standardised form aimed at identifying potentially HNPCC related cancers may be beneficial.

1209 Conclusion: This study shows that it is feasible to modify purified DNA from cellular breast duct fluid for detection of methylated products by methylation-specific PCR. These data hold promise for ductal lavage as an indicator of breast carcinogenesis but the sensitivity of the test depends upon a high rate of duct-specific cannulation to obtain adequate cellular material for the methylation specific PCR assay.

P12. The presentation and management of primary squamous carcinoma of the colon. Three cases in 10 years Stephanie Newmarcha, W. Laia, A. Griceb a Peninsula School of Medicine & Dentistry, Barrack Road, Exeter, Devon, EX2 5DW b Dept of Anaesthesia, Royal Devon and Exeter Hospital Introduction: Primary squamous carcinoma of the colon and rectum is rare, with less than 100 cases described in the medical literature. Three cases have been diagnosed at our institution in the last ten years and we have reviewed their management and the literature. Methods: From a colorectal cancer database, all cases of squamous carcinoma were reviewed and those non-anal primary cases reviewed. Results: From 3357 cases of colorectal cancer managed between 19982009, 3 cases of primary squamous carcinoma of the colon were identified. Two cases involved the sigmoid colon, the other the hepatic flexure. Histological proof of type was confirmed and all the patients were treated by surgical resection. The hepatic flexure tumour involved resection of the right kidney and duodenum. The sigmoid cases were resected by high anterior resection. At MDT we discussed the use of adjuvant chemotherapy. Survival in the literature is reported as 71-91% at 5-years. All our cases are still disease free. Conclusion: Primary squamous carcinoma of the colorectum is rare (1:1000 cases of CRC). The literature does not provide a clear management plan and each case should be managed individually. Central recording of these cases would allow larger series for outcome management.

P11. Intraductal promoter hypermethylation profiles in breast in cancer Dominique Twelvesa, S. Tanga, P. Osina, A. Nerurkara, C. Isackeb, G. Guia a Academic Surgery, The Royal Marsden NHS Foundation Trust, 203 Fulham Road, London, SW3 6JJ b Institute of Cancer Research

P13. Investigation of convergence between Epidermal Growth Factor and hypoxia on the pro-angiogenic switch in colorectal cancer Tak Khonga, E. Paleologb, P. Dawsona a Charing Cross Hospital, Fulham Palace Road, London, W6 8RF b Kennedy Institute of Rheumatology, Imperial College London

Introduction: Breast duct lavage (DL) for analysis by methylationspecific PCR is a novel concept for detecting the presence of cancer and may contribute additional information about prognosis and response to treatment. The aim of this series was to investigate qualitative methylation of 6 published tumour suppressor genes in breast cancer tissue, duct lavage fluid and plasma. Methods: 34 patients with breast cancer and 23 controls were studied. Of these 57 patients, 22 of 34 (65%) cancer patients provided complete sets of tumour and adjacent normal tissue cores, plasma, ipsilateral and contralateral duct lavage fluid. Matched samples were similarly collected from 23 non-cancer patients. DNA was purified from microdissected tissue, plasma and breast duct biofluids using the QUIAGEN DNeasy kit. Purified DNA was then modified, using EZ Zymo methylation kit, for detection of methylated regions in 6 genes, HIN-1, RIL, RASSF1A, CDH13, RARß2 and IGFBP7, by optimised specific-PCR. Results: In 34 cancer patients, methylated DNA products were qualitatively scored and, using Fisher’s exact test, a positive association has been found between tumour tissue and ipsilateral duct lavage with HIN1 (p ¼ 0.0001), CDH13 (p ¼ 0.0039) and RARß2 (p ¼ 0.0061). The estimated probability of cancer given detection of methylation in duct lavage fluid for individual genes was HIN (0.5), RIL (0.44), RASSF1A (0.61), CDH13(0.78), RARß2(0.44), IGFBP7(0.73). A four-gene predictor applied to duct lavage, using (HIN1, RASSF1, CDH13, IGFBP7) detected 82% of cancers in this study with a false positive detection rate of 19%. A ROC curve analysis indicates that this can be biased to detect 91% cancers with a 27% false positive rate.

Background: Over-expression of Epidermal Growth Factor (EGF) and hypoxia are features of colorectal cancer (CRC), thus the development of novel treatments targeting EGF and its receptors, such as cetuximab. Recent studies uncovered a pro-angiogenic role for EGF but involvement by Vascular Endothelial Growth Factor (VEGF) is unknown. Moreover, it is unknown whether EGF can synergise with hypoxia in CRC. Aim of the study was to investigate the pro-angiogenic effect induced by EGF in combination with hypoxia in CRC. Methods: CRC cell lines Colo201 and Caco2 were stimulated with EGF and/or exposed to 1% O2 or dimethyloxalylglycine (DMOG), a hypoxia-mimetic. Gene and protein expression of hypoxia inducible factor (HIF)-1{alpha} and VEGF was assessed. Functional significance was assessed by human umbilical vein endothelial cell (HUVEC) migration assay co-cultured with Caco-2. Results: HIF-1{alpha} and VEGF protein were upregulated in Caco2 with EGF stimulation, with further increase in VEGF and HIF-1{alpha} when EGF was combined with DMOG. However, Colo201 demonstrated an increase in VEGF mRNA and protein only under hypoxia but not with EGF. Discrepancy in responses to EGF was due to differences in ERK kinase signalling. HUVEC migration assay demonstrated increased migrated HUVEC cell numbers in co-cultures with Caco2 stimulated with EGF, and this effect was further increased in combination with DMOG and EGF. Conclusion: EGF receptor activation plays a role in CRC angiogenesis through HIF-1{alpha}-dependent mechanisms. Hypoxia however appears to provide the over-riding stimulus in driving endothelial migration and angiogenesis in CRC, synergising also with EGF in Caco2 CRC cells.

1210 P14. Dukes C colorectal cancer; is the negative lymph node count important? Somita Biswas, F. Mohamed, M. Thomas, M. Jha, R. Wilson James Cook University Hospital, Marton Road, Middlesbrough, TS4 3BW Objectives: Presence of lymph node metastasis has important implications regarding survival in colorectal cancer. The relationship between total number of lymph nodes assessed and survival is not clear. Our aim was to examine the impact of negative lymph nodes on survival in patients with Dukes C (Any T N1/2) colorectal cancer. Methods: All patients with Dukes C histology were selected from a prospectively collected database of all colorectal cancers resected between 1997 and 2007 at our institution. Data including demographics, histopathology and adjuvant treatment were analysed. The number of positive and negative lymph nodes evaluated was determined. Survival from date of operation was calculated using Kaplan-Meier estimates and compared using the log-rank test. Results: Of 1098 patients who underwent colorectal cancer resections, 41 % (448/1098) were staged as Dukes C (295 males). Mean age at surgery was 68 years (range 26-93). Median follow up was 30 months. Tumours were colonic in 55% (246/448) and rectal in 45% (202/448). 64% (286/ 448) of patients received chemotherapy. The median number of lymph nodes evaluated was 11 (range 1-52). The median number of positive and negative lymph nodes identified were 4 (range 1-28) and 7 (range 0 30) respectively. In patients who received chemotherapy, 5 year survival was 27% for those with 3 or less negative lymph nodes and 63% in those with 13 or more negative lymph nodes (p ¼ 0.0001). When no chemotherapy was given 5 year survival was 12% for those with 3 or less negative nodes and 51% in those with 13 or more negative nodes (p ¼ 0.0006). Conclusions: The number of negative lymph nodes is an important factor in staging Dukes C colorectal cancer. Combining this with the number of positive lymph nodes would provide better prognostic information. Maximizing lymph node harvest allows more accurate estimation of long term survival. P15. Changing trends in sarcoma management in the UK Sally E. Erskinea, C. Stampsb, R. Waldocka, L. Wylda a Academic Unit of Surgical Oncology, University of Sheffield, Royal Hallamshire Hospital, Sheffield, S10 2JF b University of Sheffield Medical School Introduction: Sarcomas are rare malignant tumours which may occur in any anatomic location; patients therefore present to many diverse specialties and management has often been non-MDT directed and sub-optimal. To improve this situation NICE published Improving Outcomes Guidelines in 2006 which recommended management of sarcomas in specialist centres. This study has examined the effect of these recommendations on the workload of a UK Regional Sarcoma Unit. Methods: The North Trent Regional Sarcoma Unit MDT referral database was studied between 2004 and 2008. Referral characteristics were compared before and after the NICE guidelines were published (2006). Results: In total, 707 patients, including 377 sarcomas, 61 GIST and 33 desmoids were referred. Overall caseload has increased annually from 41 in 2004 to 311 in 2008, (P < 0.001). The number of sarcoma diagnoses increased from 31 to 104, (P < 0.001). The proportion of referrals diagnosed as sarcomas has decreased from 76% to 33% due to increased levels of pre-diagnosis referrals of potential sarcomas. The proportion of patients given a benign diagnosis has increased from 5% to 40%, (P < 0.001). Despite these positive trends, a significant number of cases are still referred after inappropriate management before MDT referral. Conclusion: Sarcoma service centralisation since 2006 has resulted in a substantial increase in workload for regional specialist centres and has increased the percentage of people with these rare tumours receiving specialist care. Despite this, patients are still referred late after

ABSTRACTS sometimes inappropriate non-MDT approved management. New strategies may be required to enhance case recognition and timely onward referral. P16. Accuracy of core needle biopsy in the diagnosis of soft tissue tumours Yassar Qureshi, D. Strauss, A. Hayes, J. Thomas The Royal Marsden Hospital, Soft Tissue Sarcoma Unit, Dept. of Academic Surgery, Postgraduate Centre, Fulham Road, London, SW3 6JJ Introduction: Soft-tissue tumours are rare and represent a heterogeneous group of pathologies. The possibility of a malignant soft-tissue tumour has to be contemplated to avoid an inappropriate operation. An accurate histological diagnosis is essential to determine the correct surgical planning and treatment protocol. The objective of this study is to evaluate the diagnostic accuracy of core needle biopsy in the management of softtissue tumours. Methods: A prospectively-kept sarcoma database was searched to identify all patients referred with a suspicion of soft-tissue tumours that underwent a preoperative core needle biopsy. The core needle result was compared to the resection specimen pathology. Specific end-points were the ability to differentiate benign from malignant soft-tissue tumours, to differentiate low grade from high grade malignant tumours and the ability to accurately assign a subtype to soft-tissue tumours. Results: There were 500 patients identified. Soft-tissue tumours were diagnosed in 436 patients, of which 358 patients underwent resection. Core needle biopsy could differentiate malignant tumours from benign tumours with a sensitivity of 96.0%, specificity of 99.4% and accuracy of 97.5%. High grade tumours were differentiated from low grade tumours with a sensitivity of 77.6%, specificity 97.1% and accuracy of 82.4%. Subtype was accurately assigned in 88.4% of benign

Accuracy of core needle biopsy in the diagnosis of soft tissue tumours to predict tumour malignancy, high grade tumour and tumour subtype Accuracy of core needle biopsy to differentiate malignant and benign pathology (n [ 358) Biopsy result Resection result Malignant Malignant 194 Malignant Benign 1 Benign Malignant 8 Benign Benign 155 Sensitivity ¼ 96.0% Specificity ¼ 99.4% Positive predictive value ¼ 99.5% Negative predictive value ¼ 95.1% Accuracy ¼ 97.5% Accuracy of core needle biopsy to differentiate high grade and low grade pathology (n [ 142) Biopsy result Resection result High grade High grade 83 High grade Low grade 1 Low grade High grade 24 Low grade Low grade 34 Sensitivity ¼ 77.6% Specificity ¼ 97.1% Positive predictive value ¼ 98.8% Negative predictive value ¼ 58.6% Accuracy ¼ 82.4% Accuracy of core needle biopsy to diagnose tumour subtype (n [ 358) Tumour subtype Correct Incorrect Indeterminate Benign ¼ 164 145 (88.4%) 15 (9.1%) 4 (2.4%) Malignant ¼ 194 170 (87.6%) 9 (4.6%) 15 (7.7%)