Final Histopathological Correlation in Breast Lesions with Indeterminate Needle Core Biopsy Results

ABSTRACTS

1121

Conclusion: Preoperative AUS and FNAC detects 32% of positive lymph nodes in early breast cancer. Intra operative molecular analysis of SLNs would spare a second operation in 8% of patients with lymph node involvement; it would also spare unnecessary axillary dissection in 12% of lymph node negative patients. P55. Breast skin envelope necrosis after skin sparing mastectomy and immediate breast reconstruction Tapan Sircar, E. Katerinaki, A. Choudhry, G. Sterne Birmingham City Hospital, Dudley Road, Birmingham, B18 7QH Aim: To establish the incidence of breast skin envelope necrosis after skin sparing mastectomy (SSM) and immediate breast reconstruction (IBR) and investigate the possible contributing factors and management of this complication. Methods: This was a retrospective case-note review of 68 patients who underwent SSM and IBR. Results: 74 SSM and IBR were carried out in 68 patients including 6 patients who had bilateral operations. Type of reconstructions included autologous myocutaneous flap only in 50 cases, autologous flap with implant in 18 cases and implant only in 6 cases. Breast skin envelope necrosis was seen in 13/65 cases (18%). Skin necrosis was 50% in smokers compared to 12% in non-smokers. 50% of patients who had type IV SSM (reduction pattern incision) developed skin necrosis compared to 11% for type I SSM(circumareolar incision). 4/5(80%) patients who were smoker and had type IV SSM developed skin necrosis. There was no significant difference in BMI, weight of the breast and grade of surgeon between the necrosis and non necrosis group. 11 patients (84%) were managed conservatively and only 2 patients needed debridement and closure in theatre. The average time for the area of skin necrosis to heal was 8 weeks. Conclusion: Breast skin envelope necrosis was noted in 18% of SSM and IBRs. Most patients can be managed conservatively. However patients should be adequately counselled preoperatively about this complication and the long time taken for it to heal. The risk is particularly high in smokers and patients having Type IV skin sparing mastectomy. P56. Can ER/PR and HER2 receptor status predict complete pathological response after neo adjuvant chemotherapy in patients with breast cancer? Tapan Sircar, H. Brown, D. Rea, F. Hoar Birmingham City Hospital, Dudley Road, Birmingham, B18 7QH Aim: The complete pathological response (CPR) rate of the breast following neo-adjuvant chemotherapy (NAC) in patients with breast cancer varies from 13% to 29%.The aim of this study was to establish the incidence of CPR in our unit and investigate if CPR could be predicted using oestrogen receptor (ER), progesterone receptor (PR) and human epidermal growth factor receptor 2 (HER2) status. Method: Patients with breast cancer diagnosed between January 2006 and October 2009 who had NAC followed by surgery were included in the study. Results: Altogether 38 patients had NAC followed by surgery. Mean clinical size of the tumour was 72mm. The commonest chemotherapy regime was Epirubicin-CMF. 8/10 HER2 positive patients received neoadjuvant trastuzumab. Overall 18% (7/38) of patients achieved CPR of the breast and 16% (6/38) achieved CPR of breast and axilla. The rate of CPR of the breast was highest in triple negative patients (36%) and ER negative patients (32%). Post NAC axillary nodes were negative in 45% of patients (n¼17) See Table 1.

Conclusions: Complete pathological response of the breast was seen in 18% of patients. ER, PR and HER2 receptor expression appears to be relevant when predicting CPR, with triple negative tumours having the highest chance of CPR (36%). P57. Re-excision rates after breast conserving surgery; before and after introducing an intra-operative specimen imaging device. ELFadl Daliaa, V. Garimellab, P. Kneeshawb, T. Mahapatrab, P. McManusb, J. Foxb a Academic Surgical Unit, Castle Hill Hospital , Cottingham, HU16 5JQ b The Breast Care Unit, Castle Hill Hospital, Hull Introduction: The NHSBSP target for re-operation rate after incomplete excision is 10% (NHSBSP and ABS at BASO). Reported figures vary between 9 - 40%. A UK national analysis reported re-excision rate of 19% (All Breast Cancer Report - NHS Screening). Intra-operative digital imaging of excised tissue can potentially improve surgical clearance. Methods: WLE procedures performed at Castle Hill Hospital during 2007 were previously studied and a re-excision rate of 24.5% was reported. Subsequently, Faxitron Ô imaging device was introduced and re-auditing performed. All symptomatic and screening breast patients undergoing WLE between 08/08 and 1/09 were included. Images were assessed by surgeons, and data was prospectively maintained. Results: 96 patients had WLE in the specified 6 months period. The mean age was 59 years. 66.7% were wire guided, 26% were clinically guided. 80% had an invasive component, while 12.5% had insitu disease only. 64.6% of specimens were  50g (21.9% were  25g). Faxitron showed suspicious margins in 26% of cases. 31% had an intra-operative shave biopsy. 19.8% required another operation, as compared with 24.5% in the pre-Faxitron group; this difference failed to reach statistical significance. Of those patients undergoing a repeat operation, 36.8% had a clear histology. Chi-Square test indicated that a satisfactory image was not predictive of the need for re-operation (p¼0.09). Conclusion: The introduction of Faxitron to our unit made a small but insignificant reduction in re-operation rates following WLE. We discuss results. Further experience and training may be required. P58. Final Histopathological Correlation in Breast Lesions with Indeterminate Needle Core Biopsy Results Mohsin Dani, M. Obeysekera, M. Davarpanah, I. Ahmed Medway Maritime NHS Foundation Trust, Windmill Road, Gillingham, Kent, ME7 5NY Introduction: There are no clear guidelines for management of patients with breast lesions whose needle core biopsy (NCB) demonstrates B3 (uncertain malignant potential) or B4 (suspicious for malignancy). We assessed the final outcome/histopathology in this cohort of patients to determine their malignant potential. Methods: Patients with NCB results of B3 and B4 were identified from prospectively maintained database between November 2006 to March 2010 in a large District General Hospital. A retrospective review of patients’ records and histopathology database was performed. Results: Of the 1159 NCB performed during the study period, 6% (63 patients) had B3 and 2% (22) had B4 lesions. 27% (17/63) B3 lesions were malignant after surgical excision. The B3 lesion specific rates of malignancy were 58% (14/24) for Atypical Intraductal Epithelial Proliferation (AIEP) (12 DCIS and 2 Invasive), 17% (2/12) for Intraductal Papilloma

Table 1 ER+

Number and % of patients Rate of CPR

ER -

HER2+

HER2-

ER+ HER2+

Total(n ¼ 38)

Total(n ¼ 38)

Total(n ¼ 38)

19 (50%) 5%

10 (26%) 10%

5(13%) 0

19 (50%) 32%

28 (74%) 21%

ER+ HER2-

ER- PR-HER2+

ER- PR- HER2- (triple-)

14 (37%) 7%

5 (13%) 20%

14 (37%) 36%

1122 (both DCIS) and 25% (1/4) for Lobular Neoplasia (Invasive lobular). Overall rate of malignancy for B4 lesions was 86% (19/22) with 83% correlation with final histology in patients suspicious for carcinoma in-situ/ invasive cancer. All B4 lesions with symptomatic presentation turned out to be malignant on surgical excision compared to 71% of screen detected B4, 28% of screen detected B3 and 24% of symptomatic B3 lesions. Conclusion: There is a high incidence of malignancy in patients with B4 NCB lesions. These warrant surgical excision. B3 lesions have a variable rate of malignancy. Our study found a high malignant potential of AIEP B3 lesions. Their management should be approached with caution. P59. Surgical Management of the Axilla in Symptomatic Invasive Breast Cancers in Clyde Region. A retrospective review of practice 2004e2008 Laura Arthur, M. McKirdy NHS Greater Glasgow and Clyde, Department of General Surgery , Royal Alexandra Hospital, Corsebar Road, Paisley, PA2 9PN Introduction: Historically axillary node clearance (ANC) was standard in the management of breast cancer. Associated morbidity was common and often debilitating. Recently techniques have developed to decrease the level of invasiveness of axillary surgery; thus reducing associated morbidity. The technique of sentinel node biopsy (SNB) has been proven to accurately stage the axilla in patients who are clinically node negative. In Clyde SNB (introduced January 2008) is now used in all patients with invasive breast cancer with a sonographically node negative axilla. We aim to illustrate the change in practice of surgical management of the axilla over the past 5 years. Nationally as the technique of SNB becomes more available, it has been suggested that the number of patients with invasive, node negative breast cancer with greater than seven nodes excised should be small. Methods: A retrospective review of the Managed Clinical Network Breast Cancer Database for Clyde region; including all operated symptomatic invasive breast cancers between 2004 and 2008 (n¼940). Results: The frequency of ANC fell year on year from 98% in 2004 to 36% in 2008. The number of axillae with >7 negative lymph nodes excised also fell year on year from 54% in 2004 to 30% in 2008. 46% of patients in 2008 underwent SNB. Conclusion: We have demonstrated a change in surgical practice and accordingly the decreasing number of node negative axillae with >7 nodes excised. We propose the number of patients with >7 nodes excised to prove the axilla is node negative should be small. P60. Breast Cancer in Reduction Mammoplasty specimens: 10-year experience Amit Goyala, S. Coulsona, K. Suvarnaa, M. Reedb, C. Caddya a Northern General Hospital, Sheffield, S5 7AU b Royal Hallamshire Hospital, Sheffield Background: The aim of this study was to report the incidence of cancer in reduction mammoplasty specimens and suggest alternative pragmatic cost-effective way of identifying patients with carcinoma. Methods: All patients who underwent breast reduction surgery at Northern General Hospital over a 10-year period were identified from a prospective database. The histopathology reports and case records of all patients with significant abnormalities were analysed. All breast reduction specimens were sliced at 1 cm intervals and examined macroscopically. At least 3 blocks per breast were examined microscopically in addition to sampling of any grossly abnormal tissue. Results: Between October 1999 and April 2010, 1,588 patients underwent reduction mammoplasty. The median age of patients was 38 years (range 16-75 years). Indications for surgery were macromastia in 1,194 (75.2%), congenital asymmetry in 182 (11.5%) and contralateral symmetry procedure post breast cancer surgery in 178 (11.2%). 9 specimens showed atypical hyperplasia (0.57%). 5 cancers were detected (0.31%). 4 of the 5

ABSTRACTS patients had normal mammograms 1-3 years before the reduction operation (not done in 1). Of these cancers, 4 were invasive (3 invasive lobular, 1 invasive ductal)(0.25%) (mean invasive tumour size 9 mm (SD 7.4)) and 1 was DCIS (4mm)(0.06%). A lump was felt macroscopically by the pathologist in 2 of the 4 patients with invasive cancer. The median age of patients with invasive cancer was 56 years (range 47-68 years). Patient found to have DCIS did not undergo further surgery while the 4 patients with invasive disease underwent mastectomy and axillary nodal staging. Conclusion: The incidence of occult carcinoma in reduction mammoplasty specimens is very low. Surgeons should feel the specimen and mark any suspicious nodularity to direct microscopic examination. Specimen x-ray may be utilized if there are any suspicious lesions on gross examination. P61. American College of Radiologists BI-RADS system e Is it useful in selecting newly diagnosed breast cancer patients for MRI assessment? Rajeshkumar Balasubramanian, D. Leff, F. Aref, L. Wilding, S. Salakianathan, R. Vashisht West Middlesex University Hospital, Twickenham Road, Isleworth, TW7 6AF Introduction: Indications for Magnetic Resonance Imaging (MRI) scan is not well established in the assessment of breast cancers. The aim of the study is to find out if American College of Radiologist BI-RADS (ACR) system of grading of mammogram is helpful in selecting patients for further assessment with MRI. Method: Retrospective review of case notes of patients with screen detected breast cancers between January 2008 and December 2009 was performed. All new patients diagnosed with breast cancer who had MRI for further assessment were reviewed. Results: Ninety seven patients who had MRI following their primary diagnosis were included. The MRI demonstrated additional information in 48/97 patients (49%) leading to further assessment with ultrasound. This led to change in patient management in 15 patients (15%). Eight patients had mastectomy. Four of these 8 patients had multifocal tumour and the other 4 had neoadjuvant chemotherapy due to tumour extension. Seven patients had conservation surgery. Three of these patients had multifocal tumour needing wider excisions, 2 had extensive tumour and one was seen only in MRI scan. The last 3 underwent Neoadjuvant chemotherapy. One patient had a contra lateral tumour and underwent bilateral wide local excision. The ACR grading of these breasts were ACR1 in 4, ACR2 in 3 and ACR 3 in 8 cases. Conclusions: Our study suggests that usefulness of MRI is independent of the ACR BI-RADS classification of mammograms. So we recommend MRI scan should be used more often in the assessment of patients diagnosed with breast cancer. P62. Micrometastasis of the Sentinel Lymph Node: Which factors can predict non-sentinel node involvement? Jamie Crichton, A. Zeiton University Hospital of South Manchester, Wythenshawe, Manchester, M23 9LR Introduction: Micrometastases in the sentinel lymph nodes (SLN) in breast cancer may be associated with an absence of disease in further non-sentinel nodes (nSLN). If absence of disease can be predicted accurately, axillary lymph node dissection (ALND) with its associated morbidity may be avoided. Aims: This study aims to investigate the rate of nSLN metastases in patients with micrometastases found by SLN biopsy, and to identify which factors correspond to an increased or decreased likelihood of nSLN disease. Methods: A retrospective analysis of histopathology reports was conducted. The study group (n¼28) consisted of patients with invasive breast