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OSNA total tumour load can predict non-sentinel axillary lymph node involvement
ABSTRACTS Introduction: Breast cancer treatment in the elderly is controversial with variation of practice between hospitals being influenced by multiple factors. This study aimed to review the management of breast cancer in patients aged 70 years or above. Method: Patients aged 70 years or older, treated for breast cancer between 2010eAugust 2015 were included. Median follow up was 25 months. Patients were divided in to three groups; Group A: 70e79 years (n¼194), Group B: 80e89 years (n¼123) and Group C: 90 years or older (n¼39). Groups were compared for tumour characteristics, treatment and survival. KaplaneMeier analysis was used for survival and Chi squared test for categorical data. Results: Three hundred and fifty-six patients (median 79; iqr 70101) were studied. Majority of tumours were invasive ductal carcinoma, ER positive and HER 2 negative with no age dependent variation. Surgery was the primary treatment in group A [78% vs. 54% in Group B & 18% in group C; (p<0.001)], while primary endocrine treatment (PET) was the mainstay in group C. Group B & C were more likely to have mastectomy (71% & 62%) compared to group A (44%) (P<0.001). Majority of patients undergoing breast-conserving surgery had adjuvant radiotherapy in Group A & B (90% & 80%; p¼0.005). Overall 5 year survival was 69%, 67.7% & 49.3% in Group A, B & C with failure of PET being more common in group A (33%, p¼0.005). Conclusion: Advancing age alone should not preclude surgery for breast cancer. PET should be reserved for those unfit for surgery. http://dx.doi.org/10.1016/j.ejso.2016.02.202
P150. OSNA total tumour load can predict non-sentinel axillary lymph node involvement Victoria Fung, Stan Kohlhardt Royal Hallamshire Hospital, Sheffield, UK Introduction: In 2013, NICE recommended the use of one-step nucleic acid amplification (OSNA) as a technique for intra-operative nodal staging in early invasive breast cancer. The intra-operative reporting of macro-metastatic sentinel lymph node (SLN) disease permits immediate level-three axillary nodal clearance (ANC) in a single procedure. This study assesses the sensitivity and specificity of OSNA to predict further non-sentinel axillary lymph node (NSLN) metastases. Methods: The pathology reports of 700 consecutive patients who received OSNA analysis for breast cancer at a single unit were reviewed. Patients who received neo-adjuvant chemotherapy, or underwent OSNA for extensive ductal carcinoma in-situ were excluded. Patients with at least one macro-metastasis (>5000 CK19 mRNA copies) on whole-node analysis underwent ANC. The total copy number (total tumour load, TTL) of the macro-metastatic SLN sample was compared with the NSLN status from routine histological assessment. Results: 122/683 patients (17.9%) were found to have OSNA CK19 mRNA copy numbers indicative of macro-metastasis and underwent ANC. 50/122 (41%) patients had NSLN metastases on ANC. Sensitivity and specificity of OSNA v NSLN status were 0.78 (95%CI: 0.66e0.88) and 0.88 (95%CI: 0.86e0.91), respectively. PPV ¼ 0.410 (95%CI: 0.322e0.503). NPV ¼ 0.975 (95%CI: 0.959e0.986). Area under curve for Receiver Operating Curve (ROC AUC) ¼ 0.86. Conclusions: The ROC AUC of 0.86 for TTL indicates that SLN TTL represents a good correlation between OSNA copy numbers and NSLN metastases. OSNA based prediction may facilitate adoption of emerging recommendations for conservative management of the node positive axilla. http://dx.doi.org/10.1016/j.ejso.2016.02.203
S53 P151. The role of MRI in the evaluation and management of patients with pathologic nipple discharge Konstantinos Zacharioudakis, Theodoros Kontoulis, Jade Zhao, Deborah Cunningham, Victoria Stewart, Ragheed Al-Mufti, Katy Hogben, Daniel Leff, Jackie Lewis, Rathi Ramakrishnan, Sami Shousha, Dimitri Hadjiminas Imperial College Healthcare NHS Trust, London, UK Introduction: In 10e15% of cases, pathologic nipple discharge (PND) is caused by an underlying malignancy, which is often not identified on standard evaluation. The aim of this prospective study is to determine the role of MRI in the management of patients with PND. Patients and methods: 63 consecutive patients with PND and ductal epithelial or red blood cells present in their nipple smear, otherwise normal clinical examination and non-diagnostic mammogram and ultrasound that presented between December 2009 and May 2015 were enrolled in our study and were offered diagnostic microdochectomy. Pre-operative bilateral breast MRI was performed on all patients. Results: Of the 63 patients enrolled in our study 10 (15.6%) had malignant histology. Of these, 8 had DCIS histologically confirmed only after microdochectomy. Pre-operative breast MRI was suspicious for cancer in 9 cases, 8 of which were confirmed histologically. The presence of an intraductal papilloma responsible for the PND was identified on MRI in 7 patients. The sensitivity of MRI in detecting an occult malignancy was 80% (95% CI 44.39%e97.48%) with 98.11% specificity (95% CI 89.93%e 99.95%) PPV 88.89% (95% CI 51.75%e99.72%) and NPV 96.3 % (95% CI 87.25%e99.55%). DCIS in all MRI-diagnosed cases had the appearance of a segmental abnormally enhancing area. Conclusions: MRI in patients with PND and normal standard evaluation identified 80% of those with a malignancy. Furthermore, MRI demonstrated a benign cause of the discharge in 7 patients where a procedure less invasive than microdochectomy might have been appropriate. http://dx.doi.org/10.1016/j.ejso.2016.02.204
P152. Visual aides to enhance training breast surgery John Dickson1,2, Vivien Ng2, Sisse Olsen2, Naren Basu1 1 Queen Elizabeth Hospital, Birmingham, UK 2 Royal Devon & Exeter Hospital, Exeter, UK Introduction: Training within surgery is difficult and there are many challenges facing our profession in relation to this. There is a great need to enhance training so as to optimize learning and improve patient care. The need for improved quality of care and the diminishing training opportunities are key challenges. Within the field of breast surgery the amount of available information and the complexity of that information is increasing, making it even more difficult to understand, both for clinicians and, more importantly, for patients. Diagrams have the potential to serve as a helpful adjunct by distilling information and making it easier to understand. Methods: We have developed a series of visual aides that aim to help trainees to assimilate information and then recall that information with greater accuracy both in the short term and the long term. Topics covered include relevant anatomy, trials, staging systems and adjuvant treatment side-effect profiles. We hope that these illustrations will aide clarity and will serve to improve the quality of consultations and also performance in the operating theatre. Results: A complete set of diagrammatic aides have been created and key examples are presented. Conclusions: We hope that this work will form the basis of a digital tool (eg smartphone application) that will serve breast surgery trainees. Such illustrations may be helpful in lots of other ways too, in relation to improving patient care. For example, enabling appropriate timely referrals,
P150. OSNA total tumour load can predict non-sentinel axillary lymph node involvement Victoria Fung, Stan Kohlhardt Royal Hallamshire Hospital, Sheffield, UK Introduction: In 2013, NICE recommended the use of one-step nucleic acid amplification (OSNA) as a technique for intra-operative nodal staging in early invasive breast cancer. The intra-operative reporting of macro-metastatic sentinel lymph node (SLN) disease permits immediate level-three axillary nodal clearance (ANC) in a single procedure. This study assesses the sensitivity and specificity of OSNA to predict further non-sentinel axillary lymph node (NSLN) metastases. Methods: The pathology reports of 700 consecutive patients who received OSNA analysis for breast cancer at a single unit were reviewed. Patients who received neo-adjuvant chemotherapy, or underwent OSNA for extensive ductal carcinoma in-situ were excluded. Patients with at least one macro-metastasis (>5000 CK19 mRNA copies) on whole-node analysis underwent ANC. The total copy number (total tumour load, TTL) of the macro-metastatic SLN sample was compared with the NSLN status from routine histological assessment. Results: 122/683 patients (17.9%) were found to have OSNA CK19 mRNA copy numbers indicative of macro-metastasis and underwent ANC. 50/122 (41%) patients had NSLN metastases on ANC. Sensitivity and specificity of OSNA v NSLN status were 0.78 (95%CI: 0.66e0.88) and 0.88 (95%CI: 0.86e0.91), respectively. PPV ¼ 0.410 (95%CI: 0.322e0.503). NPV ¼ 0.975 (95%CI: 0.959e0.986). Area under curve for Receiver Operating Curve (ROC AUC) ¼ 0.86. Conclusions: The ROC AUC of 0.86 for TTL indicates that SLN TTL represents a good correlation between OSNA copy numbers and NSLN metastases. OSNA based prediction may facilitate adoption of emerging recommendations for conservative management of the node positive axilla. http://dx.doi.org/10.1016/j.ejso.2016.02.203
S53 P151. The role of MRI in the evaluation and management of patients with pathologic nipple discharge Konstantinos Zacharioudakis, Theodoros Kontoulis, Jade Zhao, Deborah Cunningham, Victoria Stewart, Ragheed Al-Mufti, Katy Hogben, Daniel Leff, Jackie Lewis, Rathi Ramakrishnan, Sami Shousha, Dimitri Hadjiminas Imperial College Healthcare NHS Trust, London, UK Introduction: In 10e15% of cases, pathologic nipple discharge (PND) is caused by an underlying malignancy, which is often not identified on standard evaluation. The aim of this prospective study is to determine the role of MRI in the management of patients with PND. Patients and methods: 63 consecutive patients with PND and ductal epithelial or red blood cells present in their nipple smear, otherwise normal clinical examination and non-diagnostic mammogram and ultrasound that presented between December 2009 and May 2015 were enrolled in our study and were offered diagnostic microdochectomy. Pre-operative bilateral breast MRI was performed on all patients. Results: Of the 63 patients enrolled in our study 10 (15.6%) had malignant histology. Of these, 8 had DCIS histologically confirmed only after microdochectomy. Pre-operative breast MRI was suspicious for cancer in 9 cases, 8 of which were confirmed histologically. The presence of an intraductal papilloma responsible for the PND was identified on MRI in 7 patients. The sensitivity of MRI in detecting an occult malignancy was 80% (95% CI 44.39%e97.48%) with 98.11% specificity (95% CI 89.93%e 99.95%) PPV 88.89% (95% CI 51.75%e99.72%) and NPV 96.3 % (95% CI 87.25%e99.55%). DCIS in all MRI-diagnosed cases had the appearance of a segmental abnormally enhancing area. Conclusions: MRI in patients with PND and normal standard evaluation identified 80% of those with a malignancy. Furthermore, MRI demonstrated a benign cause of the discharge in 7 patients where a procedure less invasive than microdochectomy might have been appropriate. http://dx.doi.org/10.1016/j.ejso.2016.02.204
P152. Visual aides to enhance training breast surgery John Dickson1,2, Vivien Ng2, Sisse Olsen2, Naren Basu1 1 Queen Elizabeth Hospital, Birmingham, UK 2 Royal Devon & Exeter Hospital, Exeter, UK Introduction: Training within surgery is difficult and there are many challenges facing our profession in relation to this. There is a great need to enhance training so as to optimize learning and improve patient care. The need for improved quality of care and the diminishing training opportunities are key challenges. Within the field of breast surgery the amount of available information and the complexity of that information is increasing, making it even more difficult to understand, both for clinicians and, more importantly, for patients. Diagrams have the potential to serve as a helpful adjunct by distilling information and making it easier to understand. Methods: We have developed a series of visual aides that aim to help trainees to assimilate information and then recall that information with greater accuracy both in the short term and the long term. Topics covered include relevant anatomy, trials, staging systems and adjuvant treatment side-effect profiles. We hope that these illustrations will aide clarity and will serve to improve the quality of consultations and also performance in the operating theatre. Results: A complete set of diagrammatic aides have been created and key examples are presented. Conclusions: We hope that this work will form the basis of a digital tool (eg smartphone application) that will serve breast surgery trainees. Such illustrations may be helpful in lots of other ways too, in relation to improving patient care. For example, enabling appropriate timely referrals,