- Email: [email protected]
P045. Vitamin D deficiency treatment improves non-cyclical breast pain
ABSTRACTS P042. One Step Nucleic Acid Amplification copy number as a predictor for non-sentinel lymph node positivity Samantha Williams, James Cook, Zenon Rayter Southmead Hospital, Bristol, UK Introduction: OSNA (One-Step Nucleic Acid Amplification) is an established technique for intra-operative assessment of sentinel lymph node (SLN) metastasis, used in 26 hospitals in the UK. The Z0011 and AMAROS trials prompted controversy over whether axillary lymph node dissection (ALND) should be performed at all. Currently we use a CK19 copy number of > 5000 (macrometastasis) to identify patients requiring ALND. We investigated whether a higher copy number of 7700 is a better predictor of non-sentinel lymph node (NSLN) positivity. Methods: Prospective data was collected on 721 patients who underwent OSNA investigation from 2010 to 2014. 238 patients (33%) had positive SLNs. Of these 103 (14%) had macrometastasis (>2mm) and were investigated to determine how a cut off of 7700 copy number would have altered their outcome. Results: Of the patients with macrometastasis, 65 (63%) had no NSLN involvement (NSLN eve group). 38 (37%) had NSLN positivity (NSLN +ve group). The cut off of 7700 better predicted patients in the NSLN +ve group (negative predictive value: 0.78, false negative: 0.05, false positive: 0.62). In the range between 5000e7700, two patients in the NSLN +ve group would not have undergone axillary dissection, whereas seven patients in the NSLN eve group would avoid unnecessary dissection. Conclusion: Revised cutoff of 7700 copy number would save 9 women from dissection, but would miss 2 patients with NSLN involvement. These women had low burden disease (which would not have dissection under POSNOC criteria). A copy number of 7700 appears to be a better discriminatory test with a higher negative predictive value and a lower false negative rate. http://dx.doi.org/10.1016/j.ejso.2015.03.080 P043. Specialist Masters Degree in Oncoplastic Breast Surgery: An update of student engagement and feedback Sue Down1,2, Jerome Pereira1,2, Sam Leinster1 1 University of East Anglia, Norwich, UK 2 James Paget University Hospital, Great Yarmouth, UK Introduction: The Specialist Mastership Degree Course in Oncoplastic Breast Surgery launched at the University of East Anglia (UEA) in 2010. This unique programme blends online learning with practical workshops and lectures. Designed to flexibly complement limited medical training, it prepares students for consultant practice via a two year PG Diploma or a three year Mastership. Now in its fifth year, we present an update of student engagement and feedback. Methods: Figures were obtained from UEA Admissions department and Learning and Teaching Hub. Student feedback was obtained prospectively by the MS e-learning team and an independently commissioned research group at University Campus Suffolk. Results: To date, 102 students have enrolled for a postgraduate qualification in Oncoplastic Breast Surgery (21 PG Diploma, and 81 Masters). 88 students are from the UK, 5 European and 10 international. 5 students have successfully completed their studies- 3 students gained a Masters award, and 2 a PG Diploma. 3 students have exited with a PG Cert. Of 77 students in the first four cohorts, 9 have withdrawn due to failed assessments and 2 for personal reasons. 5 are currently intercalating. Feedback for all modules has improved year-on-year due to dynamic changes to both course delivery and assessment structure. Conclusion: The Masters programme in oncoplastic breast surgery has become established as the only globally accredited higher qualification in this specialty, with the support of our professional bodies and expert
S39 faculty. Applicant numbers are increasing annually, and the first international programme will commence in India in July 2015. http://dx.doi.org/10.1016/j.ejso.2015.03.081
P044. The value of Oncotype DX testing in a District General Hospital Aish Sinha, Iain Carr, Harriet Pomeroy, Amanda Taylor, Raju Kuzhively, Kian Chin Milton Keynes Hospital, Milton Keynes, Bucks, UK Introduction: Oncotype DX is a 21 gene array test that can be used to aid the decision for adjuvant chemotherapy following surgery for breast cancer. The testing is recommended for breast cancers that are oestrogen receptor positive, human epidermal growth factor receptor negative without lymph node involvement where the chance of recurrence is intermediate as predicted by a Nottingham Prognostic Indicator of 3.4 or greater. The use of Oncotype DX testing has been recommended by NICE but is not funded by NHS England. The purpose of this study is to establish the value of Oncotype DX testing in our unit. Methods: The pathology database was searched to identify patients diagnosed with breast cancer who had surgery as their first treatment over a three year period. The pathology reports were obtained and those suitable for Oncotype DX testing were identified. The electronic patient records were reviewed, noting those who were unsuitable for chemotherapy due to comorbidities, those suitable for chemotherapy and those who underwent chemotherapy. Results: Over 3 years 588 patients were identified who had surgery as their first treatment. 102 (17.3%) of these patients met the criteria for Oncotype DX testing. Of these patients 20 (19.6%) would not have been offered chemotherapy or Oncotype DX testing due to comorbidities. Of the 82 suitable to undergo Oncotype DX testing, chemotherapy was given to 24 (29%) of them. Oncotype DX testing costs £2580 and after the test 34.7% are likely to be offered chemotherapy. The cost of Oncotype DX testing to our unit over 3 years would be £211560 and 29 (34.7% of 82) patients would be offered chemotherapy. Discussion: The use of Oncotype DX will increase costs to our unit both for the test and the small increase in chemotherapy usage. Although the cost increases the use of the test could allow better targeting of chemotherapy to those at highest risk of recurrence. http://dx.doi.org/10.1016/j.ejso.2015.03.082
P045. Vitamin D deficiency treatment improves non-cyclical breast pain Elizabeth Li, Nagy Rizkalla, Simerjit Rai, Hamish Brown, Fiona Hoar, Mehboob Mirza, Martin Sintler, Luna Vishwanath Sandwell NHT Trust, Birmingham, UK Introduction: Non-cyclical mastalgia (NCM) is a common presenting complaint, which has a poorly understood and can be difficult to manage in the outpatient setting. Is there an association between NCM and Vitamin-D deficiency? If so, will treatment improve NCM symptoms? Methods: Retrospective pilot survey of all patients with NCM seen at City Hospital within a two year period. All patients had Vitamin-D levels checked and the results were subsequently relayed to GPs for appropriate management. A total of 110 surveys were sent to all Vitamin-D deficient patients. Final response rate was 62%. Results: A total of 68 patients with NCM, Vitamin-D deficiency and completed questionnaires were included. 63% of patients were prescribed Vitamin-D supplementation by their GP and complied with the therapy. 51% of these noted complete or near complete remission of all symptoms following therapy. 26% noted a pain score of <5 following therapy. 23%
S40 noted a residual pain score of >5 despite therapy. 3 out of the 18 patients who did not receive Vitamin-D supplementation noted spontaneous improvement in their pain. Conclusion: There appears to be a correlation between Vitamin-D deficiency and NCM. This is supported by; an improvement in symptoms of NCM noted in 77% of patients following Vitamin-D supplementation; and only 17% of spontaneous improvement without treatment (p < 0.01 Fisher exact test). Further analysis is required to quantify this correlation and the degree of improvement, which may heavily impact morbidity from NCM and rapid access clinic pressures and demands. http://dx.doi.org/10.1016/j.ejso.2015.03.083
P046. Lymphaticovenular anastomosis improves quality of life in patients with secondary lymphoedema Alex Ramsden, Amy Sharkey, Dominic Furniss Department of Plastic and Reconstructive Surgery, Oxford University, Oxford, UK Secondary lymphoedema affects around 125,000 people in the UK. Lymphaticovenular anastomosis (LVA) is a super-microsurgical treatment for lymphoedema. To our knowledge, all studies on LVA to date have used volumetric measurements of the limb as their outcome measure. The deleterious effects of lymphoedema go beyond the physical effects of increased size of the affected limb. We aimed to assess the effect of LVA on quality of life for patients with secondary lymphoedema using validated patient reported outcome measures. We prospectively recorded both lymphoedema-specific (LYMQOL) and general quality of life before LVA and at the first post-operative clinic visit. We used descriptive statistics to determine the change in quality of life, the global rating of change (GROC) reported by patients and changes in limb measurements. At a mean of 5 months post-op, the LYMQOL increased by an average of 15 points (absolute increase 15%; relative increase 26%). Similarly, there was an average 1.32-point increase in general quality of life (absolute increase 13%; relative increase 30%). The average reduction of excess volume of the affected limb of unilateral cases was 52.6%. The GROC showed 75% of patients had a perceived improvement and volumetric measurements demonstrated improvement in 83% limbs. These results from this small study of minimally invasive surgery for lymphoedema show great promise in terms of improving patient reported quality of life and volumetric measurements. http://dx.doi.org/10.1016/j.ejso.2015.03.084
P047. Outcomes in loco regional breast cancer recurrence Samuel Shillito, Angela Volleamere, Jane Ooi Bolton Royal Hospital, Greater Manchester, UK Introduction: Breast cancer survival data is widely available but there is less information available on local recurrence rates. Breast cancer recurrence (BCR) was highlighted in the Breast Cancer Care’s campaign in 2006. Through ‘Improving Outcomes: a Strategy for Cancer’ in 2011 a better understanding of BCR was advocated. We present the 5 year locoregional recurrence rate (LRR) in a large screening and symptomatic unit. Methods: All patients diagnosed with breast cancer between September 2008 and September 2009 were included. Type of recurrence, presentation, management and outcomes were identified from patient’s casenotes. Results: 353 patients were diagnosed with breast cancer in the 12 month period. 278 underwent surgical treatment in our unit. The age range was 31e90 (median 60 years). The median time of follow up was 61 months. The majority of recurrence was systemic (5.4%). Locoregional recurrence occurred in 2.9% overall.
ABSTRACTS Screen detected
Symptomatic
Total
2.1% (n ¼ 2/91)
3.2% (n ¼ 1/31)
2% (n ¼ 1/50)
3.8% (n ¼ 3/80)
Skin sparing mastectomy Duct excision
0% (n ¼ 0/14)
9.1% (n ¼ 1/11)
2.5% (n [ 3/122) 3.1% (n [ 4/130) 4% (n [ 1/25) 0% (n [ 0/1)
Total
1.9% (n [ 3/155)
Wide Local excision Mastectomy
0% (n ¼ 0/1) 4.0% (n [ 5/123)
Time to recurrence was 25e55 months (median 47). 62.5% of locoregional recurrences were identified through self examination. 5 year disease free survival in patients undergoing surgery was 88.5% and 5 year survival in patients with LRR was 62.5%. Discussion: Overall a low LRR has been seen but once seen it is associated with an increased mortality rates. http://dx.doi.org/10.1016/j.ejso.2015.03.085
P048. Service evaluation of the use of blue dye for sentinel lymph node biopsy for breast cancer in a single unit in a UK hospital Gazalla Safdar, Amanda Taylor, Kian Chin Milton Keynes Hospital, Milton Keynes, UK Introduction: NICE recommends that sentinel node biopsy is performed using radioactive isotope and patent blue dye. In our unit over the last year there have been two cases of anaphylaxis following the injection of the patent blue dye. Despite subsequent confirmation that the reactions were not due to the blue dye, it was decided to perform a review of the practice of using both the blue dye and radioactive isotope. The aim of the review was to discover if using the blue dye increased the yield of sentinel nodes compared to using the isotope alone. Methods: A retrospective case note review was conducted of cases having a sentinel node biopsy between December 2010 and May 2014. The information collected at the time of surgery included the number of nodes removed, the in vivo and ex vivo radioactive count and intensity of blue staining for each node. This was used to calculate the number of nodes that were either, hot (positive radioactive signal) and blue, hot and not blue, cold (no radioactive signal) and blue, cold and not blue. Results: A total of 490 nodes where identified in patients who had both radioactive isotope and blue dye. 51 nodes were excluded due to incomplete records, including 40 nodes not having the intensity of blue staining recorded. Of the 439 nodes, 373 (84.9%) were both hot and blue. 47 (10.7%) nodes were hot but no blue dye was detected. 9 (2.1%) nodes were both isotope and blue dye negative. 10 (2.3%) nodes were blue but cold. Conclusion: Blue dye may not be required in selected cases where there is a good radioactive signal. We concluded that using use blue dye in cases where no radioactivity was detected after isotope injection allows the identification of sentinel lymph nodes in these cases. Non use of the blue dye would result in no detection of the sentinel node. The practice of the unit has been changed since this analysis. All cases who have no radioactive isotope signal detected immediately prior to surgery selectively receive blue dye. This reduces the use of blue dye minimising the chances of an allergic reaction. A prospective study will be conducted to see the impact of the change in the use of blue dye on the yield of sentinel nodes. http://dx.doi.org/10.1016/j.ejso.2015.03.086
S39 faculty. Applicant numbers are increasing annually, and the first international programme will commence in India in July 2015. http://dx.doi.org/10.1016/j.ejso.2015.03.081
P044. The value of Oncotype DX testing in a District General Hospital Aish Sinha, Iain Carr, Harriet Pomeroy, Amanda Taylor, Raju Kuzhively, Kian Chin Milton Keynes Hospital, Milton Keynes, Bucks, UK Introduction: Oncotype DX is a 21 gene array test that can be used to aid the decision for adjuvant chemotherapy following surgery for breast cancer. The testing is recommended for breast cancers that are oestrogen receptor positive, human epidermal growth factor receptor negative without lymph node involvement where the chance of recurrence is intermediate as predicted by a Nottingham Prognostic Indicator of 3.4 or greater. The use of Oncotype DX testing has been recommended by NICE but is not funded by NHS England. The purpose of this study is to establish the value of Oncotype DX testing in our unit. Methods: The pathology database was searched to identify patients diagnosed with breast cancer who had surgery as their first treatment over a three year period. The pathology reports were obtained and those suitable for Oncotype DX testing were identified. The electronic patient records were reviewed, noting those who were unsuitable for chemotherapy due to comorbidities, those suitable for chemotherapy and those who underwent chemotherapy. Results: Over 3 years 588 patients were identified who had surgery as their first treatment. 102 (17.3%) of these patients met the criteria for Oncotype DX testing. Of these patients 20 (19.6%) would not have been offered chemotherapy or Oncotype DX testing due to comorbidities. Of the 82 suitable to undergo Oncotype DX testing, chemotherapy was given to 24 (29%) of them. Oncotype DX testing costs £2580 and after the test 34.7% are likely to be offered chemotherapy. The cost of Oncotype DX testing to our unit over 3 years would be £211560 and 29 (34.7% of 82) patients would be offered chemotherapy. Discussion: The use of Oncotype DX will increase costs to our unit both for the test and the small increase in chemotherapy usage. Although the cost increases the use of the test could allow better targeting of chemotherapy to those at highest risk of recurrence. http://dx.doi.org/10.1016/j.ejso.2015.03.082
P045. Vitamin D deficiency treatment improves non-cyclical breast pain Elizabeth Li, Nagy Rizkalla, Simerjit Rai, Hamish Brown, Fiona Hoar, Mehboob Mirza, Martin Sintler, Luna Vishwanath Sandwell NHT Trust, Birmingham, UK Introduction: Non-cyclical mastalgia (NCM) is a common presenting complaint, which has a poorly understood and can be difficult to manage in the outpatient setting. Is there an association between NCM and Vitamin-D deficiency? If so, will treatment improve NCM symptoms? Methods: Retrospective pilot survey of all patients with NCM seen at City Hospital within a two year period. All patients had Vitamin-D levels checked and the results were subsequently relayed to GPs for appropriate management. A total of 110 surveys were sent to all Vitamin-D deficient patients. Final response rate was 62%. Results: A total of 68 patients with NCM, Vitamin-D deficiency and completed questionnaires were included. 63% of patients were prescribed Vitamin-D supplementation by their GP and complied with the therapy. 51% of these noted complete or near complete remission of all symptoms following therapy. 26% noted a pain score of <5 following therapy. 23%
S40 noted a residual pain score of >5 despite therapy. 3 out of the 18 patients who did not receive Vitamin-D supplementation noted spontaneous improvement in their pain. Conclusion: There appears to be a correlation between Vitamin-D deficiency and NCM. This is supported by; an improvement in symptoms of NCM noted in 77% of patients following Vitamin-D supplementation; and only 17% of spontaneous improvement without treatment (p < 0.01 Fisher exact test). Further analysis is required to quantify this correlation and the degree of improvement, which may heavily impact morbidity from NCM and rapid access clinic pressures and demands. http://dx.doi.org/10.1016/j.ejso.2015.03.083
P046. Lymphaticovenular anastomosis improves quality of life in patients with secondary lymphoedema Alex Ramsden, Amy Sharkey, Dominic Furniss Department of Plastic and Reconstructive Surgery, Oxford University, Oxford, UK Secondary lymphoedema affects around 125,000 people in the UK. Lymphaticovenular anastomosis (LVA) is a super-microsurgical treatment for lymphoedema. To our knowledge, all studies on LVA to date have used volumetric measurements of the limb as their outcome measure. The deleterious effects of lymphoedema go beyond the physical effects of increased size of the affected limb. We aimed to assess the effect of LVA on quality of life for patients with secondary lymphoedema using validated patient reported outcome measures. We prospectively recorded both lymphoedema-specific (LYMQOL) and general quality of life before LVA and at the first post-operative clinic visit. We used descriptive statistics to determine the change in quality of life, the global rating of change (GROC) reported by patients and changes in limb measurements. At a mean of 5 months post-op, the LYMQOL increased by an average of 15 points (absolute increase 15%; relative increase 26%). Similarly, there was an average 1.32-point increase in general quality of life (absolute increase 13%; relative increase 30%). The average reduction of excess volume of the affected limb of unilateral cases was 52.6%. The GROC showed 75% of patients had a perceived improvement and volumetric measurements demonstrated improvement in 83% limbs. These results from this small study of minimally invasive surgery for lymphoedema show great promise in terms of improving patient reported quality of life and volumetric measurements. http://dx.doi.org/10.1016/j.ejso.2015.03.084
P047. Outcomes in loco regional breast cancer recurrence Samuel Shillito, Angela Volleamere, Jane Ooi Bolton Royal Hospital, Greater Manchester, UK Introduction: Breast cancer survival data is widely available but there is less information available on local recurrence rates. Breast cancer recurrence (BCR) was highlighted in the Breast Cancer Care’s campaign in 2006. Through ‘Improving Outcomes: a Strategy for Cancer’ in 2011 a better understanding of BCR was advocated. We present the 5 year locoregional recurrence rate (LRR) in a large screening and symptomatic unit. Methods: All patients diagnosed with breast cancer between September 2008 and September 2009 were included. Type of recurrence, presentation, management and outcomes were identified from patient’s casenotes. Results: 353 patients were diagnosed with breast cancer in the 12 month period. 278 underwent surgical treatment in our unit. The age range was 31e90 (median 60 years). The median time of follow up was 61 months. The majority of recurrence was systemic (5.4%). Locoregional recurrence occurred in 2.9% overall.
ABSTRACTS Screen detected
Symptomatic
Total
2.1% (n ¼ 2/91)
3.2% (n ¼ 1/31)
2% (n ¼ 1/50)
3.8% (n ¼ 3/80)
Skin sparing mastectomy Duct excision
0% (n ¼ 0/14)
9.1% (n ¼ 1/11)
2.5% (n [ 3/122) 3.1% (n [ 4/130) 4% (n [ 1/25) 0% (n [ 0/1)
Total
1.9% (n [ 3/155)
Wide Local excision Mastectomy
0% (n ¼ 0/1) 4.0% (n [ 5/123)
Time to recurrence was 25e55 months (median 47). 62.5% of locoregional recurrences were identified through self examination. 5 year disease free survival in patients undergoing surgery was 88.5% and 5 year survival in patients with LRR was 62.5%. Discussion: Overall a low LRR has been seen but once seen it is associated with an increased mortality rates. http://dx.doi.org/10.1016/j.ejso.2015.03.085
P048. Service evaluation of the use of blue dye for sentinel lymph node biopsy for breast cancer in a single unit in a UK hospital Gazalla Safdar, Amanda Taylor, Kian Chin Milton Keynes Hospital, Milton Keynes, UK Introduction: NICE recommends that sentinel node biopsy is performed using radioactive isotope and patent blue dye. In our unit over the last year there have been two cases of anaphylaxis following the injection of the patent blue dye. Despite subsequent confirmation that the reactions were not due to the blue dye, it was decided to perform a review of the practice of using both the blue dye and radioactive isotope. The aim of the review was to discover if using the blue dye increased the yield of sentinel nodes compared to using the isotope alone. Methods: A retrospective case note review was conducted of cases having a sentinel node biopsy between December 2010 and May 2014. The information collected at the time of surgery included the number of nodes removed, the in vivo and ex vivo radioactive count and intensity of blue staining for each node. This was used to calculate the number of nodes that were either, hot (positive radioactive signal) and blue, hot and not blue, cold (no radioactive signal) and blue, cold and not blue. Results: A total of 490 nodes where identified in patients who had both radioactive isotope and blue dye. 51 nodes were excluded due to incomplete records, including 40 nodes not having the intensity of blue staining recorded. Of the 439 nodes, 373 (84.9%) were both hot and blue. 47 (10.7%) nodes were hot but no blue dye was detected. 9 (2.1%) nodes were both isotope and blue dye negative. 10 (2.3%) nodes were blue but cold. Conclusion: Blue dye may not be required in selected cases where there is a good radioactive signal. We concluded that using use blue dye in cases where no radioactivity was detected after isotope injection allows the identification of sentinel lymph nodes in these cases. Non use of the blue dye would result in no detection of the sentinel node. The practice of the unit has been changed since this analysis. All cases who have no radioactive isotope signal detected immediately prior to surgery selectively receive blue dye. This reduces the use of blue dye minimising the chances of an allergic reaction. A prospective study will be conducted to see the impact of the change in the use of blue dye on the yield of sentinel nodes. http://dx.doi.org/10.1016/j.ejso.2015.03.086