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Prone abdominoperineal excision results in lower rates of involved circumferential resection margins than the standard approach
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ABSTRACTS
Parallel Session 2 e Ronald Raven Prize Papers Monday 23rd November 2009, 08:45e09:45 7. Primary endocrine therapy for early operable primary breast cancer in elderly women - A large series from a single institution Waleed Al-Khyatta, B. Syeda, D. Morganb, K. Cheunga a Professorial Unit of Surgery, Nottingham University Hospital - City Campus, Nottingham, NG5 1PB b Department of Oncology, Nottingham University Hospital
Conclusion: Introduction of the prone technique by a single surgeon led to a greatly reduced CRM rate compared to other surgeons using the traditional technique. With the use of MRI staging, neo-adjuvant chemoradiotherapy and multidisciplinary team (MDT) assessment, a change of surgical technique is necessary. Improved surgical training and regional centralisation for this technique may be necessary in future to achieve this.
Background: A recent Cochrane review of randomised trials involving 1,446 elderly women shows no significant difference in overall survival between surgery and primary endocrine therapy (PET). We report our experience of using PET in a dedicated elderly breast cancer service. Methods: Over a 20-year period, 825 elderly (>70 years) women with early operable primary breast cancer were treated with PET due to patient choice or being unfit for surgery. All patients had disease assessable according to UICC criteria, and had treatment for 6 months unless the disease progressed prior. Results: Median age was 80 (range: 70e99) years. When the disease progressed, some patients received further lines of therapy, with results summarised:
9. Do isolated cells (pN0i+) in the sentinel lymph node change the postoperative treatment in breast cancer? Se´verine Alrana, C. Charlesa, Y. De Ryckeb, M. Berrya, B. Sigalc, R. Salmona a Department of Surgery, Institut Curie, 25 Rue d’Ulm, 75005 Paris, France b Department of Biostatistics, Institut Curie c Department of Pathology, Institut Curie
PET
Response at 6 months CR PR SD CB PD (%) (%) (%) (%) (%)
DoCB Median TTP Median (Months) (Months) [longest] [longest]
First-line 11.9 35.4 50.7 98 2 26 [157] (N ¼ 825) Second-line 12.4 19.6 62.8 94.8 5.2 19 [144] (N ¼ 364) Third-line 13.2 10.5 65.8 89.5 10.5 16 [102] (N ¼ 157)
24 [163] 13 [149] 9 [107]
CR: complete response; PR: partial response; SD: stable disease; CB: clinical benefit ¼ CR + PR + SD; PD: progressive disease; DoCB: duration of CB; TTP: time to progression Conclusion: Compared to the general use of endocrine therapy reported in advanced breast cancer (where CB rate is around 70%), PET in this context appears to produce superior results. They support its use as an excellent alternative in elderly women who refuse or are unfit for surgery. 8. Prone abdominoperineal excision results in lower rates of involved circumferential resection margins than the standard approach Wesley Lai, T. Edwards, H. Windak, I. Daniels Exeter Colorectal Unit, Royal Devon & Exeter Hospital, Barrack Road, Exeter, Devon, EX2 5DW
Introduction: Traditionally the abdominoperineal excision (APE) has been associated with higher rates of involved circumferential resection margins (CRM) than anterior resections. Recent developments have focused upon a cylindrical excision and the use of a prone approach. This technique together with pelvic floor reconstruction using porcine collagen (Permacol) has been pioneered in our unit. Method: Retrospective review of data from the Exeter Colorectal Cancer Database. Results: Between 1998-2008, 963 cases of rectal cancer were treated. 248 (26%) APEs were performed by all surgeons, although from 2006 by only coloproctologists. The overall involved CRM rate was 23% (95% CI 17-28), for general surgeons 24% (95% CI 15-38). For the prone APE, the rate is 3.4% (95% CI 0-10). However, only 29/248 cases have been performed prone, and all by a single coloproctologist.
Purpose: Immunohistochemical (IHC) analysis of the sentinel lymph node (SLN) allows detection of occult metastases. Does IHC-positive node (pN0i+) change the post-operative treatment in breast cancer patients? Patients and methods: A total of 2692 patients with early invasive breast cancer underwent breast surgery with SLN biopsy between 2000 and 2006. SLNs were evaluated with frozen section, serial sectioning with Haematoxylin-Eosin-Safran (HES) and/or IHC staining. In 1506 patients with IHC-analyzed SLN, 143 were pN0i+ and underwent complementary axillary dissection (CAD). Their post-operative treatment were compared with pN0 patients. Results: A total of 10.5% of pN0i+ patients (15/143) had additional metastases in their CAD. Univariate analysis showed that pN0i+ patients had more chemotherapy compared to pN0 patients (24.5% vs. 9.1%; p < 0.0001) and significant modifications in lymph node (LN) irradiation: internal mammary (43.6% vs. 23.5%), supra clavicular (40.9% vs. 21.5%) and infra clavicular (13.5% vs. 3.7%); p < 0.0001. Multivariate analysis showed that the only decisive factor for chemotherapy in pN0i+ patients was the presence of metastasis in CAD; OR 15.83[3.265; 76.745], p < 0.001 and extension of irradiation was significant in pN0i+ compared to pN0 for internal mammary, supra clavicular LN (p < 0.0001). Conclusion: Immunohistochemistry played a decisive role for chemotherapy in metastatic CAD in 10% of pN0i+ patients. The decision for chemotherapy was influenced primarily by other prognostic factors such as age, tumor size, tumor grade, and hormonal receptor status. In patients with pN0i+, an extension of irradiation lymphatic fields was more frequent than in pN0 ones.
10. The influence of oestrogen receptor (ER) status on the pattern of recurrence in early breast cancer (EBC) James Mansell, C. Wilson, W. Angerson, J. Doughty Western Infirmary, Dumbarton Rd, Glasgow, G11 6NT
Introduction: There is an early peak in recurrence in women with early breast cancer (EBC). This may be related to underlying tumour biology or secondary to a reaction to surgery. We aim to determine if ER expression influences the pattern of recurrence. Methods: Data from 3 centres in Glasgow of consecutive women with EBC diagnosed between 1995 and 2001 were examined. Recurrence was defined as invasive disease at any site. Patients were grouped as high ER (70% expression), low ER (<70% expression) and ER negative. Kaplan Meier and time dependent Cox survival analysis was performed. Results: 2779 women were included with a median follow up of 5.5yrs. 1915 (68.9%) had high ER, 310 (11.2%) had low ER and 554 (19.9%) were ER negative. At 5yrs the cumulative recurrence rates were
ABSTRACTS
Parallel Session 2 e Ronald Raven Prize Papers Monday 23rd November 2009, 08:45e09:45 7. Primary endocrine therapy for early operable primary breast cancer in elderly women - A large series from a single institution Waleed Al-Khyatta, B. Syeda, D. Morganb, K. Cheunga a Professorial Unit of Surgery, Nottingham University Hospital - City Campus, Nottingham, NG5 1PB b Department of Oncology, Nottingham University Hospital
Conclusion: Introduction of the prone technique by a single surgeon led to a greatly reduced CRM rate compared to other surgeons using the traditional technique. With the use of MRI staging, neo-adjuvant chemoradiotherapy and multidisciplinary team (MDT) assessment, a change of surgical technique is necessary. Improved surgical training and regional centralisation for this technique may be necessary in future to achieve this.
Background: A recent Cochrane review of randomised trials involving 1,446 elderly women shows no significant difference in overall survival between surgery and primary endocrine therapy (PET). We report our experience of using PET in a dedicated elderly breast cancer service. Methods: Over a 20-year period, 825 elderly (>70 years) women with early operable primary breast cancer were treated with PET due to patient choice or being unfit for surgery. All patients had disease assessable according to UICC criteria, and had treatment for 6 months unless the disease progressed prior. Results: Median age was 80 (range: 70e99) years. When the disease progressed, some patients received further lines of therapy, with results summarised:
9. Do isolated cells (pN0i+) in the sentinel lymph node change the postoperative treatment in breast cancer? Se´verine Alrana, C. Charlesa, Y. De Ryckeb, M. Berrya, B. Sigalc, R. Salmona a Department of Surgery, Institut Curie, 25 Rue d’Ulm, 75005 Paris, France b Department of Biostatistics, Institut Curie c Department of Pathology, Institut Curie
PET
Response at 6 months CR PR SD CB PD (%) (%) (%) (%) (%)
DoCB Median TTP Median (Months) (Months) [longest] [longest]
First-line 11.9 35.4 50.7 98 2 26 [157] (N ¼ 825) Second-line 12.4 19.6 62.8 94.8 5.2 19 [144] (N ¼ 364) Third-line 13.2 10.5 65.8 89.5 10.5 16 [102] (N ¼ 157)
24 [163] 13 [149] 9 [107]
CR: complete response; PR: partial response; SD: stable disease; CB: clinical benefit ¼ CR + PR + SD; PD: progressive disease; DoCB: duration of CB; TTP: time to progression Conclusion: Compared to the general use of endocrine therapy reported in advanced breast cancer (where CB rate is around 70%), PET in this context appears to produce superior results. They support its use as an excellent alternative in elderly women who refuse or are unfit for surgery. 8. Prone abdominoperineal excision results in lower rates of involved circumferential resection margins than the standard approach Wesley Lai, T. Edwards, H. Windak, I. Daniels Exeter Colorectal Unit, Royal Devon & Exeter Hospital, Barrack Road, Exeter, Devon, EX2 5DW
Introduction: Traditionally the abdominoperineal excision (APE) has been associated with higher rates of involved circumferential resection margins (CRM) than anterior resections. Recent developments have focused upon a cylindrical excision and the use of a prone approach. This technique together with pelvic floor reconstruction using porcine collagen (Permacol) has been pioneered in our unit. Method: Retrospective review of data from the Exeter Colorectal Cancer Database. Results: Between 1998-2008, 963 cases of rectal cancer were treated. 248 (26%) APEs were performed by all surgeons, although from 2006 by only coloproctologists. The overall involved CRM rate was 23% (95% CI 17-28), for general surgeons 24% (95% CI 15-38). For the prone APE, the rate is 3.4% (95% CI 0-10). However, only 29/248 cases have been performed prone, and all by a single coloproctologist.
Purpose: Immunohistochemical (IHC) analysis of the sentinel lymph node (SLN) allows detection of occult metastases. Does IHC-positive node (pN0i+) change the post-operative treatment in breast cancer patients? Patients and methods: A total of 2692 patients with early invasive breast cancer underwent breast surgery with SLN biopsy between 2000 and 2006. SLNs were evaluated with frozen section, serial sectioning with Haematoxylin-Eosin-Safran (HES) and/or IHC staining. In 1506 patients with IHC-analyzed SLN, 143 were pN0i+ and underwent complementary axillary dissection (CAD). Their post-operative treatment were compared with pN0 patients. Results: A total of 10.5% of pN0i+ patients (15/143) had additional metastases in their CAD. Univariate analysis showed that pN0i+ patients had more chemotherapy compared to pN0 patients (24.5% vs. 9.1%; p < 0.0001) and significant modifications in lymph node (LN) irradiation: internal mammary (43.6% vs. 23.5%), supra clavicular (40.9% vs. 21.5%) and infra clavicular (13.5% vs. 3.7%); p < 0.0001. Multivariate analysis showed that the only decisive factor for chemotherapy in pN0i+ patients was the presence of metastasis in CAD; OR 15.83[3.265; 76.745], p < 0.001 and extension of irradiation was significant in pN0i+ compared to pN0 for internal mammary, supra clavicular LN (p < 0.0001). Conclusion: Immunohistochemistry played a decisive role for chemotherapy in metastatic CAD in 10% of pN0i+ patients. The decision for chemotherapy was influenced primarily by other prognostic factors such as age, tumor size, tumor grade, and hormonal receptor status. In patients with pN0i+, an extension of irradiation lymphatic fields was more frequent than in pN0 ones.
10. The influence of oestrogen receptor (ER) status on the pattern of recurrence in early breast cancer (EBC) James Mansell, C. Wilson, W. Angerson, J. Doughty Western Infirmary, Dumbarton Rd, Glasgow, G11 6NT
Introduction: There is an early peak in recurrence in women with early breast cancer (EBC). This may be related to underlying tumour biology or secondary to a reaction to surgery. We aim to determine if ER expression influences the pattern of recurrence. Methods: Data from 3 centres in Glasgow of consecutive women with EBC diagnosed between 1995 and 2001 were examined. Recurrence was defined as invasive disease at any site. Patients were grouped as high ER (70% expression), low ER (<70% expression) and ER negative. Kaplan Meier and time dependent Cox survival analysis was performed. Results: 2779 women were included with a median follow up of 5.5yrs. 1915 (68.9%) had high ER, 310 (11.2%) had low ER and 554 (19.9%) were ER negative. At 5yrs the cumulative recurrence rates were