Ashu Gandhi

Extent of excision margin width required in breast conserving surgery for ductal carcinoma in situ

Breast conserving surgery (BCS) is common practice for unifocal ductal carcinoma in situ (DCIS) less than 4 cm in size, but the extent of tumor free margin width around DCIS necessary to minimize recurrence is unclear.

Anti-estrogen Resistance in Human Breast Tumors Is Driven by JAG1-NOTCH4-Dependent Cancer Stem Cell Activity.

Summary Breast cancers (BCs) typically express estrogen receptors (ERs) but frequently exhibit de novo or acquired resistance to hormonal therapies. Here, we show that short-term treatment with the anti-estrogens tamoxifen or fulvestrant decrease cell proliferation but increase BC stem cell (BCSC) activity through JAG1-NOTCH4 receptor activation both in patient-derived samples and xenograft (PDX) tumors. In support of this mechanism, we demonstrate that high ALDH1 predicts resistance in women treated with tamoxifen and that a NOTCH4/HES/HEY gene signature predicts for a poor response/prognosis in 2 ER+ patient cohorts. Targeting of NOTCH4 reverses the increase in Notch and BCSC activity induced by anti-estrogens. Importantly, in PDX tumors with acquired tamoxifen resistance, NOTCH4 inhibition reduced BCSC activity. Thus, we establish that BCSC and NOTCH4 activities predict both de novo and acquired tamoxifen resistance and that combining endocrine therapy with targeting JAG1-NOTCH4 overcomes resistance in human breast cancers.

Acellular dermal matrix (ADM) assisted breast reconstruction procedures: joint guidelines from the Association of Breast Surgery and the British Association of Plastic, Reconstructive and Aesthetic Surgeons.

Tissue expansion with delayed insertion of a definitive prosthesis is the most common form of immediate breast reconstruction performed in the United Kingdom. However, achieving total muscle coverage of the implant and natural ptosis is a key technical challenge. The use of acellular dermal matrices (ADM) to supplement the pectoralis major muscle at the lower and lateral aspects of the breast has been widely adopted in the UK, potentially allowing for a single stage procedure. There is however little published data on the clinical and quality criteria for its use, and no long term follow-up. The guidelines have been jointly produced by the Association of Breast Surgery and the British Association of Plastic, Reconstructive and Aesthetic Surgeons and their aims are: to inform those wishing to undertake ADM assisted breast reconstruction and, to identify clinical standards and quality indicators for audit purposes. The guidelines are based on expert opinion of a multi-disciplinary working group, who are experienced in the technique, and a review of the published data.

Cost minimisation analysis of using acellular dermal matrix (Strattice™) for breast reconstruction compared with standard techniques.

BACKGROUND We performed a cost analysis (using UK 2011/12 NHS tariffs as a proxy for cost) comparing immediate breast reconstruction using the new one-stage technique of acellular dermal matrix (Strattice™) with implant versus the standard alternative techniques of tissue expander (TE)/implant as a two-stage procedure and latissimus dorsi (LD) flap reconstruction. METHODS Clinical report data were collected for operative time, length of stay, outpatient procedures, and number of elective and emergency admissions in our first consecutive 24 patients undergoing one-stage Strattice reconstruction. Total cost to the NHS based on tariff, assuming top-up payments to cover Strattice acquisition costs, was assessed and compared to the two historical control groups matched on key variables. RESULTS Eleven patients having unilateral Strattice reconstruction were compared to 10 having TE/implant reconstruction and 10 having LD flap and implant reconstruction. Thirteen patients having bilateral Strattice reconstruction were compared to 12 having bilateral TE/implant reconstruction. Total costs were: unilateral Strattice, £3685; unilateral TE, £4985; unilateral LD and implant, £6321; bilateral TE, £5478; and bilateral Strattice, £6771. CONCLUSIONS The cost analysis shows a financial advantage of using acellular dermal matrix (Strattice) in unilateral breast reconstruction versus alternative procedures. The reimbursement system in England (Payment by Results) is based on disease-related groups similar to that of many countries across Europe and tariffs are based on reported hospital costs, making this analysis of relevance in other countries.

Bioprosthetics: changing the landscape for breast reconstruction?

Approximately 20% of the 17 000 women undergoing mastectomy annually in the UK proceed with immediate breast reconstruction. The commonest type of reconstruction is the two stage Tissue Expander/Implant based operation (37%) followed by use of pedicled myocutaneous flaps either autologous (27%) or with implant (22%). Difficulties with implant based reconstructions such as capsular contraction or malposition are well documented. Pedicled myocutaneous flaps are popular and versatile techniques for breast reconstruction but patients can suffer functional deficits and donor site morbidity. These issues have promoted the development and use of bioprosthetics, namely acellular dermal matrices (ADM), in breast reconstruction. Originally derived from human cadevaric dermis these biological allografts were used for reconstruction following extensive burns, soft tissue defects and large ventral hernias. Their use in breast reconstruction cases has been rising in the USA and more recently in Europe. To render ADMs suitable for human use cells within the donor skin containing or presenting major histocompatibility complex antigens (keratinocytes, Langerhans’ cells and melanocytes within the epidermis, dendritic cells and endothelial cells of the dermis) have to be removed whilst leaving behind the dermal matrix components such as collagen fibres, elastin and proteoglycans. Once implanted, histological studies of human ADMs show that within seven days of being placed in vivo there is active host myofibroblast and endothelial cell infiltration into the graft dermal matrix with development of large numbers of microvessels. The complexity of supply of human cadaveric skin, limitations due to size and consistency of harvested tissue and the risk of disease transmission has led to the development of ADM derived from porcine skin such as Permacol (Covidien, Boulder, CO) and Strattice (LifeCell), the latter having a licence for use in the UK. Collagen fibre arrangement and dermal structure are similar in human and porcine dermis though in the latter the collagen fibres are more densely packed and contain less elastin which may contribute to reduced fibroblast infiltration seen in vivo when compared to human derivedADM.Humans have a cellular and humoral immune response to the immunogenic epitope galactosea-1,3-galactose contained within porcine dermis. Removal

Breast Volume Measurement Using a Games Console Input Device

The automated measurement of breast volume has applications both in facilitating the decisions made by surgeons prior to breast reconstruction and in improving density estimation. We describe a novel approach to volume measurement for surgical planning, using a games console input device - the Microsoft Kinect. We have explored the ability of the device to measure surface depth for a range of distances and angles, demonstrating a mean depth error of below 1.5 mm for a distance range of interest (0.5 - 0.8 m). We have also validated the use of the system for volume measurement using a full-sized model female torso. The Kinect-based result is in good agreement with the volume measured by filling a mould of the breast with water (225.5±8.7 ml, 229.4 ±9.7 ml respectively). The method has the potential to provide convenient, cost- and time-effective measurement of breast volume in clinical practice.

A Multi-Center Study To Determine the Optimum Duration of Neoadjuvant Letrozole on Tumour Regression To Permit Breast Conserving Surgery – An Interim Analysis.

Background: Neoadjuvant letrozole is an attractive alternative to chemotherapy for post menopausal women with large, ER positive breast cancer, who are destined for mastectomy but would prefer breast conservation. Prospective studies have not investigated treatment duration beyond 6 months and retrospective studies suggest useful responses can occur after this period.Materials and Methods: This trial is a prospective, UK centrally quality assured, multi-centre, longitudinal study to assess the optimal duration of neoadjuvant letrozole treatment to allow breast conserving surgery for a period of up to12 months. Post menopausal women with large (≥T2), ER and/or PgR positive primary tumours, not considered eligible for breast conservation, were commenced on neoadjuvant letrozole and response was assessed every 2 months with clinical and ultrasound examination until sufficient shrinkage for breast conservation, progression or 12 months had been reached. Ultrasound and Mammography were undertaken at baseline and end-point. We present the initial analysis for time to response and breast conservation.Results: By January 2009, 103 women were available for analysis. 23 (22.3%) had undergone a mastectomy, 60 (58.3%) had achieved breast conservation and 20 (19.4%) remained under evaluation within the trial. The mean age of the group was 74.1 years (52-92). 25 (24.3%) had invasive lobular cancer and 13 (12.6%) had grade 3 tumours. 22 (21.4%) were node positive.Figure 1. Kaplan-Meier plot for time (days) to response sufficient for breast conservation.25% had breast conservation by 5.8 months, 50% by 8.2 months and 75% by 12 months. Median time to breast conservation was 8.2 months (95% CI 6.4-9.3)Figure 2. Median change in tumour volume from baselineAfter an initial rapid response in the first 4 months, the rate of response was slower and constant for a further 6 months. Tumour volume reduction to permit breast conservation varied between 65 and 80% .Discussion: This interim analysis indicates that the conventional treatment period of 4 to 6 months of neoadjuvant letrozole should be revised. For most women longer duration will increase the likelihood of achieving sufficient volume reduction to allow breast conserving surgery. Citation Information: Cancer Res 2009;69(24 Suppl):Abstract nr 1082.

Abstract P2-06-02: Breast cancer stem-like cell activity correlates with tumour progression to metastasis but not with clinical or tumour characteristics

Introduction: Breast cancers exhibit cellular heterogeneity, containing both stem-like and more differentiated cells. The activity of cancer stem cells (CSC) is likely to be dependent on the microenvironment or niche. Using 158 patient tumour samples, correlations between niche-independent breast CSC activity and clinical and tumour characteristics were tested. Methods: 104 early breast cancer surgical samples and 54 unrelated metastatic samples from pleural or ascitic fluid were harvested. To test CSC activity, isolated cells were grown in both primary (formation) and secondary (self-renewal) mammosphere (MS) culture. Tumour initiating activity was also tested by transplanting breast cancer fragments or cells into the sub-cutaneous flanks of NSG mice (n=84 early and n=10 metastatic). Results: No correlation was found between MS growth, MS formation (%), MS self-renewal (%) or in vivo tumour initiation and breast cancer sub-type, grade, node status or Nottingham prognostic index. 33% of the samples that formed MS in vitro initiated tumours in vivo while only 9% that failed to form MS initiated tumour growth. Metastatic compared to early BC samples grew MS more frequently (53/54 compared to 81/104), and had a higher primary MS formation efficiency (1% vs 0.6%; P Conclusions: In summary, niche-independent breast CSC activity measured in vitro by MS assay and in vivo by xenograft growth is not directly correlated with standard clinical parameters. However, both in vitro and in vivo CSC activity are increased in metastatic samples. These results suggest that breast CSC activity is independent of other prognostic indicators but may predict for poor outcome tumours. Relapse free survival data are maturing and will be presented with analysis of primary tumour ALDH1 expression. Citation Format: Sacha J Howell, Denis Alferez, Katherine Spence, Rachel Eyre, Fran Shaw, Bruno Simoes, Angelica Santiago-Gomez, Maria Bramley, Mohamed Absar, Zahida Saad, Sumohan Chatterjee, Cliona Kirwan, Ashu Gandhi, Anne C Armstrong, Andrew M Wardley, Gillian Farnie, Robert B Clarke. Breast cancer stem-like cell activity correlates with tumour progression to metastasis but not with clinical or tumour characteristics [abstract]. In: Proceedings of the Thirty-Seventh Annual CTRC-AACR San Antonio Breast Cancer Symposium: 2014 Dec 9-13; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2015;75(9 Suppl):Abstract nr P2-06-02.

Abstract P4-04-14: High mammographic density is associated with deposition of organised fibrillar collagen and increased stiffness in periductal breast stroma

Introduction High mammographic density (MD) in women is strongly associated with breast cancer risk. However the structural and compositional differences between dense and non-dense breast tissues are not well defined. We determined the relationship between MD, collagen deposition and fibril alignment, and tissue micro-stiffness, in similarly aged individuals without adjacent cancer. Methods Fresh tissue samples were collected from post-menopausal women undergoing breast screening. Collagen deposition and fibril organisation were analysed using light microscopy of wax-sections stained with HE YM). Results Volumetric MD (Volpara TM ) was determined in 22 women (54-66y) undergoing risk-reducing surgery or mastectomy. Localised regions of elevated density, determined from digital mammograms, were isolated from patients of low and high overall MD, using a new collaborative workflow linking radiologist, surgeon, pathologist, and tissue biobank. All elevated-density regions contained considerable amounts of stromal connective tissue. However, there were significant differences in these regions from women with low vs high overall MD. Picrosirius Red staining of the localised areas of density revealed that the percentage organised fibrillar collagen content, particularly in the periductal breast stroma, strongly correlated with overall MD. AFM showed that the localised micro-stiffness of dense areas increased significantly in the breast stroma of patients with high overall MD (Volpara score > 15) compared with those of low overall MD (Volpara score Conclusions High MD is a significant risk factor for breast cancer, yet its molecular determinants in the normal, non-cancerous breast are poorly defined. We have shown that high MD is associated with more organised fibrillar collagen, leading to increased stiffness of the periductal breast stroma. Women with low and high MD all have regions with localised density, which contain both stromal connective tissue and epithelial ducts/lobules. However, our results show that these localised areas have differences in collagen organisation and tissue micro-mechanics. We now hypothesise that in the connective tissue of women with high MD, altered synthesis, deposition and turnover of stromal proteins alters the local biomechanical properties within the breast, providing a stiffer microenvironment, and contributing to cancer onset. Citation Format: Ashu Gandhi, Cliona C Kirwan, James C McConnell, Oliver V O9Connell, Michael J Sherratt, Charles H Streuli. High mammographic density is associated with deposition of organised fibrillar collagen and increased stiffness in periductal breast stroma [abstract]. In: Proceedings of the Thirty-Seventh Annual CTRC-AACR San Antonio Breast Cancer Symposium: 2014 Dec 9-13; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2015;75(9 Suppl):Abstract nr P4-04-14.

Abstract P2-14-09: Variation in UK reconstructive practice in the face of post-mastectomy radiotherapy

Approximately 30-40% of women are not offered immediate breast reconstruction because the possibility of post-mastectomy radiotherapy (PMRT) is unknown at the time of mastectomy. Breast reconstruction may be delayed until final pathology is available and need for radiotherapy established. Surgical literature is replete with studies of varying quality, reporting complication rates for a range of reconstructive procedures, highlighting the need for surgical trials of reconstructive techniques in women at risk of PMRT. Decisions for these patients are complex, involving multiple clinicians including surgeons and oncologists. To inform a surgical trial design, we aimed to determine current UK surgical practice and gain an understanding of the drivers behind decision-making. Methods: A questionnaire, validated in a pilot population, was posted to Consultant members of the Association of Breast Surgery (UK). We collected data on current practice in conducting Delayed, Immediate and Delayed-immediate reconstructive surgery. We collated data on type and volume of procedure performed and factors affecting decision-making including delay to adjuvant treatment, risk of complications, perception of patients’ quality of life (QoL) and aesthetic satisfaction. Results: Of 355 surgeons, 130(37%) responded. Of these, 77% felt the current evidence base was not adequate to guide surgical decisions and 80% felt a need for further trials to guide best treatment. Despite a lack of scientific evidence demonstrating a difference in cosmesis or QoL between Immediate and Delayed reconstruction, 85% felt there is not equivalent cosmesis and 71% felt there is not equivalent QoL between the two groups. There is considerable heterogeneity in reconstructive approach to patients at risk of PMRT (Table 1). Delayed reconstruction remains the most popular option, being regularly used by 94% of surgeons despite only 34% of surgeons believing the majority of patients are satisfied with the approach. Significantly fewer surgeons perform Immediate implant based reconstruction (with or without ADM) than Delayed (p The three most important drivers in making a reconstructive choice were 1. Effect of PMRT on the cosmetic result 2. Minimising risk of complications and avoiding delay to adjuvant treatment 3. Pre-operative uncertainty over the need for PMRT. Conclusions: Surgeons employ a variety of approaches to reconstruction in the face of PMRT, the most common approach being delayed reconstruction. Decision-making is based upon individual surgeon’s perception of risks including likely delay to adjuvant therapy and effect of PMRT on the reconstruction. Drivers appeared to be more surgeon-centred rather than patient-based. There is awareness of a lack of evidence to support decision-making and the need for high quality studies. Randomised clinical trials are needed to provide an evidence base for outcomes. Citation Format: James R Harvey, Nigel J Bundred, Cliona C Kirwan, Ashu Gandhi, Paula J Duxbury. Variation in UK reconstructive practice in the face of post-mastectomy radiotherapy [abstract]. In: Proceedings of the Thirty-Seventh Annual CTRC-AACR San Antonio Breast Cancer Symposium: 2014 Dec 9-13; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2015;75(9 Suppl):Abstract nr P2-14-09.