Kwadwo Boachie-Adjei

Do additional shaved margins at the time of lumpectomy eliminate the need for re-excision?

BACKGROUND Most women diagnosed with breast cancer undergo breast-conservation surgery. Re-excision rates for positive margins have been reported to be greater than 50%. The purpose of our study was to determine if removing additional shaved margins from the lumpectomy cavity at the time of lumpectomy reduces re-excisions. METHODS A retrospective study was performed on 125 women who had undergone lumpectomy with additional shaved margins taken from the lumpectomy cavity. Pathology reports were reviewed for tumor size and histology, lumpectomy and additional margin status, and specimen and margin volume. RESULTS If additional margins were not taken, 66% would have required re-excision. Because of taking additional shaved margins, re-excision was eliminated in 48%. CONCLUSION Excising additional shaved margins at the original surgery reduced reoperations by 48%. There is a balance between removing additional margins and desirable cosmesis after breast-conservation surgery. The decision to take extra margins should be based on the surgeons judgment.

Abstract P4-15-03: Patterns of relapse following re-irradiation of the breast using partial breast brachytherapy (PBB)

Purpose: This study is undertaken to evaluate the patterns of relapse among patients with a prior history of irradiation where the RT field included the breast, and who received re-irradiation using PBB for a localized second cancer event in the breast using partial breast. Materials and Methods: Twenty-seven patients were enrolled in an IRB approved study. Nineteen patients had prior history of breast cancer treated with lumpectomy and external beam therapy (ERT), and 8 patients had prior history of mantle RT. All patients underwent lumpectomy with negative margins and received a median dose of 45Gy PBB. The median time interval between the primary breast cancer diagnosis and the second cancer event in the ipsilateral breast is 94-months (range 28-months to 211-months). The median time between mantle RT and the breast cancer is 245 months. Results: At a median follow up of 73 months following lumpectomy and PBB 14.8 % (4/27) patients developed a local recurrence and were salvaged by mastectomy. The 5-year Kaplan Meier local disease-free survival and mastectomy-free survival is 100% and 81%, respectively. Remarkably, one third of patients with prior history of mantle RT developed third primary cancers (pancreas, lung and renal). All patients with the third primary cancers died free of any relapse from the breast cancer. None of the patients with prior history of breast cancer developed a second malignancy, and 3/21 developed distant metastases. Conclusions: In appropriately selected patients with prior history of lumpectomy and ERT for breast cancer we observed a high rate of local control and freedom from mastectomy. Patterns of relapse among patients with prior mantle RT suggest that breast conservation and PBB was appropriate for treating early stage disease. Breast conservation therapy did not have a detrimental effect on breast cancer specific outcome and eventual patient survival. Patients motivated for breast conservation may have an alternative to mastectomy at initial diagnosis. Citation Information: Cancer Res 2012;72(24 Suppl):Abstract nr P4-15-03.

Abstract P6-07-34: Disease-related outcomes with adjuvant chemotherapy in HER2 positive or triple negative T1a/bN0 breast cancers

Background: Previous studies reported higher relapse rates in T1a/bN0 breast cancers characterized by high-risk biology (HER2 positive or triple negative). The benefits of adjuvant chemotherapy in this group have not been evaluated. The purpose of our study was to determine potential impact of chemotherapy on incidence of relapses and to define the population appropriate for treatment based on observational data. Methods: We pooled data from two multi-institutional databases spanning the period of 1996–2008 (Beth Israel Medical Center) and 2000–2010 (Brown University). We fitted a propensity score model to adjust for unbalanced confounders between the groups treated or untreated with adjuvant chemotherapy and, in case of HER2+ disease, with trastuzumab. Competing risk analysis was employed to study the effect of chemotherapy on cancer relapses in the matched population. Results: The study included 321 patients (160 from Beth Israel and 161 from Brown) with a median age of 57 years (range 28–88). 111 (35%) cases were triple negative (TN) and 210 (65%) were HER2+ (of which 64% were ER+). 41% patients received adjuvant chemotherapy and 22% of HER2+ cases received trastuzumab. The treated group differed from untreated with regards to distribution of age, menopausal status, year of diagnosis, histological subtype and grade, tumor size, rates of mastectomy, and adjuvant endocrine therapy. All confounders were successfully balanced with the propensity score analysis. With a median follow-up of 56 months, 20 relapses (12 locoregional and 8 distant) and 10 unrelated deaths occurred. The cumulative incidence of relapse at 5 years was 7.3% (95% CI, 4.3–11.4) and relapse-free survival was 90.2% (95% CI, 85.2–93.6). Age less then 35 years (46.4% vs. 6.1%, p = 0.0004) and TN status (12.9% for TN versus 4.8% for HER2+, p = 0.03) were associated with higher risk of relapse. No significant differences with regards to tumor size (T1a or T1b), surgery type and other variables were observed. There was no significant effect of chemotherapy on incidence of relapse (Hazard ratio 1.2, 95% CI 0.34–4.23, p = 0.78), relapse-free survival or distant recurrence-free interval after propensity score adjustment. Additionally in the HER2+ patients, no benefit of trastuzumab was detected (hazard ratio 0.78, 95% CI 0.06–9.85, p = 0.85). Adjuvant endocrine therapy was associated with lower risk of relapse in the ER+ subgroup (p = 0.04). Conclusion: Survival outcomes in very early stage breast cancer are excellent with current therapy even in biologically aggressive subtypes. Triple negative status and very young age correlate with higher incidence of relapse. While adjuvant endocrine therapy may be effective in ER positive subset, the risk/benefit ratio of chemotherapy with or without trastuzumab remains uncertain. Citation Information: Cancer Res 2012;72(24 Suppl):Abstract nr P6-07-34.

Abstract P3-08-08: Vitamin D status at breast cancer diagnosis: correlation with patient and tumor characteristics

Background: Despite many preclinical studies showing anti-neoplastic activities of vitamin D on breast cancer, findings from epidemiologic studies and randomized trials on the relationship between vitamin D and breast cancer remains inconclusive. It is possible that tumor heterogeneity in breast cancer may mask these associations. Variations in vitamin D metabolism might explain some racial disparities in breast cancer. We aimed to examine the association of serum vitamin D levels with patient and tumor characteristics. Methods: We conducted an IRB approved retrospective chart review, identifying all breast cancer patients with documented pretreatment serum level of 25-hydroxyvitamin D (25(OH)D) between February 2011-May 2012. The following clinical data were collected for each patient: age at diagnosis, ethnicity, menopausal status, largest tumor size (mm), lymph node status, estrogen receptor (ER), progesterone receptor (PR), and HER2 status. Based on ER, PR, and HER2, patients were categorized into three molecular subtypes: 1) Hormone receptor (HR)+ (ER or PR positive, HER2 negative), HER2+, triple negative (TN) (ER, PR, and HER2 negative). Vitamin D deficiency, insufficiency, and sufficiency were defined as 25(OH)D Results: Among 86 breast cancer patients identified, median age was 60 years (range 27–88). Ethnicities of the patients: 47 (55%) Caucasian, 18 (21%) African American, 15 (17%) Hispanic, and 6 (7%) Asian. Twenty eight (33%) were premenopausal, and 58 (67%) were postmenopausal. African Americans had the lowest mean 25(OH)D levels among different ethnicities (p = 0.0042). Patients with tumors >2 cm had lower mean vitamin D levels compared to those with tumors ≤ 2 cm (p = 0.037). When stratifying by menopausal status, serum 25(OH)D levels differed more by tumor characteristics among premenopausal women than postmenopausal women. In premenopausal women, lower vitamin D levels were seen in patients who were African Americans (p Conclusion: In premenopausal women, lower vitamin D levels were associated with African American race, larger tumor size, and ER negativity. African Americans with TN breast cancer were more likely to be vitamin D deficient. This might support the hypothesis that African Americans have defective vitamin D metabolism that may contribute to a more aggressive breast cancer phenotype. Further studies are warranted. Citation Information: Cancer Res 2012;72(24 Suppl):Abstract nr P3-08-08.