Lucie Jones

Early multicentre experience of pre-pectoral implant based immediate breast reconstruction using Braxon ®

Background The last two decades have seen significant changes in surgical management of breast cancer. The offer of immediate breast reconstruction (IBR) following mastectomy is currently standard practice. Skin sparing and nipple sparing mastectomy with implant-based IBR have emerged as oncologically safe treatment options. Prepectoral implant placement and complete coverage of implant with acellular dermal matrix (ADM) eliminates the need to detach the muscle from underlying chest wall in contrast to the subpectoral technique. We report short-term outcomes of a multicentre study from the United Kingdom (UK) using Braxon® in women having an IBR. Methods A prospective study was conducted from December 2015 to October 2016 and included all patients from three breast units in the UK who underwent a mastectomy and an implant-based IBR using Braxon®. The demographic details, co-morbidities, operative details, immediate and delayed complications were recorded. Specific complications recorded were infection, seroma, unplanned readmission and loss of implant. A comparison was made with complications reported in the National Mastectomy and Reconstruction Audit. Results Seventy-eight IBRs were included in the analysis with a median follow-up of 9.98 months. Mean age of the cohort was 50 years with a mean body mass index of 25.7 kg/m2. Mean implant volume was 365 cc. The inpatient hospital stay was 1.48 days. About 23% of patients had a seroma, 30% had erythema requiring antibiotics and the explant rate was 10.2 percent. Bilateral reconstructions were significantly associated with implant loss and peri-operative complications on univariate analysis. Conclusions Our early experience with this novel prepectoral technique using Braxon® has shown it to be an effective technique with complication rates comparable to subpectoral IBR. The advantages of prepectoral implant-based IBR are quicker postoperative recovery and short post-operative hospital stay. Long-term studies are required to assess rippling, post-operative animation, capsular contracture and impact of radiotherapy.

The Warwick Experience of the Oncotype DX® Breast Recurrence Score® Assay as a Predictor of Chemotherapy Administration

Introduction: Oncotype DX® analyses the expression of 21 genes within tumour tissue to determine a Recurrence Score® (RS). RS is a marker of risk for distant recurrence in oestrogen receptor-positive early breast cancer, allowing patient-specific benefit of chemotherapy to be evaluated. Our aim was to determine whether the introduction of Oncotype DX led to a net reduction in chemotherapy use. Methods: Consecutive patients that underwent Oncotype DX at Warwick Hospital were reviewed. Patients were anonymised and re-discussed at a multidisciplinary team meeting (MDM; without RS), and treatment recommendations were recorded. This was compared to the original MDM outcome (recommendations made with RS). Differences were analysed using Wilcoxon signed-rank test. Results: 67 patients were identified. Proportions of high, intermediate and low risk were 28, 33 and 39% (n = 19/22/26), respectively. Without RS, 56 (84%) patients were recommended for chemotherapy and 3 were not. The remaining 8 patients were deemed borderline for requiring chemotherapy and referred for discussion with an oncologist. With availability of RS, 34 (50%) patients were recommended for chemotherapy, and 24 (43%) patients were spared chemotherapy (p < 0.0005). The net reduction in chemotherapy was 33%. Conclusion: There has been a significant reduction in chemotherapy usage in patients at Warwick since the introduction of Oncotype DX.

Patient anxiety on the use of one step nucleic acid amplification (OSNA) during breast cancer surgery

INTRODUCTION Assessment of the sentinel lymph node biopsy (SLNB) is used to stage the axilla in patients with breast cancer. There are a variety of methods to assess metastatic disease within the SLN. One-step nucleic acid amplification (OSNA) has a high sensitivity for detecting metastatic disease within the SLN and avoids the use of staged axillary surgery. However there remains a paucity of data within the literature on the psychological effects upon patients with the use of OSNA. METHODS All patients undergoing breast surgery (breast-conserving surgery or mastectomy) and assessment of the SLNB with OSNA from December 2011 to June 2012 were included in the study. A questionnaire was sent to patient within four weeks of surgery to assess their understanding and satisfaction with the OSNA procedure. RESULTS 60 patients responded to the questionnaire (83% response rate). All patients were female with a mean age of 63 years (range 38-71 years). 19 patients had positive SLNB as assessed by OSNA and all had ALND. 15 patients expressed pre-operative anxiety about having OSNA although 97% stated that they would be happy to undergo the same procedure again. CONCLUSION Our study has identified the anxiety points that patients experience with OSNA based management and this will allow improved direct emotional support and provision of information.

P3-07-38: Selective Omission of Blue Dye in Patients Undergoing Sentinel Lymph Node Biopsy for Breast Cancer.

Background Combined blue dye and radioisotope colloid injection with scintigraphy is standard practice for mapping and biopsy of sentinel lymph node in breast cancer within the UK. Whilst this combination aids sentinel node detection rate, blue dye has a number of possible adverse effects including anaphylaxis (reported as 1–3% of patients), semi-permanent skin tattooing and staining of bodily fluids which may cause distress for the unwary patient. It can also cause obscuration of the operating field, making identification and dissection of planes more difficult. Methods : Patients undergoing sentinel lymph node biopsy (SLNB) using either a combination of blue dye and radioactive colloid, or radioactive colloid alone during a 14 month period were compared for identification rate, node harvest number and final positive rate. A total of 122 axillary sentinel node biopsies in 121 patients were identified. All patients scheduled for sentinel lymph node biopsy had intradermal injection of radiocolloid and lymphoscintigram preoperatively and were checked for radioactive intensity with gamma probe on the table before draping for surgery. Patients with good signal proceeded to surgery without blue dye. Those with more than 3 nodes (n=9), radioisotope skin contamination (n=2), absent signal on scintigraphy (n=7) and/or with weak pre-operative radioactive signal (n=22) were given 2 millilitres of patent V dye subdermally in the periareolar region. Sentinel node biopsy then proceeded in the standard fashion. Data was also collected from the year prior to be used as a control group, where the combination of blue dye and radioisotope was used for all patients (n=90), and compared with the group receiving radioisotope alone. Results : The rate of identification for single agent and dual agent was 100% and 97.5% respectively, with no significant difference in mean node harvest using radioisotope alone (1.80) as compared to combined technique (1.87 p= 0.88, 95%CI −0.39 to 0.34). There was no significant difference in the number of patients with positive nodes on final histology when using single agent (13 (14%)) when compared to the dual agent technique (10 (25%) p=0.21). There was also no difference in the rate or number of node harvest in the group who underwent the single agent technique when compared to the control group (100% identification, mean harvest 1.84, p=0.77, 95% CI −0.36 to 0.27), with no difference in node positivity (16 (17%) p=0.68). No intra operative adverse reaction was reported in any of the groups. Discussion : This study has shown no significant difference in the localisation rate when selectively omitting blue dye in suitable patients compared to the combined technique. This may be due to significant operator experience or change in the method of radioisotope injection since initial studies were performed. In this study, 86 out of 126 SLNB proceeded without blue dye, meaning not only a reduction in the number of patients with minor adverse effects, but also a potential reduction in severe adverse reaction of 68% or 2 patients per year within this breast unit. Citation Information: Cancer Res 2011;71(24 Suppl):Abstract nr P3-07-38.