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2 Scientific Session Awards Abstracts presented at the Society s annual meeting will be considered for the following awards: The George Peters Award recognizes the best presentation by a breast fellow. In addition to a plaque, the winner receives $1,000. The winner is selected by the Society s Publications Committee. The award was established in 2004 by the Society to honor Dr. George N. Peters, who was instrumental in bringing together the Susan G. Komen Breast Cancer Foundation, The American Society of Breast Surgeons, the American Society of Breast Disease, and the Society of Surgical Oncology to develop educational objectives for breast fellowships. The educational objectives were first used to award Komen Interdisciplinary Breast Fellowships. Subsequently the curriculum was used for the breast fellowship credentialing process that has led to the development of a nationwide matching program for breast fellowships. The Scientific Presentation Award recognizes an outstanding presentation by a resident, fellow, or trainee. The winner of this award is also determined by the Publications Committee. In addition to a plaque, the winner receives $500. All presenters are eligible for the Scientific Impact Award. The recipient of the award, selected by audience vote, is honored with a plaque. All awards are supported by The American Society of Breast Surgeons Foundation. The American Society of Breast Surgeons ii 2016 Official Proceedings
3 Publications Committee Co-Chairs Judy C. Boughey, MD Jill R. Dietz, MD Members Michael D. Alvarado, MD Charles Balch, MD Sarah Blair, MD David R. Brenin, MD Katherina Zabicki Calvillo, MD Suzanne Brooks Coopey, MD Steven L. Chen, MD Brian Czerniecki, MD Mahmoud El-Tamer, MD Mehra Golshan, MD E. Shelley Hwang, MD Susan Kesmodel, MD Brigid Killelea, MD Michael Koretz, MD Henry Kuerer, MD, PhD Swati A Kulkarni, MD Elizabeth A. Mittendorf, MD, PhD Roshni Rao, MD Elizabeth Shaughnessy, MD Stephanie Valente, DO Jan H. Wong, MD Katharine A. Yao, MD The American Society of Breast Surgeons iii 2016 Official Proceedings
4 This supplement was not sponsored by outside commercial interests. It was funded entirely by the publisher. The American Society of Breast Surgeons iv 2016 Official Proceedings
5 Table of Contents Scientific Session Oral Presentations Survey of Patient Perspectives on Receiving a New Breast Cancer Diagnosis and Testing Results: Can We Do Better? Deanna Attai, Regina Hampton, Alicia Staley, Andrew Borgert, Jeffrey Landercasper Complications of Oncoplastic Breast Surgery vs Breast-Conserving Surgery: An Analysis of the NSQIP Database Tulin Cil, Erin Cordeiro A Prospective, Single-Arm, Multi-Site Clinical Evaluation of a Nonradioactive Surgical Guidance Technology for the Location of Nonpalpable Breast Lesions During Excision Charles Cox, Peter Blumencranz, Pat Whitworth, Kristi Funk, Julie Barone Alice Police, Freya Schnabel, Beth Anglin, Lynn Canavan, Alison Laidley, Mary Jane Warden, Scott Russell, Ebonie Carter, Jeff King, Steven Shivers Anti-HER-3 CD4 Th1 Response Correlates With Invasive Breast Cancer Phenotypes and Prognosis Megan Fracol, Jashodeep Datta, Shuwen Xu, Elizabeth Fitzpatrick, Lea Lowenfeld, Paul Zhang, Carla Fisher, Brian Czerniecki Postmastectomy Radiation Therapy and Overall Survival After Neoadjuvant Chemotherapy Olga Kantor, Catherine Pesce, Chi-Hsiung Wang, David Winchester, Katharine Yao Are We Overtreating Ductal Carcinoma In Situ (DCIS)? Sadia Khan, Melinda Epstein, Michael Lagios, Melvin Silverstein Fertility in Young Women of Child-Bearing Age After Breast Cancer: Are We Giving Them a Better Chance? Devina McCray, Ashley Simpson, Yitian Liu, Colin O'Rourke, Joseph Crowe, Rebecca Flyckt, Stephen Grobmyer, Halle Moore, Stephanie Valente Re-excision Rates After Breast Conservation Surgery in the American Society of Breast Surgeons (ASBrS) Mastery Database Following the SSO-ASTRO No Tumor on Ink Guidelines Jennifer Mirrielees, Amanda Schulman, Caprice Greenberg, Jeffrey Landercasper, Lee Wilke Application of the 2015 ACS and ASBS Screening Mammography Guidelines: Risk Assessment Is Critical for Women Ages Jennifer Plichta, Suzanne Coopey, Michelle Specht, Michele Gadd, Erin Sullivan, Constance Roche, Barbara Smith, Kevin Hughes Time to Treatment Among Stage III Patients: Measuring Quality Breast Cancer Care Amy Polverini, Rebecca Nelson, Emily Marcinkowski, Veronica Jones, Lily Lai, Joanne Mortimer, Lesley Taylor, Courtney Vito, John Yim, Laura Kruper The American Society of Breast Surgeons v 2016 Official Proceedings
6 Quickshot Presentations Saturday, April 16, :45 pm 1:15 pm Validation of the CPS+EG Staging System for Disease-Specific Survival in Breast Cancer Patients Treated With Neoadjuvant Chemotherapy Jad Abdelsattar, Zahraa Al-Hilli, Tanya Hoskin, Courtney Heins, Judy Boughey Management of Phyllodes Tumors of the Breast: Applying the Correct Treatment Paradigm? Taiwo Adesoye, Heather Neuman, Jessica Schumacher, Jennifer Steiman, Lee Wilke, Caprice Greenberg Contrast-Enhanced Digital Mammography in the Surgical Management of Breast Cancer Mariam Ali-Mucheru, Bhavika Patel, Barbara Pockaj, Victor Pizzitola, Nabil Wasif, Chee-Chee Stucky, Richard Gray Analysis of Operative and Oncologic Outcomes in 5351 Patients With Operable Breast Cancer: Support for Breast Conservation and Oncoplastic Reconstruction Stacey Carter, Genevieve Lyons, Roland Bassett, Scott Oates, Isabelle Bedrosian, Alastair Thompson, Elizabeth Mittendorf, Mediget Teshome, Min Yi, Gildy Babiera, Sarah DeSnyder, Abigail Caudle, Merrick Ross, Patrick Garvey, Donald Baumann, Henry Kuerer, Kelly Hunt, Rosa Hwang Combining Pathologic Data With Axillary Ultrasound Information Reliably Identifies a Large Number of Newly Diagnosed Breast Cancer Patients As Node-Negative Tiffany Chichester, Charles Mylander, Rubie Sue Jackson, Martin Rosman, Sophia Cologer, Reema Andrade, Lorraine Tafra Breast Cancer Recurrence Following Radio-Guided Seed Localization and Standard Wire Localization of Nonpalpable Breast Cancers 5-Year Follow-Up From a Randomized Controlled Trial Filgen Fung, Sylvie Cornacchi, Michael Reedijk, Nicole Hodgson, Charlie Goldsmith, David McCready, Gabriela Gohla, Colm Boylan, Peter Lovrics Trends in Breast Reconstruction After Mastectomy and Associated Postoperative Outcomes Nicole Ilonzo, Alison Estabrook, Ayemoe Ma Multi-institutional Study of the Oncologic Safety of Prophylactic Nipple-Sparing Mastectomy in a BRCA Population James Jakub, Anne Peled, Richard Gray, Rachel Greenup, John Kiluk, Sarah McLaughlin, Julia Tchou, Shawna Willey Factors Associated With Recurrence Rates and Long-Term Survival in Women Diagnosed With Breast Cancer Ages 40 and Younger Jennifer Plichta, Suzanne Coopey, Michele Gadd, Michelle Specht, Kevin Hughes, Alphonse Taghian, Barbara Smith The Role of Surgical Primary Tumor Extirpation in De Novo Stage IV Breast Cancer in the Era of Targeted Treatment Judy Tjoe, Danielle Greer, Ahmed Dalmar Posters Risk Factors of Breast Cancer Related Lymphedema Mokhtar Abdulwahid, Yehia Safwat Metaplastic Breast Cancer Has a Poor Response to Neoadjuvant Systemic Therapy Zahraa Al-Hilli, James Jakub, Daniel Visscher, James Ingle, Matthew Goetz The Impact of Molecular Subtype on Breast Cancer Recurrence in Young Women Treated With Contemporary Adjuvant Therapy Hanan Alabdulkareem, Sara Khan, Alyssa Landers, Paul Christos, Rache Simmons, Tracy-Ann Moo Management of Positive Margins in Elderly Women With Breast Cancer: Is Reoperation Necessary? Fernando Angarita, Sergio Acuna, Jaime Escallon The American Society of Breast Surgeons vi 2016 Official Proceedings
7 The Specimen Margin Assessment Technique (SMART) Trial: A Novel 3D Method of Identifying the Most Accurate Method of Breast Specimen Orientation Angel Arnaout, Sara Saeed, Genevieve Dostaler, Susan Robertson A Randomized, Double-Blind, Placebo-Controlled Window-of-Opportunity Trial Evaluating Clinical Effects of High-Dose Vitamin D in Patients With Breast Cancer Angel Arnaout, Christina Addison, Susan Robertson, Nina Chang, Mark Clemons Breast Cancer Staging and Presentation in HIV-Positive Patients: A Multi-Institutional Retrospective Review Cassandra Baker, Patricia Wehner Could Ductoscopy Be Used to Identify Breast Cancer in Patients With Pathologic Nipple Discharge? Fatih Levent Balci, Omer Bender, Neslihan Cabioglu, Mahmut Muslumanoglu, Vahit Ozmen, Abdullah Iğci Influence of the SSO/ASTRO Margin Re-excision Guidelines on Costs Associated With Breast-Conserving Surgery Christopher Baliski, Reka Pataky Influence of Patient, Disease, and Physician-Related Factors on Reoperation Rates After Attempted Breast-Conserving Surgery Christopher Baliski, Lauren Hughes, Colleen McGahan Disparities in Endocrine Risk Reduction for Young Adult Women With Lobular Carcinoma In Situ Bradley Bandera, Amy Voci, Jihey Lee, Melanie Goldfarb, Maggie DiNom Mammary Tuberculosis: Clinical Presentation, Treatment, and Outcome of 50 Cases Razia Bano, Farhan Majeed, Amna Sharaf Outcomes in Patients With Small Node-Negative Invasive Breast Cancer Jean Bao, Cory Donovan, Farin Amersi, Xiao Zhang, Armando Giuliano, Alice Chung Incidence Rate and Outcomes for Palpable Ductal Carcinoma In Situ in the Contemporary Era Dany Barrak, Lily Tung, Zeina Ayoub, Alexander Ring, Akshara Singareeka Raghavendra, Debu Tripathy, Stephen Sener, Heather MacDonald, Maria Nelson, Meenakshi Bhasin, Julie E Lang Is Routine Axillary Imaging Necessary in Clinically Node-Negative Patients Undergoing Neoadjuvant Chemotherapy? Andrea Barrio, Anita Mamtani, Michelle Stempel, Anne Eaton, Monica Morrow Patient-Reported Satisfaction Following Oncoplastic Breast-Conserving Therapy Amy Bazzarelli, Jing Zhang, Angel Arnaout Comparison of MammaPrint and BluePrint Genetic Signatures in Pre- and Post- Neoadjuvant Chemotherapy-Treated Breast Cancer Peter Beitsch, Pat Whitworth, Paul Baron, James Pellicane, Pond Kelemen, Andrew Ashikari, Beth Ann Lesnikoski, Cristina Lopez-Penalver, Arnold Baskies, Michael Rotkis, David Rock, Elena Rehl, Heidi Memmel, Hanadi Bu-Ali, David Carlson, Laura Lee, Robert Reilly, William Dooley, Angela Mislowsky, Jia-Perng Wei, Mark Gittleman NAPBC Accreditation Demonstrates Increasing Compliance With Postmastectomy Radiation Therapy Quality Improvement Measure Elizabeth Berger, Cary Kaufman, Ted Williamson, Julio Ibarra, Karen Pollitt, Richard Bleicher, James Connolly, David Winchester, Katharine Yao Preventative Health Maintenance and Screening Adherence Among Breast Cancer Survivors Laura Bozzuto, Rose Li Yun, Laura Steel, Elena Carrigan, Vicky Ro, Julia Tchou Use of Hydrogel-Based Clip for Localization of Nonpalpable, Ultrasound-Visible Breast Lesions Reduces Need for Needle Localization Magdalene Brooke, Elizabeth Cureton, Alice Yeh, Rhona Chen, Nicole Mazzetti-Barros, Nicole Datrice Hill, Reza Rahbari, Sherry Butler, Veronica Shim, Sharon Chang Clinicopathological Characteristics of Nipple Discharge Associated Breast Cancer Neslihan Cabioglu, Omer Bender, Fazilet Ergozen, Enver Ozkurt, Mustafa Tukenmez, Fatih Balci, Ravza Yilmaz, Semen Onder, Mahmut Muslumanoglu, Vahit Ozmen, Ahmet Dinccag, Abdullah İgci The American Society of Breast Surgeons vii 2016 Official Proceedings
8 The Added Value of Radiology Reviews: Additional Cancers and Avoiding False Positives Sarah Cate, Alyssa Gillego, Shannon Scrudato, Rita Vaszily, Tamara Fulop, Lisa Abramson, Alex Sarosi, Rachelle Leong, Manjeet Chadha, Susan Boolbol Cryoablation for Breast Cancers Less Than 1.5 cm: An Early Update on the ICE 3 Trial Recruitment and Short-Term Follow-Up Sarah Cate, Alex Sarosi, Karen Columbus, Linsey Gold, Richard Fine, Andrew Kenler, Alyssa Gillego, Christopher Mills, Susan Boolbol Tumor Board Review Impacts NCCN Guideline Concordance for Breast Cancer Patients Jamie Caughran, Jessica Keto, Susan Catlin, Mary May, Elle Kalbfell Impact of the Timing of Diagnosis of Genetic Mutation on the Choice of Surgical Procedure in BRCA1/BRCA2 Mutation Carriers With Breast Cancer Akiko Chiba, Tanya Hoskin, Emily Hallberg, Jamie Hinton, Courtney Heins, Fergus Couch, Judy Boughey Should Repeat HER2 Testing Be Done on the Surgical Specimen? Tiffany Chichester, Lauren Greer, Rubie Sue Jackson, Charles Mylander, Martin Rosman, Thomas Sanders, Kristen Sawyer, Lorraine Tafra Reporting Guidelines Improve Information in Axillary Ultrasound Reports Tiffany Chichester, Rubie Sue Jackson, Daina Pack, Charles Mylander, Martin Rosman, Reema Andrade, Lorraine Tafra The Effect of Marital Status on Breast Cancer Related Outcomes in Younger Women Jennifer Clancy, Leslie Hinyard, Theresa Schwartz Utility of Screening MRI in Women With a Personal History of Breast Cancer Audree Condren, Brittany Arditi, Margaux Wooster, Christina Weltz, Elisa Port, Laurie Margolies, Hank Schmidt Oncologic Safety of Nipple-Sparing Mastectomy in Women With Breast Cancer Suzanne Coopey, Rong Tang, Upahvan Rai, Jennifer Plichta, Amy Colwell, Michele Gadd, Michelle Specht, William Austen, Barbara Smith Effects of Obesity and Overweight on Survival in Patients With Breast Cancer Chiappa Corrado, Anna Fachinetti, Gianlorenzo Dionigi, Francesca Rovera Establishing a New Normal : A Qualitative Exploration of Women s Body Image After Mastectomy Andrea Covelli, Nancy Baxter, Frances Wright Invasive Lobular vs Invasive Ductal Carcinoma: Are They Different? Melanie Crutchfield, Melinda Epstein, Colleen O Kelly Priddy, Julie Sprunt, Sadia Khan, Melvin Silverstein Comparison of Breast Volumes Excised Through Bracketed Radioactive Seed vs Bracketed Wire Localization Monica DaSilva, Amanda Chu, Meghan Hansen, Jessica Porembka, Stephen Seiler, Marilyn Leitch, James Huth, Aeisha Rivers, Rachel Wooldridge, Deborah Farr, Ali Mokdad, Jean Bao, Emily Brown, Roshni Rao A Multicenter Prospective Evaluation of a Radiofrequency Identification Tag in the Localization of Nonpalpable Breast Lesions Christine Dauphine, Lawrence Goldberger, Jerome Schroeder, Julie Barone Outcomes After Oncoplastic Surgery in Breast Cancer Patients: A Systematic Literature Review Lucy De La Cruz, Stephanie Blankenship, Abhishek Chatterjee, Rula Geha, Brian Czerniecki, Julia Tchou, Carla Fisher Is Beauty in the Eye of the Beholder? Comparison of Patient Satisfaction Using the BREAST-Q and Surgeon-Rated Aesthetic Outcome in Autologous Breast Reconstruction Tanya DeLyzer, Xi Liu, Shaghayegh Bagher, Brett Beber, Anne O'Neill, Stefan Hofer, Toni Zhong Does Sentinel Lymph Node Biopsy Impact Systemic Therapy Recommendations? Diana Dickson-Witmer, Michael Guarino, Hunter Witmer, Emily Murphy, Dennis Witmer, Robert Hall-Long, Alexandra Hanlon Low Upstage Rate of Imaging-Detected Intraductal Papillomas Without Atypia May Not Necessitate Surgical Excision Emilia Diego, Paul Waltz, Priscilla McAuliffe, Atilla Soran, Ronald Johnson, Gretchen Ahrendt FEA on Core Needle Biopsy Does Not Always Mandate Excisional Biopsy Cory Donovan, Attiya Harit, Alice Chung, Jean Bao, Armando Giuliano, Farin Amersi The American Society of Breast Surgeons viii 2016 Official Proceedings
9 Oncological and Surgical Outcomes After Nipple-Sparing Mastectomy: Do Incisions Matter? Cory Donovan, Attiya Harit, Alice Chung, Jean Bao, Armando Giuliano, Farin Amersi The Effect of BMI on OR Utilization in Breast Surgery Julie Dunderdale, Borko Jovanovic, Swati Kulkarni The Cost of Efficiency: Budget Impact Analysis of a Breast Rapid Diagnostic Unit Maryam Elmi, Sharon Nofech-Mozes, Belinda Curpen, Angela Leahey, Nicole Look Hong Excisional Biopsy by Seed Localization Decreases Amount of Excised Tissue Compared to Wire Localization Claire Edwards, Anita Sambamurty, Eric Brown, Anita McSwain, Christine Teal STAT Reasons and Ordering Outcomes for Hereditary Breast Cancer Genetic Testing Caroline Elsas, Michelle Jackson, Emily Dalton, Patrick Reineke, Sara Calicchia, Holly LaDuca, Jill Dolinsky, Robina Smith Patients Treated With Intraoperative Radiation Therapy (IORT): Initial Report Melinda Epstein, Sadia Khan, Peter Chen, Brian Kim, Lisa Guerra, Lincoln Snyder, Colleen Coleman, January Lopez, Ralph Mackintosh, Cristina DeLeon, Melvin Silverstein Complications in 640 Patients Treated With Intraoperative Radiation Therapy (IORT) Melinda Epstein, Sadia Khan, Peter Chen, Brian Kim, Lisa Guerra, Lincoln Snyder, Colleen Coleman, January Lopez, Ralph Mackintosh, Cristina DeLeon, Melvin Silverstein Institutional Experience of Applying ACOSOG Z0011 Criteria to Breast Cancer Patients Underrepresented in the ACOSOG Z0011 Trial Daniel Farrugia, Emilia Diego, Atilla Soran, Alessandra Landmann, Priscilla McAuliffe, Marguerite Bonaventura, Ronald Johnson, Gretchen Ahrendt The Impact of Body Mass Index on the Prognostic Power of Circulating Tumor Cells and Pathologic Complete Response Following Neoadjuvant Chemotherapy for Breast Cancer Oluwadamilola Fayanju, Carolyn Hall, Jessica Bauldry, Mandar Karhade, Lily Valad, Henry Kuerer, Sarah DeSnyder, Carlos Barcenas, Anthony Lucci Who Bleeds After Breast Cancer Resection? A Contemporary Analysis of the ACS-NSQIP Database Ann-Kristin Friedrich, Kevin Baratta, Connie Lee, Anne Larkin, B. Marie Ward, Ashling O Connor, Robert Quinlan, Jennifer LaFemina Acupuncture As Treatment for Flap/Nipple Ischemia Following Nipple-Sparing Mastectomy Jennifer Garreau, Heather Farley, Margie Glissmeyer, Nathalie Johnson A Cost-Effective Handheld Breast Scanner for Use in Low-Resource Environments: A Validation Study Rula Geha, Robyn Broach, Mihir Shah, Matthew Campisi, Lucy De La Cruz, Brian Englander, Ari Brooks Successful Ultrasound-Guided Segmental Mastectomy and Excisional Biopsy Using Hydrogel-Encapsulated Clip Localization As an Alternative to Wire Localization Lori Gentile, Amber Himmler, Elizabeth Vohris, Julia Marshall, Christiana Shaw, Lisa Spiguel Does Exogenous Insulin Contribute to the Development of More Aggressive Subtypes of Breast Cancer? Victoria Gershuni, Yun Li, Elena Carrigan, Steel Laura, Vicky Ro, Jenny Nguyen, Laura Bozzuto, Julia Tchou Take It All! - The Decision to Pursue Bilateral Mastectomy for Ductal Carcinoma In Situ (DCIS) Katherine Glover-Collins, Julie Margenthaler Evaluation of Percutaneous Vacuum-Assisted (VA) Intact Specimen Breast Biopsy Device for Ultrasound (U/S) Visualized Breast Lesions: Upstage Rates and Long-Term Follow-Up (F/U) for High-Risk Lesions (HRL) and DCIS Cathy Graham Symptomatic Axillary Seroma After Sentinel Node Biopsy: Incidence and Treatment Jinny Gunn, Tammeza Gibson, Zhou Li, Nancy Diehl, Sanjay Bagaria, Sarah McLaughlin The American Society of Breast Surgeons ix 2016 Official Proceedings
10 Barriers to Genetic Testing in Newly Diagnosed Breast Cancer Patients: Where Can We Improve? Laura Hafertepen, Alyssa Pastorino, Nichole Mormon, Deepa Halaharvi, Lindsey Byrne, Mark Cripe Triple-Negative Breast Cancer: Identifying an Unacceptable Time to Treatment Meghan Hansen, James Huth, Rachel Wooldridge, Monica DaSilva, Marilyn Leitch, Roshni Rao, Aeisha Rivers, Lynn Van Hooser, William Lodrigues Margin Consensus Guideline Effect on Re-Excision Rates, Conversion to Mastectomy and Specimen Volumes Samantha Heidrich, Jack Rostas, Reiss Hollenbach, Robert Martin, Nicolas Ajkay SONIC-PBI A Novel Protocol to Complete Breast Cancer Surgery and Radiation Within 10 Days Tina Hieken, Robert Mutter, James Jakub, Judy Boughey, Amy Degnim, William Sukov, Stephanie Childs, Keith Furutani, Thomas Whitaker, Sean Park Radiographically Guided Shave Margins May Reduce Lumpectomy Re-Excision Rates: A Single-Surgeon Experience Priya Iyer, Alison Marko, Veeraj Jadeja, Debra Pratt Does Axillary Nodal Metastasis Detected on Ultrasound Mandate Axillary Lymph Node Dissection? Rubie Sue Jackson, Charles Mylander, Martin Rosman, Reema Andrade, Thomas Sanders, Kristen Sawyer, Lorraine Tafra Impact of Genetic Evaluation on Treatment Decisions in Early-Stage Breast Cancer Mona Janfaza, Nayana Dekhne Post-Traumatic Stress and Fear of Progression Symptoms in Breast Cancer Patients Comparing Stage, the Use of Adjuvant Chemotherapy, and Breast Conservation Jessica Johnson, Sean Boyle, Ashar Ata, Steven Stain, Todd Beyer Predictors of Complete Response to Neoadjuvant Chemotherapy in Breast Cancer Jeffrey Johnson, Galinos Barmparas, Alice Chung, Armando Giuliano, Farin Amersi Prognostic Factor for Partial Responder and Validation of Tumor Response Ratio After Neoadjuvant Chemotherapy in Breast Cancer Patients Seung Pil Jung, Sang Wook Woo, Jeoung Won Bae Trends in Autologous Breast Reconstruction: A National and Regional Overview Parisa Kamali, Marek Paul, Pieter Koolen, Ahmed Ibrahim, Winona Wu, Marc Schermerhorn, Bernard Lee, Samuel Lin The Rise and Fall of Breast-Conserving Surgery in the United States Olga Kantor, Catherine Pesce, David Winchester, Chi-Hsiung Wang, Katharine Yao Rational Use of MRI in Clinical Stage 2 Breast Cancer John Kennedy, Patrick Robbins Does MRI Deliver the Goods in Women With DCIS? John Kennedy, Patrick Robbins Do Women Aim to Please? Partner Satisfaction As a Driver of Surgical Decision-Making in Breast Cancer Treatment Rebecca Kwait, Sarah Pesek, Michaela Onstad, David Edmonson, Christy Gandhi, Melissa Clark, Christina Raker, Ashley Stuckey, Jennifer Gass Preserving Sexual Function in Breast Cancer Survivorship: Does Surgical Modality Matter? Rebecca Kwait, Sarah Pesek, Michaela Onstad, David Edmonson, Christy Gandhi, Melissa Clark, Christina Raker, Ashley Stuckey, Jennifer Gass Toxicity Symptoms and Local Recurrence Are Low in Breast Cancer Patients Treated With External Beam Accelerated Partial Breast Irradiation Alexandra Kyrillos, Arif Shaikh, William Bloomer, Hussain Habib, Megan Tobias, Katharine Yao Implementing the Prospective Surveillance Model of Rehabilitation (PSM) for Breast Cancer Patients With 1-Year Postoperative Follow-Up A Prospective Observational Study Lisa Lai, Jill Binkley, Veronica Jones, Stephanie Kirkpatrick, Cathy Furbish, Paul Stratford, Winifred Thompson, Amanjyot Sidhu, Clara Farley, Joel Okoli, Derrick Beech, Sheryl Gabram The American Society of Breast Surgeons x 2016 Official Proceedings
11 When, Where, and How: Timing, Pattern, and Diagnosis of Metastatic Recurrence in Young Women <40 Years With Breast Cancer Kelsey Larson, Stephen Grobmyer, Stephanie Valente Intraoperative Margin Assessment in Wire-Localized Breast-Conserving Surgery for Nonpalpable Cancers: A Population-Level Comparison of Techniques Alison Laws, Mantaj S Brar, Antoine Bouchard-Fortier, Brad Leong, May Lynn Quan Evaluation and Risk Assessment for Breast Cancer: An Integrated Health System Approach Rosemary Leeming, Eileen Maney, Audrey Fan, Heather Rocha, Juliann Koenig, Alanna Rahm, Susan Snyder, Jing Hao, James Pitcavage Prediction of Surgical Upgrade Rate of Breast Atypia to Malignancy: An Academic Center s Experience and Validation of a Predictive Model Ali Linsk, Tejas Mehta, Vandana Dialani, Alexander Brook, Tamuna Chadashvili, Mary Jane Houlihan, Ranjna Sharma The Cost of Accuracy: A Budget Impact Analysis of Whole-Mount Histopathology Processing for Patients With Breast Cancer Undergoing Breast Conservation Nicole Look Hong, Gina Clarke, Martin Yaffe, Claire Holloway Mammogram Detection Is a Surrogate for Favorable Tumor Biology--Analysis and Outcomes of Mammogram-Detected Breast Cancer in a Community Setting Anthony Maganini, Robert Maganini Early-Stage Breast Cancer in the Octogenarian: Tumor Characteristics, Treatment Choices, and Clinical Outcomes Anita Mamtani, Julie Gonzalez, Dayna Neo, Priscilla Slanetz, Mary Jane Houlihan, Christina Herold, Abram Recht, Michele Hacker, Ranjna Sharma Early Complications After Oncoplastic Reduction Anne Mattingly, Zhenjun Ma, Paul Smith, John Kiluk, Nazanin Khakpour, Susan Hoover, Christine Laronga, Marie Lee Understanding Current Practices and Barriers to the Integration of Oncoplastic Breast Surgery: A Canadian Perspective Jessica Maxwell, Amanda Roberts, Tulin Cil, Ron Somogyi 2, Fahima Osman Does Body Mass Index Affect the Accuracy of Preoperative Clinical Axillary Nodal Assessment in Breast Cancer Patients? Damian McCartan, Anne Eaton, Michelle Stempel, Monica Morrow, Melissa Pilewskie Preoperative Breast MRI Utilization After Implementation of a Care Path: Progressing Toward Value-Based Care Devina McCray, Ashley Simpson, Najaah Hussain, Yitian Liu, Colin O'Rourke, Stephanie Valente, Joseph Crowe, Stephen Grobmyer, Holly Pederson Are the Current Screening Guidelines Appropriate for All Populations? A Review of Breast Cancer Incidence in an Urban Minority Population Christopher McGreevy, Lucas Ohmes, Ogori Kalu Outcomes Disparities for Invasive Breast Cancer in Southeast Rural Communities May Be Related to Delays in Treatment James McLoughlin, Amila Orucevic, Jillian Lloyd, R. Eric Heidel Overutilization of Axillary Surgery for Patients With Ductal Carcinoma In Situ Megan Miller, Alexandra Kyrillos, David Winchester, Katharine Yao American Society of Breast Surgeons Nipple-Sparing Mastectomy Registry Preliminary Oncologic Outcome Sunny Mitchell, Peter Beitsch, Shawna Willey, Sheldon Feldman, Ameer Gomberawalla, Timothy Hall, Andrew Ashikari, Claire Carman, Leigh Neumayer, Alison Laidley, Robert Maganini, Aislinn Vaughan, Suzanne Hoekstra, Ingrid Sharon, Mary Pronovost, Eric Brown, Elizabeth Dupont, Jeannie Shen, Erna Busch-Devereaux, Leah Gendler, Barbara Ward Oncologic Outcomes Following Nipple-Sparing Mastectomy Tracy-Ann Moo, Tiffany Pinchinat, Simone Mays, Alyssa Landers, Paul Christos, Eleni Tousimis, Alexander Swistel, Rache Simmons The American Society of Breast Surgeons xi 2016 Official Proceedings
12 Improved Survival with Postmastectomy Radiation Therapy in Premenopausal Patients With T1-T2 Breast Cancer and 1 3 Positive Lymph Nodes Yijia Mu, Emilia Diego, Priscilla McAuliffe, Kandace McGuire, Atilla Soran, Marguerite Bonaventura, Ronald Johnson, Sushil Beriwal, Gretchen Ahrendt Use of Intraoperative Frozen-Section Analysis in Ductal Carcinoma In Situ for Detecting Upstaging to Invasive Disease Brittany Murphy, Alexandra Gonzalez Juarrero, Amy Degnim, Tashinga Musonza, William Harmsen, Judy Boughey, Tina Hieken, Elizabeth Habermann, Beiyun Chen, Amy Conners, James Jakub Contralateral Prophylactic Mastectomy in Women With T4 Locally Advanced Breast Cancer Brittany Murphy, Tanya Hoskin, Judy Boughey, Amy Degnim, Katrina Glazebrook, Tina Hieken Locoregional Recurrence and Adverse Events in Single-Lumen vs Multi-Lumen Catheter: A Single-Center Experience Using MammoSite Balloon Catheter 5-Day Targeted Radiation Therapy Mary Murray, Shannon Schwartz, Sommer Gunia, Ashley McCorkle, Katherine Billue Does the High Axillary False-Negative Sentinel Lymph Node Rate Reported in the Neoadjuvant Clinical Trials Translate Into a High Axillary Local Recurrence Rate? Salvatore Nardello, Elizabeth Handorf, Elin Sigurdson, John Daly, Marcia Boraas, Richard Bleicher Utility of Clinical Breast Exams in Detecting Local-Regional Recurrence in Women With a Personal History of High-Risk Breast Cancer Heather Neuman, Jessica Schumacher, Amanda Francescatti, Taiwo Adesoye, Menggang Yu, Yajuan Si, Daniel McKellar, David Winchester, Caprice Greenberg Routine Overnight Admissions for Mastectomy Patients Are Unnecessary: Contemporary Insights From a Patient-Centered Outcome Study Toan Nguyen, Caitlyn Lesh, Vivian Lindfield A Comparison of Selective Shaved Margins With Intraoperative Specimen Radiography and Routine Shaved Margins to Decrease Re-Excision Rates in Patients With Clinically Occult Breast Cancer Stefania Nolano, Liza Thalheimer, Edena Grujic, Eddy Yu, William Carter, Thomas Frazier Intraoperative Radiation Therapy (IORT) in Patients With Breast Augmentation Colleen O Kelly Priddy, Melinda Epstein, Julie Sprunt, Melanie Crutchfield, Sadia Khan, Peter Chen, Brian Kim, Lisa Guerra, Lincoln Snyder, Colleen Coleman, January Lopez, Ralph Mackintosh, Cristina DeLeon, Melvin Silverstein A New Era of Neoadjuvant Treatment With Pertuzumab: Should the 10-Lymph Node Guideline for Axillary Lymph Node Dissection in Breast Cancer Be Revised? Michael O Leary, Brian Beckord, Kyle Mock, Rose Venegas, James Yeh, Christine Dauphine, Junko Ozao-Choy The Impact of the Affordable Care Act on North Carolinian Breast Cancer Patients Seeking Financial Support for Treatment Samilia Obeng-Gyasi, Lisa Tolnitch, Shelley Hwang Criteria for the Clinical Use of MarginProbe in Breast-Conserving Surgery Oded Olsha, Mahmoud Salman, Tal Hadar, Ribhi Abu Dalo, Moshe Carmon Re-excision Rates for Breast-Conserving Surgery Less Than 5% How We Do It Rodrigo Oom, Catarina Santos, Francisco Cabral, Mariana Sousa, Ricardo Nogueira, João Leal-Faria, António Bettencourt Impact of ACOSOG Z0011 Study How Many Axillary Lymph Node Dissection Can We Avoid? Rodrigo Oom, Catarina Santos, Francisco Cabral, Mariana Sousa, João Leal-Faria, António Bettencourt Hormone Receptor Profile Cannot Predict Upstage Risk of Atypical Ductal Hyperplasia Tawakalitu Oseni, John Childs, Angela Bachmann, Ryan Rockhill, Cary Goepfert, Peter Soballe Shifting Paradigms in Breast Cancer Screening for Women Younger Than 45 Years Seyed Pairawan, Karen Koehn, Sharon Lum Percutaneous Sentinel Node Biopsy in Breast Cancer: Results of a Phase I Study Seyed Pairawan, Cherie Cora, Windy Olaya, Sharon Lum The American Society of Breast Surgeons xii 2016 Official Proceedings
13 Racial Disparities in Lumpectomy and Mastectomy Rates Narrowing the Gap? Caitlin Patten, Kendall Walsh, Terry Sarantou, Lejla Hadzikadic-Gusic, Meghan Forster, Deba Sarma, Yimei Han, Richard White, Jr The Effect of MarginProbe in the Era of No Ink on Tumor Clear Margin Definition James Pellicane, Misti Wilson, Kathryn Childers, Polly Stephens Impact of Salvage Surgery on Survival in Stage IV Breast Cancer Patients Muhammad Pirzada, Irfan Ul Islam Nasir, Awais Malik, Razia Bano, Muhammad Shah, Amina Khan, Muhammad Chaudry Factors Associated With the Decision to Pursue Elective Surgery Among Women Enrolled in TBCRC013: A Prospective Registry of Surgery in Patients Presenting With Stage IV Breast Cancer Jennifer Plichta, Sylvia Reyes, Elizabeth Frank, Mithat Gonen, Amy Voci, Camilla Boafo, Shelley Hwang, Hope Rugo, Michael Alvarado, Minetta Liu, Judy Boughey, Lisa Jacobs, Helen Krontiras, Kandace McGuire, Anna Storniolo, Rita Nanda, Mehra Golshan, Claudine Isaacs, Ingrid Meszoely, Catherine Van Poznak, Gildy Babiera, Larry Norton, Monica Morrow, Eric Winer, Antonio Wolff, Clifford Hudis, Tari King DCIS Among Males and Females: Are There Outcome Differences? Amy Polverini, Leanne Goldstein, Rondi Kauffmann, Veronica Jones, Lily Lai, Lesley Taylor, John Yim, Laura Kruper, Courtney Vito Patient Satisfaction, Oncologic Outcomes, and Complications Following Nipple-Sparing Mastectomy in the Radiated Patient Lindsay Potdevin, Aiste Gulla, Sulakshana Seevaratnam, Bridget Oppong, Shawna Willey, Eleni Tousimis Feasibility of the LUM Imaging System for Real-Time, Intraoperative Detection of Residual Breast Cancer in Lumpectomy Cavity Margins Upahvan Rai, Rong Tang, Jennifer Plichta, Andrea Merrill, Travis Rice-Stitt, Michele Gadd, Michelle Specht, Elena Brachtel, Barbara Smith Margins in Lumpectomy. Transition From a Full Cavity Shave Approach to a Targeted Shaving Approach Using MarginProbe Vincent Reid, Jeffrey Coble Factors Associated With Unplanned Reoperations Following Postmastectomy Breast Reconstruction: A Population-Based Study Amanda Roberts, Nancy Baxter, Rinku Sutradhar, Cindy Lau, Toni Zhong The Impact of Body Mass Index (BMI) on Satisfaction With Appearance and Preservation of the Breast s Role in Intimacy Before and After Breast Cancer Surgery Kristin Rojas, Christina Raker, Natalie Matthews, Melissa Clark, Erin Kunkel, Michaela Onstad, Ashley Stuckey, Jennifer Gass Early Adoption of the SSO-ASTRO Consensus Guidelines on Margins for Breast- Conserving Surgery with Whole-Breast Irradiation in Stages I and II Invasive Breast Cancer: Initial Experience Laura Rosenberger, Anita Mamtani, Sarah Fuzesi, Michelle Stempel, Anne Eaton, Monica Morrow, Mary Gemignani Calculation of Breast Volumes from Mammogram: Comparison of Four Separate Equations Relative to Mastectomy Specimen Volumes Jack Rostas, Morgan Crigger, Reiss Hollenbach, Stacey Crawford, Nicolas Ajkay Clinical Utility of Axillary Ultrasound Before Surgery in Breast Cancer Patients With Biopsy-Proven Node-Positive Before Neoadjuvant Treatment Isabel Rubio, Antonio Esgueva-Colmenarejo, Roberto Rodriguez-Revuelto, Rafael Salvador Sentinel Lymph Node Mapping in Breast Cancer After Neoadjuvant Chemotherapy: A Single Institution Experience Walid Salamoun, Dani Abi Gerges, Saad Khairallah, Ahmad Yatim, Michel El-Houkayem, Georges Chahine, Elias El Ghoul Local Recurrence After Breast-Conserving Therapy: Single-Center Study of Population With High Percentage of Bad Prognostic Factors Mariam Salim, Jamshaid Hameed, Muhammad Pirzada, Razia Bano, Amina Khan, M. Zulqarnain Chaudhary, Huma Majeed Khan The American Society of Breast Surgeons xiii 2016 Official Proceedings
14 Breast Density and Positive Lumpectomy Margins Freya Schnabel, Jennifer Chun, Shira Schwartz, Deborah Axelrod, Amber Guth, Richard Shapiro, Roses Daniel, Karen Hiotis, Agnes Radzio Replacing Open Surgical Lumpectomy With a Percutaneous Approach for Small Breast Cancers Steven Schonholz Is Immunohistochemistry Necessary for Diagnosing Sentinel Lymph Node Metastasis in Invasive Lobular Breast Cancer? Piyush Sharma, Amy Cyr Diagnostic Performance of Molecular Breast Imaging in Women With Complex Mammographic Findings Robin Shermis, Haris Kudrolli A Novel Form of Breast Intraoperative Radiation Therapy With CT-Guided HDR Brachytherapy: Results of a Phase I Trial Shayna Showalter, David Brenin, Anneke Schroen, Kelli Reardon, Bruce Libby, Gina Petroni, Timothy Showalter Immediate Reconstruction in Inflammatory Breast Cancer: Challenging Current Care Ashley Simpson, Devina McCray, Joseph Crowe, Risal Djohan, Rahul Tendulkar, Colin O'Rourke, Stephen Grobmyer, Stephanie Valente Piloting of Psychosocial Distress Monitoring in a Multidisciplinary Breast Center Kristin Skinner, Linda Bell, Martha Neubert Age Under 40 Is a Predictor of Poor Breast Cancer Outcome Julie Sprunt, Melinda Epstein, Melanie Crutchfield, Colleen O Kelly Priddy, Sadia Khan, Melvin Silverstein Diagnostic Dilemma of Preoperative Differentiation of Fibroepithelial Lesions of the Breast Heather Stuart, Keren Braithwaite, Gregory Tiesi, Eli Avisar, Frederick Moffat, Dido Franceschi, Danny Yakoub Nipple Changes During and After Pregnancy in Women Who Have Undergone Nipple- Sparing Mastectomy Rong Tang, Suzanne Coopey, Jennifer Plichta, Upahvan Rai, Amy Colwell, Michele Gadd, Michelle Specht, William Austen 1, Barbara Smith Evaluation of Shaved Cavity Margins with Microcomputed Tomography A Novel Method for Predicting Lumpectomy Margin Status Intraoperatively Rong Tang, Molly Griffin, Mansi Saksena, Suzanne Coopey, Daniel DiCorpo, Michele Gadd, Michelle Specht, Elena Brachtel, James Michaelson, Barbara Smith Sentinel Lymph Node Biopsy (SLNB) in Low-Risk Settings Marios Tasoulis, Tyler Hughes, Gildy Babiera, Anees Chagpar The Impact of Obesity on the Rate of Surgical Biopsy After Identification of a Mammographic Abnormality Sarah Tevis, Heather Neuman, Jennifer Steiman, Caprice Greenberg, Lee Wilke A Comparison of Interval-Detected and Screening-Detected Breast Cancer in a Community Breast Center Liza Thalheimer, Stefania Nolano, Eddy Yu, Anne Marie McGrath, William Carter, Thomas Frazier MRI in Invasive Lobular Carcinoma Improves Preoperative Tumor Size Determination But Increases Mastectomy Rate Anjali Thawani, Serine Baydoun, Charmi Vijapura, Sonia Sugg, Carol Scott-Conner, Ronald Weigel, Lillian Erdahl, Junlin Liao, Limin Yang, Ingrid Lizarraga Primary Radiotherapy and DIEP [Deep Inferior Epigastric Perforator] Flap Reconstruction (PRADA) Study: Findings From the Pilot Study Paul Thiruchelvam, Susan Cleator, Simon Wood, Daniel Leff, Navid Jallali, Fiona MacNeill, Dimitri Hadjiminas Racial Differences in Utilization of Breast Conservation Surgery: Results From the National Cancer Database (NCDB) Princess Thomas, Brigid Killelea, Nina Horowitz, Anees Chagpar, Donald Lannin Drain Care After Mastectomy: Practice Patterns Among Members of The American Society of Breast Surgeons Alyssa Throckmorton, Barbara Wexelman, Jeffrey Landercasper, Amy Degnim The American Society of Breast Surgeons xiv 2016 Official Proceedings
15 Disease-Free Survival Using Lymph Node Ratio Analysis After Neoadjuvant Chemotherapy Jacqueline Tsai, Danielle Bertoni, Ching Ya Tsai, Tina Hernandez-Boussard, Irene Wapnir A Population-Based Study of the Effects of a Regional Guideline for Completion Axillary Node Dissection on Axillary Surgery in Patients With Breast Cancer Miriam Tsao, Sylvie Cornacchi, Nicole Hodgson, Marko Simunovic, Ji Cheng, Lehana Thabane, Mary Ann O Brien, Barbara Strang, Som Mukherjee, Peter Lovrics Clinical Benefit and Accuracy of Preoperative Breast Magnetic Resonance Imaging for Breast Cancer Jennifer Tseng, Chi-Hsiung Wang, Erik Liederbach, Olga Kantor, Jacob Ecanow, Georgia Spear, Alexandra Kyrillos, Katharine Yao Process of Care in Breast Reconstruction and the Impact of a Dual-Trained Surgeon Jonathan Unkart, Christopher Reid, Anne Wallace Clinical Presentation and Management Considerations for Breast Cancer Patients With Germline PALB2 Mutations Karen Vikstrom, Jennifer Fulbright, Scott Michalski, Shan Yang, Steve Lincoln, Ed Esplin Upper Extremity Port Placement Is a Safe and Preferred Approach for Women With Breast Cancer: Patient-Reported Outcomes Amy Voci, David Lee, Nicole Andal, Rebecca Crane-Okada, Maggie DiNome Comparison of Toxicity and Cosmesis Outcomes of Single Fraction and Hypofraction With Intraoperative Radiation Therapy Boost in Breast Cancer Lawrence Wagman, Wesley Babaran, Monica Hanna, Robert Ash, Jay Harness, Afshin Forouzannia, Michele Carpenter, Venita Williams, Gobran Maher, Tanuja Bhandari, Rajesh Khanijou, Brian Kaltenecker, Brittany Wagman Incidence in DCIS in Over-80 Population and Survival Benefits of Treatment Erin Ward, Weiss Anna, Sarah Blair How Reliably Does Magnetic Resonance Imaging Predict Pathologic Complete Response in the Breast and Axilla Following Neoadjuvant Chemotherapy for Breast Cancer? Joseph Weber, Anne Eaton, Michelle Stempel, Imelda Burgan, Maxine Jochelson, Andrea Barrio, Deborah Capko, Hiram Cody, Mary Gemignani, Alexandra Heerdt, Monica Morrow, Melissa Pilewskie, Plitas George, Virgilio Sacchini, Lisa Sclafani, Kimberly Van Zee, Mahmoud El-Tamer The Level of Estrogen and Progesterone Receptor Immunoreactivity Correlates With Time to Disease Recurrence in Hormone Receptor-Positive Breast Cancer Megan Winner, Martin Rosman, Charles Mylander, Rubie Sue Jackson, Marcos Pozo, Christopher Umbricht, Lorraine Tafra Surgical Breast Cancer Care for Hispanic Patients Who Travel to an Academic Cancer Center Rachel Yang, Kim Rhoads, Irene Wapnir Cost Analysis of a Surgical Margin Consensus Guideline in Breast-Conserving Surgery Jennifer Yu, Amy Cyr, Rebecca Aft, William Gillanders, Timothy Eberlein, Julie Margenthaler The American Society of Breast Surgeons xv 2016 Official Proceedings
16 Scientific Presentations 2016 Note: Presenter indicated with underscore. Scientific Session Oral Presentations I Friday, April 15, :15 pm 3:15 pm Moderators: Judy Boughey, MD; Mahmoud El-Tamer, MD Scientific Session Oral Presentations II Saturday, April 16, :00 pm 3:00 pm Moderators: Michael Alvarado, MD; Jill Dietz, MD Survey of Patient Perspectives on Receiving a New Breast Cancer Diagnosis and Testing Results: Can We Do Better? Deanna Attai 1, Regina Hampton 2, Alicia Staley 3, Andrew Borgert 4, Jeffrey Landercasper 4 1 David Geffen School of Medicine at UCLA, Burbank, CA, 2 Comprehensive Breast Care, Doctors Community Hospital, Lanham, MD, 3 Akari Health, Charlestown, MA, 4 Gundersen Medical Foundation, La Crosse, WI Objective: There is conflicting information in the literature regarding how and when physicians deliver test results to patients, and how patients prefer to receive test results. A recent discussion on a private online breast surgeon forum (The American Society of Breast Surgeons Mastery of Breast Surgery) noted variation in the way breast surgeons delivered test results. Our aim was to survey cancer patient communities to determine if there was a difference between how test results were delivered compared to how patients prefer to receive cancer-related test results. Methods: IRB approval with waiver of informed consent was obtained for a de-identified survey, which was distributed over 11 days to both in-person and online cancer support groups. Associations of patient characteristics with their actual and preferred wait times for a new breast cancer diagnosis was performed by Pearson s chi-square or Fisher exact test. Bowker s test of symmetry was used to test for nonreciprocal association between actual and preferred patient experiences, and a significant P value (<0.05) was interpreted to signify a systematic preference among respondents regarding possible patient care experiences. Results: One thousand patients completed the survey. The analysis was restricted to 784 breast cancer survivors. Survey responders were predominately white (non-hispanic) (89.2%), college educated (78.7%), and social media savvy (online medical media usage, 97%). Fifty percent lived in communities with a population greater than 100,000. There were no differences between patient characteristics and time to receive biopsy results. Differences between patients and their timeliness and preferences were identified in other domains. Ninety-eight (79%) of 124 patients age <45 and 434 (65.8%) of 660 patients age >45 preferred an appointment within 24 hours after receipt of cancer diagnosis (P = ). Other significant differences in mode of communication for test results were identified by race, level of education, and online medical usage, with non-white race, non-college educated, and lower online usage associated with more preference for faceto-face mode, compared to phone and electronic modes. (See table for comparison of actual to preferred care.) continues The American Society of Breast Surgeons Official Proceedings
17 Comparison of Actual and Preferred Breast Cancer Patient Care (N = 784) Care Domain Actual Care (N/D) % Preferred Care (N/D) % P Communication of new cancer diagnosis Telephone 419/784 (54%) 268/784 (34%) < Face to face 309/784 (39%) 394/784 (50%) Other 56/784 (7%) 122/784 (16%) Wait time for biopsy results 2 days 315/784 (40%) 646/784 (82%) < days 309/784 (40%) 121/784 (16%) 6 days 160/784 (20%) 17/784 (2%) Communication of recurrent or metastatic diagnosis Telephone 68/156 (43%) 43/156 (27%) Face to face 71/156 (46%) 93/156 (60%) Other 17/156 (11%) 20/156 (13%) Wait time for radiology results 2 days 397/784 (51%) 660/784 (84%) < days 221/784 (28%) 110/784 (14%) 6 days 166/784 (21%) 14/784 (2%) Wait time for blood tests 2 days 416/784 (53%) 616/784 (79%) < days 220/784 (28%) 150/784 (19%) 6 days 148/784 (19%) 18/784 (2%) Conclusion: This study is limited by its narrow demographic profile; yet, even within this cohort presumed to have ready access to healthcare resources, actual care for timeliness and modes of communication did not reflect achievable or patient-desired care. In particular, patients want more timely appointments and patientspecific modes of communication than they are receiving. They also want more rapid receipt of testing results. National and local initiatives to improve performance are needed, as well as interrogation of other demographic groups. As a first step, we recommend that each patient be queried about their preference for mode of communication and timeliness, and that efforts are made to comply Complications of Oncoplastic Breast Surgery vs Breast-Conserving Surgery: An Analysis of the NSQIP Database Tulin Cil 1, Erin Cordeiro 2 1 Women s College Hospital and University Health Network, Toronto, ON, Canada, 2 Ottawa Hospital, Ottawa, ON, Canada Objective: Oncoplastic breast surgery aims to provide breast cancer patients with optimum oncologic outcomes and excellent cosmesis. The purpose of this study was to determine if there was a difference in surgical complications associated with oncoplastic breast surgery, compared to the traditional breastconserving surgical approach. Methods: We analyzed the American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) database. The study included breast cancer patients who underwent primary breast surgery from Patients undergoing concurrent high-risk nonbreast surgery, male patients, and those with metastatic disease were excluded. Univariable analysis and multivariable logistic regression were performed to determine the independent effect of oncoplastic breast surgery on postoperative morbidity and mortality, and identify predictors of postoperative complications. The American Society of Breast Surgeons Official Proceedings
18 Results: We identified 66,821 patients who underwent breast-conserving surgery for invasive breast cancer and/or ductal carcinoma in situ between 2005 and Patients who underwent lumpectomy with concomitant CPT (Current Procedure Terminology) codes identifying tissue transfer were categorized as having an oncoplastic procedure (n = 1,016; 1.5%). There was a steady increase in the proportion of oncoplastic cases over the study period. Compared to the standard lumpectomy group, patients in the oncoplastic group were more likely to be younger (60 vs 62 years, p < 0.01), have lower body mass index (29 vs 30, p < 0.01), were less likely to be smokers (9% vs 11%, p < 0.01), and more often received neoadjuvant chemotherapy (4.4% vs 2.1%, p < 0.01). They also had a significantly longer operative time (80 vs 59 min, p < 0.01). The 30-day unadjusted overall morbidity rate was not different in the oncoplastic group compared to the standard lumpectomy group (1.48% vs 1.97%, p = 0.26). The multivariable analysis also confirmed that oncoplastic surgery was not an independent predictor of overall complications (OR = 0.64 [0.37, 1.10]). Conclusion: These data confirm that the use of oncoplastic techniques during breast-conserving surgery for breast cancer treatment does not confer an increased risk of surgical complications, despite the longer operative time. This is important given the increasing use of oncoplastic surgery within North America. Demographics Number of Patients (%) Total (n = 63,913) Patients Who Underwent an Oncoplastic Type Lumpectomy (n = 1,016) Patients Who Underwent a Routine Lumpectomy (n = 62,897) P value Mean age (years) [SD] [12.64] [12.35] [12.64] < Mean BMI (kg/m 2 ) [SD] [7.40] [7.35] [7.40] Smoker 7,588 (11.87) 94 (9.25) 7,494 (11.91) Year of surgery ,259 (1.97) 24 (2.36) 1,235 (1.96) < ,189 (6.55) 60 (5.91) 4,129 (6.56) ,443 (10.08) 47 (4.63) 6,396 (10.17) ,483 (10.14) 52 (5.12) 6,431 (10.22) ,048 (12.59) 56 (5.51) 7,992 (12.71) ,243 (12.90) 125 (12.30) 8,118 (12.91) ,446 (13.21) 199 (19.59) 8,247 (13.11) ,585 (15.00) 219 (21.56) 9,366 (14.89) ,217 (17.55) 234 (23.03) 10,983 (17.46) Undergoing ALND 9,123 (14.27) 108 (10.63) 9,015 (14.33) Contralateral mastectomy 93 (0.15) 0 93 (0.15) 0.22 Diabetes 7,465 (11.68) 121 (11.91) 7,344 (11.68) ASA Class 1 5,066 (7.94) 93 (9.15) 4,973 (7.92) 2 40,047 (62.78) 679 (66.83) 39,368 (62.72) 3 17,891 (28.05) 237 (23.33) 17,654 (28.12) (1.03) 7 (0.69) 648 (1.03) 5 2 (0) 0 2 (0) Missing (ASA class) 252 History of COPD 1,674 (2.62) 15 (1.48) 1,659 (2.64) History of myocardial infarction (MI) 45 (0.11) 1 (0.18) 44 (0.1) Missing (MI) 21,172 (33%) Hypertension 29,416 (46.03) 392 (38.58) 29,024 (46.15) < The American Society of Breast Surgeons Official Proceedings
19 Demographics Number of Patients (%) Received chemotherapy within 30 days pre-op Total (n = 63,913) Patients Who Underwent an Oncoplastic Type Lumpectomy (n = 1,016) Patients Who Underwent a Routine Lumpectomy (n = 62,897) P value 925 (2.16) 24 (4.40) 901 (2.14) Received radiation in 90 days pre-op 95 (0.22) 1 (0.18) 94 (0.22) Missing (chemo and/or radiation receipt) Total operation time (min) (median) [IQR] 21,213 (33%) 59.0 [46.0] 80.0 [55.0] 59.0 [45.0] < Bleeding disorder 964 (1.51) 13 (1.28) 951 (1.51) Pregnant 26 (0.07) 0 26 (0.07) 1 Preoperative steroid use 960 (1.50) 15 (1.48) 945 (1.50) Median length of stay (days) [range] 0.0 [0 94] 0.0 [0 37] 0.0 [0 94] Type of surgeon performing the primary surgery (eg, lumpectomy) General surgeon 63,689 (99.65) 1,015 (99.90) 62,674 (99.65) Plastic surgeon 144 (0.23) (0.23) Ob/Gyn 22 (0.03) 0 22 (0.03) Other 58 (0.09) 1 (0.10) 57 (0.09) Resident involvement Attending alone 19,646 (30.74) 247 (24.31) 19,399 (30.84) Attending in OR 15,028 (23.51) 144 (14.17) 14,884 (23.66) Attending and resident in OR 8,180 (12.80) 157 (15.45) 8,023 (12.76) Missing (resident involvement) 21,059 (33%) 0.44 < A Prospective, Single-Arm, Multi-Site Clinical Evaluation of a Nonradioactive Surgical Guidance Technology for the Location of Nonpalpable Breast Lesions During Excision Charles Cox 1, Peter Blumencranz 2, Pat Whitworth 3, Kristi Funk 4, Julie Barone 5, Alice Police 6, Freya Schnabel 7, Beth Anglin 8, Lynn Canavan 9, Alison Laidley 10, Mary Jane Warden 11, Scott Russell 1, Ebonie Carter 1, Jeff King 1, Steven Shivers 1 1 USF Breast Health Program, Tampa, FL, 2 Morton Plant Mease Hospital, Clearwater, FL, 3 Nashville Breast Center, Nashville, TN, 4 Pink Lotus Breast Center, Beverly Hills, CA, 5 Cancer Centers of Colorado, Denver, CO, 6 UC Irvine Health Pacific Breast Care Center, Irvine, CA, 7 NYU Langone Medical Center, New York, NY, 8 Medical Center of Plano, Plano, TX, 9 Baylor Regional Medical Center at Plano, Plano, TX, 10 Texas Breast Specialists, Dallas, TX, 11 Hackensack University Medical Center, Hackensack, NJ Objective: The standard technique for localization of nonpalpable breast lesions is wire localization (WL), which has been found to have several procedural and workflow-related pitfalls. Radioactive seed localization (RSL) and intraoperative ultrasound (IOUS) have been shown to result in lower margin positivity, fewer reexcisions, increased patient satisfaction, and better patient care coordination, but they too have challenges that have adversely impacted their adoption. The SAVI SCOUT surgical guidance system is a new FDA-cleared medical device that utilizes nonradioactive, electromagnetic wave and infrared light technology to provide real-time guidance during excisional breast procedures. The purpose of this study is to evaluate the performance of SCOUT in guiding the removal of nonpalpable breast lesions across multiple sites and physicians. The American Society of Breast Surgeons Official Proceedings
20 Methods: Institutional Review Board approval was granted for all institutions to enroll women with a nonpalpable breast lesion requiring preoperative localization for excision. Participating patients underwent localization and excision with SCOUT, which consists of an infrared-activated electromagnetic wave reflective device (reflector), handpiece, and console. Using mammographic or ultrasound guidance, the reflector was implanted into the target tissue up to 7 days prior to the scheduled excisional procedure. Before making an incision, the surgeon used the handpiece, which emits infrared light and electromagnetic waves, to detect the location of the reflector and subsequently plan the surgical incision. During the procedure, the surgeon used the handpiece to guide the localization and removal of the reflector along with the surrounding breast tissue. The console provides audible feedback on handpiece-to-reflector proximity. Primary endpoints included successful reflector placement, localization, and retrieval. Results: To date, 128 pts have participated in the study, along with 17 surgeons and 23 radiologists from 11 institutions. The reflectors were successfully placed in 127 (99%) pts under either radiographic (mammography or stereotactic) or ultrasound guidance, either on the day of surgery or up to 7 days (avg, 2.6 days) before surgery. Thirty-seven pts underwent excisional biopsy and 85 pts had a lumpectomy. The intended lesion and reflector were successfully removed in all pts. No adverse events occurred. For 83 pts with in situ and/or invasive cancer and complete data, 13 (15.7%) had positive margins and 12 (14.5%) were recommended for reexcision. Conclusion: The preliminary data show that real-time surgical guidance with SCOUT is an accurate technique for directing the removal of nonpalpable breast lesions and reproducible at multiple sites. The study has yielded 100% surgical success with a re-excision rate comparable to that of RSL and IOUS. Ongoing accrual to this study will validate these findings with planned enrollment of 150 pts from 11 sites Anti-HER-3 CD4 Th1 Response Correlates With Invasive Breast Cancer Phenotypes and Prognosis Megan Fracol 1, Jashodeep Datta 1, Shuwen Xu 1, Elizabeth Fitzpatrick 1, Lea Lowenfeld 1, Paul Zhang 1, Carla Fisher 1, Brian Czerniecki 1 1 University of Pennsylvania, Philadelphia, PA Objective: We have previously shown a stepwise decline in native CD4 Th1 cell immune response to human epidermal growth factor receptor 2 (HER-2), going from healthy donors (HD) to HER-2pos ductal carcinoma in situ (DCIS) to HER-2pos invasive breast cancer (IBC). It is unknown whether other anti-oncodriver Th1 responses, specifically HER-3, are similarly lost during breast tumorigenesis. Methods: Peripheral blood from 131 subjects, including HDs, benign breast disease (BD), DCIS, and IBC patients was collected. Immune responses to 4 different HER-3 immunogenic peptides were tested via enzymelinked immunosorbent (ELISpot) assay. Three immune response parameters were compared: (1) responsivity, or percent of subjects responding to at least 1 peptide, (2) repertoire, or number of peptides with a response, and (3) cumulative peptide response, or the summed total of the 4 peptide responses. Results: There was a significant decline in the anti-her-3 CD4 Th1 cell response going from HDs to IBC. Triple-negative (TN) IBC had the lowest response across all 3 immune parameters. HDs had significantly higher immune responses than both ERpos IBC and TN IBC patients across all 3 immune parameters (cumulative response: 90 vs 48 vs 40, p = 0.03 and p = 0.002, respectively; repertoire: 1.0 vs 0.5 vs 0.3, p = and p = , respectively; and responsivity: 76.7% vs 45.0% vs 33.3%, p = 0.03 and p = 0.001, respectively). Interestingly HER-2pos IBC displayed immune responses similar to that of HDs and BDs. There was antigen expression correlation with HER-3 expression being significantly higher in TN IBC compared to HER-2pos IBC (43.8% vs 0%, p = 0.03, respectively) but not significantly different between TN IBC and ERpos IBC (43.8% vs 18.8%, p = 0.25, respectively). Clinically, patients with recurrent breast cancer had significantly lower immune responses than patients with no subsequent recurrences across all 3 immune parameters (cumulative response: 17 vs 66, p = 0.04, respectively; repertoire: 0.0 vs 0.6, p < 0.05, respectively; and responsivity: 0% vs 55.6%, p = 0.01, respectively). Patients with pathologic complete responses (pcr) to The American Society of Breast Surgeons Official Proceedings
21 neoadjuvant treatment also had significantly higher cumulative response (144 vs 32, p = 0.004, respectively) and repertoire (0.8 vs 0.4, p = 0.05, respectively) than those with residual disease. Conclusion: CD4 Th1 cell anti-her-3 immune responses progressively decline during breast tumorigenesis, most notably in TN IBC, a group with limited treatment options and markedly worse prognosis with HER-3 overexpression. Restoring anti-her-3 Th1 may offer opportunity for improving outcomes in high-risk TN IBC patients Postmastectomy Radiation Therapy and Overall Survival After Neoadjuvant Chemotherapy Olga Kantor 1, Catherine Pesce 2, Chi-Hsiung Wang 2, David Winchester 2, Katharine Yao 2 1 University of Chicago, Chicago, IL, 2 NorthShore University HealthSystem, Evanston, IL Objective: The survival benefit of postmastectomy radiation therapy (PMRT) after neoadjuvant chemotherapy (NAC) is unclear; especially in patients who have a pathologic compete response (pcr) to NAC. Methods: We queried the National Cancer Data Base to identify 19,526 women who had PMRT after NAC and mastectomy for ct3n0, cn1, and cn2 disease from pcr was determined based on final pathologic stage compared to clinical stage. Patients with metastatic disease were excluded. Chi-square tests and Cox regression survival modeling were used for analysis. Results: Our cohort of patients included 2,536 women (13.0%) with ct3n0 disease, 13,026 (66.7%) with cn1 disease, and 3,964 (20.3%) with cn2 disease. Overall, 1,685 (66.4%) of ct3n0 patients, 8,920 (68.5%) of cn1 patients, and 2,885 (72.8%) of cn2 patients received PMRT. Mean follow-up time was 74 months. After adjusting for patient, tumor, and facility factors, including tumor size, grade, and estrogen receptor status, PMRT was associated with a significant overall survival (OS) benefit in patients with ct3n0 disease (5-yr OS, 81.3% with PMRT vs 78.4% no PMRT, p < 0.01), cn1 disease (5-yr OS, 74.5% with PMRT vs 69.5% no PMRT, p < 0.01), and cn2 disease (5-yr OS, 64.4% with PMRT vs 55.2% no PMRT, p < 0.01). In the subgroup of patients who had a nodal pcr to NAC, PMRT was not associated with an OS difference in ct3n0 (87.8% with PMRT vs 86.1% no PMRT, p = 0.22), cn1 (5-yr OS, 85.6% with PMRT vs 83.5% no PMRT, p = 0.13), or cn2 (89.4% with PMRT vs 84.7% no PMRT, p = 0.09) disease. In patients 45 years old or in patients with high-grade tumors, PMRT was associated with an OS benefit for the entire cohort of patients with cn1 and cn2 disease, but not in patients who had a nodal pcr (p > 0.10) on adjusted survival modeling. Conclusion: PMRT is associated with improved OS in patients with ct3n0, cn1, and cn2 disease after NAC and mastectomy but there is no OS benefit for those patients with a nodal pcr. Prospective studies will provide definitive data on the need for PMRT in patients with pcr Are We Overtreating Ductal Carcinoma In Situ (DCIS)? Sadia Khan 1, Melinda Epstein 1, Michael Lagios 2, Melvin Silverstein 1 1 Hoag Memorial Hospital Presbyterian, Newport Beach, CA, 2 The Breast Cancer Consultation Service, Tiburon, CA Objective: During early 2015, the media was flooded with the issue of whether or not ductal carcinoma in situ (DCIS) was being overtreated and whether favorable cases could be simply watched (core biopsy only, followed by surveillance). To help answer this question, we considered patients with DCIS treated with excision alone, with a final margin width less than 1 mm, as inadequately treated and a surrogate for no treatment (surveillance). We compared this group to patients with margin widths of 1 mm or more treated by excision alone. Methods: We queried a prospective database for patients with DCIS treated with excision alone. Seven hundred twenty patients with pure DCIS (no invasion or microinvasion) were treated with excision alone and stratified into 2 groups based on margin width: 124 with margins less than 1 mm vs 596 with margins 1 mm. The American Society of Breast Surgeons Official Proceedings
22 All patients with margins <1 mm were advised to undergo re-excision but refused further treatment. Both groups were subdivided by grade. Nuclear grades I and II DCIS were statistically similar and grouped together as low-grade DCIS and compared to high grade (Grade III). Kaplan-Meier analysis was used to determine local recurrence-free survival. Differences in outcome were analyzed using the log-rank test. Results: The results are tabulated below. The 5- and 10-year local recurrence probabilities are statistically significant (<0.001) for low grade vs high grade and for narrow margins <1 mm vs wide margins 1 mm. The comparison of excision alone with margins 1 mm for low-grade DCIS vs high-grade DCIS shows a 10-year local recurrence-free survival rate of 13% vs 36% (p < 0.001). The patients who had margins of <1 mm with no further treatment had higher rates of recurrence in both the low-grade group (55%) and high-grade group (67%) (p < 0.001). These data show that leaving low-grade DCIS untreated would lead to local recurrence in more than half the patients over 5 10 years. Mean tumor size was 17 mm, mean age was 55 years, and mean follow-up was 79 months. Conclusion: For patients with low-grade DCIS excised with margins 1 mm, excision alone results in local recurrence rates of 8% and 13% at 5 and 10 years. Local recurrence rates for patients with margins less than 1 mm are simply too high to consider this adequate treatment, regardless of grade. Core biopsy and surveillance alone for DCIS, regardless of grade is not adequate. DCIS Excision Alone Margin <1 mm DCIS Excision Alone Margin >1 mm Grades Grades Grade III I & II I & II Grade III N # Distant recurrences # Breast cancer deaths yr probability, local recurrence 18% 55% 8% 23% 10-yr probability, local recurrence 53% 67% 13% 36% Fertility in Young Women of Child-Bearing Age After Breast Cancer: Are We Giving Them a Better Chance? Devina McCray 1, Ashley Simpson 1, Yitian Liu 1, Colin O'Rourke 1, Joseph Crowe 1, Rebecca Flyckt 1, Stephen Grobmyer 2, Halle Moore 1, Stephanie Valente 1 1 Cleveland Clinic, Cleveland, OH, 2 Cleveland Clinic Foundation, Cleveland, OH Objective: Breast cancer is the most frequent cancer occurring in women of reproductive age. Because chemotherapy and/or anti-hormonal therapy is usually recommended, it becomes important to consider fertility preservation before undergoing cytotoxic therapies that impair ovarian function and interrupt childbearing plans. There is significant advancement in assisted reproductive technologies and increasing use of gonadotropin-releasing hormone (GnRH) agonists for ovarian protection during chemotherapy. We evaluated whether patients had a fertility discussion (FD) with their physician, what options were chosen, and if pregnancy was achieved. Methods: A retrospective chart review was performed of all women 40 and younger diagnosed with breast cancer, treated with chemotherapy and/or anti-hormonal therapy, and followed at our facility from 2006 to Patient demographics, treatment regimens, FD, in vitro fertilization (IVF) consultation, GnRH used, and successful pregnancy were evaluated. Results: We identified 303 patients meeting inclusion criteria. Average age at diagnosis was 35.1 years (range, years) with median follow-up of 3.7 years (range, 4 months 9.5 years). At diagnosis, 32% of women were single and 68% were married. Eighty-two (27%) women had no children at time of diagnosis. Eighty (26%) of all women had a documented FD. Of those undergoing chemotherapy, 77/262 (29%) had an FD. The American Society of Breast Surgeons Official Proceedings
23 Twenty-one (26%) of those women were prescribed GnRH agonist for ovarian protection while on chemotherapy, 55 (69%) underwent IVF consultation, and 5 (6%) had both GnRH agonist and IVF consultation. Nine (11%) patients who had FD chose no fertility options. Of 303 patients, pregnancy after treatment was seen in 22 (7%) women. Of women who had GnRH agonist prescribed, 5/21 (24%) became pregnant. Of the 55 patients who had an IVF consultation, 17 (31%) pursued oocyte retrieval and 4/17 (24%) became pregnant with embryo transfer. Three of 17 (18%) women became pregnant without embryo transfer and, of those, 2 women had GnRH agonist prescribed. Three of 9 (33%) patients having an FD but not pursuing further options became pregnant spontaneously. Seven patients (3%) not having an FD became pregnant spontaneously. Evaluation of patient demographics and tumor characteristics identified that successful pregnancy was associated with being younger at time of diagnosis (P < 0.001), and having a tumor that was ER negative (P = 0.009) and PR negative (P = 0.04). Conclusion: Despite advances in fertility options for young women, documented FD and referral in this age group remains low. Although not every woman in this group desired pregnancy, 71/80 (89%) of those having a documented FD sought some form of fertility preservation. It is important to improve fertility option awareness in both physicians and women of childbearing age, as patients who had an FD and consultation had a higher chance of pregnancy compared to those who did not Re-excision Rates After Breast Conservation Surgery in the American Society of Breast Surgeons (ASBrS) Mastery Database Following the SSO-ASTRO No Tumor on Ink Guidelines Jennifer Mirrielees 1, Amanda Schulman 1, Caprice Greenberg 2, Jeffrey Landercasper 3, Lee Wilke 2 1 University of Wisconsin, Madison, WI, 2 University of Wisconsin School of Medicine and Public Health, Madison, WI, 3 Gundersen Medical Foundation, La Crosse, WI Objective: In February 2014, the Society of Surgical Oncology (SSO) and the American Society for Radiation Oncology (ASTRO) released new guidelines for standardizing a negative margin status after breast conservation surgery (BCS) as no tumor on ink in patients with an early invasive cancer. These new guidelines were widely hypothesized to reduce re-excision rates. We sought to determine if re-excision rates after initial BCS decreased in ASBrS members surgical practices after guideline publication. To evaluate if a change occurred in the year after distribution, the ASBrS Mastery of Breast Surgery Program, a voluntary quality outcomes program, was queried for re-excision rates for BCS from January 2013 to June The American Society of Breast Surgeons Official Proceedings
24 Methods: De-identified data documenting BCS procedures for the study time periods of Jan 2013 to Jan 2014 and then June 2014 to June 2015 were extracted from the ASBrS Mastery of Breast Surgery Program after obtaining institutional IRB approval. The time period of Jan 2014 to June 2014 was not included in the analysis to allow for review and adoption of the published guidelines. Patients undergoing excisional biopsy for diagnosis were excluded. Procedures were analyzed by reasons for re-excision (combined from several locations in the Mastery database). Statistical t test was used to determine significance (p < 0.05) Results: Among providers (n = 252) who recorded greater than 10 BCS procedures in both the pre- and post- no tumor on ink guideline periods, the overall re-excision rate after initial BCS was 17.7% (2457/13870) in the pre period, and 13.7% (1836/13370) in the post period (p = ). The time periods were then analyzed to determine causes for the re-excision and notable was a decrease in the percentage of re-excisions being done for close margins (<1 mm and 1 2 mm) from 36.8% (624/1693) in the pre period to 23.4% in the post period (379/1619) (p = ). Yet the re-excision rate in each time period for positive margins and those coded as other did not change significantly. The percentage of the re-excisions that were due to positive margins was 56.2% (952/1693) pre guideline publication and was 70.3% post-publication (1139/1619) (p = 0.109). Conclusion: Following the publication of the 2014 SSO-ASTRO no tumor on ink guidelines, a reduction in overall re-excision rates after initial BCS was observed in the ASBrS Mastery database. The reason for this reduction appears to be attributable to a decrease in re-excisions for close margins. The ASBrS Mastery represents the outcomes from a dedicated group of surgeons interested in quality improvement through selfreporting and highlights its ability to evaluate a timely response to published guidelines for breast cancer patient care Application of the 2015 ACS and ASBS Screening Mammography Guidelines: Risk Assessment Is Critical for Women Ages Jennifer Plichta 1, Suzanne Coopey 1, Michelle Specht 1, Michele Gadd 1, Erin Sullivan 1, Constance Roche 1, Barbara Smith 1, Kevin Hughes 1 1 Massachusetts General Hospital, Boston, MA Objective: The newly updated 2015 American Cancer Society (ACS) screening mammography guidelines suggest that women at average risk of breast cancer may not require screening mammograms before age 45, whereas those with an above average risk (defined as a personal history of breast cancer, confirmed or suspected genetic mutation, or history of thoracic radiotherapy at a young age) may require alternate screening regimens. The 2015 American Society of Breast Surgeons (ASBrS) guidelines are similar, with the addition of recommended screening mammograms for women with a lifetime risk of 15% 20%. In addition, the ACS MRI guidelines recommend yearly MRI plus mammography if the calculated lifetime risk is 20%. We sought to determine how many women ages 40 to 44 in our specialty breast practice would be eligible for screening mammograms, genetic testing, and MRIs based on the new guidelines. Methods: Under IRB approval, we reviewed a database of patient-reported risk factors and family history of all new female patients at a single academic institution from 3/3/2011 through 10/26/2015. We excluded patients with a personal history of breast cancer. Those with a 5% risk of BRCA mutation by the Tyrer- Cuzick, Myriad, or BRCAPRO models or who met the NCCN guidelines were considered at risk for a genetic mutation. Those with a 20% lifetime risk of breast cancer by the Tyrer-Cuzick, Claus, or BRCAPRO models were considered eligible for MRI. Results: Six thousand nine hundred sixty-four women age 40 and above who did not have a breast cancer diagnosis were seen as new patients in our breast clinic during this time period. Of these, 909 (13%) were ages 40 to 44 and make up our cohort. Of this group, our risk assessment identified 352 women (39%) deemed above average risk by the ACS criteria and an additional 103 (11%) by the ASBrS guidelines who were eligible to start screening mammography at age 40. Fifty-nine (6.5%) were found to be at risk for a suspected genetic mutation, 127 (13.8%) qualified for screening MRI, and 166 (18.3%) qualified for both genetic testing and screening MRI. The American Society of Breast Surgeons Official Proceedings
25 Conclusion: Fifty percent of women in our breast practice would have been eligible for screening mammography beginning at age 40, as identified by risk assessment. Some were also found to be at risk for a genetic mutation and/or qualify for MRI. It is essential that women age 40 to 44 have formal risk assessment in order to identify those who would qualify for screening mammography, screening MRIs, and genetic testing Time to Treatment Among Stage III Patients: Measuring Quality Breast Cancer Care Amy Polverini 1, Rebecca Nelson 1, Emily Marcinkowski 1, Veronica Jones 1, Lily Lai 1, Joanne Mortimer 1, Lesley Taylor 1, Courtney Vito 1, John Yim 1, Laura Kruper 1 1 City of Hope National Medical Center, Duarte, CA Objective: To optimize cancer care, several organizations have crafted guidelines to define best practices for treating breast cancer. Timeliness of treatment has been proposed as one of the quality metrics. Evidence to substantiate the survival benefit of timely treatment, especially for the shortest time points, such as <4 weeks, is limited. This study evaluates time to treatment in stage III breast cancer patients, the population in whom treatment time would have the most impact. Methods: Using the American College of Surgeons and American Cancer Society jointly sponsored National Cancer Data Base, time to treatment in women diagnosed with stage III breast cancer between 2004 and 2012 was evaluated. The analyses were restricted to patients who received both surgery and chemotherapy. Time from diagnosis to first treatment (chemotherapy or surgery) was calculated and grouped according to previously proposed benchmarks: <4 weeks, 4 8 weeks, 8 12 weeks, >12 weeks. Univariate and multivariate Cox proportional hazard models were used to assess patient and treatment factors related to overall survival (OS) and are expressed as hazard ratio (HR) and 95% CIs. Kaplan-Meier curves were generated to calculate 1-, 3- and 5-year OS, with group differences assessed using the log-rank test. Results: A total of 53,026 patients were identified, the majority of whom received first-line treatment within 4 weeks of diagnosis (N = 22,150). On univariate and multivariate analysis, increased time to treatment was associated with a decreased risk of mortality (table). The type of first-line treatment was more often surgery (65%, N = 30,134) than chemotherapy (35%, N = 16,130). When first line of treatment was surgery, mortality risk was decreased (HR, 0.60; 95% CI, ) relative to chemotherapy. Having Medicaid or Medicare insurance were both associated with an increased risk of mortality (1.38, , and 1.43, , respectively). Compared to whites, black patients had increased risk (1.34, ) while Asian/Pacific Islanders had decreased risk (0.66, ). Hispanic ethnicity was also associated with decreased risk (0.68, ). Treatment at an academic/research program was associated with a decreased risk (0.91, ), whereas treatment at a community cancer program had increased risk (1.11, ) when compared to comprehensive cancer programs. Time to treatment (Surgery/chemo) Univariate Multivariate * N (%) HR (95% CI) P value HR (95% CI) P value <4 weeks 22,150 (48) (reference) (reference) to <8 weeks 17,570 (38) ( ) ( ) to <12 weeks 4,588 (10) < ( ) ( ) 2, >12 weeks ( ) (4) ( ) *Multivariate analyses adjusted for type of first-line therapy, hospital type, insurance type, age, race, ethnicity, comorbidity index, grade, surgery type, adjuvant hormone therapy status, and adjuvant radiation therapy status. The American Society of Breast Surgeons Official Proceedings
26 Conclusion: Our study of 53,026 stage III breast cancer patients was unable to corroborate current quality initiatives aimed at shorter time to treatment. While this study is likely confounded by factors not available in large population-based public datasets, the findings highlight the need for more information in determining time-to-treatment guidelines. With an increased focus on multidisciplinary coordinated care for breast cancer patients, further study is warranted to establish evidence-based treatment standards and delineate subgroups that are most impacted by treatment delays. The American Society of Breast Surgeons Official Proceedings
27 Quickshot Presentations Saturday, April 16, :45 am 1:15 pm Moderators: Brian Czerniecki, MD, PhD; Roshni Rao, MD Validation of the CPS+EG Staging System for Disease-Specific Survival in Breast Cancer Patients Treated With Neoadjuvant Chemotherapy Jad Abdelsattar 1, Zahraa Al-Hilli 1, Tanya Hoskin 1, Courtney Heins 1, Judy Boughey 1 1 Mayo Clinic, Rochester, MN Objective: Neoadjuvant chemotherapy is increasingly used in the management of early-stage operable and locally advanced breast cancer. The CPS+EG staging system, which incorporates estrogen receptor status and tumor grade along with pretreatment clinical stage and post-treatment pathologic stage, has been reported to have better correlation with outcome than classic TNM staging for breast cancer patients treated with neoadjuvant chemotherapy. Our aim was to evaluate the performance of the CPS+EG staging system in an external cohort of women treated with neoadjuvant chemotherapy. Methods: We reviewed all patients treated with neoadjuvant chemotherapy for stage I IIIC disease and undergoing surgery for loco-regional control at our institution between 1988 and Patients with bilateral disease, inflammatory breast cancer, and angiosarcoma of the breast were excluded. Tumor biology, Nottingham grade, clinical stage at presentation, treatment, AJCC stage after neoadjuvant chemotherapy, and follow-up data were collected. The CPS+EG score was calculated for each case and analyzed using the Kaplan-Meier method and log-rank test for the outcome of breast cancer specific survival. The discrimination of CPS+EG and pathologic AJCC stage were assessed using the C-statistic for survival data from Cox proportional hazards regression. Results: Seven hundred sixty-nine patients were analyzed, of whom 103 died of breast cancer during a median follow-up of 2.6 (range, ) years. Median age at surgery was 51.4 (range, ). Two hundred ninety-three (38%) had ER-negative tumors, and 458 (60%) were grade 3. The 5-year cause-specific survival was 82% (95% CI, 78 86) for our cohort overall. The distribution of CPS+EG scores were 6%, score 0; 12%, score 1; 26%, score 2; 29%, score 3; 21%, score 4; 6%, score 5; and 0.4%, score 6. CPS+EG groups 0 and 1 and groups 5 and 6 were collapsed due to small sample size within these groups. The 5-year cause-specific survival by CPEG score was 91%, score 0/1; 90%, score 2; 85%, score 3; 67%, score 4; and 43%, score 5/6 (figure). The CPS+EG score was significantly associated with cause-specific survival (P < 0.001) and showed good discrimination with a C-statistic of 0.69 (95% CI, ), while AJCC pathologic stage showed a C- statistic of 0.65 (95% CI, ). continues The American Society of Breast Surgeons Official Proceedings
28 Conclusion: This study validates the CPS+EG staging system in an external cohort using Nottingham grade. CPS+EG staging system showed a significant association with cause-specific survival and good discrimination, particularly for patients in poorer prognosis groups. Inclusion of tumor biology and treatment response shows promise in improving survival estimates for patients treated with neoadjuvant chemotherapy Management of Phyllodes Tumors of the Breast: Applying the Correct Treatment Paradigm? Taiwo Adesoye 1, Heather Neuman 1, Jessica Schumacher 1, Jennifer Steiman 1, Lee Wilke 1, Caprice Greenberg 1 1 University of Wisconsin School of Medicine and Public Health, Madison, WI Objective: National Comprehensive Cancer Network (NCCN) guidelines recommend wide excision without axillary staging to treat phyllodes tumors of the breast, which have sarcomatous stroma. Without prospective trials to guide management, NCCN also recommends consideration of radiation therapy (RT) similar to soft tissue sarcoma treatment principles. Using the Surveillance, Epidemiology and End Results Program (SEER) database, we report temporal trends in initial management and factors associated with receipt of surgical and adjuvant therapy. Methods: Using the SEER registry, we identified adult women (age >18 yr) diagnosed with phyllodes tumors who underwent surgical therapy between 2000 and Patients with a diagnosis of other breast histologies were excluded. Rates of breast-conserving surgery (BCS), lymph node evaluation, and adjuvant RT over time were assessed using the Cochran-Armitage test for trend. Factors associated with receipt of BCS, lymph node evaluation, and RT were analyzed using multivariable logistic regression. Results: We identified 1,366 patients with a mean age of 51.3 years. In our cohort, 733 (53.7%) underwent BCS while 347 patients (25%) underwent nodal sampling. Nodal sampling was more common for patients receiving mastectomy, compared to BCS (43% vs 10%). Over the study period, BCS rates (p = 0.41) and rates of nodal examination (p = 0.59) were unchanged. Overall, 202 patients (14.8%) received adjuvant radiotherapy after surgery (17.4% after mastectomy vs 12.6% after BCS). Over time, there was a significant increase in RT utilization regardless of surgery type (BCS, 3.45% to 21.43%, p = ; mastectomy, 8.93% to 21.5%, p =<.0001). Women were less likely to receive BCS if they were older than 60 years (OR, 0.47; 95% CI, 0.33 The American Society of Breast Surgeons Official Proceedings
29 0.66) and had tumor size >5 cm (OR, 0.13; 95% CI, ). Women were significantly more likely to receive RT if they were diagnosed in later years (OR, 2.33; 95% CI, ), had tumor size >5 cm (OR, 2.94; 95% CI, ), and if they had lymph nodes evaluated, compared to patients with no nodal examination (OR, 1.92; 95% CI, ). Conclusion: Over time, an increasing number of women are receiving RT after surgical management of their phyllodes tumors, regardless of whether BCS or mastectomy is performed. Additionally, 1 in 4 women have axillary nodal sampling despite lack of guidelines to support this additional surgical procedure. These practices may represent application of adenocarcinoma rather than sarcoma treatment paradigms and identify an educational gap in the care of breast diseases Contrast-Enhanced Digital Mammography in the Surgical Management of Breast Cancer Mariam Ali-Mucheru 1, Bhavika Patel 1, Barbara Pockaj 1, Victor Pizzitola 1, Nabil Wasif 1, Chee-Chee Stucky 1, Richard Gray 2 1 Mayo Clinic Arizona, Phoenix, AZ, 2 Mayo Clinic, Scottsdale, AZ Objective: Contrast-enhanced digital mammography (CEDM) is a new breast imaging technique. The role of CEDM in the surgical management of breast cancer has not yet been characterized. Methods: A review of prospective breast surgery and breast imaging databases for patients who underwent CEDM prior to surgery between December 2014 and October Medical records were reviewed to supplement database information. Results: A total of 275 patients had CEDM; 99 had malignant lesions, and 73 had surgery with 76 cancer lesions identified on pathology. The mean age was 68 years (range, 25 85). The indications for CEDM among surgical patients included: diagnostic evaluation for abnormal imaging (BIRADS 0, 4, 5, n = 46), assessment of response to neoadjuvant treatment (n = 9), and complicated imaging or dense breasts (n = 18, 9/18 surgeon requested). The histology was 67% invasive ductal carcinoma (IDC), 17% invasive lobular carcinoma (ILC), 8% ductal carcinoma in situ, 4% mixed IDC/ILC, and 4% other with 81% ER+, 65% PR+, 13% HER-2+, and 11% triple negative. CEDM identified the index cancer and extent of disease in 95% of cases (figure). It also led to additional imaging in 12% (n = 9) of cases and additional biopsies in 8% (n = 6) of cases. Of the additional biopsies, 5 cases (83%) were invasive carcinoma and 1 case (17%) was benign fibroadipose tissue. CEDM was prospectively identified as changing the surgical management in 15% (n = 11) of cancer cases. In addition to CEDM, 27 patients underwent breast magnetic resonance imaging (MRI). Among this subset of patients, MRI and CEDM identified the index cancer and extent of disease in 93% vs 89% of cases, respectively. MRI identified additional lesions not seen on CEDM in 5 cases, of which 4 had contralateral lesions with no correlation on second-look ultrasound or diagnostic mammogram; only 1 was biopsied and found to be atypical ductal hyperplasia. There were 2 cases where CEDM identified additional and contralateral lesions not seen on MRI and no biopsies were obtained. Cancer lesion size was within 5 mm of pathologic measurement in 70% of CEDM vs 72% MRI cases. continues The American Society of Breast Surgeons Official Proceedings
30 Conclusion: CEDM appears to be a valuable breast imaging modality for diagnostic, staging, treatment monitoring, and surgical planning. CEDM provides high-quality anatomic information, albeit with the need for intravenous contrast. This initial experience suggests that CEDM has the potential to perform as well as breast MRI for surgical planning, while being much less expensive and simpler for patients. Further study is warranted Analysis of Operative and Oncologic Outcomes in 5351 Patients With Operable Breast Cancer: Support for Breast Conservation and Oncoplastic Reconstruction Stacey Carter 1, Genevieve Lyons 1, Roland Bassett 1, Scott Oates 1, Isabelle Bedrosian 1, Alastair Thompson 1, Elizabeth Mittendorf 1, Mediget Teshome 1, Min Yi 1, Gildy Babiera 1, Sarah DeSnyder 1, Abigail Caudle 1, Merrick Ross 1, Patrick Garvey 1, Donald Baumann 1, Henry Kuerer 1, Kelly Hunt 1, Rosa Hwang 1 1 University of Texas, MD Anderson Cancer Center, Houston, TX Objective: Despite the proven oncologic safety of breast-conserving surgery (BCS) with radiation for patients with early-stage breast cancer, there has been a marked increase in the total mastectomy (TM) rate over the past decade for BCS-eligible patients. Oncoplastic reconstruction is an approach that enables patients with locally advanced or poorly located tumors to undergo BCS. The objectives of this study were to identify the use of BCS with oncoplastic reconstruction (BCS+R) and determine the operative and oncologic outcomes as compared to other surgical procedures for breast cancer. Methods: We interrogated a single institution s prospectively maintained databases to identify patients who underwent surgery for breast cancer between 2007 and Surgeries were categorized as BCS, BCS+R, TM, or TM with reconstruction (TM+R). Demographic and clinicopathologic characteristics and postoperative complications were analyzed and comparisons made using Wilcoxon, chi-square, or Fisher exact tests. Survival analysis was performed using the Kaplan-Meier method. Results: Over 7 years, 5651 operations were completed in 5351 patients. The use of BCS+R increased steadily over the study period surpassing BCS after 2011 (figure). Patients who had BCS+R were younger than BCS The American Society of Breast Surgeons Official Proceedings
31 patients (57 vs 58 years old, p < ) but older than those who had TM+R (50 years old, p < ). The rate of obesity (BMI > 30) in BCS+R patients was higher compared to TM+R patients (31.0 vs 20.8%, p < ). There were no differences seen in clinical stage, lymphovascular invasion, triple-negative status, and treatment with neoadjuvant or adjuvant chemotherapy in patients with BCS+R and TM+R. At an overall median follow-up of 3.3 years (range, years), BCS+R patients had the lowest locoregional recurrence rate (LRR) when compared to any other group (2.4%, p < ). Overall survival (OS) for BCS+R patients was not different from BCS patients (p = 0.29) but lower than TM+R patients (p = 0.003), which is potentially due to the older age and fewer in situ cancers in the BCS+R group. Median OS was not reached for any group. Five-year survival probabilities and corresponding 95% confidence intervals were 93% (0.90; 0.95) for BCS+R patients and 96% (0.94; 0.97) for TM+R patients. Despite having an older, more obese patient population, BCS+R had fewer complications of postoperative seroma/hematomas (p < ), surgical site infections (p < 0.001), and readmission within 30 days (p < 0.001) compared with TM+R patients. Conclusion: The increasing use of oncoplastic reconstruction after BCS is an attractive alternative to TM+R for similar-stage breast cancer patients. In our study, this approach was associated with a lower rate of postoperative complications and LRR Combining Pathologic Data With Axillary Ultrasound Information Reliably Identifies a Large Number of Newly Diagnosed Breast Cancer Patients As Node-Negative Tiffany Chichester 1, Charles Mylander 1, Rubie Sue Jackson 1, Martin Rosman 1, Sophia Cologer 1, Reema Andrade 1, Lorraine Tafra 1 1 Anne Arundel Medical Center, Annapolis, MD Objective: Breast cancer patients require axillary staging, which is currently performed surgically, primarily to aid in adjuvant treatment decisions. Patients who undergo negative sentinel lymph node (SLN) biopsy incur risk of surgical complications with no therapeutic benefit. It is hoped that preoperative axillary ultrasound (AXUS), alone or in combination with clinicopathological factors, could identify patients with an extremely low likelihood of harboring nodal metastasis, and who could thus avoid surgical staging of the axilla. We undertook a study to examine whether the combination of AXUS results and clinicopathological information The American Society of Breast Surgeons Official Proceedings
32 can reliably identify such a subset of patients. The Memorial Sloan-Kettering Cancer Center (MSKCC) nomogram for prediction of SLN metastasis was used to integrate clinicopathological information. Methods: We utilized a retrospective database of all newly diagnosed invasive breast cancers (February 2011 October 2014) at a single institution with both preoperative AXUS and surgical staging of the axilla. Exclusions were for palpable adenopathy or neoadjuvant chemotherapy. For all patients, the MSKCC nomogram estimates were calculated, and patients were divided into quintiles by nomogram estimates. AXUS results were categorized as suspicious or nonsuspicious. Nodal burden from surgical pathology was compared across 10 categories defined by nomogram quintile and AXUS result. Results: In 520 cancers, 406 (78%) had a nonsuspicious AXUS. Examining the 10 categories defined by MSKCC nomogram/axus results, the combination of (1) MSKCC nomogram-predicted likelihood of SLN metastasis 45% and (2) nonsuspicious AXUS was able to identify a subset of 302 patients (58% of the cohort; 95% CI, 54% 62%) with low likelihood of nodal metastasis. Only 32 of 302 low-risk patients (11%; 95% CI, 7% 15%) had SLN metastasis and only 1 patient had >2 positive lymph nodes. Axillary Ultrasound Findings MSKCC Nomogram Prediction of Probability of SLN Mets Number of Positive Nodes Found Surgically No suspicious nodes (406 of 520 patients studied) 45% (302) 270 (89%) 31 (10%) 1 (0.3%) >45% (104) 63 (61%) 28 (27%) 13 (11%) Conclusion: Using a combination of AXUS and MSKCC nomogram estimates, a sizable percentage of newly diagnosed breast cancer patients can be identified as being at low risk of nodal metastasis. There are currently at least 2 clinical trials underway to evaluate omission of SLN biopsy in AXUS-negative patients (principal investigators: O. Gentilini and A. Cyr). A more conservative approach would be to use a combination of MSKCC nomogram estimates and negative AXUS to identify patients who might be spared a SLN biopsy. A limitation of this study is it was a small, single-institution, retrospective analysis. AXUS is operator-dependent, and it is important that qualified radiologists or breast surgeons perform these examinations and systematically document results Breast Cancer Recurrence Following Radio-Guided Seed Localization and Standard Wire Localization of Nonpalpable Breast Cancers 5-Year Follow-Up From a Randomized Controlled Trial Filgen Fung 1, Sylvie Cornacchi 1, Michael Reedijk 2, Nicole Hodgson 1, Charlie Goldsmith 3, David McCready 2, Gabriela Gohla 4, Colm Boylan 5, Peter Lovrics 1 1 Department of Surgery, McMaster University, Hamilton, ON, Canada, 2 Department of Surgical Oncology, Princess Margaret Hospital, University Health Network, Toronto, ON, Canada, 3 Faculty of Health Sciences, Simon Fraser University, Burnaby, BC, Canada, 4 St. Joseph s Healthcare, Department of Pathology and Molecular Medicine, McMaster University, Hamilton, ON, Canada, 5 St. Joseph s Healthcare, Department of Radiology, McMaster University, Hamilton, ON, Canada Objective: Radio-guided seed localization (RSL) has been compared with wire localization (WL) techniques for early-stage nonpalpable breast cancer (BC), but there is only 1 nonrandomized cohort study reporting recurrence rates using the RSL technique. The purpose of this study is to compare 5-year breast cancer (BC) recurrence rates in patients randomized to RSL or WL for nonpalpable invasive and in situ BC undergoing breast-conserving surgery (BCS). Methods: Chart review of follow-up visits and surveillance imaging were collected on patients from a multicentered, randomized control trial that compared RSL to WL for nonpalpable invasive and in situ BC. Study inclusion criteria for the original trial were age 18 years or older, histologically confirmed invasive or in situ The American Society of Breast Surgeons Official Proceedings
33 BC, nonpalpable tumor requiring localization, and candidate for breast-conserving surgery (BCS). Data collected included patient and tumor characteristics, adjuvant therapies, and details of follow-up clinical visits, and type and results of surveillance imaging. Univariate analysis was used for the recurrence outcome (which included local recurrence [LR], regional recurrence [RR], and distant metastasis [DM]). Results: Of the 305 patients from the original trial, follow-up data were available for 298 patients (98%) and median follow-up time was 65 months (5.4 years). Overall positive margin rates (tumor on inked margin) were similar for WL and RSL (11.8% and 10.5%, respectively). In total, there were 11 (4%) cases of BC recurrence and median time to BC recurrence was 26 months. LR occurred in 8 patients (6 WL and 2 RSL; p = 0.28). One WL patient had RR (this patient also had LR and DM). All 4 patients with DM died due to BC (2 WL, 2 RSL; p = 1.00). New contralateral BC developed in 8 patients (3 WL, 5 RSL; p = 0.49). Positive margins at first surgery (p = 0.024) and final surgery (p = 0.004) predicted for BC recurrence. There were no tumor characteristics or adjuvant therapies related to BC recurrence outcomes. Conclusion: There was no difference in BC recurrence between WL and RSL groups in patients undergoing BCS for early-stage nonpalpable BC. Positive margins at initial or final surgery both predicted for BC recurrence. Tumor characteristics and adjuvant treatments of radiation, medical, or hormonal therapies did not affect BC recurrence Trends in Breast Reconstruction After Mastectomy and Associated Postoperative Outcomes Nicole Ilonzo 1, Alison Estabrook 2, Ayemoe Ma 1 1 Mount Sinai St. Luke s Roosevelt, New York, NY, 2 Mount Sinai Roosevelt Hospital, New York, NY Objective: The landscape of breast reconstruction has changed significantly in the past decade. This study seeks to assess trends in type of reconstruction performed after mastectomy and the impact of these approaches on immediate postoperative complications. Methods: Data for 19,665 patients undergoing mastectomy for breast cancer were analyzed using the National Surgical Quality Improvement Program (NSQIP) database for years Baseline demographics, comorbidities, and reconstruction type were collected. Primary outcomes were wound complications (dehiscence, superficial surgical site infection SSI, deep incisional SSI), non wound-related infections, such as pneumonia and UTI, and postoperative transfusion within 30 days of surgery. Data were analyzed by univariate and multivariate analysis. Results: The utilization of TE after mastectomy has increased dramatically from 57.59% of reconstructions in 2005 to 71.52% in 2013 (P =.008). Immediate implant placement has increased from 10.27% in 2005 to 15.68% in 2009 (P =.03) and then stabilized to 16.18% between 2010 and 2013 (P =.11). There was no significant difference between TE and immediate implant placement (P >.05) when comparing rates of wound-related, bleeding, or non wound-related infectious complications. Of note, the rate of wound complications after implant exchange (0.44%) was less than wound complications after immediate implant surgery (3.48%, P =.013). With respect to flaps, the rate of TRAM flap procedures significantly decreased from 22.32% to 3.05% of total reconstructions and LDMF decreased from 6.25% to 3.73% (P <.05) during this period. The overall rate of non wound-related infections after all reconstructions decreased from 2.96% to 1.36% between 2005 and 2013 (P =.035), but wound complication rates were unchanged during this time (P =.08). As expected, there were fewer wound complications after TE (3.11%) than after LDMF (3.63%) or TRAM flap (7.06%), P <.001. There was also less postoperative blood transfusions after TE (.69%) than after TRAM flap (4.93%) or LDMF (2.81%) P <.001. There was no difference between non wound-related infections after each procedure (P =.11). Conclusion: TE and immediate implant utilization have drastically increased in the United States, with both surgeries having similar complication rates in select patients. The rate of non-wound complications after all reconstructions has also decreased. Further studies are needed to evaluate flap reconstruction and costeffectiveness of each type of reconstruction. The American Society of Breast Surgeons Official Proceedings
34 Multi-institutional Study of the Oncologic Safety of Prophylactic Nipple-Sparing Mastectomy in a BRCA Population James Jakub 1, Anne Peled 2, Richard Gray 3, Rachel Greenup 4, John Kiluk 5, Virgilio Sacchini 6, Sarah McLaughlin 7, Julia Tchou 8, Shawna Willey 9 1 Mayo Clinic, Rochester, MN, 2 University of California San Francisco, San Francisco, CA, 3 Mayo Clinic, Scottsdale, AZ, 4 Duke University School of Medicine, Durham, NC, 5 Moffitt Cancer Center, Tampa, FL, 6 Memorial Sloan Kettering, New York, NY, 7 Mayo Clinic, Jacksonville, FL, 8 University of Pennsylvania Health System, Philadelphia, PA, 9 Georgetown University, Washington, DC Objective: Nipple-sparing mastectomy (NSM) is gaining wide acceptance as a result of the superior cosmetic results when successful; however, its role in a BRCA population remains controversial. Our aim was to determine the incidence of breast cancer developing in female BRCA carriers following a prophylactic NSM. Methods: Multi-institutional retrospective review of patients with a deleterious BRCA mutation undergoing a risk-reducing NSM between January 1, 1960, and December 31, Patients with a diagnosis of breast cancer and undergoing a contralateral risk-reducing mastectomy were included, but only the risk-reducing side was included in the analysis. Breasts with high-risk lesions (ALH, ADH, ADP, FEA, or LCIS) identified preoperatively or on final pathologic analysis of the mastectomy specimen were included in the analysis. Patients found at the time of prophylactic mastectomy to have an occult cancer in the prophylactic breast were excluded, as were patients with a variant of unknown significance (VUS) or a free nipple graft. The primary endpoint was development of a new primary breast cancer (DCIS and/or invasive breast cancer) in the surgical field following a risk-reducing NSM. This included events of the ipsilateral skin flaps, subcutaneous tissue, nipple areolar complex (NAC), chest wall, or regional lymph nodes ipsilateral to the riskreducing mastectomy. Results: A total of 551 risk-reducing NSMs were performed in 348 patients from 9 institutions over the time period (cases per institution, 1-91). Two hundred three patients underwent a bilateral prophylactic NSM and 145 patients underwent a unilateral risk-reducing NSM secondary to a previous or current breast cancer in the contralateral breast. Two hundred four patients had a BRCA1 mutation and 144 a BRCA2 mutation. With a median follow of 34 months and mean follow-up is 56 months, no breast cancers developed in the ipsilateral skin flaps, subcutaneous tissue, NAC, mastectomy scar, chest wall, or regional lymph nodes on the side of the prophylactic procedure. None of the patients who underwent a bilateral risk-reducing NSM developed breast cancer at any site. Twelve patients died during follow-up--7 from breast cancer, 3 from ovarian or fallopian tube cancer, and 2 from other causes. All 7 patients who died from breast cancer had a previous or synchronous contralateral breast cancer at the time of their prophylactic procedure and their stage IV disease was attributed to the known cancer. Conclusion: NSM is highly preventative against breast cancer in a BRCA population Factors Associated With Recurrence Rates and Long-Term Survival in Women Diagnosed With Breast Cancer Ages 40 and Younger Jennifer Plichta 1, Suzanne Coopey 1, Michele Gadd 1, Michelle Specht 1, Kevin Hughes 1, Alphonse Taghian 1, Barbara Smith 1 1 Massachusetts General Hospital, Boston, MA Objective: Young age at breast cancer diagnosis has been associated with higher risks of recurrence and mortality. We reassessed this assumption in a large, modern cohort of women diagnosed with breast cancer at age 40 and younger. Methods: We identified women diagnosed with breast cancer at age 40 years at our institution from We assessed loco-regional recurrence (LRR), distant recurrence (DR), and overall survival (OS), and correlated patient and tumor characteristics with outcomes. Kaplan-Meier estimates were calculated. The American Society of Breast Surgeons Official Proceedings
35 Results: Among 584 women with breast cancer at <40 years (table), median age was 37 years (range, 21-40). Median follow-up was 71.5 months (range, 5 236). Kaplan-Meier estimates for LRR rates were 4.5% at 5 years and 11.5% at 10 years; DR rates were 11% at 5 yrs and 16.5% at 10 yrs. OS was 93% at 5 years and 86.5% at 10 years. For DCIS alone (n = 120), OS was 99% at 67.5 months median follow-up, with 6 LRR and 1 DR. For invasive cancer (n = 447), OS was 87% at 73 months median follow-up, with 40 LRR and 77 DR. Among 336 lumpectomy patients, 95.5% received radiation. Of 248 mastectomy patients, 36.3% received radiation. Among 464 patients with invasive cancer, 80.5% received chemotherapy, 67% received endocrine therapy, and 54% received both. Of 120 DCIS patients, 26% received endocrine therapy. On univariate analysis of the entire cohort (n = 584), development of any recurrence was associated with a personal history of thoracic radiation, invasive disease, larger tumor size, presence of lymphovascular invasion (LVI), positive lymph nodes, chemotherapy receipt, and adjuvant radiation administration (all p 0.05). There was no association with age at diagnosis, family history, multifocality, type of surgery (lumpectomy vs mastectomy), initial margin status, tumor grade, ER/PR status, HER2 status, triple-negative disease, endocrine therapy, or the presence of a genetic mutation. On multivariate analysis of pathology features, only tumor size (OR, 1.2; CI, ) remained significant. On univariate analysis (n = 584), a worse OS was associated with a positive family history, personal history of thoracic radiation, invasive disease, larger tumor size, higher tumor grade, presence of LVI, positive lymph nodes, and recurrence (all p 0.05); improved OS was associated with receipt of adjuvant radiation (p 0.05). OS was not associated with age at diagnosis, multifocality, type of surgery, initial margin status, ER/PR status, HER2 status, triple-negative disease, adjuvant endocrine therapy, or the presence of a genetic mutation. On multivariate analysis of pathologic features, tumor size (OR, 1.2; CI, ) and tumor grade 3 (OR, 2; CI, ) remained significant. Patient and Tumor Characteristics of Breast Cancer Patients Ages 40 and Younger Patient/Tumor Characteristic N = 584 Age (yr) < Positive family history Genetic mutation 4 (0.6%) 34 (5.8%) 116 (19.8%) 430 (73.6%) 300 (51.3%) 73 (26.6%) Prior thoracic radiation 13 (2.2%) Type of surgery Mastectomy Lumpectomy Tumor type DCIS IDC ILC Other 248 (42.5%) 336 (57.5%) 120 (20.6%) 429 (73.5%) 18 (3.1%) 17 (2.9%) The American Society of Breast Surgeons Official Proceedings
36 Tumor stage 0 I II III Tumor grade I II III Unknown Invasive tumor size <2 cm 2 5cm >5 cm Nodal status Positive Negative Not staged Receptor status ER+ PR+ Her2neu+ Triple negative Radiation therapy Lumpectomy + radiation PMRT Systemic therapy Neoadjuvant Adjuvant Endocrine Therapy None 135 (23.1%) 196 (33.6%) 183 (31.3%) 70 (12.0%) 51 (8.7%) 150 (25.7%) 231 (39.6%) 152 (26.0%) 289 (49.5%) 151 (25.9%) 24 (4.1%) 218 (37.3%) 300 (51.4%) 66 (11.3%) 403 (69.0 %) 388 (66.4%) 91 (15.6%) 71 (12.2%) 321 (95.5%) 90 (36.3%) 86 (14.7%) 322 (55.1%) 334 (82.8%) 123 (21.0%) Conclusion: Women diagnosed with breast cancer at age 40 and younger have a good prognosis, with survival at 5 and 10 years now approaching that of older women. Rates of local recurrence after lumpectomy are low, making breast conservation a reasonable option for young breast cancer patients The Role of Surgical Primary Tumor Extirpation in De Novo Stage IV Breast Cancer in the Era of Targeted Treatment Judy Tjoe 1, Danielle Greer 2, Ahmed Dalmar 3 1 Aurora Health Care, Milwaukee, WI, 2 Center for Urban Population Health, Aurora UW Medical Group, Milwaukee, WI, 3 Aurora Research Institute, Milwaukee, WI Objective: Previous reports evaluating primary tumor extirpation (hereafter, surgery) in patients presenting with de novo stage IV breast cancer describe mixed results regarding overall survival (OS). In this modern era of treatment, the impact of surgery was assessed, both controlling and adjusting for potential confounders, including comorbidities, tumor burden, vitality impact of distant metastatic site, hormonal therapy of ER/PR+ disease, and targeted therapy of HER-2+ disease. Methods: Women presenting with de novo stage IV breast cancer during were retrospectively studied using a single institution s cancer registry data. Patients with severe competing comorbidities (heart failure, chronic kidney disease) were excluded, as well as those missing data for patient, tumor, or treatment variables used in matching or analysis. As primary tumor extirpation was of principal interest, patients who The American Society of Breast Surgeons Official Proceedings
37 underwent surgery as a first course of treatment were 1:1 matched with those treated without surgery by patient age (within ± 20 years), number of cardiovascular risk factors (smoking, hypertension, dyslipidemia, diabetes mellitus, obesity; within ± 1 factor), coronary artery disease, HER-2/neu and ER/PR, tumor grade, number of metastatic sites (tumor burden within ± 1 site), vitality impact of metastatic sites (CNS, visceral, bone), and first-course systemic and site-specific radiation (breast/chest, metastatic site) therapies received. The adjusted effects of surgery and other patient, tumor, and treatment characteristics on OS were quantified using hazard ratios (HR) derived from marginal Cox proportional hazards models, all containing surgery. Through estimation of the survivor function, OS rates were computed per study group. Results: Of 609 total patients identified, 280 entered the matching algorithm. Women who underwent surgery (n = 58) vs those who did not undergo surgery (n = 58) within the matched-pairs population did not differ by age (mean, 62 yr) or other matched characteristics, but did significantly differ by length of follow-up (3.03 vs 1.97 yr, respectively). Single-variable adjustment led to detection of a significant surgery effect (P < 0.04) in 4 of 10 models of OS (table). Across models of nonsignificant surgery effects (P = ), HRs were within the range of values produced by models revealing significance. All models suggested a 40% reduction in risk for patients receiving surgery, and 9 of the 10 models suggested 3-yr OS rates of approximately 60% for patients undergoing surgery vs. 45% for patients treated without surgery. Age, number of risk factors, ER/PR, and vitality impact of metastatic sites impacted OS. continues The American Society of Breast Surgeons Official Proceedings
38 Hazard Ratios and Adjusted 3-Year Overall Survival Rates Derived From Cox Proportional Hazards Models of Overall Survival in Women Who Presented With Stage IV Breast Cancer During and Were Matched by Primary Tumor Extirpation (Surgery, N = 116) Model No. Model Variable 1 HR (95% CI) Surgery Performed 0.65 ( ) 0.60 ( ) Not performed Reference 0.46 ( ) Surgery Performed 0.61 ( )* 0.59 ( ) Not performed Reference 0.43 ( ) Surgery Performed 0.65 ( ) 0.58 ( ) Not performed Reference 0.43 ( ) Surgery 3-year OS rate (95% CI) Model Variable 2 HR (95% CI) Patient age a 1.50 ( )* Number of risk factors b 1.33 ( )* Tumor size c 0.98 ( ) HER2neu expression Performed 0.65 ( ) 0.58 ( ) Positive 0.89 ( ) Not performed Reference 0.43 ( ) Negative Reference Surgery ER/PR expression d Performed 0.59 ( )* 0.17 ( ) Positive 0.23 ( )* Not performed Reference 0.05 ( ) Negative Reference Surgery Grade Performed 0.61 ( )* 0.63 ( ) I or II Reference Not performed Reference 0.49 ( ) III or IV 1.51 ( ) Surgery Performed 0.66 ( ) 0.58 ( ) Not performed Reference 0.43 ( ) Surgery Tumor burden e 1.30 ( ) Metastatic site impact Performed 0.59 ( )* 0.58 ( ) Visceral 1.93 ( )* Not performed Reference 0.42 ( ) Bone Reference Surgery Chemotherapy Performed 0.68 ( ) 0.52 ( ) Performed 0.70 ( ) Not performed Reference 0.38 ( ) Not performed Reference Surgery Radiation therapy Performed 0.65 ( ) 0.55 ( ) Performed 0.66 ( ) Not Performed Reference 0.40 ( ) Not performed Reference HR indicates hazard ratio; OS, overall survival; CI, confidence interval; HER2neu, human epidermal growth factor receptor 2; ER, estrogen receptor; PR, progesterone receptor; CNS, central nervous system. *Hazard ratio significantly differs from 1. a Number of times the hazard increases per 10-year increase in age. b Number of times the hazard increases per 1-factor increase in cardiovascular risk. c Number of times the hazard increases per 10-mm increase in tumor size. d Classified as positive when either ER or PR or both are overexpressed and negative when neither ER or PR are overexpressed. e Number of times the hazard increases per 1-metastatic site increase in tumor burden. Conclusion: Even after accounting for hormonal therapy, targeted therapy, and radiation to local and distant metastatic sites, surgical extirpation of the primary tumor remains associated with an OS improvement in patients with de novo stage IV breast cancer. The American Society of Breast Surgeons Official Proceedings
39 Posters Risk Factors of Breast Cancer Related Lymphedema Mokhtar Abdulwahid 1, Yehia Safwat 1 1 Cairo University, Cairo, Egypt Objective: To determine the risk factors associated with the presence and severity of breast cancer related upper arm lymphedema. Methods: This is a prospective case control study. Patients included had breast carcinoma (128) and all had operable breast cancer that will undergo loco-regional therapy (surgery ± radiotherapy). Diagnosis for lymphedema was stated as by measurement method in which a difference of 2 cm at either level between the 2 arms is generally accepted for diagnosis for lymphedema. Assessment of lymphedema and risk factors was performed by logistic regression. Results: Univariate analysis showed significant difference between the groups of patients with and those without lymphedema regarding older age (0.014), BMI > 30 (0.005), hard work (0.004), ipsilateral dominant arm (0.021), history of injury (0.001) and infection (0.001) to ipsilateral arm, positive lymphadenopathy (0.020), advanced stage of cancer (0.009), positive HER- 2 / neu receptor ( 0.001), level III axillary dissection (0.001) and patients who did not receive information about BCRL and /or did not follow prophylactic advice (0.001). Meanwhile, multiple logistic regression analysis showed only age (0.003), history of injury (0.004), cellulitis (0.017), advanced cancer stage (0.033), positive HER- 2/neu receptor (0.037), level III axillary dissection (0.001), and patients who did not receive information about BCRL and /or did not follow prophylactic advice (0.016) had significant relation to lymphedema. Regarding the severity of lymphedema, history of injury (0.017), cellulites (0.044), and obesity (BMI 30) (0.018) had significant association with the degree of severity. Conclusion: Health teams and patients must be aware of the prevention and early treatment of lymphedema Metaplastic Breast Cancer Has a Poor Response to Neoadjuvant Systemic Therapy Zahraa Al-Hilli 1, James Jakub 1, Daniel Visscher 1, James Ingle 1, Matthew Goetz 1 1 Mayo Clinic, Rochester, MN Objective: Metaplastic breast cancer (MetaBC) has been shown to exhibit a poor response to systemic therapy in the metastatic setting and high rates of recurrence in the adjuvant setting, and limited data are available regarding the response to neoadjuvant chemotherapy (NAC). We aimed to report our institutional experience with the neoadjuvant treatment of MetaBC. Methods: Patients with MetaBC were identified from our institutional medical index. Patient demographics, tumor characteristics, treatment received, and pathological complete response (pcr) rates were reviewed. Results: Twenty-one female patients with MetaBC received NAC from January 1991 to June The mean age at diagnosis was 52 years (range, 33 79). Four patients (19%) had a previous history of breast cancer. Five of 16 had BRCA testing and 2 of 5 were BRCA-2 positive. The tumor size distribution was T2 (n = 8), T3 (n = 9), and T4 (n = 4), and 8 had clinically node-positive disease (6 were cytology/pathology confirmed). The majority (16/21;76%) were estrogen receptor (ER), progesterone receptor (PR), and HER-2 negative, and 1/21 (5%) was HER-2 positive. The chemotherapy regimen combinations included anthracycline/taxane-based regimens in 7, anthracycline/taxane/platinum-based regimens in 9, taxane/platinum-based regimens in 3, taxane regimen in 1, and taxane/trastuzumab in 1. Twenty patients received NAC prior to surgery; of these 4 (20%) progressed on initial treatment and required change of chemotherapeutic agent used. One patient did not proceed to have surgery because of disease progression. Two patients (9.5%) with triple-negative disease achieved a complete pathological response (n = 2). Of the 8 patients with positive nodes at presentation, 3 with biopsy-proven nodal disease had a complete pathologic response in the axilla. The American Society of Breast Surgeons Official Proceedings
40 Conclusion: The response of MetaBC to various regimens of NAC is low and the risk for progressive disease is high with current standard regimens. At the present time, patients with MetaBC who have resectable disease should proceed directly to definitive operative management in the absence of a clinical trial directed at NAC for MetaBC The Impact of Molecular Subtype on Breast Cancer Recurrence in Young Women Treated With Contemporary Adjuvant Therapy Hanan Alabdulkareem 1, Sara Khan 2, Alyssa Landers 1, Paul Christos 1, Rache Simmons 1, Tracy-Ann Moo 1 1 Weill Cornell Medical College, New York, NY, 2 Weill Cornell Breast Center, New York, NY Objective: Breast cancer is the leading cause of cancer death in women below 40 years. Triple-negative and HER2 subtypes have a particularly poor prognosis in this age group. The purpose of this study was to compare rates of recurrence among breast cancer subtypes in young patients treated with modern adjuvant systemic therapy. Methods: A retrospective review of breast cancer patients managed at a major academic breast center between 2000 and 2015 was performed. We included 250 women with breast cancer who were diagnosed and treated at 40 years. Clinical, histopathological, therapeutic, and outcome data were recorded. Patients were classified into the following molecular subtypes: luminal A/B (ER+, PR+, HER2-), luminal /HER2 (ER+, PR+, HER2+), HER2 (ER-, PR-, HER2+), and triple-negative (ER-, PR-, HER2-). Descriptive statistics were used to characterize the study cohort. Kaplan-Meier survival analysis was performed to estimate recurrence-free survival (RFS). Results: Median follow-up time was 27 months (range, months). Mean age was 35 ± 4.0 years. Among all patients, 81.2% presented with invasive ductal carcinoma and 18.8% with DCIS +/- micro-invasion. 43.2% of the patients were classified as luminal A/B; 18.0%, luminal/her2; 10.0%, HER2; and 12.8%, triplenegative. Of the patients with invasive cancer, 29% received neoadjuvant chemotherapy and 56% received adjuvant chemotherapy. Among HER2-positive patients, 74.2% received HER2-directed therapy. Twenty-nine (11.6%) patients had recurrences (14 loco-regional, 8 distant, and 7 both). At 3 years, HER2 subtype had the highest RFS, 100%; compared to 91.2% in luminal A/B; 85.6% in luminal/her2, and 81.9% in triplenegative. Molecular Subtype N = 250* Three Year Recurrence-Free Survival (%) 95% CI Luminal A/B (n = 108, 43.2%) 91.2% HER-2 (n = 25, 10%) 100% Luminal /HER-2 (n = 45, 18%) 85.6% Triple-negative (n = 32, 12.8%) 81.9% P = 0.06 *Total percentage does not total 100% due to 40 patients (16%) with indeterminate molecular subtype status (DCIS +/- micro-invasion) Conclusion: In comparing outcomes among breast cancer subtypes, the HER2-positive subtype was associated with improved RFS, likely reflecting the impact of HER2-directed therapy. Those young patients with triplenegative subtype continued to have the poorest outcomes. The American Society of Breast Surgeons Official Proceedings
41 Management of Positive Margins in Elderly Women With Breast Cancer: Is Reoperation Necessary? Fernando Angarita 1, Sergio Acuna 2, Jaime Escallon 1 1 Division of General Surgery, Department of Surgery, University of Toronto, Toronto, ON, Canada, 2 University of Toronto, Toronto, ON, Canada Objective: Breast-conserving surgery (BCS) is the most common surgical procedure for elderly women with breast cancer. Management of breast cancer between young and elderly women differs, but it is unknown whether this extends to the management of positive margins after BCS. This study evaluated the management of positive margins and its effect on risk of recurrence in elderly women with breast cancer who were treated at 2 high-volume cancer centers. Methods: Women 50 years diagnosed with stage I III breast cancer who underwent BCS from 2004 to 2011 were identified from an institutional database. Data were collected across 2 subgroups: years and 70 years. Negative margin was defined as no ink on tumor. Disease-free survival (DFS) was estimated by Kaplan-Meier analysis and compared by log-rank test. A multivariable logistic regression was used to evaluate whether elderly women with positive margins were less likely to undergo reoperation after adjusting by confounders. Incidence of recurrence was evaluated by plotting the cumulative incidence function of recurrence and death without recurrence (competing risk); groups were compared using Gray's test. Results: In total 1670 women were identified: years (n = 1177) and 70 years (n = 493). Compared to younger patients, elderly women had tumors that were larger (2 cm vs 1.4 cm, p < 0.001), more differentiated (34% vs 25%, p = 0.003), more ER/PR positive (92% vs 66%, p < 0.001), and more HER2 negative (75% vs 71%, p = 0.04). Elderly women were more frequently diagnosed with stage II tumors (49%), while younger women had stage I (57%) (p < 0.001). Positive margins were less common in elderly than younger women (11% vs 16%, p = 0.004). Single BCS was provided in 89%. Of patients with positive margins, 72% had reexcision and 14% had mastectomy. Age was inversely associated with reoperation ( 70 yr, 5%, vs yr, 15%; p < 0.001). After adjusting by size, grade, and positive lymph nodes, elderly women with positive margins had lower odds of undergoing reoperation (OR, 0.1; 95% CI, ). Compared to younger women, elderly patients were less likely to undergo adjuvant radiation (71% vs 81%, p < 0.001) and chemotherapy (5% vs 41%, p < 0.001). The recurrence rate was 5% and did not differ between age groups ( 70 years, 5%, vs years, 4%; p = 0.6). Although the cumulative incidence of death without recurrence in patients with positive margins was higher in elderly women (p < 0.001), the cumulative incidence of recurrence did not differ (p = 0.2). Five-year DFS was similar between the groups ( 70 years, 86%, vs years, 86%; p = 0.8). Conclusion: Elderly women with positive margins after BCS are less likely to undergo re-operation than younger women independent of poor prognostic factors, including size, grade, and lymph node status. Differences in the risk of recurrence and DFS were not observed between these age subgroups, suggesting that reoperation may not be necessary in elderly women. However, larger studies are necessary to confirm these findings The Specimen Margin Assessment Technique (SMART) Trial: A Novel 3D Method of Identifying the Most Accurate Method of Breast Specimen Orientation Angel Arnaout 1,2, Sara Saeed 1, Genevieve Dostaler 2, Susan Robertson 2 1 Ottawa Hospital Research Institute, Ottawa, ON, Canada 2 Ottawa Hospital, Ottawa, ON, Canada Objective: Achieving negative margins remains one of the most important determinants for local recurrence following breast-conserving therapy. Re-excision of a positive margin is recommended in order to reduce recurrence. Inaccuracies in margin labeling or orientation during surgery translate into additional unnecessary surgery or wrong margin re-excision. We report the results of the world s first prospective clinical trial that evaluates the accuracy of intraoperative specimen inking vs suturing on the same lumpectomy specimen, in a blinded fashion, using a novel 3D technique. The American Society of Breast Surgeons Official Proceedings
42 Methods: A prospective clinical trial was performed using sham lumpectomies within the prophylactic mastectomy or breast reduction tissue. The specimen was inked using special phospholuminescent inks that dry clear but glow under black light. In addition, specimen suturing using 2 labeled sutures was performed by the surgeon as per usual. A third mystery suture was placed, the location of which is known only to the surgeon but blinded to the pathologist. Results: Seventy-three patients were accrued for the study. There was a 45% discordance between the pathologist and surgeon in identification of the mystery suture and a 76% discordance in identification of surface area of each margin. A median of 3 additional surgeon identified margins were included in the pathologist identified anterior margin. Using 3D imaging, we demonstrated how the specimen center of gravity and volume changes en route to the pathology department. Conclusion: This is the first trial of its kind, comparing the 2 methods of specimen orientation in a blinded fashion on the same lumpectomy specimen. Discordance between the surgeon and the pathologist in margin orientation would influence the accuracy of margin identification and the subsequent directed re-excisions, as well as subject patients to unnecessary surgeries or prevent them from having re-excisions they need. Intraoperative specimen inking by the surgeon is a more accurate method of margin assessment. Results of this trial can be extended to other cancers in which a negative margin is prognostic. The American Society of Breast Surgeons Official Proceedings
43 A Randomized, Double-Blind, Placebo-Controlled Window-of-Opportunity Trial Evaluating Clinical Effects of High-Dose Vitamin D in Patients With Breast Cancer Angel Arnaout 1,2, Christina Addison 1, Susan Robertson 2, Nina Chang 2, Mark Clemons 3 1 Ottawa Hospital Research Institute, Ottawa, ON, Canada, 2 Ottawa Hospital, Ottawa, ON, 3 Ottawa Hospital Cancer Center, Ottawa, ON, Canada Objective: Considerable epidemiologic and preclinical laboratory data suggest that there is a role for vitamin D in breast cancer therapy through its tumor-suppressive effects. Window-of-opportunity trials in breast cancer are a feasible way of assessing the biologic efficacy of therapies in the pre-surgical setting. It takes advantage of the current wait times (2 6 weeks) for breast cancer surgery as a window of opportunity to rapidly assess biological changes in vivo with short-term administration of novel potentially therapeutic agents. The objective of this study was to assess the biologic effects of short-term, high-dose vitamin D intake on breast tumor biology, as demonstrated by changes in biomarkers of proliferation and apoptosis. Methods: This is a prospective, randomized, double-blind, placebo-controlled phase 2 trial assessing the effect of high dose (40,000 IU) of oral vitamin D3 on breast cancer biology in patients awaiting surgical management of their primary breast cancer. Eligible patients took the study drug for at least 2 weeks leading up to the day of surgery. Pre- and post- 25-OH vitamin D blood levels were obtained. In addition, tumor biomarkers, including the Ki67 index (marker of proliferation) and caspase 3 (marker of apoptosis), were analyzed on the original diagnostic core biopsy sample and then compared to a repeated analysis on the tissue obtained at the time of the definitive surgical procedure. Results: Eighty patients completed the study, 38 in the control group and 42 in the vitamin D group. The mean duration on the study was 19 days. Within the study cohort, 16/80 (64%) were ER positive, 55/80 (55%) were PR positive, and 65/80 (61%) were Her2 negative. Mean overall baseline blood 25-OH Vitamin D levels in the study cohort was 76.4 nmol/l, which increased to nmol/l in the vitamin D-treated group (p = ). Mean Ki67 level at baseline was 35.4% overall and there was no statistically significant difference in the Ki67 obtained from the surgical specimen between the treatment group (mean = 39.3%) and the control group (41.0%). Baseline caspase 3 level was 31.2% overall and there was no statistically significant difference in the caspase 3 obtained from the surgical specimen between the treatment group (mean = 13.1%) and the control group (15.6%). However, the overall caspase 3 level (14%) obtained from the surgical specimen from both study groups was significantly lower than that obtained from the core biopsy at baseline (31.2%) (p = 0.04). Conclusion: This is the first prospective randomized trial evaluating the effect of high-dose vitamin D on breast cancer proliferation and apoptosis. No significant difference was seen in these markers, despite significantly higher circulating levels of 25-OH vitamin D in the treatment arm. A significant reduction in caspase 3 was noted at surgery, which could be due to a reduction in apoptosis or technical factors affecting the measurement of caspase Breast Cancer Staging and Presentation in HIV-Positive Patients: A Multi-Institutional Retrospective Review Cassandra Baker 1, Patricia Wehner 2 1 Georgetown University School of Medicine, Washington, DC, 2 MedStar Washington Hospital Center, Washington, DC Objective: The National Cancer Institute does not recognize an association between HIV and an increased risk of breast cancer; however, people infected with HIV are living longer secondary to anti-retroviral therapy. The incidence of breast cancer in HIV-positive patients continues to increase as the population ages, yet there are limited data on the presentation and stage of breast cancer at diagnosis in HIV patients treated in the U.S., as most data comes from Africa. Because of the current HIV epidemic and one of the nation s highest breast cancer mortality rate, the District of Columbia is a potential population for analysis. Given the immunecompromising effects of HIV, it was hypothesized that HIV infection would correlate with earlier age and breast cancer stage at diagnosis. The American Society of Breast Surgeons Official Proceedings
44 Methods: This study analyzed all breast cancer diagnoses in HIV-positive patients between January 1, 2004, and December 31, 2014, at 4 hospitals in the Baltimore-Washington, DC, area. Female patients were identified using the diagnosis codes of malignant breast cancer (ICD-9 233, 174) and HIV (ICD-9 042, V08). This study population (n = 43) was compared with all women diagnosed with breast cancer between the same dates in a Washington, DC, cancer registry (n = 3012). Age, race, receptor status, stage at diagnosis, and treatment were analyzed using logistical regression. Results: The average age at breast cancer diagnosis, 53 years old, was significantly lower (p < 0.001) in HIVpositive individuals than the control, 60 years old (table). Similarly, the percent of HIV-positive patients diagnosed with breast cancer who were African-American, 90.7%, was significantly higher than the control of 80.6% (p = 0.04), correlating with the demographics of the population. However, the stage at diagnosis showed no significant differences between the 2 groups (p = 0.42) (table). Conclusion: As HIV patients continue to live longer, their risk for developing breast cancer continues to increase. In this study, HIV-positive patients presented at a significantly lower age. This suggests that it is The American Society of Breast Surgeons Official Proceedings
45 imperative that HIV-positive female patients start annual screening mammography at 40 years old. Although no significant correlation was found for stage at diagnosis, earlier presentation can translate into more aggressive cancer if treatment is delayed. Further research is recommended to account for potential confounding variables and to evaluate longer follow-up in larger populations Could Ductoscopy Be Used to Identify Breast Cancer in Patients With Pathologic Nipple Discharge? Fatih Levent Balci 1,4, Omer Bender 2, Neslihan Cabioglu 3, Mahmut Muslumanoglu 3, Vahit Ozmen 3, Abdullah Iğci 3 1 Department of Breast Surgery, Acibadem University, Istanbul, Turkey, 2 Yeniyuzyil University, Istanbul, Turkey, 3 Istanbul University Faculty of Medicine, Istanbul, Turkey, 4 Department of Breast Surgery, Columbia University Medical Center, New York, NY Objective: An accurate preoperative identification of malignant tissue is a challenge in the surgical management of nipple discharge associated breast cancer. Ductoscopy could contribute to more accurate diagnosis by entering and targeting the interested duct. The aim of the study was to determine whether the ductoscopic findings are significant predictors of cancer associated with nipple discharge and correlated with any clinicopathological features. Methods: Patients who had pathologic nipple discharge (PND) were recruited to have ductoscopic exploration from January 2007 to January Those with abnormal findings on ductoscopy underwent subsequent surgery. Patients with histopathologically proven in situ or invasive cancer (n = 33) were enrolled into the study. Ductoscopic abnormalities included hairy, irregular or hyperemic duct, presence of red patches or orange color, fragile or obstructed duct were considered as malignant, whereas duct ectasia, intraductal papilloma(s), or debris were considered as benign. Pathologic cytology was considered as presence of malignant or suspicious cells. Results: The median age was 48 (30 81), and 1 of 33 patients was male. Cancer was diagnosed with duct excision following prolene-guided ductoscopy (n = 26), US/MRI-guided core biopsy (n = 6), or wire-localized excisional biopsy (n = 1). Seventeen patients (51.5%) underwent breast conservation, whereas the remaining had mastectomy with (n = 20) or without (n = 13) sentinel node biopsy. There were 19 cases diagnosed with DCIS (57.5%), whereas 14 cases had invasive cancer (42.5%). The majority had early-stage cancer (n = 17, stage 0; n = 13, stage I; n = 3, stage II). The most common ductoscopic images were as follows: hyperemic hairy irregular duct (n = 9, 27.3%), hairy irregular duct (n = 7, 21.2%), red patches/orange color (n = 4, 12.1%), and fragile intraductal lesion (n = 2, 6.1%). Patients diagnosed with DCIS were more likely to have a malignant finding in ductoscopy (79% vs 50%; p = 0.086) in comparison to cases with invasive cancer. Furthermore, cases with a malignant ductoscopic finding were more likely to have a pathologic cytology than patients with benign findings (38% vs 10%; p = 0.116). The accompanying high-risk lesions associated with cancer were intraductal papilloma (n = 5) and atypical lobular hyperplasia (n = 1). However, 3 patients who were diagnosed as intraductal papilloma in ductoscopy were found to have invasive cancer without papilloma. Conclusion: Ductoscopy is a better identifier for DCIS in comparison to invasive cancer associated with PND. More advanced technologies are warranted for detecting early invasive cancer missed by conventional imaging. The American Society of Breast Surgeons Official Proceedings
46 Influence of the SSO/ASTRO Margin Re-excision Guidelines on Costs Associated With Breast-Conserving Surgery Christopher Baliski 1, Reka Pataky 2 1 BC Cancer Agency, Kelowna, BC, Canada, 2 BC Cancer Agency, Vancouver, BC, Canada Objective: There is significant variability in the reported re-excision rates in patients with invasive breast cancer undergoing attempted breast-conserving surgery (BCS). This variability is a function of both the positive pathologic margin rate, and interpretation of an adequate pathologic margin. The influence of the SSO/ASTRO margin guidelines on reoperation rates, and the potential cost savings is of interest from both a quality and health economics perspective. Methods: A retrospective analysis of all patients undergoing BCS over a 3-year period was performed (January 1, 2011, to December 31, 2013). Previously identified physician and facility related costs associated with both initial BCS, and projected costs related to reoperation was utilized to determine the potential savings associated with avoidance of reoperation. Results: Over a 3-year period 512 patients underwent attempted BCS for invasive breast cancer. The pathologic margin status was positive in 97 (19%) patients, close but negative in 59 (12%), and 1 2 mm in 98 (19%). Reoperations occurred in 25% (126 of 512) of the BCS cohort. Based upon the pathologic margin status, reoperation occurred in 85% of those with positive margins (82/97), 25% (39 of 157) with negative margins of less than 2 mm, and 2% (5 of 257) of those with widely negative margins. Nine percent (44 of 512 patients) of the entire BCS cohort underwent reoperation in the setting of negative initial pathologic margins. Based upon our cost model, avoidance of a reoperation in these patients would result in a cost savings of $697 (95% CI, ) per patient undergoing attempted BCS in our population. Conclusion: Adherence to the SSO/ASTRO margin guidelines would result in 9% of patients avoiding unnecessary reoperation after attempted BCS, which represents approximately one third of reoperations after BCS. This guideline may help reduce some of the reported variability in the re-excision rates, and has significant cost savings associated with it. Both of these are important with respect to the quality of care provided and the costs associated with treatment Influence of Patient, Disease, and Physician-Related Factors on Reoperation Rates After Attempted Breast-Conserving Surgery Christopher Baliski 1, Lauren Hughes 1, Colleen McGahan 2 1 BC Cancer Agency, Kelowna, BC, Canada, 2 BC Cancer Agency, Vancouver, BC, Canada Objective: Breast-conserving surgery (BCS) is the preferred surgical approach for the majority of patients with early-stage breast cancer. With BCS there are frequently issues regarding the pathologic margin status, with population-based studies reporting reoperation rates between 17% and 35%. While reoperations are inevitable, there is significant variability in the literature, suggesting this is a quality-of-care issue. Understanding the patient-, disease-, and physician-related factors influencing reoperation rates is of importance in an effort to minimize this occurrence. Methods: A retrospective analysis of all patients referred to our cancer center over a 3-year period (January 1, 2011, to December 31, 2013) was performed. Patients undergoing initial breast-conserving surgery for either ductal carcinoma in-situ or T1 and T2 breast cancers were included. Factors considered for analysis included: patient s age at diagnosis; tumor size, histology, grade, ER/PR and HER-2, and lymph node status; and facility and surgeon case volume. Surgeon volume was treated categorically based on surgeon cases per year as: low (1 5), intermediate (6 10), high (11 24), and very high (25 or more) volume. Multivariate logistic regression analysis was performed to identify variable of significance influencing reoperation rates after attempted BCS. The general estimating equations method was applied to account for the correlation of patients operated on by a specific surgeon. The American Society of Breast Surgeons Official Proceedings
47 Results: Five hundred ninety-four patients underwent initial BCS, with 159 (26.8%) patients required at least 1 reoperation to ensure appropriate pathologic margins. On univariate analysis the following were associated with an increased need for reoperation including: younger age, larger tumor, lobular carcinoma, higher tumor grade, and low surgeon volume. On multivariate analysis, patient age (under 46 years age), tumor size (greater than 2 cm), and lobular carcinoma were associated with the need for reoperation after attempted BCS. Although a trend to increased need for reoperation was noted with lower volume surgeon, it did not reach statistical significance. Conclusion: Reoperation rates after attempted breast-conserving surgery is within the expected range in our population. Younger patients and those with tumors larger than 2 cm, along with lobular histology were more likely to require secondary operations. These factors should be considered when counseling patients about the potential for reoperation if breast-conserving surgery is being considered Disparities in Endocrine Risk Reduction for Young Adult Women With Lobular Carcinoma In Situ Bradley Bandera 1, Amy Voci 1, Jihey Lee 1, Melanie Goldfarb 1, Maggie DiNome 1 1 John Wayne Cancer Institute, Santa Monica, CA Objective: Lobular carcinoma in situ (LCIS) is associated with up to a 21% 10-year risk of breast cancer development. Tamoxifen can reduce that risk to as low as 7%, but the side effects of this agent and similar endocrine therapies might affect their use in women of reproductive age. Therefore, this study examines patterns in the recommendation for and compliance with endocrine therapy for LCIS in women <40 years of age. Methods: The National Cancer Database was queried for all women between ages 15 and 39 who were diagnosed with LCIS between 2000 and Patients were excluded if they had previous/synchronous ductal carcinoma in situ or invasive cancer. Compliance with endocrine treatment was assessed at the time of NCDB data capture. Socioeconomic, demographic, and treatment variables were examined to determine their impact on endocrine therapy recommendations and compliance. Results: Of the 1650 patients identified, only 45.4% had been recommended for endocrine therapy. After adjustment for competing factors, patients recommended for endocrine therapy were more likely to be at least 35 years of age (OR, 1.4; CI, ), and more likely to be black than non-hispanic white (OR, 1.5; CI, ). Endocrine therapy was less likely to be recommended for women residing in Pacific Coast regions compared to all other regions except for South Central and Mountain (p <.001), and less likely to be recommended for women residing more than 100 miles from the diagnosing facility (OR, 0.3; CI, ). Of the 749 patients recommended for endocrine therapy, 598 (79.8%) were initially compliant with the recommendations. Of those who refused (21.2%), only residing in the Pacific Coast region increased the likelihood of refusing therapy (p <.001). continues The American Society of Breast Surgeons Official Proceedings
48 Variable Odds Ratio 95% CI P value Recommended (Rec) vs Not Rec vs < Black vs White N. Central vs Pacific (Pac) < Mid-Atlantic (Atl) vs Pac < New England (Eng) vs Pac < S. Atl vs Pac >100 miles vs < Taking vs Rec but refused S. Central vs Pac Mid Atl vs Pac New Eng vs Pac S. Atl vs Pac S. Cen vs Pac Conclusion: A low rate of recommended therapy and a high rate of compliance suggest that the underuse of endocrine therapy in younger women with LCIS is more dependent on disparities in recommendation rather than patient compliance. This may reflect regional practice patterns, community standards of care, and/or physician bias regarding the significance of LCIS as a risk factor for invasive disease. When it comes to risk reduction, however, patients should have greater opportunity for shared decision-making. Recognizing that certain factors impact physician recommendations for patients with LCIS is the first step toward remedying this disparity Mammary Tuberculosis: Clinical Presentation, Treatment, and Outcome of 50 Cases Razia Bano 1, Farhan Majeed 2, Amna Sharaf 2 1 Shaukat Khanum Memorial Cancer Hospital & Research Centre, Lahore, Pakistan, 2 Combined Military Hospital, Rawalpindi, Pakistan Objective: Breast tuberculosis (TB) is a rare entity. It may mimic either carcinoma or pyogenic abscess. Clinical presentation may range from abscess, discharging sinuses, lump, or skin ulceration. Breast TB may be classified into 3 types, namely nodular, disseminated, and sclerosing varieties. We present demographic features, clinical presentation, treatment details, and outcome of tuberculosis in 50 patients. Methods: Retrospectively, data were retrieved from the electronic records of 35 patients from one institute and 15 patients from the second institute; we included all patients from 2006 to Their demographics searched were age at presentation, gender, clinical presentation, laterality, site of the lesion, histopathology, acid fast bacilli (AFB), response to anti-tuberculosis treatment (ATT), and role of surgery in diagnosis and management. Results: A total of 50 patients were included from both centers, age range was years; median age, 38. All were female patients. Twenty-nine patients had right breast involvement, while remaining had left breast involvement. Demographic and treatment details are summarized in the table. Most common presentation was breast lump in center A and discharging sinuses, indurations in center B. Upper outer quadrant was the most common site involved. Primary tuberculosis was more common as compared to secondary; patients with either prior history of tuberculosis, axillary lymph adenopathy, fever, night sweats were considered to have secondary tuberculosis. Radiological features range from ill-defined opacity, abscess formation to well-defined solid masses. Diagnosis was made on core biopsy in 22 patients; incision and drainage followed by tissue sampling was performed in 16 cases. Almost all patients had granulomatous mastitis (GM); 3 of our patients had diagnosis of tuberculosis mast. The American Society of Breast Surgeons Official Proceedings
49 Characteristics Frequency Center A Center B Total Percentage Clinical presentation Lump Abscess Discharging sinus Nipple retraction % 18% 26% 52% Site of lesion Upper outer quadrant Central Upper inner quadrant Lower outer quadrant % 30% 6% 8% Type Primary Breast TB Secondary Breast TB % 36% Histopathology Granulomatous mastitis GM + invasive ductal carcinoma % 6% Anti-tuberculous treatment CR PR NR % 8% 10% Surgical treatment Incision & drainage + tissue biopsy Lumpectomy Modified radical mastectomy % 14% 6% The American Society of Breast Surgeons Official Proceedings
50 Conclusion: Mammary tuberculosis may mimic pyogenic abscess or carcinoma; mainstay of treatment is antituberculosis drugs; role of surgery is limited for tissue diagnosis, abscess drainage, or excision of residual lump after anti-tuberculosis therapy Outcomes in Patients With Small Node-Negative Invasive Breast Cancer Jean Bao 1, Cory Donovan 1, Farin Amersi 1, Xiao Zhang 1, Armando Giuliano 1, Alice Chung 1 1 Cedars Sinai Medical Center, Los Angeles, CA Objective: Patients with T1mi,a,b ( 1 cm) node-negative tumors generally have an excellent prognosis, but there is controversy whether systemic therapy is warranted in this population, especially among the more aggressive molecular subtypes. The objective of this study was to compare survival and recurrence rates in patients with small node-negative invasive breast cancer. Methods: Review of a prospectively maintained database identified 669 patients with T1mi,a,bN0M0 invasive breast cancer from January 1, 2000, through December 31, Among those with complete tumor marker data, 71 patients had HER2+ tumors, 467 had hormone receptor (HR)+/HER2 tumors, and 45 had triplenegative breast cancer (TNBC). The 3 groups were compared with respect to patient and tumor characteristics, surgical treatment, adjuvant therapies, recurrence rate (RR), disease-free survival (DFS), and overall survival (OS). Analysis was performed to determine covariates that correlate with DFS and OS. Results: Mean age was 60.6 years with a mean tumor size of 6.7 mm. At mean follow-up of 4.9 years, the 5- year OS was 95% and 5-year DFS was 98%. Patients with HER2+ tumors were significantly younger and had smaller tumors than the other subtypes (table). HER2+ and TNBC patients were more likely to have poorly differentiated tumors and were more likely to undergo mastectomy than HR+/HER2 patients. The HR+/HER2 group was the least likely to receive chemotherapy and the most likely to receive hormonal therapy, more so than HR+/HER2+ patients, of whom 52.3% received hormonal therapy. RR for HER2+, HR+/HER2, and TNBC was 7.0%, 3.7%, and 4.4%, respectively (p = 0.2). Breast cancer specific death rate was 1.4%, 0.9%, and 2.2%, respectively. There was no significant difference in OS (p = 0.9) and DFS (p = 0.5) among the 3 groups. On multivariable analysis, smaller tumor size (p = 0.04) and the use of adjuvant hormonal therapy (p = 0.08) were correlated with improved DFS, while younger age at diagnosis (p < 0.01) and the use of hormonal therapy (p = 0.05) were the only significant predictors of improved OS. Use of adjuvant chemotherapy was not associated with improvement in DFS or OS. Patient and Tumor Characteristics and Survival Outcomes in T1mi,a,bN0M0 Invasive Breast Cancer by Tumor Subtype HER2+ (n = 71) HR+/HER2-* (n = 467) Triple Negative (n = 45) p value Mean age (years) Mean tumor size (mm) Histology 0.3 Ductal 54 (76.1%) 347 (74.3%) 40 (88.9%) Lobular 6 (8.5%) 27 (5.8%) 1 (2.2%) Ductal + others 9 (12.7%) 77 (16.5%) 2 (4.4%) Others 2 (2.8%) 16 (3.4%) 2 (4.4%) Grade <0.001 Well differentiated 5 (8.2%) 208 (45.8%) 3 (7.0%) Moderately differentiated 22 (36.1%) 207 (45.6%) 4 (9.3%) Poorly differentiated 34 (55.7%) 39 (8.6%) 36 (83.7%) The American Society of Breast Surgeons Official Proceedings
51 Surgery type <.001 Lumpectomy 41 (57.8%) 335 (72.0%) 29 (65.9%) Unilateral mastectomy 22 (31.0%) 48 (10.3%) 7 (15.9%) Bilateral mastectomy 8 (11.3%) 82 (17.6%) 8 (18.2%) Adjuvant chemotherapy <0.001 No 38 (55.9%) 438 (94.6%) 27 (61.4%) Yes 30 (44.1%) 25 (5.4%) 17 (38.6%) Adjuvant radiotherapy 0.1 No 39 (54.9%) 187 (42.4%) 22 (51.2%) Yes 32 (45.1%) 254 (57.6%) 21 (48.8%) Adjuvant hormonal therapy No 41 (58.6%) 142 (33.3%) 44 (97.8) <0.001 Yes 29 (41.4) 285 (66.7%) 1 (2.2%) Recurrence 0.2 Death Locoregional 4 (5.6%) 7 (1.5%) 0 (0.0%) Contralateral breast 0 (0.0%) 4 (0.9%) 1 (2.2%) Distant 1 (1.4%) 6 (1.3%) 1 (2.2%) All 8 (11.3%) 41 (8.8%) 3 (6.7%) Breast cancer 1 (1.4%) 4 (0.9%) 1 (2.2%) *HR = hormone receptor Conclusion: Patients with T1mi,a,bN0M0 invasive breast cancer have an excellent prognosis. The 3 molecular subtypes of T1mi,a,bN0M0 invasive breast cancer differed significantly in age, tumor size, and tumor grade, but had similar RR, DFS, and OS. Hormonal therapy use was strongly associated with improved DFS and OS, but chemotherapy was not. Tumor subtype may not influence recurrence and survival in such small early-stage tumors Incidence Rate and Outcomes for Palpable Ductal Carcinoma In Situ in the Contemporary Era Dany Barrak 1, Lily Tung 1, Zeina Ayoub 2, Alexander Ring 1, Akshara Singareeka Raghavendra 3, Debu Tripathy 3, Stephen Sener 1, Heather MacDonald 1, Maria Nelson 1, Meenakshi Bhasin 1, Julie E Lang 1 1 University of Southern California, Norris Cancer Center, Los Angeles, CA, 2 American University of Beirut Medical Center, Beirut, Lebanon, 3 University of Texas MD Anderson Cancer Center, Houston, TX Objective: Palpable ductal carcinoma in situ (DCIS) is known to be more aggressive than nonpalpable DCIS. With the advent of screening mammography, many DCIS cases are nonpalpable, but the incidence of palpable DCIS in underserved populations is not well described. We aimed to determine the incidence rate, local recurrence-free survival (LRFS), disease-free survival (DFS), and overall survival (OS) rates for palpable vs nonpalpable DCIS after controlling for relevant covariates. Methods: We performed a retrospective single-institutional cohort study comparing palpable vs nonpalpable DCIS. We defined palpable DCIS as presenting with a breast mass in the absence of an a priori finding on screening mammography. We included newly diagnosed female DCIS patients treated between 2006 and 2013 at a large urban safety-net hospital for medically underserved populations. We excluded patients with concomitant invasive or microinvasive carcinomas that were detected either on core biopsy or definitive surgical treatment. Univariate analyses were performed using chi-square and the Kaplan-Meier method. For The American Society of Breast Surgeons Official Proceedings
52 multivariate analysis, we used the Cox proportional hazards model to evaluate association with LRFS, DFS, and OS. Results: We identified 321 patients who met our inclusion criteria, the majority of which were of Hispanic background (66%). The median age was 51. Among these patients, 137 presented with palpable DCIS (42%) and 184 with nonpalpable DCIS (58%). Median follow-up time was 73 months. Univariate analysis showed that the proportion of local recurrences were higher in the palpable (n = 12, 8.6%) vs the nonpalpable cohorts (n = 9, 4.7%), p = The rates of DFS were worse in the palpable (n = 120, 87%) vs the nonpalpable cohorts (n = 172, 93%), p = The rates of OS were worse in the palpable (n = 125, 91%) vs the nonpalpable cohorts (n = 171, 96%), p = Histology showed comedonecrosis for n = 87 (63%) of palpable DCIS vs nonpalpable DCIS (n = 62, 34%), p = The results of our multivariate analysis for factors that were statistically correlated with LRFS, DFS, or OS in the palpable DCIS cohort are summarized in the table. Surgery type and receipt of radiation therapy were not statistically significant predictors and were excluded due to collinearity. Multivariable Proportional Hazard Modeling Results Factor HR 95% CI P LRFS Age to ER-positive to Size of DCIS to Histology to DFS Age to ER-positive to Grade to OS Age to ER-positive to Receipt of endocrine therapy to HR hazard ratio, CI confidence interval; LRFS local recurrence free survival, DFS disease free survival, OS overall survival; ER estrogen receptor, DCIS ductal carcinoma in situ Conclusion: Palpable DCIS occurred at a higher than expected rate in our study population at a safety-net hospital. Palpable DCIS was associated with worse LRFS, DFS, and OS. Comedonecrosis was the most common histology found in palpable DCIS. Our study confirms that palpable DCIS is a particularly aggressive subset of DCIS. The American Society of Breast Surgeons Official Proceedings
53 Is Routine Axillary Imaging Necessary in Clinically Node-Negative Patients Undergoing Neoadjuvant Chemotherapy? Andrea Barrio 1, Anita Mamtani 1, Michelle Stempel 1, Anne Eaton 1, Monica Morrow 1 1 Memorial Sloan Kettering Cancer Center, New York, NY Objective: Current National Comprehensive Cancer Network guidelines recommend routine axillary imaging prior to neoadjuvant chemotherapy (NAC) in breast cancer patients considered clinically node-negative (cn0) by physical exam alone. Given that a major benefit of NAC is axillary downstaging, the role of axillary imaging in cn0 patients pre-nac remains uncertain. The purpose of this study was to determine whether abnormal axillary imaging pre-nac was predictive of nodal metastases post-nac (ypn+) in cn0 patients. Methods: cn0 patients undergoing NAC followed by sentinel node biopsy (SNB) or axillary lymph node dissection (ALND) were identified from a prospectively maintained database. Pathologic nodal status after NAC was assessed. ALND was performed for a positive sentinel node, T4 disease, failed mapping, or surgeon discretion. Rates of ypn+ and ALND were compared among patients with abnormal pre-treatment axillary imaging vs normal or no pre-treatment imaging using Fisher exact test. Results: From 7/2008 9/2015, 259 cn0 patients received NAC followed by axillary surgery; 187 (72%) had SNB, 72 (28%) had ALND. Median age was 49 years; median tumor size was 4 cm. Forty percent were ER+/HER2, 29% HER2+, and 31% triple-negative. All patients had pre-nac mammogram, 26% axillary ultrasound (US), 85% MRI, and 51% PET. Abnormal nodes were seen in 97 patients (37%) by any imaging modality; pre-nac lymph node biopsy was performed in 41 with negative (n = 39) or nondiagnostic (n = 2) results. Overall, 20% of cn0 patients were ypn+ after NAC with a median of 3 positive nodes (range, 1 15). The incidence of ypn+ was similar in patients with abnormal vs normal nodes by mammogram (p = 0.06), axillary US (p = 0.9), MRI (p = 0.2), or PET (p = 0.8) (table). Specifically, in the subset of patients who underwent axillary US, there was no difference in the incidence of ypn+ in patients with abnormal vs normal nodes (18% vs 22%). The presence of abnormal nodes on pre-nac imaging did not make ALND more likely (p = 0.7). Rates of ypn+ and ALND Among cn0 patients With Abnormal vs Normal or No Pre-Treatment Axillary Imaging Imaging Modality # of Patients (n = 259) # Patients ypn+ (n = 52) P value ALND (n = 72) P value Mammogram Normal nodes (22%) 71 (30%) Abnormal nodes 23 1 (4%) 1 (4%) Axillary ultrasound Normal nodes 27 6 (22%) 7 (26%) Abnormal nodes 40 7 (18%) 8 (20%) Not done (20%) 57 (30%) MRI Normal nodes (18%) 39 (26%) Abnormal nodes (19%) 17 (24%) Not done (32%) 16 (42%) PET Normal nodes (20%) 23 (27%) Abnormal nodes (23%) 14 (30%) Not done (19%) 35 (27%) Any Normal nodes (21%) 47 (29%) Abnormal nodes (19%) 25 (26%) ypn+, post-treatment nodal metastases; ALND, axillary lymph node dissection; cn0, clinically node negative; PET, positron emission tomography The American Society of Breast Surgeons Official Proceedings
54 Conclusion: Only 20% of cn0 patients were ypn+ after NAC. However, the presence of abnormal nodes on pre-treatment imaging in cn0 patients did not identify a group of patients who were more likely to be ypn+ or require an ALND after NAC; the routine use of pre-treatment axillary imaging in cn0 patients is not supported by this study Patient-Reported Satisfaction Following Oncoplastic Breast-Conserving Therapy Amy Bazzarelli 1, Jing Zhang 1, Angel Arnaout 1 1 University of Ottawa, Ottawa, ON, Canada Objective: Oncoplastic breast surgical techniques are becoming increasingly used to limit deformity in breastconserving therapy (BCT) for breast cancer. We aimed to evaluate patient- reported satisfaction following breast-conserving level II oncoplastic techniques (reduction/mammoplasty techniques) in terms of patient satisfaction with cosmesis, as well as psychosocial and sexual well-being postoperatively. Methods: This was a 5-year prospective study whereby patients who underwent BCT with the use of level II oncoplastic techniques were given the Breast-Q questionnaire postoperatively at 3 months. Clinical and pathological characteristics were identified from patient charts. Results: Since 2010, a total of 802 patients underwent breast cancer surgery, of whom level II oncoplastic techniques were used in 130 (16%). A total of 88 patients completed Breast-Q questionnaires (response rate, 67.7%). Patient average age at the time of surgery was 59 years (standard deviation [SD] = 12.5 years). Tumor characteristics demonstrated a median T stage of 1 and a median N stage of 0. The average volume of breast tissue resected was cm 3 (SD = cm 3 ). Mean satisfaction with Breast-Q score was 75.1/100 (SD = 13.4) and satisfaction with nipples was 80.5/100 (SD = 22.7), while mean psychosocial well-being score was 85.4/100 (SD = 16.0) and sexual well-being was 65.7/100 (SD = 24.0). Conclusion: Results demonstrate a high satisfaction in patients who underwent BCT aided by level II oncoplastic techniques on the Breast-Q patient-reported outcome measure. These findings demonstrate that oncoplastic breast-conserving therapy has an equivalent or higher satisfaction amongst patients when compared with those in the literature undergoing mastectomy and reconstruction. Further larger prospective studies comparing patient satisfaction of oncoplastic BCT to standard BCT and mastectomy with reconstruction are required Comparison of MammaPrint and BluePrint Genetic Signatures in Pre- and Post- Neoadjuvant Chemotherapy-Treated Breast Cancer Peter Beitsch 1, Pat Whitworth 2, Paul Baron 3, James Pellicane 4, Pond Kelemen 5, Andrew Ashikari 5, Beth Ann Lesnikoski 6, Cristina Lopez-Penalver 7, Arnold Baskies 8, Michael Rotkis 9, David Rock 10, Elena Rehl 11, Heidi Memmel 12, Hanadi Bu-Ali 13, David Carlson 14, Laura Lee 15, Robert Reilly 16, William Dooley 17, Angela Mislowsky 18, Jia-Perng Wei 19, Mark Gittleman 20 1 Dallas Surgical Group, Dallas, TX, 2 Nashville Breast Center, Nashville, TN, 3 Breast & Melanoma Specialists of Charleston, Charleston, SC, 4 Virginia Breast Center-Bon Secours Cancer Institute, Midlothian, VA, 5 Ashikari Breast Center, Dobbs Ferry, NY, 6 The Breast Institute at JFK Medical Center, Atlantis, FL, 7 Miami Cancer Institute, Miami, FL, 8 Virtua Health, Willingboro, NJ, 9 Northern Indiana Cancer Research Consortium, South Bend, IN, 10 Regional Breast Care, Fort Myers, FL, 11 Center for Breast Care at Anderson Cancer Institute, Savannah, GA, 12 Advocate Lutheran General Hospital, Park Ridge, IL, 13 Wheaton Franciscan Healthcare, Milwaukee, WI, 14 Evansville Surgical Associates, Evansville, IN, 15 Tenet Health Comprehensive Cancer Center, Palm Springs, CA, 16 St. Mary Medical Alliance Cancer Specialists, Langhorne, PA, 17 University of Oklahoma Health Sciences, Oklahoma City, OK, 18 Coastal Carolina Breast Center, Murrells Inlet, SC, 19 Agendia, Inc, Irvine, CA, 20 Coordinated Health Breast Care, Allentown, PA The American Society of Breast Surgeons Official Proceedings
55 Objective: Neoadjuvant chemotherapy (NCT) has been shown to clinically down-stage many large or locally advanced breast cancers. For patients who do not achieve a pathologic complete response (pcr), limited research has been performed to evaluate how NCT affects the gene signature profile on the residual tumor. The Neoadjuvant BReast Symphony Trial (NBRST) enrolled over 1,000 US breast cancer patients who received NCT between June 2011 and December MammaPrint (MP), BluePrint (BP), and TargetPrint were performed on all patients pre-nct biopsy. A pilot group of 36 patients who did not achieve pcr had MP and BP signatures performed on their post-nct breast tumor. The purpose of this pilot study is to determine if there is a meaningful difference in signatures between pre-nct and post-nct breast tumors. Methods: The current analysis includes women from the NBRST study with histologically proven breast cancer who received neoadjuvant chemotherapy +/ trastuzumab, +/ pertuzumab. Pathological assessment of ER, PR, and HER2 was done according to ASCO CAP guidelines at the time of diagnosis. MP and BP assays were performed on both the pre-nct and post-nct breast tumor samples. The MP Index is a continuous score that is used to classify patients into high or low risk of distant metastases. In combination with MP, BP classifies patients into molecular subtypes: luminal A & B, HER2, or basal type. The Fisher exact test was used to compare outcome rates within different subgroups. Results: Thirty-six patients with residual disease at the completion of NAC had their remaining cancer reanalyzed with MP and BP. Four of the 36 patients switched from MP high risk to MP low risk following NCT (p < 0.001). The change in MP Index following NCT also varied by molecular subtype. The average change in MP Index between pre- and post-treatment samples was an increase of for luminal A (n = 12), for luminal B (n = 12), for HER2-type (n = 1), and for basal type (n = 11). Overall, 4 posttreatment samples changed to luminal A subtype, 3 from luminal B (p < 0.001), and 1 from HER2 subtype before NCT. Pre-treatment MP Classification MP Low Risk MP High Risk Total Post-treatment MP low risk MP high risk Total Conclusion: This pilot study shows that NCT significantly changed MP risk classification in post-treatment tumors for patients of particular molecular subtypes, who did not achieve pcr. This finding suggests that the treatment may have eliminated the most susceptible tumor subclone or altered molecular characteristics of the remaining tumor. Further work will be performed to determine if the degree of change in MP Index correlates with reduction in tumor size. This correlation would allow MP to be used as a tool to monitor response to a particular therapeutic regimen in mid- and/or post-treatment samples. The American Society of Breast Surgeons Official Proceedings
56 NAPBC Accreditation Demonstrates Increasing Compliance With Postmastectomy Radiation Therapy Quality Improvement Measure Elizabeth Berger 1, Cary Kaufman 2, Ted Williamson 3, Julio Ibarra 4, Karen Pollitt 1, Richard Bleicher 5, James Connolly 6, David Winchester 7, Katharine Yao 8 1 American College of Surgeons, Chicago, IL, 2 Bellingham Regional Breast Center, University of Washington, Bellingham, WA, 3 Willamette Valley Medical Center Radiation Oncology, McMinnville, OR, 4 MemorialCare Breast Center at Orange Coast Memorial, Long Beach, CA, 5 Fox Chase Cancer Center, Philadelphia, PA, 6 Brigham and Women s Hospital, Boston, MA, 7 Medical Director of American College of Surgeons Cancer Programs, Chicago, IL, 8 NorthShore University HealthSystem, Evanston, IL Objective: The National Accreditation Program for Breast Centers (NAPBC) was established in 2008 by the American College of Surgeons as a quality improvement program for patients with breast disease. A quality measure exists within the standards of the NAPBC that every post-mastectomy patient with 4 positive lymph nodes should receive chest wall and regional lymph node radiation therapy. Our objective was to examine how NAPBC accreditation has affected compliance with this quality measure at individual centers, offering a first look at care delivered by NAPBC-accredited centers. Methods: Women who underwent mastectomy at NAPBC-accredited centers were identified ( ) in the NCDB. Centers that were accredited from were included in the analysis. Patients were nested within centers using a mixed effects model to identify PMRT rates at each center prior to accreditation and after accreditation, adjusting for patient and tumor characteristics. Results: Of the 18,754 patients who underwent mastectomy and had 4 positive lymph nodes at NAPBC centers, 12,614 (67%) received radiation at 386 centers. The median age was 58, 77% (n = 14,482) of the patients were white, 71% (n = 13,240) had invasive ductal carcinoma, and the median number of positive lymph nodes was 7 (IQR 5 12). The overall national trend of PMRT rates increased from 2006 to 2012 ( 4 positive lymph nodes, 57% to 71%). The baseline radiation rate among all NAPBC centers prior to accreditation was 62%. For each year of accreditation ( ), centers had statistically significantly higher rates of radiation post-accreditation than pre-accreditation (p < 0.001). The rate of radiation increased post-accreditation in each accreditation year (2009, 61% to 72%; 2010, 64% to 71%; 2011, 62% to 70%). For each year post-accreditation, a center s radiation rate increased by an average of 7%. In an adjusted analysis, independent predictors of receiving radiation in patients with 4 positive nodes were age <60 years old (OR = 1.13; 95% CI, ), lobular carcinoma (OR = 1.26; 95% CI, ), ER-positive (OR = 1.16; 95% CI, )/PR-positive tumors (OR = 1.12; 95% CI, ), and were treated at NCI centers (OR = 1.16; 95% CI, ). Patients were significantly less likely to receive radiation if they had Medicare/Medicaid (OR = 0.79; 95% CI, ), lived in the South (OR = 0.50; 95% CI, ), or had a Charlson/Deyo score 2 (OR = 0.76; 95% CI, ). Conclusion: NAPBC accreditation is associated with higher PMRT rates and thus better adherence to the PMRT quality measure. Future studies with more centers and longer follow-up are needed to determine if this trend continues Preventative Health Maintenance and Screening Adherence Among Breast Cancer Survivors Laura Bozzuto 1, Rose Li Yun 1, Laura Steel 1, Elena Carrigan 1, Vicky Ro 1, Julia Tchou 2 1 University of Pennsylvania, Philadelphia, PA, 2 University of Pennsylvania Health System, Philadelphia, PA Objective: As breast cancer patients survive longer after diagnosis, they are at risk of other chronic diseases and cancers. To address this gap in survivorship care, a retrospective cohort of breast cancer patients treated at a single academic institution was examined for rates of health maintenance procedures. We compared The American Society of Breast Surgeons Official Proceedings
57 screening rates for common conditions between those with more aggressive tumor and staging characteristics to those with less aggressive tumors to determine if those with more aggressive cancers had lower rates of adherence. Methods: All patients treated for invasive breast cancer from 1996 to 2013 with at least 30 days of follow-up in the health system were included. Patients with advanced cancers were defined as those with stage III or higher. High-risk tumor markers were hormone receptor negative and Her2 positive. For the primary analysis, overall adherence was defined as at least 3 of 5 health maintenance procedures. For the secondary analysis, individual rates were examined for influenza vaccination, Pap smear testing, colon cancer screening, DEXA, and mammography. Groups were analyzed using Fisher exact test. Results: One thousand one hundred fifty-eight patients met inclusion criteria. The mean follow-up time was 63 months. Patients with lower stage cancers were more likely to engage in health maintenance (p = 0.03). Of all health maintenance procedures, patients were most likely to have had contralateral breast screening (777 of 1158 patients [67%]). Patients with less advanced tumors were more likely to have mammography (p < 0.001). Patients with hormone receptor positive tumors were more likely to undergo mammography (p = 0.01) than those with hormone receptor negative tumors. Three hundred two of 1158 (26%) patients engaged in colon cancer screening. There was no statistically significant correlation between tumor stage and likelihood of screening. A marginal association was observed between patients with hormone receptor positive tumors and likelihood for colon cancer screening (p = 0.06). For influenza immunization and Pap smear screening, 306 and 349 of 1158 (26 and 30%, respectively) were screened. There were no statistically significant associations between stage and the likelihood of undergoing these screenings. Conclusion: Patients with higher stage cancer and more aggressive tumor characteristics were less likely to engage in health maintenance. Similar to the general U.S. population, health maintenance adherence varied depending on type of intervention and was overall low. Although this study has a limited sample size and is limited to a single academic institution, these results help expose a clear gap in health maintenance care for breast cancer survivors. Continued research to examine the interaction between survival time, disease recurrence, and patient preference is warranted to explore how these may affect adherence to screening recommendations and overall survivorship Use of Hydrogel-Based Clip for Localization of Nonpalpable, Ultrasound-Visible Breast Lesions Reduces Need for Needle Localization Magdalene Brooke 1, Elizabeth Cureton 2, Alice Yeh 3, Rhona Chen 3, Nicole Mazzetti-Barros 3, Nicole Datrice Hill 4, Reza Rahbari 4, Sherry Butler 3, Veronica Shim 2, Sharon Chang 5 1 UCSF East Bay, Oakland, CA, 2 Kaiser Oakland, Oakland, CA, 3 Kaiser South San Francisco, South San Francisco, CA, 4 Kaiser Fresno, Fresno, CA, 5 Kaiser Fremont/San Leandro, Fremont, CA Objective: Preoperative wire placement is the standard technique currently employed for localization of nonpalpable breast lesions. However, this technique requires an additional procedure and has the drawbacks of scheduling difficulties, significant patient discomfort, and risk of additional complication. This study examines the use of an ultrasound-visible clip (HydroMARK ) to localize nonpalpable breast lesions. The objective is to determine whether use of this clip reduces need for needle localization, and what effect the technique has on margin positivity. Methods: As part of a performance improvement project, a retrospective chart review was performed on all patients with ultrasound-visible, nonpalpable breast lesions who underwent lumpectomy between January and October of The 7 operating surgeons across 4 Kaiser Northern California surgical centers identified for each case the type of localization, pathology and margin results, volume of tissue excised, and time from biopsy to surgery in patients who received neoadjuvant therapy. Results: Charts were reviewed for the 171 patients who underwent lumpectomy for ultrasound-visible lesions between January and October of Type of localization for surgery fell into 3 categories: localization by ultrasound alone (USL), localization by skin marking (SM), or needle localization (NL). NL was performed The American Society of Breast Surgeons Official Proceedings
58 under either mammogram or ultrasound guidance. Only 23.4% of patients required NL, while 76.6% of patients with ultrasound-visible lesions required no needle localization procedures (14.0% SM and 62.6% USL). Margin positivity rate was 6.4% overall. Margins were positive in 5.4% of non-nl patients vs 11.1% in the NL group, a nonsignificant difference (p = 0.27). The volume of tissue excised was found to be lower in USL patients than NL patients, though this difference also did not reach statistical significance (92.9 vs cm 3, p = 0.29). Notably, the hydrogel clip migrated in only 3 cases (1.8%). There were 11 patients who had undergone neoadjuvant chemotherapy, with an average of 182 days between clip placement and surgery. In 82% of these patients, no NL was necessary. The mean time from biopsy to surgery was significantly longer among those requiring NL at 215 days vs 174 in non- NL patients (p = 0.005). Conclusion: Hydrogel-based clip is a useful localization technique which reduces the number of wire localization procedures required in nonpalpable, ultrasound-visible breast lesions. We found no statistically significant difference in positive margins rates among patients with NL vs no NL. When examined across multiple centers with a range of practice settings, this technique shows great potential to become the standard localization method in this subset of patients. The technique also shows promise in patients who receive neoadjuvant therapy Clinicopathological Characteristics of Nipple Discharge Associated Breast Cancer Neslihan Cabioglu 1, Omer Bender 2, Fazilet Ergozen 3, Enver Ozkurt 4, Mustafa Tukenmez 5, Fatih Balci 6, Ravza Yilmaz 7, Semen Onder 8, Mahmut Muslumanoglu 4, Vahit Ozmen 4, Ahmet Dinccag 4, Abdullah İgci 4 1 Istanbul University Faculty of Medicine, Istanbul, Turkey, 2 Yeniyuzyil University, Istanbul, Turkey, 3 Haseki Research Hospital, Department of Surgery, Istanbul, Turkey, 4 Istanbul University Istanbul Faculty of Medicine, General Surgery, Istanbul, Turkey, 5 Istanbul University Faculty of Medicine, Department of Surgery, Istanbul, Turkey, 6 Acibadem University Medical Faculty, Department of Surgery, Istanbul, Turkey, 7 Istanbul University Faculty of Medicine, Department of Radiology, Istanbul, Turkey, 8 Istanbul University Istanbul Faculty of Medicine, Pathology, Istanbul, Turkey Objective: Previous studies indicated that breast cancer associated with nipple discharge presents mostly as early breast cancer. The aim of the current study was to determine the clinicopathological features and molecular profiles of patients diagnosed with breast cancer presenting with pathological nipple discharge (PND). Methods: Between January 1993 and April 2015, 132 patients diagnosed with breast cancer associated with pathologic nipple discharge were identified from 3 different cohorts. Clinicopathological characteristics were analyzed, including tumor type (ductal carcinoma in situ vs invasive cancer) and molecular subtypes (luminal A, B, nonluminal HER2-neu, and triple-negative type), according to the St Gallen Breast Cancer Conference 2015 criteria. Results: Median age was 50 (28 83). Of 132, there were 5 male breast cancers. Cancer diagnosis was made by fine needle aspiration or US/MRI-guided core biopsy (n = 54, 42.2%), by stereotactic biopsy (n = 3, 2.3%), by excisional biopsy in 64 patients (wire-localized, n = 14, 10.9%; ductoscopy-guided, n = 22, 17.2%; other, n = 28, 21.9%) or by incisional/punch biopsy (n = 7, 5.5%). Fifty-four patients (41%) underwent breast conservation, whereas mastectomy was performed in the remaining 78 patients (59%) with (n = 80, 60.6%) or without (n = 52, 39.8%) sentinel lymph node biopsy. After final pathology, the majority of the patients were found to have ductal carcinoma in situ (DCIS) (n = 35, 26.5%) or 54 patients stage 1 cancer (40.9%), whereas 38 patients were diagnosed with stage 2 disease (28.8%) or 5 patients (3.8%) with stage 3 disease. The molecular subtypes of invasive cancer of 71 patients were as follows: luminal A (n = 35, 49.1%), luminal B (n = 23, 32.4%), nonluminal HER2-neu (n = 6, 8.5%), and triple-negative (n = 7, 9.9%). The majority of tumors were estrogen (77.1%) and/or progesterone receptor positive (70%) and had low ( 20%) Ki-67 levels (61.5%), whereas 17.6% of patients were found to have HER2-neu positivity. Patients with invasive cancer were more likely to have a serous/bloody nipple discharge (invasive cancer, 88%, vs other, 70%, p = 0.026) and a malignant cytology (invasive cancer, 33.3%, vs other, 11.1%, p = 0.038), compared to patients with The American Society of Breast Surgeons Official Proceedings
59 DCIS or DCIS and micro-invasion (n = 9). The median follow-up time was 32.5 months (6 135 months). In Kaplan-Meier survival analyses, 5-year disease-free survival rates were 82% and 92.6% in patients with DCIS/DCIS and micro-invasion and invasive cancer, respectively, whereas 5-year disease-specific survival rates were 100% in patients with DCIS/DCIS and micro-invasion and 98.6% in patients with invasive cancer, respectively. Conclusion: Breast cancer associated with nipple discharge presents mostly with DCIS and early invasive breast cancer with a luminal A molecular subtype. The excellent clinical outcome might be therefore due the tumor biology associated with good prognostic biomarkers The Added Value of Radiology Reviews: Additional Cancers and Avoiding False Positives Sarah Cate 1, Alyssa Gillego 1, Shannon Scrudato 1, Rita Vaszily 1, Tamara Fulop 1, Lisa Abramson 1, Alex Sarosi 1, Rachelle Leong 1, Manjeet Chadha 1, Susan Boolbol 1 1 Mount Sinai Beth Israel, New York, NY Objective: At our institution, it is standard practice to review all outside radiological breast imaging prior to patients undergoing image guided biopsies or surgery. To date, there is limited data in the literature examining the change in management as a result of these reviews. This study was undertaken in order to examine the effect of these radiology reviews on clinical management. Methods: A retrospective chart review of all imaging consultations from January 1, 2013, to June 30, 2015, was performed. This study includes 304 women who had outside mammograms and breast ultrasounds re-read by dedicated breast imagers at our institution. Sixteen patients were lost to follow-up and therefore excluded from the study. With respect to the initial outside report, the consultation reports were then classified as concordant, with no further work up needed, or as discordant, with additional imaging and/or biopsy recommended. If a biopsy was performed, the results were then grouped based on the final pathology findings. Results: A total of 304 women were included in this study. Of these women, 242 (79.6%) had no change in their management and 62 (20.4%) had a change in their work-up. This included 26 (8.6%) women who were initially BIRADS 4 and after additional imaging were spared an image guided biopsy. An image guided biopsy was performed in 11 women (3.6%) and pathology was benign. Additional imaging followed by an image guided biopsy with a high risk finding was diagnosed in 10 women (3.3%). New or additional areas of breast cancer were identified in 15 women (4.9%) who underwent a biopsy, based on our additional imaging and recommendation. Of these 15 women, 3 (20%) had a new diagnosis of contralateral breast cancer. Results # of Studies No change 242 (79.6%) Downgrade 26 (8.6%) Biopsy - benign pathology 11 (3.6%) Biopsy high-risk pathology 10 (3.3%) Biopsy - additional cancer 15 (4.9%) Total 304 Conclusion: Based on official review of breast imaging and additional evaluation, 26 (8.6%) women did not have a biopsy as originally recommended by an outside facility. This avoided a false positive finding in a substantial number of women. Additional areas of breast cancer, both ipsilateral and contralateral, were diagnosed in 4.9% of patients. Review by dedicated breast imagers should be strongly considered and incorporated into practice based on the fact that overall management was changed in 16.8% of women. The American Society of Breast Surgeons Official Proceedings
60 Cryoablation for Breast Cancers Less Than 1.5 cm: An Early Update on the ICE3 Trial Recruitment and Short-Term Follow-Up Sarah Cate 1, Alex Sarosi 1, Karen Columbus 2, Linsey Gold 3, Richard Fine 4, Andrew Kenler 5, Alyssa Gillego 1, Christopher Mills 1, Susan Boolbol 1 1 Mount Sinai Beth Israel, New York, NY, 2 Cincinnati Breast Surgeons, Inc., Cincinnati, OH, 3Comprehensive Breast Care, Troy, MI, 4 The West Clinic Comprehensive Breast Center, Memphis, TN, 5 Bridgeport Hospital, Bridgeport, CT Objective: Cryoablation has been shown to be effective in eliminating small breast cancers, as demonstrated in ACOSOG Cryoablation is an office procedure that percutaneously destroys malignant lesions by exposing them to extremely low temperatures. It eliminates the need for general anesthesia, thus making it ideal for patients who desire a less invasive approach to breast cancer treatment and those with multiple comorbidities. Methods: The ICE3 trial is currently enrolling patients at 14 sites nationwide. This trial is predicated on the ACOSOG 1072 trial, which found that 100% of breast cancers treated with cryoablation less than 1 cm in size were successfully ablated. In this trial, the tumors were treated initially with cryoablation and then surgically excised. The ICE3 trial eliminates surgical excision. Eligibility criteria include tumors less than 1.5 cm in size, patients aged 65 and older, estrogen and/or progesterone positive, and HER2-negative and clinically negative lymph nodes. Results: Thus far, 41 patients with low-risk breast cancer have been treated with cryoablation on the ICE3 trial. The mean age of these patients was 76.1, with a range of 66 years to 90 years. The mean tumor size was 0.87 cm in the sagittal dimension, with a range of 0.3 cm 1.4 cm. All patients were estrogen receptor (ER) positive, and 94.7 % were progesterone receptor (PR) positive. All patients were HER2-negative on either IHC or FISH. Patients have reported excellent cosmesis. Their distress levels were assessed on the NCCN Distress Thermometer and found to be low/medium at the time of the procedure and low at 6 months follow-up. Twenty-two patients have been followed for more than 6 months. The longest follow-up is 12 months (n = 1). To date, with this short-term follow-up, there are no recurrences. Adjuvant treatment is at the discretion of the treating physician, according to the protocol. No patients have undergone adjuvant radiation, and no patients received chemotherapy. Sentinel node biopsy is at the discretion of the treating surgeon. Three patients have undergone sentinel node biopsy. One patient had positive sentinel nodes. No serious complications or adverse events have been reported so far. Conclusion: According to this interim review of the data for the ICE3 trial, cryoablation offers relatively small subprocedure risks to the subjects with the benefits of a minimally invasive alternative to surgical treatment of early-stage, low-risk breast cancer. Continued enrollment of patients in ICE3 trial to a goal of participants for the largest validated breast cancer, liquid nitrogen based cryoablation database with long-term follow-up in this population Tumor Board Review Impacts NCCN Guideline Concordance for Breast Cancer Patients Jamie Caughran 1, Jessica Keto 1, Susan Catlin 1, Mary May 1, Elle Kalbfell 2 1 Mercy Health St. Mary s, Grand Rapids, MI, 2 Michigan State University, Grand Rapids, MI Objective: Plans of care for breast cancer patients can have high variability due to factors such as patient preference, comorbidities, and physician choice. We implemented a multidisciplinary case review of 100% of all NCCN (National Comprehensive Cancer Network) guideline discordant cases over a 6-year period at regular breast tumor boards with hopes to minimize discordance in treatment plans. Methods: Using a novel data collection process, all Michigan Breast Oncology Quality Initiative (MiBOQI) eligible patients (newly diagnosed breast cancer patients ages receiving any combination of therapy except radiation alone and neoadjuvant chemotherapy), were reviewed for NCCN guideline concordance monthly to quarterly. 69.8% of patients with breast cancer in our Cancer Registry (1103/1578) were MiBOQI- The American Society of Breast Surgeons Official Proceedings
61 eligible and reviewed during this time period. If a patient was considered discordant, an was sent to the primary oncology physician to notify them of the issue. Each discordant case was individually presented at the multidisciplinary tumor board for discussion, facilitating open dialogue, transparency, and education about proper NCCN guideline adherence. Results: From August 2009 to March 2015, 1103 eligible cases were reviewed with a total of 153 discordant cases (13.9%). The 2 most common reasons for discordant care were: patient refusal of treatment (24%) and omission of care in elderly/severe comorbid patients (21%). There were 13% of discordant cases related to variations in chemotherapy treatment and 1% due to breakdown in care coordination. Overall, discordant case volume showed a significantly decreasing trend over time (p < 0.001) with medically preventable reasons for discordance minimized or eliminated. Notable outcomes included a QI project to minimize incorrect menopausal status coding, eliminating this as a discordant variable; eliminating delays in administration of hormone therapy for patients receiving trastuzumab; a reduction of frontline systemic chemotherapy in metastatic patients; as well as a reduction in total axillary nodal surgery. Conclusion: Regular systematic review of NCCN guideline discordant cases at multidisciplinary tumor boards decreases variability in care delivery and improves adherence with NCCN guidelines. Investing time and resources toward meaningful data abstraction in short time intervals can positively impact patient care quality. The American Society of Breast Surgeons Official Proceedings
62 Impact of the Timing of Diagnosis of Genetic Mutation on the Choice of Surgical Procedure in BRCA1/BRCA2 Mutation Carriers With Breast Cancer Akiko Chiba 1, Tanya Hoskin 1, Emily Hallberg 1, Jamie Hinton 1, Courtney Heins 1, Fergus Couch 1, Judy Boughey 1 1 Mayo Clinic, Rochester, MN Objective: BRCA mutation carriers are at increased lifetime risk of developing breast cancer. Deleterious BRCA mutation status can influence surgical treatment decisions when diagnosed with breast cancer. We sought to evaluate how the surgical decisions of BRCA mutation carriers diagnosed with breast cancer varied, based on knowledge of BRCA status at time of cancer diagnosis. Methods: With IRB approval we reviewed all BRCA carriers at our institution who were diagnosed with breast cancer between 01/1996 and 06/2015. Patient surveys, medical record review, and institutional databases were used to identify breast operation performed for the index breast cancer, timing of BRCA test result relative to breast cancer surgery, and outcomes. Differences in surgical choice were analyzed using a chi-square test, and the Kaplan-Meier method was used to estimate breast cancer free survival. Results: Of 184 BRCA carriers (102 BRCA1, 82 BRCA2), index breast cancer was unilateral in 170 (92%) and bilateral in 14 (8%). Median age at cancer diagnosis was 45 (range, 21 78) and at BRCA+ identification was 46.5 (range, 12 79). Clinical stage was 10%, stage 0; 34%, stage 1; 30%, stage 2; 22%, stage 3; and 4%, stage 4. Twenty-four (13%) were known BRCA carriers who subsequently developed breast cancer, 86 (47%) were identified BRCA+ at time of cancer diagnosis, 72 (40%) had BRCA+ status identified after definitive breast cancer surgery, and timing was unclear in 2 patients. For women with known BRCA mutation prior to surgery, 14% underwent lumpectomy, 14% unilateral mastectomy, and 73% bilateral mastectomy, which differed significantly (p < ) from initial surgery choice in those whose BRCA mutation was not identified until after surgery (57%, lumpectomy; 25%, unilateral mastectomy; 18%, bilateral mastectomy). In patients with BRCA mutation identified after surgery who had breast(s) remaining, 11/35 (31%) ultimately underwent bilateral mastectomy for risk reduction. During a median follow-up of 3 (range, 0 20) years among patients with stage 0 3 disease, there were 15 local-regional recurrences, 12 distant recurrences, and 15 new contralateral primary breast cancers for a 5-year breast cancer free survival estimate of 81% (95% CI,75% 89%). Conclusion: BRCA-positive mutation status influences surgical decision-making. Rates of bilateral mastectomy were significantly higher in patients with known BRCA mutation. Identification of BRCA mutation after definitive surgery leads to a surgical management in a delayed setting. This study supports the importance of genetic testing prior to definitive surgical treatment of breast cancer in patients at elevated risk of deleterious BRCA mutation Should Repeat HER2 Testing Be Done on the Surgical Specimen? Tiffany Chichester 1, Lauren Greer 1, Rubie Sue Jackson 1, Charles Mylander 1, Martin Rosman 1, Thomas Sanders 1, Kristen Sawyer 1, Lorraine Tafra 1 1 Anne Arundel Medical Center, Annapolis, MD Objective: Breast cancer biomarkers allow for directed and effective medical therapy. Tumor heterogeneity and unreliable core needle biopsy testing may lead to inaccurate biomarker profiling and ineffective therapy. HER2 has been identified as a biomarker which displays variable activity in the core needle biopsy. To identify discordance in HER2 levels between initial diagnostic core needle biopsy and surgical specimens in a high-risk population of women with breast cancer. Methods: A prospective study at a single institution of newly diagnosed breast cancer patients presenting with HER2-negative disease on core biopsy and meeting 1 of the following criteria: tumor size >2 cm, multifocal, or multicentric. Patients were excluded for receipt of neoadjuvant chemotherapy. HER2 testing was repeated on surgical specimens (breast and/or lymph node[s]) of enrolled patients, and comparison was made to HER2 The American Society of Breast Surgeons Official Proceedings
63 testing from the core biopsy. The protocol specifies recruitment of 110 patients; we report an interim analysis of the first 45 patients enrolled (April 2014 October 2015). Results: Forty-five patients were included. Forty-four patients (98%) had HER2-negative disease on re-testing of breast (n = 94) and nodal (n = 16) specimens, concordant with initial HER2 results. One patient (2%; 95% CI, 0% 13%) had a HER2-positive surgical specimen, discordant from her core biopsy. This patient s preoperative breast core biopsy showed infiltrating ductal carcinoma (IDC), grade III; ER, 100%; PR, 98%; HER2, 1+; and Ki-67, 85%. Preoperative lymph node core biopsy showed metastatic IDC. Pathology from modified radical mastectomy revealed multifocal IDC (3.5-cm main tumor with 8 satellite lesions), grade III, and metastatic carcinoma in 11/22 lymph nodes. Three foci in the mastectomy specimen and 1 metastatic axillary lymph node underwent HER2 IHC and FISH testing. The results were IHC 1+ but FISH positive; FISH testing was performed in error on this patient. Tumor heterogeneity was not identified in any patients on hematoxylin and eosin staining. Conclusion: The incidence of HER2 discordance between core biopsy and surgical specimen was low (2%), but the confidence interval overlaps with the expected 6% based on previous literature. A significant discordance does not appear to exist between HER2 levels expressed in the diagnostic core needle biopsy and surgical specimen. Limitations of this study are the lack of patients with tumor heterogeneity and small sample size. Repeat HER2 testing on the surgical specimen will likely not alter treatment planning for the majority of patients Reporting Guidelines Improve Information in Axillary Ultrasound Reports Tiffany Chichester 1, Rubie Sue Jackson 1, Daina Pack 1, Charles Mylander 1, Martin Rosman 1, Reema Andrade 1, Lorraine Tafra 1 1 Anne Arundel Medical Center, Annapolis, MD Objective: We have previously shown that negative axillary ultrasound (AUS) predicts a very low likelihood of heavy nodal disease burden. However, our analysis of the significance of positive findings on AUS has been hampered by inconsistent reporting of abnormalities. In November 2014, our institution implemented AUS reporting guidelines (figure). To identify differences in historical AUS reports generated without guidelines, compared to reports generated retrospectively using institutional AUS reporting guidelines. The American Society of Breast Surgeons Official Proceedings
64 Methods: A retrospective analysis was performed at a single institution of consecutive newly diagnosed breast cancer patients from February 2011 October 2014 with suspicious or indeterminate AUS. Patients were excluded for receipt of neoadjuvant chemotherapy or clinically palpable axillary adenopathy. Static images from all identified ultrasounds were retrospectively reviewed by a single fellowship-trained breast radiologist using institutional reporting guidelines. For each patient, a comparison was made between the initial ultrasound report and the revised guideline-based report. An increase in precision was defined as a change from the characteristics of cortical thickening not otherwise specified, enlarged node, or abnormality not otherwise specified, to another characteristic found in the guidelines, including focal cortical thickening, focal cortical nodule, or loss of fatty hilum. Results: One hundred fourteen patients with suspicious or indeterminate axillary ultrasound reports were identified. After 9 patients with insufficiently recorded ultrasound images were excluded, 105 patients were included in the analysis. Fifty-four patients (51%) had no change in ultrasound report. Fifty-one patients (49%) had changes in the ultrasound report. Thirty-nine (37%) patients had ultrasound reports that became more precise. Of the patients who had a change in content, 76% of these became more precise. Conclusion: Reporting guidelines for axillary ultrasounds have the potential to make reports more precise. This may allow for better prediction of the likelihood of nodal positivity. Improved preoperative nodal staging may allow for better treatment planning, for example by identifying candidates for neoadjuvant chemotherapy or predicting the likelihood of postmastectomy radiation. This study is limited by its retrospective nature; reviewed images were static so it was impossible to comment on the number of suspicious lymph nodes or ensure that all suspicious features were identified The Effect of Marital Status on Breast Cancer Related Outcomes in Younger Women Jennifer Clancy 1, Leslie Hinyard 2, Theresa Schwartz 1 1 Saint Louis University School of Medicine, Saint Louis, MO, 2 Saint Louis University Center for Outcomes Research, Saint Louis, MO Objective: Marital status has been shown to affect outcomes in patients with multiple different types of malignancy, including breast cancer related outcomes in women over the age of 65. The purpose of this study is to investigate the effect of marital status on diagnosis, treatment, and survival of women with breast cancer under the age of 65. Methods: The SEER database was queried for all women years of age diagnosed with an invasive breast cancer from Age, race, stage at diagnosis, insurance status, education level, median income, breast cancer subtype, tumor grade, and choice of breast operation were collected and compared according to marital status. Chi-square analyses were used to identify associations between marital status and the remaining variables. Multivariate logistic regression analyses were used to predict stage at diagnosis according to marital status. Cox proportional hazards models were used to compare breast cancer survival rates according to marital status. Results: The sample consisted of 81,964 women aged years of age who were diagnosed with invasive breast cancer between 2010 and Unmarried women were more likely to be uninsured, present at a higher overall and T-stage, have a triple-negative phenotype, and have a poorly differentiated tumor. There was no statistically significant difference in breast operation chosen according to marital status. Despite controlling for stage, age, race, insurance status, tumor phenotype, median income and education level, unmarried women were at an increased risk of death from breast cancer than married women (HR, 1.453; 95% CI, ). Conclusion: Previous research has shown improved breast cancer related outcomes based on marital status in women over the age of 65. However, there is no evidence examining this association in women under the age of 65. Our results demonstrate that unmarried women between the ages of 25 and 64 are more likely to present with more advanced disease and have a statistically significant higher risk of death from breast cancer, even after controlling for age, stage, race, tumor phenotype, median income, education level, and insurance status. The results of this study suggest that attention should be paid to marital status in women aged years of The American Society of Breast Surgeons Official Proceedings
65 age at the time of a breast cancer diagnosis so that the appropriate resources can be mobilized and implemented. Based on this data, unmarried women with breast cancer may benefit from additional counseling, psychosocial support, and case management at the time of diagnosis to ensure their overall outcomes are optimized Utility of Screening MRI in Women With a Personal History of Breast Cancer Audree Condren 1, Brittany Arditi 1, Margaux Wooster 1, Christina Weltz 1, Elisa Port 1, Laurie Margolies 1, Hank Schmidt 1 1 Dubin Breast Center, Icahn School of Medicine, New York, NY Objective: The optimal surveillance regimen for women with a personal history of breast cancer has not been well established and the role of MRI remains to be determined. MRI as a screening tool for women with a personal history of breast cancer in this setting may lead to earlier stage at detection and offer an improved survival benefit, but may also lead to increased number of unnecessary biopsies. We sought to determine the positive predictive value of biopsy in women with a positive personal history of breast cancer screened with MRI. Methods: This retrospective review identified patients with a personal history of breast cancer who underwent screening MRI in addition to routine follow-up from 2007 to Total number of biopsies, biopsies due to MRI, and subsequent breast cancers were examined. Results: The average age of patients in our study was 50.3 (range, ). Of the 186 patients identified who had 491 screening MRI examinations, 44 patients (23.7%) had DCIS on initial histologic diagnosis and 142 patients (76.3%) had invasive cancer. The average length of follow-up was 77 months and average number of screening MRIs during the study period was 2.64 per person. A total of 107 biopsies were performed in 74 patients, an average of 0.09 biopsies per person year. Of these, 34 (32%) were due to MRI findings alone. The PPV for biopsies prompted by MRI findings was 0.24 (95% CI, ). Patients with a personal history of invasive cancer were more likely to have positive biopsy results when compared to patients with a history of DCIS (PPV, 0.25 [95% CI, ] vs 0.17 [95% CI, ]). Ten of the 142 patients (7%) with a history of invasive cancer had a subsequent breast cancer (5, local recurrence; 1, ipsilateral new primary; 2, contralateral; 2, metastatic). Of the 8 breast tumors, 5 were invasive and 3 were DCIS. Four of the 8 (50%) subsequent breast cancers were identified on MRI alone. One of the 44 patients (2%) with initial DCIS had a subsequent breast cancer. This patient had local recurrence as invasive ductal carcinoma found exclusively on MRI. Conclusion: The majority of biopsies performed in women with a personal history of breast cancer undergoing screening MRI in conjunction with routine follow-up are not due to MRI-only findings. However, of the patients with a history of invasive breast cancer that were found to have a local recurrence or new breast cancer, 50% were identified by MRI alone. The PPV for patients undergoing biopsy prompted by MRI findings was significant for patients with a history of invasive cancer, but not for those with history of DCIS in this patient population Oncologic Safety of Nipple-Sparing Mastectomy in Women With Breast Cancer Suzanne Coopey 1, Rong Tang 1, Upahvan Rai 1, Jennifer Plichta 1, Amy Colwell 1, Michele Gadd 1, Michelle Specht 1, William Austen 1, Barbara Smith 1 1 Massachusetts General Hospital, Boston, MA Objective: Nipple-sparing mastectomy (NSM) is being performed in an increasing number of women with breast cancer. There are limited data regarding the oncologic safety of this procedure. The American Society of Breast Surgeons Official Proceedings
66 Methods: Review of oncologic outcomes of consecutive therapeutic NSM from at a single institution. Nipple-sparing mastectomy was offered to patients with no radiologic or clinical evidence of nipple involvement. Results: Among 312 NSMs performed in 301 patients (table), 240 were for invasive cancer and 72 for ductal carcinoma in situ (DCIS). Thirty-three patients (11%) were documented mutation carriers (20, BRCA1; 10, BRCA2; 2, p53; 1, PTEN). Mean patient age was 48 years (range, 28 78). Ninety-two percent of patients were white. Twenty-two patients (7%) received neoadjuvant chemotherapy and 95 (32%) received adjuvant chemotherapy. Fifty-six breasts (18%) received postmastectomy radiation. One hundred seventy-four patients with invasive cancer and 3 patients with DCIS received endocrine therapy. At 38 months median follow-up (range, 2 93), there were 4 (1.3%) isolated chest wall recurrences, 1 (0.3%) simultaneous chest wall and regional nodal recurrence, 4 isolated regional nodal recurrences (1.3%), and 5 (1.6%) distant recurrences. No recurrence involved the retained nipple areola complex. Three of the 5 chest wall recurrences occurred in mutation carriers (2 in the same p53 patient with bilateral cancers, 1 in a BRCA1 patient), and 1 chest wall recurrence occurred in a patient who declined endocrine therapy. There were 2 cancer-related deaths in patients who developed isolated distant recurrences. Patient characteristics Patient and Tumor Characteristics Mean patient age 48 years (28 78) Mean body mass index 24.1 kg/m 2 ( ) Mean calculated breast volume 479 cm 3 ( ) Cancer details Mean invasive tumor size* 1.5 cm ( ) Tumor grade (n = 312) 1 36 (11.5%) (52.6%) 3 98 (31.4%) Unknown 14 (4.5%) Cancer stage (n = 283)* 0 72 (25.4%) (47.0%) 2 54 (19.1%) 3 18 (6.4%) Unknown 6 (2.1%) Receptor profile, invasive cancer (n = 240) ER+, PR+/, HER2-181 (75.4%) ER+, PR+/, HER2+ 24 (10.0%) ER, PR, HER2 26 (10.8%) ER, PR, HER2+ 7 (2.9%) Unknown 2 (0.8%) Receptor profile, DCIS (n = 72) ER+ 64 (88.9%) ER 5 (6.9%) Unknown 3 (4.2%) *Excluded breasts with neoadjuvant chemotherapy. The American Society of Breast Surgeons Official Proceedings
67 Conclusion: Rates of locoregional and distant recurrence are low after nipple-sparing mastectomy in patients with DCIS and invasive carcinoma. No patient in our series has had a recurrence involving the retained nipple areola complex Effects of Obesity and Overweight on Survival in Patients With Breast Cancer Chiappa Corrado 1, Anna Fachinetti 1, Gianlorenzo Dionigi 1, Francesca Rovera 1 1 1st Division of Surgery, Senology Research Center, Department of Surgical and Morphological Sciences, Varese, Italy Objective: The bodyweight, defined by BMI (body mass index), is an important risk factor influencing the development of breast cancer, mainly in women during the postmenopausal period. Moreover obesity seems to reduce overall survival in breast cancer patients. Methods: From February 2010 to December 2014, 93 breast cancer patients with BMI > 25 were surgically treated in our breast unit. All patients were female. We analyzed the clinical and pathological aspects, the outcome, and the follow-up. Results: Twenty-six patients (24%) of the 93 analyzed were obese at diagnosis with BMI > 30; 6 were class III obese. The average age was 63 years (32 85 years). Fifty-six patients underwent quadrantectomy. In 82 patients sentinel lymph node biopsy was performed; of these, 15 underwent axillary lymph node dissection with an average of 21 lymph nodes removed. Thirty-seven patients underwent mastectomy with a simultaneous plastic reconstruction in 10 patients. Thirty-three patients (30%) had a tumor greater than 2.5 cm, unifocal in most cases. The histological type was ductal carcinoma in 78 patients, 15 patients had lobular carcinoma. The grading was G2 in most cases (72%). Twenty-nine patients received adjuvant chemotherapy. The most frequent comorbidities were cardiovascular diseases and diabetes mellitus type II. The median follow-up was 48 months. During this period we observed 3 locoregional recurrences, 4 systemic recurrences, and 3 deaths. Conclusion: Obesity seems to be a significant risk factor concurring in the development of breast cancer, and in many literatures it is associated with a worse prognosis. It is suggested that reduction of obesity can decrease breast cancer cases by one tenth in Europe with a consequent reduction in mortality. Our results confirm that obesity is a negative factor. Since obesity is a risk factor modifiable throughout life, we hope that health education programs will be planned to address the rising problems of obesity and breast cancer Establishing a New Normal : A Qualitative Exploration of Women s Body Image After Mastectomy Andrea Covelli 1, Nancy Baxter 2, Frances Wright 3 1 University of Toronto, Toronto, ON, Canada 2 St. Michael s Hospital, Toronto, ON, Canada, 3 Sunnybrook Health Sciences Centre, Toronto, ON, Canada Objective: Rates of unilateral mastectomy (UM) and contralateral prophylactic mastectomy (CPM) for earlystage breast cancer (ESBC) have been increasing. Concurrently, an increase in the rates of immediate breast reconstruction has also been described. However, not all women who undergo mastectomy undergo reconstruction. We wished to explore women s perceptions of body image after UM +/ CPM, and to understand decision-making around the choice for breast reconstruction. Methods: We previously described the surgical decision-making process of women with ESBC who chose UM +/ CPM. As part of this process we wished to explore the meaning that reconstruction holds for these women and their postoperative experiences. Purposive sampling was used to identify women with ESBC who underwent UM +/ CPM across the Toronto (Ontario, Canada) area. Patients varied in their age, location of The American Society of Breast Surgeons Official Proceedings
68 treatment, and extent of surgery. Data were collected through semistructured interviews. Constant comparative analysis identified key concepts and themes. Results: Data saturation was achieved after 29 in-person interviews. Fifteen women underwent UM; 14 underwent UM + CPM. Eleven women underwent reconstruction; 8 underwent UM + CPM and 3 underwent UM alone (table). Four patients were awaiting reconstruction (2 UM + CPM, 2 UM). Median age was 55. Establishing a new normal was the dominant theme. All women, whether they had immediate or delayed or did not undergo breast reconstruction, described their immediate postoperative period as a time of disfigurement and/or loss. Women felt that within society breasts define women as feminine and normal. In contrast, postmastectomy women were seen as abnormal or ill. For some women, appearing normal was achieved through reconstruction. For those who did not want reconstruction, this was equally achieved through the use of prostheses. Reasons for choosing reconstruction included becoming almost normal and desiring symmetry/balance. Reasons women did not choose reconstruction included not wanting further surgery, wanting to move on with their lives, and satisfaction with prostheses. With or without reconstruction, most women continued to experience some degree of self-consciousness, which they addressed through camouflaging with clothing. Some women were bothered by ongoing changes in skin sensation and postsurgical pain. Despite these concerns, no woman voiced regret around her decision for mastectomy +/ reconstruction. The only women who expressed dissatisfaction were those awaiting reconstruction. Patient Characteristics Location of surgery Reconstruction No Reconstruction Academic cancer center 5 7 Academic non cancer center 3 3 Community center 3 8 Extent of surgery Unilateral mastectomy Immediate reconstruction Delayed reconstruction Unilateral mastectomy and contralateral prophylactic mastectomy Immediate reconstruction Delayed reconstruction Disease stage 4 (4) (0) 7 (3) (4) 12 (2 awaiting reconstruction) 6 (2 awaiting reconstruction) Stage Stage Conclusion: Most women who chose to undergo mastectomy described establishing a new normal after their surgery. These findings are important as despite choosing mastectomy, with or without reconstruction, most women experienced some degree of self-consciousness. While women reflected that they were not completely satisfied with their new body image, no woman regretted the extent of surgery, except those waiting for breast reconstruction. The American Society of Breast Surgeons Official Proceedings
69 Invasive Lobular vs Invasive Ductal Carcinoma: Are They Different? Melanie Crutchfield 1, Melinda Epstein 2, Colleen O Kelly Priddy 2, Julie Sprunt 2, Sadia Khan 2, Melvin Silverstein 2 1 University of Southern California/Keck School of Medicine/Hoag Memorial Hospital Presbyterian, Los Angeles, CA, 2 Hoag Memorial Hospital Presbyterian, Newport Beach, CA Objective: Invasive lobular carcinoma represents about 10% of invasive breast cancer. The remainder are predominantly invasive ductal carcinomas. Invasive lobular cancers are typically more difficult to diagnose by clinical examination and mammography. This study details the demographics and clinical outcomes when invasive lobular and ductal carcinomas are compared. Methods: A prospective database containing 4,363 women with invasive breast cancer diagnosed between 1979 and 2015 was analyzed. Variables studied included age, tumor size, nuclear grade, palpability, hormone receptor status, HER2, the presence of lymphovascular invasion (LVI), node positivity, and molecular subtype. The patients were subdivided into invasive ductal carcinoma (n = 3858) and invasive lobular carcinoma (n = 505). Kaplan-Meier curves were generated to graphically show the difference between survival and recurrence distributions. The log-rank test was used to evaluate the difference between curves. Results: The table compares 3,858 patients with invasive ductal carcinoma with 505 patients with invasive lobular carcinoma. Follow-up, age, palpability, LVI, nodal positivity, local recurrence, distant recurrence, and breast cancer specific survival were similar for both groups. Invasive lobular tumors were larger, a higher percentage were estrogen and progesterone receptor positive, and a lower percentage were HER2 positive. Molecular subtyping favored the lobular cancers. InfDuct InfLob p Value N 3858 (88%) 505 (12%) Avg follow-up (mo) 77 mo 79 mo NS Avg age (yr) 56 yr 58 yr NS Avg tumor size (mm) 22 mm 30 mm <0.001 % palpable 65% 66% NS Avg. nuclear grade <0.001 % ER positive 78% 91% <0.001 % HER2 positive 17% 5% <0.001 Lymphovascular invasion 21% 16% NS % Node positive 30% 30% NS % Basal % HER2 % Luminal A % Luminal B 232/1535 (15%) 128/1535 (8%) 659/1535 (43%) 516/1535 (34%) 3/168 (2%) 0/168 (0%) 126/168 (75%) 39/168 (23%) <0.001 <0.001 <0.001 <0.01 Probability local recurrence, 10 years 11% 10% NS Probability distant recurrence, 10 years 20% 19% NS Probability BC death, 10 years 16% 14% NS continues The American Society of Breast Surgeons Official Proceedings
70 Conclusion: Because of their growth pattern, lobular cancers are more difficult to diagnose. That results in tumors that are generally larger than invasive ductal carcinomas. However, all prognostic factors favor invasive lobular lesions. The probability of local recurrence, distant recurrence, and breast cancer specific death is slightly lower for invasive lobular carcinomas but the difference is not statistically significant Comparison of Breast Volumes Excised Through Bracketed Radioactive Seed vs Bracketed Wire Localization Monica DaSilva 1, Amanda Chu 2, Meghan Hansen 3, Jessica Porembka 1, Stephen Seiler 1, Marilyn Leitch 1, James Huth 4, Aeisha Rivers 1, Rachel Wooldridge 1, Deborah Farr 3, Ali Mokdad 4, Jean Bao 5, Emily Brown 1, Roshni Rao 6 1 University of Texas Southwestern, Dallas, TX, 2 University of Texas Southwestern Medical Center, Department of Radiology, Dallas, TX, 3 University of Texas Southwestern Medical Center, Division of Surgical Oncology, Dallas, TX, 4 University of Texas Southwestern Medical Center, Dallas, TX, 5 Cedars Sinai Medical Center, Los Angeles, CA, 6 University of Texas, Dallas, TX Objective: Resection of radiographic breast lesions large enough to require bracketed localization poses a significant challenge to minimize volume loss and yet ensure complete resection with adequate margins. Previous studies have demonstrated that localization with a single radioactive seed decreases excision volume and improves cosmesis. In this study, we compared the volume of tissue excised in bracketed seed localization (BSL) vs bracketed wire localization (BWL) and hypothesized that BSL excision would be associated with a lower tissue volume excised. Methods: A retrospective review was performed of patients undergoing localization of benign and malignant breast lesions using 2 or more localizers in a bracketed approach at an academic medical center from 2004 to Data collected included demographics, histology, tumor size, volume initially excised, total volume including re-excisions, and neoadjuvant and adjuvant therapies. Student t test and Pearson s chi-square test were used to compare continuous and categorical data. Multivariable linear regression model was used to evaluate the association between excision volume and localization technique after adjusting for clinically relevant variables. Results: A total of 163 bracketed localization excisional procedures (93 BSL and 70 BWL) were performed. There was no difference in median age, race, BMI, and tumor type between the 2 groups. The largest pretreatment tumor diameter was significantly greater in BSL excision group (P < 0.01). There was a trend toward a decrease in the initial volume and total volume excised in the BSL excision group in comparison to BWL excision group (P = 0.4, initial volume; P = 0.32, total volume). In the multivariable model, tissue volume did not differ between the localization groups after adjusting for clinically relevant variables. Reexcision rates in this study were, as expected, lower for BSL. Overall Wire Seed P value Number (43%) 93 (57%) Age <50 y 36 (22%) 15 (21%) 21 (23%) y 55 (34%) 25 (36%) 30 (32%) y 42 (26%) 14 (20%) 28 (30%) >70 y 30 (18%) 16 (23%) 14 (15%) The American Society of Breast Surgeons Official Proceedings
71 Race Caucasian 79 (49%) 32 (46%) 47 (51%) 0.56 Black 45 (28%) 23 (33%) 22 (24%) Hispanic 28 (17%) 10 (14%) 18 (19%) Other 10 (6%) 4 (6%) 6 (6%) BMI (mean) Largest pretreatment diameter, cm (mean) <0.01 Tumor type In situ 64 (40%) 34 (50%) 30 (32%) 0.07 IDC 75 (47%) 27 (40%) 48 (52%) ILC 11 (7%) 5 (7%) 6 (6%) Other 11 (7%) 2 (3%) 9 (10%) Re-excision of margin 59 (36%) 38 (55%) 21 (23%) <0.01 Initial volume, cm 3 (mean/median) 234 (167) 234 (171) 206 (164) 0.4 Total volume, cm 3 (mean/median) 232 (172) 251 (186) 218 (168) 0.32 Conclusion: A trend toward lower tissue volume excision, despite slighter larger tumor size, was observed for bracketed seed excisions compared to bracketed wire excisions. Bracketed seed localization is an acceptable alternative to facilitate breast-conserving therapy in patients with large areas of radiographic abnormality A Multicenter Prospective Evaluation of a Radiofrequency Identification Tag in the Localization of Nonpalpable Breast Lesions Christine Dauphine 1, Lawrence Goldberger 2, Jerome Schroeder 3, Julie Barone 3 1 Harbor-UCLA Medical Center, Torrance, CA, 2 Sharp Memorial Hospital and Comprehensive Breast Care of San Diego, San Diego, CA, 3 Saint Joseph Hospital Breast Care Center, Denver, CO Objective: The purpose of this study was to evaluate the safety and efficacy of a radiofrequency identification (RFID) tag in the localization of nonpalpable breast lesions. Methods: Institutional Review Board approval was obtained at each of the 2 participating institutions prior to initiation of this study at each site. Consecutive adult patients undergoing excision of a nonpalpable breast lesion were approached to participate. Enrolled subjects underwent placement of an RFID tag on the same day as elective operative excision. The implanted RFID tag is detected utilizing a handheld reader device placed over the skin. The sound emitted from the reader device increases in volume and pitch as the reader approaches the tag. A hookwire was also placed in the initial patients at each study site and in cases where the RFID tags were placed under stereotactic guidance. The RFID tag was the primary method utilized by the operating surgeon to localize each lesion during excision, with the hookwire serving as backup in case of tag migration or failed localization. Patient data, including breast size and lesion location (quadrant of the breast, distance to areola, depth from the skin), were collected. Successful localization and removal of the intended lesion were the primary outcomes measured. Potential complications, such as tag migration and postoperative infection, were also recorded in order to assess safety. Results: Forty-six patients underwent placement of 47 RFID tags, 39 under ultrasound guidance and 8 with stereotactic guidance. Thirty-five patients had breast cancer, and 11 had benign lesions. In all 47 excisions, the RFID tag was successfully localized by the reader at the level of the skin prior to incision, and the target lesion was visualized within the excised specimen. There were no localization failures and no postoperative infections. Tag migration did not occur prior to incision, but in 13 cases, the tag slipped out of the lesion as it The American Society of Breast Surgeons Official Proceedings
72 was being retracted to make the final cut along the deep surface of the specimen. Six cancer patients had positive margins, one of which ultimately underwent mastectomy due to patient choice. Conclusion: The use of an RFID tag system is an effective and safe method of localization of nonpalpable breast lesions in this investigation. RFID localization of nonpalpable breast tumors for surgical excision may represent an alternative method to hookwire localization Outcomes After Oncoplastic Surgery in Breast Cancer Patients: A Systematic Literature Review Lucy De La Cruz 1, Stephanie Blankenship 2, Abhishek Chatterjee 3, Rula Geha 1, Brian Czerniecki 4, Julia Tchou 5, Carla Fisher 4 1 Department of Surgery, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, 2 University of Miami, Miami, FL, 3 Tufts Medical Center, Boston, MA, 4 University of Pennsylvania, Philadelphia, PA, 5 University of Pennsylvania Health System, Philadelphia, PA Objective: Breast surgeons have increasingly performed oncoplastic resection and reconstruction for surgical management of breast cancer. The present study assesses oncologic, surgical and cosmetic outcomes after oncoplastic surgery in the setting of breast cancer. Methods: A systematic literature review identified peer-reviewed articles in PubMed using key search terms ( breast, surgery, operative surgical procedures, and general surgery ). Two reviewers independently screened articles pertaining to oncoplastic surgery for breast cancer using PRISMA guidelines. Selected studies reported one or more of the following outcomes: positive margin rate (PMR), re-excision rate (RR), conversion to mastectomy rate (CMR), overall survival (OS), disease-free survival (DFS), local recurrence (LR), distant recurrence (DR), complication rate, and cosmesis outcomes. Results: The search yielded 474 articles; 55 studies published from 1998 to 2015 met inclusion criteria. The selected studies collectively evaluated 6,011 patients with a mean age of 53.2 years over an average follow-up of 41.6 months. T1 (43.8%) and T2 (39.3%) invasive ductal carcinoma were the most common tumor histopathology, with a mean tumor size of 19.9 mm and mean specimen weight of g (table). Wise pattern mastopexy was the most commonly utilized oncoplastic technique performed in 31.1% of patients. Positive margin rate, RR, and CMR were 10.9%, 6.0%, and 6.2%, respectively; OS and DFS were 95.1% and 85.9%, and LR and DR occurred in 3.9% and 7.5% of patients. Positive margins were widely classified throughout the studies as <10 mm, <5 mm, < 2 mm, <1 mm, and no ink on tumor. There was no statistically significant difference for PMR among these subgroups (p = 0.162). Ten studies reported specific margins for 1,455 patients. Among these patients, 143 (9.8%) were classified as having positive margins, of which 113 (7.8%) had tumor on ink (p = 0.072). Postoperative complications occurred in 14.3% of patients. Among 25 studies that evaluated cosmesis outcomes in 1,962 patients, oncoplastic surgery achieved excellent, good, fair, or poor outcomes in 55.2%, 31.0%, 9.4% and 4.4% of patients, respectively. continues The American Society of Breast Surgeons Official Proceedings
73 Study Characteristics Study (Year) Type No. of Cases Mean Age Mean Follow-up (Months) Tumor Size (mm) Most Most Common Common Most Positive Tumor Tumor Common Lymph Adjuvant Grade Location Pathology Nodes Radiation Neoadjuvant Chemotherapy Most Common Cosmesis Outcome AcostaMartin (2014) P Excellent Aljarrah (2012) P T1 UIQ IDC Excellent Bouvet (1998) R Caruso (2008) R T1 - IDC Caruso (2011) R T1 - IDC Chakravorty (2012) R T Chang (2004) R IDC Excellent Clough (2001) P T2 Central IDC Clough (2014) P T2 UOQ IDC Colombo (2015) R T2 LOQ IDC Good Crown (2015) R Cutress (2011) R UOQ IDC Da Silva (2007) R T1 - IDC Egro (2014) P UOQ IDC El-Marakby (2011) P T2 UOQ IDC Good Emiroglu (2015) R T2 - IDC Good Emiroglu (2015) R T1 UOQ IDC Fitoussi (2009) R UOQ IDC Giancalone (2007) P T1/T Grubnik (2012) P T1 UOQ IDC Good Hamdi (2013) R Hernanz (2011) R UOQ IDC Good Huemer (2006) P T1 Central IDC Excellent Kaur (2005) P T1 UOQ Kaviani (2013) R T2 UOQ IDC Kim (2012) P LOQ IDC Good Kronowitz (2006) R T1 UOQ Lorenzi (2015) R T Losken (2006) R T1 - DCIS/LCIS Losken (2014) R T Malhaire (2015) R Mansell (2015) R T Mazouni (2013) R T2 - IDC Excellent McCulley (2005) P Excellent McCulley (2005) P Central Good Mendonca (2005) P T1 UOQ Excellent Meretoja (2010) P T1 - IDC Moustafa (2014) R Conclusion: The present study is the largest comprehensive literature review to date on oncoplastic surgery for breast cancer. The results confirm that oncoplastic surgery is a safe treatment option that preserves cosmesis without compromising recurrence or survival in patients with T1-T2 invasive breast cancer. Reported PMR and RR are low, though rates reported in this study may not reflect current rates in oncoplastic surgery given recent changes in margin guidelines. Future studies should evaluate the feasibility of classifying negative margins as no ink on tumor in oncoplastic surgery. The American Society of Breast Surgeons Official Proceedings
74 Is Beauty in the Eye of the Beholder? Comparison of Patient Satisfaction Using the BREAST-Q and Surgeon-Rated Aesthetic Outcome in Autologous Breast Reconstruction Tanya DeLyzer 1, Xi Liu 2, Shaghayegh Bagher 2, Brett Beber 1, Anne O'Neill 1, Stefan Hofer 1, Toni Zhong 1 1 University of Toronto, Toronto, ON, Canada 2 University Health Network, Toronto, ON, Canada Objective: As breast reconstruction techniques continue to be refined, it is becoming increasingly important for surgeons to be able to evaluate aesthetic outcome and relate this to patient satisfaction. The BREAST-Q is a validated patient-reported outcome measure for patient satisfaction following breast reconstruction, and currently there are no studies on the relationship to surgeon-rated aesthetic outcome. Therefore the objective of this study is to compare a newly developed, surgeon-rated 10-point aesthetic assessment scale with the Satisfaction with Breast subscale of the BREAST-Q following autologous breast reconstruction. Methods: Forty-five patients who underwent breast reconstruction using either a free muscle-sparing TRAM or DIEP flap between 2009 and 2013 by a single surgeon were randomly selected. Standardized preoperative and postoperative photographs (minimum, 6 months) were provided to 3 uninvolved breast reconstruction surgeons. Surgeon-rated aesthetic assessment evaluated 5 sub-items: volume, shape, symmetry, position, and scarring, as well as overall aesthetic appearance using a 10-point scale. The scale was designed based on recommendations made from our systematic review on aesethetic scoring tools (Ann Surg Onc, Online First, Feb 2015). The Satisfaction with Breast subscale of the BREAST-Q was completed by patients after a minimum of 1-year follow-up. The surgeon-rated scale was evaluated for internal consistency by Cronbach alpha statistic and the inter-rater agreement by weighted kappa statistic. The relationship between the surgeonrated aesthetic assessment and BREAST-Q patient satisfaction scores was studied by Spearman correlation. Results: The mean BREAST-Q patient satisfaction score was of 100 (range, 22 to 100). The new surgeon-rated 10-point aesthetic assessment scale demonstrated high internal consistency (Cronbach α range, 0.87 to 0.96), and mean overall aesthetic appearance was 6.87 (range, 2 to 10). The inter-rater agreement among the 3 surgeons was fair for all items (kappa, 0.24 to 0.35) except volume, position, and scarring (0.07 to 0.21). For all 3 surgeons, the surgeon-rated aesthetic score on each sub-item correlated strongly with the overall aesthetic score given by that surgeon (Spearman coefficient, 0.69 to 0.91), except for scarring (0.27 to 0.48). However, weak correlation was found between surgeon-rated aesthetic scores and patient-reported BREAST-Q scores (Spearman coefficient, 0.00 to 0.27). Correlation Between Surgeon s Overall Aesthetic Scores and Patient Satisfaction BREAST-Q Scores Overall Score N Correlation 95% Confidence Limits P Value Surgeon * Surgeon Surgeon * Mean * *Statistically significant correlation coefficients with significant level set at p < 0.1 Conclusion: The newly developed, surgeon-rated 10-point assessment scale demonstrated high internal consistency; however, it displayed only fair inter-rater agreement and had only weak correlation with the BREAST-Q patient satisfaction scores. These findings are consistent with previous literature and suggest that the patient s own evaluation and level of satisfaction with their reconstructed breast are not directly related to the aesthetic ideals of the surgeon. The American Society of Breast Surgeons Official Proceedings
75 Does Sentinel Lymph Node Biopsy Impact Systemic Therapy Recommendations? Diana Dickson-Witmer 1, Michael Guarino 1, Hunter Witmer 2, Emily Murphy 3, Dennis Witmer 3, Robert Hall-Long 1, Alexandra Hanlon 4 1 Helen F Graham Cancer Center and Research Institute, Newark, DE, 2 Sidney Kimmel College of Medicine of Thomas Jefferson University, Philadelphia, PA, 3 Christiana Care Health System, Newark, DE, 4 University of Pennsylvania, Philadelphia, PA Objective: Decisions regarding systemic therapy of breast cancer are increasingly made based on biologic characteristics of the breast cancer rather than tumor size and lymph node status. 1 Sentinel lymph node biopsy (SLN) is not without morbidity (5% risk of lymphedema and 11% risk of neuropathy). 2 There is an active prospective trial in Milan (SOUND) to examine the safety of omitting SLN in stage I-III breast cancer. 3 We hypothesize that a subset of breast cancer patients can be identified where SLN would not influence systemic therapy recommendations. Methods: Data were evaluated from a consecutive sample of 107 patients with stage I III breast cancer diagnosed in who had SLN performed. Variables collected included age, race (white vs non-white), tumor size, receptor status, HER2 status, OncotypeDx recurrence score (RS), SLN results, and systemic chemotherapy and/or endocrine therapy. A board-certified senior medical oncologist reviewed these data, blinded to the SLN results. He was asked if his recommendation for systemic therapy for each patient would require knowledge of the SLN result. In those cases where systemic therapy decisions could be made without the SLN result, the SLN blinded recommendation was compared to actual treatment recommended. Results: Of 107 cases, SLN status would have impacted chemotherapy recommendations in only 14.0% (n = 15). In 85.9% of cases (n = 92), SLN results did not impact chemotherapy recommendation. SLN result did not impact endocrine therapy recommendation in any patient. Of the 15 patients for whom SLN did impact chemotherapy recommendation, 9 were receptor positive and HER2 negative, 4 were triple negative, and 2 were receptor negative and HER2 positive. Among these 6 receptor-negative cases, all had either T1b or smaller tumors or multiple co-morbidities. Of the 9 receptor-positive HER2-neg cases for whom SLN made a difference, 7 were 2 cm or larger, and none had a high RS. The 2 receptor-positive HER2-neg patients with tumors <2 cm had RS < 14. Conclusion: SLN does not impact endocrine therapy recommendation for any patient. SLN does not impact chemotherapy recommendation for the majority of stage I III breast cancer patients. Subsets of patients for whom SLN results are less likely to impact systemic therapy recommendations include (1) receptor-positive, HER2-neg patients with RS >29; (2) receptor-positive, HER2-neg patients with RS <29 and tumors 2 cm or larger; and (3) receptor-negative, HER2-pos or neg patients, with tumors T1c or larger and not a large number of co-morbidities. References 1. Goldhirsch A. Thresholds for therapies: highlights of the St Gallen International Expert Consensus on the primary therapy of early breast cancer Ann Oncol. 2009;20: Mansel RE. Randomized multicenter trial of sentinel node biopsy versus standard axillary treatment in operable breast cancer: The ALMANAC Trial. J Natl Cancer Inst. 2006;98: Gentilini O, Abandoning sentinel lymph node biopsy in early cancer? A new trial in progress at European Institute of Oncology of Milan (SOUND: Sentinel node vs Observation after axillary UltraSouND ). Breast.2012; 21: The American Society of Breast Surgeons Official Proceedings
76 Low Upstage Rate of Imaging-Detected Intraductal Papillomas Without Atypia May Not Necessitate Surgical Excision Emilia Diego 1, Paul Waltz 2, Priscilla McAuliffe 1, Atilla Soran 1, Ronald Johnson 1, Gretchen Ahrendt 1 1 University of Pittsburgh Medical Center - Magee Womens Hospital, Pittsburgh, PA, 2 University of Pittsburgh School of Medicine, Pittsburgh, PA Objective: Intraductal papillomas (IPs) represent 5% of pathology found on percutaneous core needle biopsy (CNB) for imaging-detected abnormalities. They present as calcifications, nodules, or intraductal filling defects that may or may not be associated with nipple discharge or breast masses. Though IPs confer a slightly higher risk for future breast cancer, the upstage rate to carcinoma on excisional breast biopsy (EBB) of these lesions with current CNB is variable and ranges from 0 to 30%. We retrospectively reviewed our institutional experience to determine upstage rate and to identify patients who may not require EBB. Methods: This project was approved by the Quality Improvement Board and deemed IRB exempt. The electronic medical records were retrospectively searched for all CNBs containing IPs across the University Health System from December 2013 to December Patient age, symptoms, imaging characteristics, method of biopsy, EBB results, and upstage rate were recorded. Data was analyzed using chi-square and oneway ANOVA on Prism 6.0 software. Significance was defined as a p value < Results: A total of 263 patients with IP on CNB were identified: 227 without atypia and 36 with atypia. In the IP without atypia group, 147 had an EBB and 80 did not. In the IP with atypia group, 31 had an EBB and 5 did not. Patients with atypia on CNB were more likely to be older. There was no significant difference in the presentation, lesion size, or method of biopsy among the groups (p = 0.10). In the group without atypia who had an EBB, 9% (14/147) had an additional high-risk lesion on final pathology. The upstage rate for pts who had an EBB was 2% (3/147) in the group without atypia and 29% (9/31) in the group with atypia (p < 0.05). In the patients who did not have surgery, 52% (44/85) had repeat imaging within 6 months to 1 year of CNB and there were no incidents of imaging change, need for another CNB, or diagnosis of cancer. Patient Characteristics and Outcomes Intraductal Papilloma Without Atypia Intraductal Papilloma With Atypia p value Surgical Excision Observation Surgical Excision Observation N Age, years (mean ± SEM) 53 ± ± ± ± 6.6 < Presentation (%) 0.45 Asymptomatic 100 (68%) 61 (76%) 24 (78%) 2 (40%) Symptoms (mass or discharge) 43 (29%) 18 (23%) 6 (19%) 3 (60%) Unknown 4 (3%) 1 (1%) 1 (3%) 0 Imaging finding (%) 0.01 Calcifications 26 (18%) 32 (40%) 10 (32%) 2 (40%) Nodule/ architectural distortion 97 (66%) 45(56%) 20 (65%) 3 (60%) Intraductal filling defect 16 (11%) 2 (3%) 1 (3%) 0 Unknown 8 (5%) 1 (1%) 0 0 Lesion size for nodule or distortion seen on imaging (mean ± SEM) 7.8 ± 0.4 mm 6.9 ± 0.6 mm 9.0 ± 1.0 mm 8.0 ± 1.0 mm 0.38 The American Society of Breast Surgeons Official Proceedings
77 Method of biopsy (%) 0.10 Stereotactic 32 (22%) 30 (37%) 9 (29%) 3 (60%) Ultrasound 109 (74%) 45 (56%) 19 (62%) 2 (40%) MRI 5 (3%) 3 (4%) 1 (3%) 0 Unknown 1 (1%) 2 (3%) 2 (6%) 0 Upstage to carcinoma on surgical excision 3 (2%) N/A 9 (29%) N/A < Conclusion: IP with atypia found on CNB still warrants surgical excision because of high upstage rates. However, for patients with IP without atypia, the low upstage rate regardless of imaging characteristics makes observation with surveillance imaging a reasonable plan of care. In a subset of patients, the additional finding of atypia on EBB may influence future screening and recommendations for risk reduction. Longer term followup is also needed for the groups who did not have an EBB FEA on Core Needle Biopsy Does Not Always Mandate Excisional Biopsy Cory Donovan 1, Attiya Harit 1, Alice Chung 1, Jean Bao 1, Armando Giuliano 1, Farin Amersi 1 1 Cedars Sinai Medical Center, Los Angeles, CA Objective: Flat epithelial atypia (FEA) is a proliferative lesion of the breast where cells demonstrate columnar change and cytologic atypia, and is distinct from classic atypical hyperplasias, including atypical ductal hyperplasia (ADH) and atypical lobular hyperplasia (ALH). While many patients undergo excisional biopsy, management of FEA-identified on core needle biopsy (CNB) is controversial, and the rate of associated DCIS and invasive cancer is not well defined. Methods: A prospective database was reviewed and identified with FEA diagnosed by CNB performed between 01/2010 and 07/2015. Data collected included age at presentation, imaging findings, pathologic findings following surgical excision, and subsequent development of breast cancer. Results: Mean age of patients was 58 years. Of the 132 patients, 62 patients had FEA associated with DCIS and invasive ductal cancer (IDC) on CNB and were excluded from analysis. Thirty-two patients had FEA plus ADH or ALH, 4 patients with FEA plus LCIS, and 37 patients had FEA alone or with other nonpathologic findings. Two (6.3%) of 32 patients with FEA plus ADH had DCIS or IDC on subsequent excisional biopsy. Of the 37 patients with FEA alone on CNB, 3 patients (8.1%) had a CNB without subsequent excisional biopsy. Of the 34 patients who underwent excisional biopsy for FEA alone, only 1 (3%) patient was found to have IDC on excision. Twenty-two (64%) of the 34 patients with FEA who underwent excisional biopsy presented with calcifications on mammography. All of these patients had benign findings on excisional biopsy. Twelve (35%) of 34 patients with FEA alone underwent CNB for a mass or asymmetry noted on imaging. Of these 12 patients, 10 (83%) had benign findings on excisional biopsy. One patient had ALH and a papilloma on excision, and 1 patient had a 3-mm invasive carcinoma with focal associated DCIS. With a mean follow-up of 24 months, only 1 patient with FEA alone subsequently developed IDC, and this was in the contralateral breast. Conclusion: FEA is often found in combination with ADH and ALH as well as carcinoma on CNB. Pure FEA was only associated with IDC in 1 of 12 (8%) of patients with a mass on imaging, however none of the patients where CNB was done for calcifications alone were upstaged on excision. These findings may suggest that excisional biopsy is not warranted in patients with pure FEA on CNB for calcifications, and these patients could be managed with imaging surveillance. The American Society of Breast Surgeons Official Proceedings
78 Oncological and Surgical Outcomes After Nipple-Sparing Mastectomy: Do Incisions Matter? Cory Donovan 1, Attiya Harit 1, Alice Chung 1, Jean Bao 1, Armando Giuliano 1, Farin Amersi 1 1 Cedars Sinai Medical Center, Los Angeles, CA Objective: While nipple-sparing mastectomy (NSM) for the treatment of breast cancer (BC) is becoming more accepted, technical aspects for performance of the operation are still evolving. NSM has been noted as a risk factor for complications following mastectomy but the data regarding specific technical factors contributing to this risk is limited. This study examined the influence of technical aspects on early postoperative outcomes of NSM. Methods: Review of a prospectively maintained database at an academic medical center identified 1054 patients who had mastectomies between 01/2012 and 06/2015; 201 patients had NSM. We compared the effect of location of incision and dissection technique on complications. Results: Three hundred and fifty-one NSMs were performed in 201 patients, of which 144 patients (72%) had BC. Forty-four (28%) patients were BRCA mutation carriers. Mean patient age was 47 years. Inframammary (47%) or periareolar (35%) incisions were most frequent. Tumescence was used in 203 (58%) NSMs. Skin flaps were created using sharp dissection in 213 (61%) and electrocautery in 138 (39%) breasts. Three patients had no reconstruction, 125 patients (62%) underwent expander-based reconstruction, 15 patients (7%) underwent autologous tissue reconstruction, and 58 patients (29%) underwent immediate implant reconstruction. Nipple areola complex (NAC) necrosis was seen in 40 (11%) breasts (table). While not impacted by dissection technique, a higher rate of NAC complications was seen with periareolar incisions (p = 0.02). Tumescence with sharp dissection did not result in statistically significant rates of increased flap necrosis. Eleven patients (7%) had a positive margin in the mastectomy specimen or nipple core biopsy. Ten patients (91%) had a positive anterior/deep margin, of which 7 (64%) had an inframammary approach. Sharp vs electrocautery dissection did not affect margin status. Fourteen (7%) patients had an infection requiring extended IV antibiotics. Sixteen (8%) patients suffered implant loss as a result of infection or skin necrosis. Dissection technique was not associated with implant loss (p = 1.0) or infection (p = 0.84). Twenty-two patients (11%) had postmastectomy radiation and, of these, 5 (22%) required implant removal due to complications. Complications of Nipple-Sparing Mastectomy (N = 351) NAC* necrosis [n = 40, 11%] Incision Technique Inframammary Periareolar Other Sharp Cautery Partial [n = 37 (%)] 14 (38) 19 (51) 4 (11) 20 (54) 17 (46) Complete [n = 3 (%)] 0 3 (100) (100) Skin flap necrosis [n = 6, 2%] Superficial [n = 4 (%)] 2 (50) 0 (0) 2 (50) 3 (75) 1 (25) Full thickness [n = 2 (%)] 1 (50) 1 (50) 0 2 (100) 0 Skin and NAC necrosis [n = 16, 5%] Superficial [n = 9 (%)] 6 (67) 2 (22) 1 (11) 4 (44) 5 (56) Full thickness [n = 7 (%)] 3 (43) 2 (29) 2 (29) 3 (43) 4 (57) Hematoma [n = 8, 2%] 3 (38) 5 (63) 0 5 (63) 3 (38) *NAC, nipple areolar complex. Conclusion: NSM has an acceptable complication rate. While minor complications are common, NAC necrosis requiring excision or implant loss is rare. Postmastectomy radiation is a significant risk factor for implant loss. Inframammary incisions have fewer complications but may result in tumor-involved margins. The American Society of Breast Surgeons Official Proceedings
79 The Effect of BMI on OR Utilization in Breast Surgery Julie Dunderdale 1, Borko Jovanovic 2, Swati Kulkarni 3 1 Northwestern Memorial Hospital, Chicago, IL, 2 The Feinberg School of Medicine, Northwestern University, Chicago, IL, 3 Northwestern University, Feinberg School of Medicine, Chicago, IL Objective: More than one third of adults in the United States are obese. Studies have shown that obesityrelated comorbidities increase health care costs, but the effect of obesity on operating room utilization has not been completely evaluated. The purpose of our study was to examine how operative time (OPT) for common procedures in breast surgery is affected by patient BMI. We hypothesized that BMI has more of an effect on OPT for extensive procedures, such as axillary lymph node dissection (ALND) and mastectomy, than for minimally invasive procedures, such as lumpectomy and sentinel lymph node biopsy (SLNB). Methods: OPT, weight, and height for 10 breast surgeries were identified from the American College of Surgeons 2010 National Surgical Quality Improvement Project database, and BMI was then calculated from these values. The procedures were sorted by CPT codes. Only female patients were included, and those who underwent additional procedures or had incomplete data were excluded. Patients were divided into groups based on their BMI (group 1: <25, group 2: 25 35, and group 3: >35). Using the 2-sample t test, OPT was compared among the lowest and highest BMI categories. We specifically looked at lumpectomy, lumpectomy plus SLNB, lumpectomy plus ALND, mastectomy, mastectomy plus SLNB, and modified radical mastectomy (MRM). Results: Overall, 16,077 patients were included in the analysis. Group 1 had 5,606 patients, group 2 consisted of 7,697 patients, and group 3 contained 2,774 patients. When BMI groups 1 and 3 were compared for all procedures, a significant difference of 14 min (p < ) was seen. As shown in the table, for these same groups, a significant difference in OPT was noted for lumpectomy alone and lumpectomy plus SLNB. However, BMI had a much more dramatic effect on OPT for procedures that included ALND and mastectomy. Results by Procedure No. of Patients OPT (min) Difference (p value) Lumpectomy BMI group 1 BMI group (<0.0001) Lumpectomy + SLNB BMI group 1 BMI group (0.0002) Lumpectomy + ALND BMI group 1 BMI group (0.0027) Mastectomy BMI group 1 BMI group (0.0002) Mastectomy +SLNB BMI group 1 BMI group (0 < ) MRM BMI group 1 BMI group (<0.0001) The American Society of Breast Surgeons Official Proceedings
80 Conclusion: Patient BMI significantly affects OPT for lumpectomy and SLNB, but the difference is much greater for ALND, mastectomy, and MRM. Therefore, when scheduling more extensive breast surgical procedures for obese patients, additional time should be allotted to improve OR utilization The Cost of Efficiency: Budget Impact Analysis of a Breast Rapid Diagnostic Unit Maryam Elmi 1, Sharon Nofech-Mozes 1, Belinda Curpen 1, Angela Leahey 1, Nicole Look Hong 1 1 Sunnybrook Health Sciences Center, Toronto, ON, Canada Objective: Recent implementation of a streamlined rapid diagnostic unit (RDU) for suspicious breast lesions has significantly decreased wait times to definitive diagnosis. However, its economic impact remains unknown. This project defines the costs associated with development, implementation, and ongoing maintenance of a breast RDU from the perspective of a universal health care system. Methods: A budget impact analysis was performed identifying all direct costs associated with planning and implementation of the RDU (consulting, personnel training, infrastructure development, pilot testing, research database management) and ongoing maintenance (scheduling, diagnostic tests, physician billings). Diagnostic fees included imaging, biopsy, pathology processing, and physician interpretation. Sensitivity analyses were performed to forecast costs based on feasible variations in key components. Costs are adjusted 2015 valuations reported in Canadian dollars using healthcare-specific Consumer Price Indices. Results: Start-up costs of the RDU were $341,822, accounting mainly for new infrastructure implementation and personnel training. Average ongoing operational costs, including database management, validation of rapid tissue processors, and support staff, was $155,137 per year. An average clinical cost for achieving a diagnosis (imaging, biopsy, physician consult) was $654 per patient. Sensitivity analysis revealed that, if running at maximal institutional capacity, the total annual clinical cost for achieving a diagnosis could range between $123,930 and $679,533. Conclusion: Establishment and maintenance of a breast RDU requires significant investment in order to achieve reductions in time to diagnosis. However, expenditures ought to be interpreted in the context of institutional patient volumes, and tradeoffs in patient-centered outcomes, including reduction in patient anxiety, and possibly shorter times to definitive treatment. This study can be used as a resource-planning tool for future RDUs in healthcare systems wishing to improve diagnostic efficiency Excisional Biopsy by Seed Localization Decreases Amount of Excised Tissue Compared to Wire Localization Claire Edwards 1, Anita Sambamurty 1, Eric Brown 1, Anita McSwain 1, Christine Teal 1 1 GW Comprehensive Breast Center, Washington, DC Objective: Surgical excision of nonpalpable breast lesions requires a localization procedure in order to accurately target the area of concern. Traditionally, this has been done by wire localization--passing a hookwire into the lesion using mammographic or sonographic guidance. An alternative is localization with a radioactive seed. Seed localization does not require the patient to have an external wire in the breast. It can be performed up to 5 days in advance. We started a seed localization program at our institution in July The purpose of this study was to determine whether seed localizations decrease operative time and the amount of tissue excised when compared to wire localizations. Methods: We retrospectively reviewed 123 surgical excisional breast biopsies done at our academic medical center. We included 64 excisional biopsies by wire localization performed between September 2013 and March 2014 and 59 excisional biopsies by seed localization performed between September 2014 and March Only excisional biopsies performed for benign or high-risk lesions were included. For each case, The American Society of Breast Surgeons Official Proceedings
81 operative time was obtained from hospital operative records, and specimen weight and volume was obtained from pathology reports. Results: The average specimen volume was significantly lower for cases performed by seed localization compared to wire localization cases (34.1 vs 51.0 cm 3, p = 0.005). The average specimen weight was also significantly lower for seed localization (14.0 vs 19.7 g, p = 0.004). There was a trend toward decreased operative time for seed localization but this was not statistically significant (32.7 vs 34.5 min, p = 0.29). Conclusion: We started a seed localization program with the aim of increasing convenience to the patient as well as flexibility of scheduling. We found that this procedure also decreases the average amount of breast tissue removed during excisional biopsy, as measured by either specimen weight or volume. This is likely because seed localization allows more precise targeting of the lesion within the breast in 3 dimensions. There was a trend toward decreased operative time, which may further decrease as our experience with the seed localization procedure continues. Based on these results, we will evaluate our results from seed localizations compared to wire localization for partial mastectomies done for invasive and in situ carcinoma to determine whether seed localizations impact the amount of tissue removed and re-excision rates STAT Reasons and Ordering Outcomes for Hereditary Breast Cancer Genetic Testing Caroline Elsas 1, Michelle Jackson 1, Emily Dalton 1, Patrick Reineke 1, Sara Calicchia 1, Holly LaDuca 1, Jill Dolinsky 1, Robina Smith 1 1 Ambry Genetics, Aliso Viejo, CA Objective: When indicated based on personal and family history, women facing a diagnosis of breast cancer often undergo hereditary cancer genetic testing. Turnaround times for genetic testing range from 7 days to 4 weeks and vary based on genes analyzed, technology, and laboratory workflow. Genetic testing is processed STAT when deemed necessary by the ordering clinician. For these cases, the laboratory uses extra resources to expedite testing, as identification of a pathogenic mutation may directly impact the patient s management plan. For example, a woman with a positive genetic test result may choose to undergo prophylactic bilateral mastectomy rather than lumpectomy in order to reduce the risk for another breast cancer primary. We evaluated a cohort of STAT hereditary cancer test orders to determine indications for these requests and potential outcomes of the results. Methods: Test request forms for 1,137 breast-related STAT orders from April June of 2015 were reviewed. Information about personal diagnosis, reason for STAT request, test performed, and genetic test results was gathered. Results: The majority of breast-related STAT requests (n = 701; 61.6%) were for multigene panel tests (MGPT). The remaining orders were for BRCA1/2 only (n = 264; 23.2%), BRCA1/2 with reflex to a MGPT (n = 165; 14.5%), and non-brca1/2 single-gene tests (n = 7; 0.6%). Most probands had invasive breast cancer or DCIS at the time of testing (n = 1,120; 98.5%) and the remainder (n = 17; 1.5%) had a past history of breast cancer or a nonmalignant breast lesion. Upcoming surgery was indicated as the reason for the majority of STAT orders (n = 1079; 94.8%), whereas nonsurgical treatment decisions, such as chemotherapy or clinical trials, were indicated less frequently (n = 33; 2.9%). Overall, 119 (10.5%) mutation-positive probands were identified; 73 of which harbored mutations in genes that would warrant consideration of bilateral prophylactic mastectomies as per current NCCN guidelines, including BRCA1 (n = 31), BRCA2 (n = 36), PTEN (n = 1), and TP53 (n = 5). Additionally, NCCN guidelines contraindicate radiation therapy for individuals carrying germline TP53 mutations. The remaining 46 probands carried mutations in genes for which no breast surgical NCCN guidelines exist (APC, ATM, BARD1, BRIP1, CHEK2, MLH1, MUTYH, NBN, PALB2, PMS2, and RAD51C). Conclusion: Most probands undergoing STAT testing were pending breast cancer surgery. Surgical decisions were potentially impacted by positive test results for at least 6.4% of patients, and many individuals who had negative test results likely elected breast-conserving surgery. STAT orders may not have been urgent in 1.5% of cases since these patients were not pending treatment. STAT testing requires extra resources and should be The American Society of Breast Surgeons Official Proceedings
82 utilized only when timing is critical; however, it can be essential in guiding medical management for patients facing immediate treatment decisions Patients Treated With Intraoperative Radiation Therapy (IORT): Initial Report Melinda Epstein 1, Sadia Khan 1, Peter Chen 1, Brian Kim 1, Lisa Guerra 1, Lincoln Snyder 1, Colleen Coleman 1, January Lopez 1, Ralph Mackintosh 1, Cristina DeLeon 1, Melvin Silverstein 1 1 Hoag Memorial Hospital Presbyterian, Newport Beach, CA Objective: Intraoperative radiotherapy (IORT) permits accurate delivery of radiation therapy directly to the tumor bed at the time of surgery, greatly simplifying breast conservation. Two prospective randomized trials have been published (ELIOT and TARGIT), supporting IORT as a possible alternative to whole-breast radiation therapy (WBRT). This report documents the study requirements, patient characteristics, and shortterm outcome for 640 breast cancer patients treated with IORT from June 2010 to June Methods: To be eligible for IORT as the only radiation therapy, final pathology had to confirm tumor size 30 mm, tumor margins 2 mm, negative lymph nodes, and no extensive lymphovascular invasion. All patients were studied preoperatively with physical examination, digital mammography, ultrasound, and MRI. These tests were used to select patients thought to meet the study criteria. Patients that violated 1 or more parameters on final pathology were referred for additional surgery and/or WBRT with IORT becoming the boost. IORT was delivered using the Xoft Axxent Electronic Brachytherapy (ebx ) System. Results: Six hundred forty patients received IORT. Four hundred thirty-seven (68%) met all study criteria and were treated with IORT as their entire course of radiation therapy. Ninety-nine (16%) additional patients failed 1 or more study criteria but elected no additional local treatment. Of the 104 remaining patients who violated IORT parameters, 17 (8.4%) underwent re-excision, 15 (7.4%) opted for mastectomies, and the remaining 72 (35.4%) were treated with WBRT. There have been 11 local recurrences (6 invasive), no distant metastases, and no breast cancer related deaths. Two local recurrences were within the IORT field, 8 outside, and 1 in a different quadrant. Four local recurrences were in patients who failed 1 of the study criteria. Of the 11 who recurred, 3 were converted to mastectomy and 8 were re-excised, 1 of whom was treated with WBRT in addition to re-excision. Currently, with limited follow-up, Kaplan-Meier analysis projects 3.5% of patients will recur at 3 years. continues The American Society of Breast Surgeons Official Proceedings
83 Variable N 640 Tumor type DCIS Infiltrating ductal Infiltrating lobular Average follow-up (mo) Average. age (yr) Average tumor size 122 (19%) 469 (73%) 49 (8%) 20 mo 64 yr 15.5 mm Average nuclear grade 2.03 Immediate IORT Delayed IORT (postpathology) Protocol violations Extensive LVI Margin <2 mm Positive lymph nodes Tumor size >30 mm 613 (96%) 27 (4%) 260 in 203 patients 23 (11%) 115 (56%) 26 (13%) 96 (47%) >1 protocol violation 203 (32%) >2 protocol violations 54 (9%) >3 protocol violations 5 (0.8%) 4 protocol violations 0 (0%) Treatment after protocol violation Mastectomy No additional local treatment Re-excision WBRT 15 (7%) 99 (49%) 17 (8%) 72 (35%) Number of local recurrences 11 (1.7%) Median time to local recurrence 24.2 mo 3-year probability local recurrence 3.5% Number of distant recurrences 0 (0%) Number of BC deaths 0 (0%) Conclusion: IORT is a promising new modality that greatly simplifies the delivery of post-excisional radiation therapy. IORT makes breast conservation possible for women who could not be available for 3 6 weeks of conventional whole-breast radiation therapy. Follow-up is too short to make any definitive conclusions about this modality other than that it can be done safely Complications in 640 Patients Treated With Intraoperative Radiation Therapy (IORT) Melinda Epstein 1, Sadia Khan 1, Peter Chen 1, Brian Kim 1, Lisa Guerra 1, Lincoln Snyder 1, Colleen Coleman 1, January Lopez 1, Ralph Mackintosh 1, Cristina DeLeon 1, Melvin Silverstein 1 1 Hoag Memorial Hospital Presbyterian, Newport Beach, CA Objective: Intraoperative radiotherapy (IORT) permits the accurate delivery of radiation therapy directly to the tumor bed at the time of surgery. Minimal data are available about the local effects and complications associated with this modality of treatment using the Xoft Axxent Electronic Brachytherapy (ebx ) System. Methods: Six hundred forty patients were treated with IORT delivered using the Xoft Axxent Electronic Brachytherapy (ebx ) System. Data were collected at 1 week, 1 month, 3 months, 6 months, and 1 year The American Society of Breast Surgeons Official Proceedings
84 postoperatively. Thereafter, data were collected yearly. Acute complications were defined as those occurring within the first month. Chronic complications were those that persisted beyond 6 months. Results: The table details patient demographics as well as acute and chronic complications. Most patients who experienced complications experienced more than one. Variable N (%) N 640 Average age 64 yr Average follow-up 19.1 mo Acute hematoma (required drainage) 10/640 (1.7%) Acute seroma (required drainage > 3 times) 2/640 (0.3%) Infection (required antibiotic or surgery) 5/640 (0.8%) Necrosis (required surgery) 1/640 (0.2%) Acute erythema Severity grade I Severity grade II Severity grade III 137/640 (21%) 114/137 (83%) 21/137 (15%) 2/137 (2%) Chronic seroma (present at 6 mo) 12/469 (2.6%) Chronic fibrosis (present at 6 mo) Severity grade I Severity grade II Severity grade III Chronic hyperpigmentation (present at 6 mo) Severity grade I Severity grade II Severity grade III 70/640 (11%) 63/70 (90%) 6/70 (8.6%) 1/70 (1.4%) 48/640 (7.5%) 48/48 (100%) 0/48 (0%) 0/48 (0%) Patients with acute complications 134/640 (21%) Patients with chronic complications 101/640 (16%) Conclusion: IORT is a promising new treatment modality that greatly simplifies the delivery of postexcision radiation therapy. While 21% of patients had acute complications and 16% had chronic complications, most were mild. If grade I erythema, fibrosis, and hyperpigmentation are removed, only 27/640 (4.2%) had significant complications. Addendum: A flexible tungsten rubber shield was used during the first 27 IORT cases to protect the internal organs from radiation therapy. Tungsten particles from these shields were identified in all 27 patients when they underwent their first postoperative mammography at 6 month. This was immediately reported to the FDA and the IORT program was halted until a stainless steel shield was available 9 months later. All 27 patients were immediately advised and referred to appropriate consultants. No significant illnesses have been reported to date, secondary to tungsten exposure. This complication is not included in the table above. The American Society of Breast Surgeons Official Proceedings
85 Institutional Experience of Applying ACOSOG Z0011 Criteria to Breast Cancer Patients Underrepresented in the ACOSOG Z0011 Trial Daniel Farrugia 1, Emilia Diego 1, Atilla Soran 1, Alessandra Landmann 1, Priscilla McAuliffe 1, Marguerite Bonaventura 1, Ronald Johnson 1, Gretchen Ahrendt 1 1 University of Pittsburgh Medical Center Magee-Womens Hospital, Pittsburgh, PA Objective: The ACOSOG Z0011 trial established the feasibility of omitting axillary lymph node dissection (ALND) in patients undergoing breast conservation therapy (BCT) for T1-T2 breast cancers who are clinically node negative and have <3 positive sentinel lymph nodes (+SLN). The majority of patients had estrogen receptor positive (ER+) tumors and micrometastatic +SLN. We hypothesized that Z0011 principles of management can be expanded to patients with criteria that were underrepresented in the trial, including age < 50, invasive lobular cancer (ILC), triple-negative breast cancers (TNBC), high-grade tumors, or evidence of extracapsular extension (ECE) on SLNB. Methods: After institutional approval, the Cancer Registry was queried for patients with T1-T2, cn0 disease undergoing BCT who proved to be pn1 on SLNB at our institution from Chart review was performed to retrieve demographic and clinicopathologic data. Patients who had neoadjuvant therapy, metastatic disease, prior history of breast cancer, ALND, or omitted adjuvant radiation therapy (RT) were excluded. Results: Of 183 patients with 1 2 +SLN on SLNB treated with BCT and omitting ALND, 118 had criteria that were under-represented in Z0011, including 47 (39.8%) under age 50 or premenopausal, 36 (30.5%) with grade 3 tumors, 43 (36.4%) with ECE on SLNB, 5 (4.2%) with TNBC, and 21 (17.8%) with ILC (table). Sixtyfive patients had demographics of the typical Z0011 patient. In patients having underrepresented criteria, 87 (73.7%) had only 1 criterion and 3 (2.5%) had >2 criteria. Patients with underrepresented criteria were more than twice more likely to receive adjuvant chemotherapy (47.5% vs 20.0%, RR = 2.37, p =.0002, 95% CI [1.41, 4.00]). Mean follow-up was 27.5 months (median, 27; range, 2 53). There was a single distant recurrence (0.85%) and no locoregional recurrences in the 118 patients with underrepresented criteria. This patient had a grade 3 tumor with ECE on SLNB and sustained recurrence in liver and bone. One patient in this group died of unrelated causes. There was no recurrence in the 65 patients with typical Z0011 demographics. Conclusion: There was no difference in LRR or overall breast cancer recurrence in this group of patients having underrepresented criteria in the Z0011 trial at a median of 27 months of follow-up. Our results support the hypothesis that Z0011 principles of axillary management may be expanded to patients under age 50, highgrade tumors, evidence of ECE on SLNB, TNBC, and ILC. We are accruing further prospective data and will update our findings after longer follow-up. Recurrence in Patients With Underrepresented Z011 Criteria Omitting ALND Underrepresented Criterion n Chemo (%) Hormone (%) Recurrence (%) Age <50/premenopausal (53.2) 45 (95.7) 0 (0) Grade 3 tumor (63.9) 27 (75) 1* (2.78) Extracapsular extension (37.2) 37 (86.0) 1* (2.33) Triple-negative cancer 5 5 (100) 0 (0) 0 (0) Invasive lobular cancer 21 7 (33.3) 21 (100) 0 (0) No underrepresented criteria (typical Z0011 demographics) (20.0) 65 (100) 0 (0) 1 underrepresented criteria (47.5) 106 (89.8) 1* (0.85) 1 underrepresented criterion (44.8) 83 (95.4) 0 (0) >1 underrepresented criteria (54.8) 23 (74.2) 1* (3.23) *This sole recurrence is shown multiple times due to the presence of multiple criteria and refers to the same patient with a grade 3 tumor and ECE on SLNB. The American Society of Breast Surgeons Official Proceedings
86 The Impact of Body Mass Index on the Prognostic Power of Circulating Tumor Cells and Pathologic Complete Response Following Neoadjuvant Chemotherapy for Breast Cancer Oluwadamilola Fayanju 1, Carolyn Hall 1, Jessica Bauldry 1, Mandar Karhade 1, Lily Valad 1, Henry Kuerer 1, Sarah DeSnyder 1, Carlos Barcenas 1, Anthony Lucci 1 1 The University of Texas MD Anderson Cancer Center, Houston, TX Objective: Pathologic complete response (pcr) after receipt of neoadjuvant chemotherapy (NACT) and the presence of systemic microscopic disease in the form of circulating tumor cells (CTCs) at diagnosis are both important prognosticators of breast cancer outcome. As rates of obesity increase in the United States, it is unclear if body mass index (BMI) affects the prognostic significance of these clinical characteristics. Here, we examine the effect of BMI at diagnosis on the predictive power of models containing pcr and CTCs in forecasting prognosis of breast cancer patients following NACT. Methods: Study participants were stage I III breast cancer patients diagnosed from 3/2005 to 3/2015 who received NACT as part of a prospective trial on CTCs and whose postoperative pathologic review definitively described pcr. Predicted event-free survival (EFS; ie, no recurrence or death) was calculated using Cox proportional hazards models that included BMI, pcr, CTCs, age, race, tumor grade/size/biomarkers, menopausal status, anthracycline/taxane type, nodal status, and the presence of inflammatory breast cancer or lymphovascular invasion as covariates. We report hazard ratios (HRs) with 95% confidence intervals (CIs) significant at 2-tailed p < 0.05 and Harrell s C indices, which indicate the ordinal predictive power of the models. Results: Of 113 patients, 93 (82%) had CTC values, and 34 (30%) had pcr; 91 (81%) had stage III disease, and 50 (44%) were obese (BMI 30). In bivariate modeling, pcr was associated with increased likelihood of EFS (HR, 0.07; CI, , p < 0.01), while presence of CTCs was associated with decreased likelihood of EFS (HR, 3.88; CI, ; p < 0.01) at 30-month follow-up. Although BMI was not associated with EFS in either model, addition of BMI stratified by obesity (BMI < 30 vs BMI 30, see figure) improved the predictive power of CTCs (Harrell s C index of 0.67 for univariate model without BMI vs 0.72 for bivariate model with BMI) and pcr (Harrell s C index of 0.65 for univariate model without BMI vs 0.68 for bivariate model with BMI). The trivariate model with CTCs, pcr, and BMI had a Harrell s C index of 0.8, while the full multivariate model had the highest Harrell s C index (0.86) among our models and, accordingly, the greatest predictive power. continues The American Society of Breast Surgeons Official Proceedings
87 Conclusion: Although BMI was not independently associated with EFS in our cohort, it may nonetheless be an important contributor to predicting the likelihood of disease recurrence in breast cancer patients who receive NACT and in whom CTCs are present at diagnosis. The significance of both CTCs and pcr as prognosticators in obese patients warrants further investigation Who Bleeds After Breast Cancer Resection? A Contemporary Analysis of the ACS-NSQIP Database Ann-Kristin Friedrich 1, Kevin Baratta 1, Connie Lee 1, Anne Larkin 1, B. Marie Ward 1, Ashling O Connor 1, Robert Quinlan 1, Jennifer LaFemina 2 1 University of Massachusetts Medical School, Worcester, MA, 2 UMass Medical School, Worcester, MA Objective: Postoperative bleeding is a common cause for unplanned return to the operating room in patients undergoing operative intervention for breast cancer. We aim to identify preoperative risk factors associated with increased risk of postoperative bleeding. Methods: All patients who underwent breast cancer surgery were identified in the ACS-NSQIP database. Patients who experienced postoperative bleeding requiring transfusion and/or an unplanned reoperation for hemorrhage or hematoma within 30 days were identified. Postoperative bleeding risk was compared by type of surgery as well as by other preoperative and perioperative risk factors. Univariate analyses and multivariate logistic regression were performed. Results: 71,294 patients were identified who underwent surgical excision of breast cancer between the years of 2006 and Of these, 28,653 (40.2%) underwent lumpectomy; 24,380 (34.2%) underwent simple or subcutaneous mastectomy; 16,858 (23.7%) underwent modified radical mastectomy; and 1,403 (1.97%) underwent radical mastectomy. Six hundred eleven (0.86%) patients experienced postoperative bleeding The American Society of Breast Surgeons Official Proceedings
88 requiring blood transfusion and/or return to the operating room. In univariate analyses, risk factors associated with postoperative bleeding episodes included younger age; higher BMI; black race; higher ASA classification; greater complexity of procedure; presence of resident in the operating room; disseminated cancer; preoperative transfusion; weight loss; chemotherapy; abnormal preoperative laboratory values, such as elevated INR and decreased hematocrit; and personal history of diabetes, bleeding disorder, and steroid use. In multivariate analysis, each BMI increase of 1 point carried increased risk of bleeding of approximately 3% (OR, 1.03; 95% CI, ). Participation of a resident in the surgery was associated with a 57% increase in risk of bleeding (OR, 1.57; 95% CI, ). Simple mastectomy carried an 8.6-fold increased risk, compared to lumpectomy (OR, 8.63; 95% CI, ); radical mastectomy had estimated 10.9 times the risk of lumpectomy (OR, 10.9; 95% CI, ). In addition, preoperative transfusion, preoperative hematocrit levels, existence of a bleeding disorder, and presence of disseminated cancer were all significant independent predictors of bleeding risk. Conclusion: In this analysis of a national cohort of breast cancer patients, multiple risk factors were associated with increased likelihood of a postoperative hemorrhage. While hemorrhage is relatively rare following breast surgery, there are significant implications to the event, including risk of reoperation. Identification of at-risk patients may enable for improved preoperative patient education and operative planning Acupuncture As Treatment for Flap/Nipple Ischemia Following Nipple-Sparing Mastectomy Jennifer Garreau 1, Heather Farley 2, Margie Glissmeyer 1, Nathalie Johnson 1 1 Legacy Good Samaritan Hospital, Portland, OR, 2 Oregon Health and Science University, Portland, OR Objective: Nipple-sparing mastectomy (NSM) can offer enhanced cosmetic outcome. Inherent with this technique is a higher risk of nipple/flap ischemia that may lead to loss of the nipple and require surgical revision. Acupuncture has been described to improve circulation. We evaluated the efficacy of acupuncture for reversing ischemia after NSM. Methods: A retrospective review of all nipple-sparing mastectomies performed at a community hospital in 2014 was evaluated. Results: There were 100 NSMs performed on 55 patients. Eleven NSM patients (20%) had some degree of nipple/flap ischemia. Eight of 11 (73%) were referred to acupuncture and reported improved flap/nipple appearance. Of these, 2 patients required additional procedures and only 1 patient had nipple loss. Patients reported improved pain control as well. Conclusion: Acupuncture techniques can improve circulation and may be used to reverse ischemic changes after NSM. It is most effective when started within the first 24 hours after surgery. The American Society of Breast Surgeons Official Proceedings
89 A Cost-Effective Handheld Breast Scanner for Use in Low-Resource Environments: A Validation Study Rula Geha 1, Robyn Broach 2, Mihir Shah 3, Matthew Campisi 3, Lucy De La Cruz 1, Brian Englander 4, Ari Brooks 2 1 Department of Surgery, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, 2 Department of Surgery, Pennsylvania Hospital, University of Pennsylvania, Philadelphia, PA, 3 UE LifeSciences Inc, Philadelphia, PA, 4 Department of Radiology, Pennsylvania Hospital, University of Pennsylvania, Philadelphia, PA Objective: The incidence of breast cancer is rising worldwide, with the majority of new breast cancers in developing nations. These countries lack healthcare infrastructure and resources to support mammogram-led screening programs. There is a need to develop low cost and widely effective screening for breast pathology. We are evaluating the IBreastExam (ibe) (UE LifeSciences Inc.), a handheld breast scanning device to palpate the breast electronically. A green/red map of the breast is constructed as the device moves. The device can be utilized by community health workers to screen women for breast abnormalities with the intent that positive findings would lead to imaging and/or biopsy. This purpose of this study is to determine the sensitivity of the ibe in a population undergoing diagnostic breast imaging for palpable and/or screeningdetected lesions. Methods: Women and men over age 18 presenting to the clinic or breast imaging center for a diagnostic workup were eligible. After obtained consent, patients underwent a 15- to 20-min ibe exam performed by an ibe-trained ultrasound technician. The patients then underwent their indicated imaging. Demographic, imaging and biopsy data were recorded. Not all patients had both breasts evaluated with the ibe. The ibe findings were grouped in 1 of 4 definitive clock quadrants in order to directly compare with the imaging position results. Each quadrant was analyzed independently. Results: Eighty-nine patients were enrolled. Seventy-eight had complete ibe exams for analysis; 77 female and 1 male. Ten patients underwent bilateral exams. The mean age of the patients was 42 (21 79). All patients were evaluated by ultrasound; 52 had diagnostic mammography and 39 had biopsies. Imaging and/or biopsy confirmed a mass (fibroadenoma, cyst, papilloma, myofibroblastoma, fat necrosis, DCIS, or cancer) in 60 patients. Eighteen were negative. Twelve patients had a cancer diagnosed; mean size was 1.9 ( cm). In total, 342 quadrants were scanned in 78 patients; 77 quadrants had lesions confirmed on imaging, and 265 quadrants were negative on imaging. ibe correctly identified 66 of 77 lesions for a sensitivity of 86%, specificity is 89%. The ibe correctly identified 10 of 12 malignancies (83%), the 2 lesions missed were under 1 cm: a 5-mm DCIS and a 7-mm mucinous carcinoma. Conclusion: This validation study demonstrated excellent sensitivity of ibe for the identification of clinically significant lesions in patients presenting for diagnostic imaging. A larger study in the general screening population will allow for better assessment of the specificity of this tool Successful Ultrasound-Guided Segmental Mastectomy and Excisional Biopsy Using Hydrogel-Encapsulated Clip Localization As an Alternative to Wire Localization Lori Gentile 1, Amber Himmler 1, Elizabeth Vohris 1, Julia Marshall 1, Christiana Shaw 1, Lisa Spiguel 1 1 University of Florida, Gainesville, FL Objective: Wire localization is currently the most widely used preoperative localization strategy for surgical guidance during excision of nonpalpable breast lesions. Disadvantages of wire localization consist of patient discomfort, wire-related complications, such as wire displacement or fracture, and operating room delay related to technical challenges during wire placement. Our institution has implemented the technique of intraoperative ultrasound (US)-guided excision using hydrogel-encapsulated (HydroMARK ) biopsy clips for lesion localization. We hypothesize that this method is as effective as wire localization for breast-conserving therapy. The American Society of Breast Surgeons Official Proceedings
90 Methods: This is a retrospective review of all patients who underwent either segmental mastectomy or excisional biopsy using wire localization or hydrogel-encapsulated clip localization between January 2014 and July Data on margin status, specimen size, need for re-excision, and procedure time for preoperative lesion localization were collected and analyzed. Statistical analyses for differences between groups were performed using t tests and Mann-Whitney rank sum analyses. Results: Two hundred and twenty consecutive patients underwent segmental mastectomy or excisional biopsy between January 2014 and July One hundred and seven excisions were performed using hydrogelencapsulated clip localization, and 113 excisions were performed using the traditional wire localization technique. Sixty-eight percent of our patients underwent excision for malignant pathology. Four patients were converted from US localization to wire localization due to inability to identify the biopsy clip preoperatively. Single-wire localization procedure time ranged from 20 min to 180 min, with an average of 46 min, as compared to 5 min for ultrasound localization (p < 0.001). Successful intraoperative US localization and excision was performed on 100% of patients, as confirmed by biopsy site changes and pathology on permanent sections. There was no difference in the rate of re-excision for margin positivity or specimen size between patients undergoing traditional wire localization techniques as compared to hydrogel-encapsulated clip guided excision. Wire Localization Intraoperative US-Guided Excision Number of excisions Specimen size (median) P Value IDC 29.0 g 29.1 g P = DCIS 17.2 g 15 g P = Re-excision rate (%) IDC 14% 16% P = DCIS 39% 40% P = Localization procedure time (mean) 46 min 4.7 min P < Conclusion: Intraoperative ultrasound-guided excision of nonpalpable breast lesions using a hydrogelencapsulated biopsy clip for breast-conserving therapy is a safe and feasible alternative to the traditional preoperative wire localization excision. This technique will lead to improvement in patient experience, operative efficiency, and alleviate wire localization-related complications Does Exogenous Insulin Contribute to the Development of More Aggressive Subtypes of Breast Cancer? Victoria Gershuni 1, Yun Li 1, Elena Carrigan 1, Steel Laura 1, Vicky Ro 1, Jenny Nguyen 2, Laura Bozzuto 1, Julia Tchou 3 1 University of Pennsylvania, Philadelphia, PA, 2 Wistar Institute, Philadelphia, PA, 3 University of Pennsylvania Health System, Philadelphia, PA Objective: Insulin resistance, as seen in type 2 diabetes (DM2) and metabolic syndrome (visceral adiposity, insulin resistance, fasting hyperglycemia, etc.), is associated with higher incidence of breast cancer and worse overall prognosis. Several studies have demonstrated a strong association between hyperinsulinemia, elevated IGF-1 levels, and poor breast cancer prognosis, including distant recurrence and mortality. Methods: Insulin is a growth-promoting hormone with tumorigenic potential via activation of IGF-1 pathways and is known to have mitogenic, anti-apoptotic, and angiogenic properties. In vitro and in vivo studies have shown insulin receptor overexpression in breast tissue. More recently, studies have highlighted an association The American Society of Breast Surgeons Official Proceedings
91 between insulin resistance and central adiposity with overexpression of HER2+ on tumors in postmenopausal women, which supports hyperinsulinemia as a pro-inflammatory and mitogenic environment allowing for proliferation of more aggressive breast cancer subtypes. It is unclear, however, whether the exogenous administration of insulin impacts breast cancer risk and survival. We hypothesize that the administration of exogenous insulin is associated with increased risk of more aggressive breast cancer subtypes (ie, HER2+), worse prognosis, and reduced survival compared to nondiabetics and diabetic patients who received medications known to decrease circulating insulin levels (ie, metformin). To test this hypothesis, we performed a retrospective chart review of breast cancer patients who had surgery at a single-institution from 1995 to 2013 (n = 1214). Results: As expected, insulin use is strongly associated with DM2 (p < 6.36 x ) and moderately associated with increased BMI (p < 0.037). Of patients taking insulin, 85% were either overweight or obese, underscoring the strong association between DM2, obesity, and insulin resistance. On multivariate analysis using a Coxproportional hazard model and stratifying by BMI, weight, and race for a preliminary subset of patients with available clinical, pathologic, and demographic covariates (n = 307), we found that insulin use, age, nodal status, and tumor size were independently predictive of survival (log-rank test, p < 1.15 x 10-6 ). Specifically, insulin use prior to breast cancer diagnosis significantly reduced overall survival as compared to those without a history of insulin use (HR = 13.09; 95% CI, ; Kaplan-Meier log-rank test, p < 2.97e-07). Data collection and analysis are ongoing for the full patient cohort. Conclusion: Our findings suggest a link between hyperinsulinemia secondary to exogenous insulin and development of more aggressive breast cancer. In light of the recent American Cancer Society report on increased incidence and higher mortality of breast cancer among black women and potential link to obesity and metabolic syndrome, it is imperative to evaluate the impact of exogenous insulin on breast cancer proliferation as a strategy for intervention Take It All! - The Decision to Pursue Bilateral Mastectomy for Ductal Carcinoma In Situ (DCIS) Katherine Glover-Collins 1, Julie Margenthaler 1 1 Washington University in St Louis, St Louis, MO Objective: Breast-conserving therapy remains a viable option for most women with DCIS, resulting in similar survival outcomes to those who pursue mastectomy. Despite this, bilateral mastectomy rates are increasing in patients with DCIS. This study was undertaken to evaluate the patient s motivation behind the choice for bilateral mastectomy for the treatment of DCIS. Methods: This was an IRB-approved retrospective chart review and questionnaire based study of women aged 18 and older in our institutionally maintained breast cancer database who have undergone a mastectomy over a 10-year period. A custom-designed written survey with 18 questions was developed and queried on demographics, surgical choices, patient rationale, and presence of known hereditary cancer syndromes. The survey also included questions to determine the involvement of specific members of the multidisciplinary team (ie, surgeons, medical oncologists, and/or radiation oncologists) and the timing of these consultations. Results: Three hundred forty-eight women who had undergone mastectomy for a diagnosis of breast cancer were included in the study. Of those, 64 (18%) were diagnosed with DCIS by final pathology. Nearly half underwent bilateral mastectomy (30/64), despite being eligible for and offered BCT by their breast surgeons. The most cited reasons for mastectomy over BCT in descending order were perceived reduction of risk of breast cancer recurrence, improvement in survival, and chance to omit radiation therapy. The decision for bilateral mastectomy in 53% of these 30 women was for prophylactic reasons without a known genetic abnormality. Thirty-seven percent of these 30 women underwent genetic testing, however there were no genetic mutations found. Thirty-three percent opted for bilateral mastectomy for improved cosmesis and 90% of these women subsequently underwent reconstruction. The American Society of Breast Surgeons Official Proceedings
92 Conclusion: These data suggest that women with stage 0 DCIS are under the impression that more extensive surgery will provide a better outcome in terms of survival and risk of recurrence. Better patient education and communication tools are needed in order to guide practitioners in their consultations so that surgical overtreatment may be avoided Evaluation of Percutaneous Vacuum-Assisted (VA) Intact Specimen Breast Biopsy Device for Ultrasound (U/S) Visualized Breast Lesions: Upstage Rates and Long-Term Follow-Up (F/U) for High-Risk Lesions (HRL) and DCIS Cathy Graham 1 1 Case Western Reserve University School of Medicine, University Hospitals of Cleveland, Cleveland, OH Objective: Percutaneous core needle biopsy (PCNB) of U/S visualized breast lesions is considered standard of care for initial diagnosis. Use of large-gauge VA-PCNB devices has improved accuracy; but there still remains 12% 18% underestimation rate of malignancy. The VA Intact biopsy device, which provides a larger, intact specimen, was assessed for upstage rates of U/S-guided percutaneous biopsies. Long term f/u for subsequent malignancy at the biopsy site was also assessed. Methods: This retrospective study reviewed 469 consecutive U/S visualized breast lesions, <2.0 cm in size, BIRADS 4 or 5, which were biopsied using the Intact Breast Lesion Excision System (BLES) between July 2007 and August 2014 at a single institution. All nonconcordant lesions (0.8%), DCIS (1.7%), and ICAs (9.8%) were surgically excised. Surgical excision was recommended for all HRLs (13.0%). The upstage rate to DCIS or ICA was determined. All patients, including those with HRL that were not surgically excised, were followed for a mean of 48 months (13 91 months) with serial imaging and clinical breast exams to determine the incidence of re-biopsy or the development of DCIS or ICA at the previously biopsied site. Results: See table. Twenty-three of 61 HRL (37.5%) were not excised (patient preference), but observed with close f/u. Five (8.5%) patients with HRL on BLES were lost to f/u before the planned 2 years. Of the 23 HRLs diagnosed with BLES but not surgically excised, none were upstaged to DCIS or ICA over a mean f/u of 48 months. During the f/u period, no patient was diagnosed with DCIS or ICA at or near the original BLES biopsy site. BLES Pathology # of Patients # Excised # Upgraded After Excision % Upgrade % With Recurrent Issues At or Near BLES Site During Follow-Up Period Benign N/A N/A 0% HRL % 0% DCIS % ICA % Total % 0% Conclusion: (1) Percutaneous biopsy of U/S visualized lesions can be performed accurately using IntactR BLES. (2) Upstage rate is significantly lower using BLES with U/S guidance than previously published data using large-gauge VA-PCNB. (3) HRLs, when diagnosed with BLES under U/S guidance, have a very low upstage rate at surgical excision. It may be possible to observe these lesions without surgical excision when they present as U/S findings and undergo BLES. The American Society of Breast Surgeons Official Proceedings
93 Symptomatic Axillary Seroma After Sentinel Node Biopsy: Incidence and Treatment Jinny Gunn 1, Tammeza Gibson 1, Zhou Li 1, Nancy Diehl 1, Sanjay Bagaria 1, Sarah McLaughlin 1 1 Mayo Clinic, Jacksonville, FL Objective: Seroma formation can be a postoperative nuisance for both the patient and surgeon. Unfortunately few studies investigate predisposing factors for symptomatic axillary seroma after sentinel lymph node biopsy. Herein we sought to quantitate the risk of symptomatic seroma and characterize necessary interventions. Methods: We performed a retrospective review of 691 women undergoing breast-conserving surgery (BCS) and sentinel node biopsy (SLNB) at our institution between 7/2007 and 1/2015. Patients were routinely mapped with technetium sulfur colloid and never had drains placed at the time of initial surgery. Blue dye was used at surgeon discretion. Surgeons dissected sharply or with standard electrocautery. We correlated patient and tumor characteristics with symptomatic seroma using logistic regression models for univariate and multivariate predictors. All statistical tests were 2-sided with p < 0.05 considered significant. Results: Overall, 128 of 691 (19%) women had clinically detected axillary seromas of which 99 of 128 (77%) required further intervention for symptom relief. Patients having seroma were similar in age, BMI, race, tumor type, T and N stage, and number of nodes removed as those without seroma (all p > 0.11). Seroma rates did not vary according to surgeon or nodal-mapping technique and were not affected by deep suture closure of the axillary cavity (p = 0.9). Multivariate analysis identified diabetes, smoking, and SSI as the only predictors of symptomatic axillary seroma with OR of 1.91, 1.85, and (all p < 0.02), respectively. Among the 99 of 128 patients with symptomatic seroma, the majority (81/99, 82%) resolved with a mean of 1.3 aspirations, while the remaining required the additional placement of an axillary drain (14/99, 14%) or additional surgery for resolution after prolonged drain placement (4/99, 4%). Conclusion: Axillary seroma occurs in 1 of 5 patients undergoing BCS with SLNB and is not influenced by tumor, nodal mapping, or surgeon characteristics. Seroma management infrequently requires more than simple aspiration though drain placement at initial surgery should be considered in smokers or patients with diabetes. Further research into seroma prevention is necessary as even simple treatment still requires multiple patient appointments for resolution Barriers to Genetic Testing in Newly Diagnosed Breast Cancer Patients: Where Can We Improve? Laura Hafertepen 1, Alyssa Pastorino 2, Nichole Mormon 3, Deepa Halaharvi 3, Lindsey Byrne 3, Mark Cripe 3 1 Grant Medical Center/OhioHealth, Columbus, OH, 2 Doctors Hospital/OhioHealth, Columbus, OH, 3 OhioHealth, Columbus, OH Objective: Results of genetic testing in breast cancer patients influences surgical treatment and modifies screening for family members. However, even at our high-volume National Accreditation Program for Breast Centers (NAPBC) and Committee on Cancer (COC) accredited breast center, not all patients at risk for a genetic mutation are seen by genetic counselors. The goal of this study was to compare characteristics between patients who complete genetic counseling vs those who do not and identify barriers limiting appointment completion. Methods: The study cohort included newly diagnosed breast cancer patients meeting National Comprehensive Cancer Network (NCCN) guidelines for genetic counseling from January 1, 2014, to June 30, Data on demographics, pathology, imaging, and genetic testing outcomes was collected. A telephone survey was performed among patients who were referred but did not complete a genetic counseling appointment to identify barriers to appointment completion. Comparisons were done using 2-sample t tests, Wilcoxon ranksum tests, and chi-square tests. Statistical significance was defined as p < Results: In total, 532 patients met NCCN criteria for referral to genetic counseling, and 313 (59%) completed an appointment. One hundred twenty-seven (24%) were not referred to genetic counseling and 89 (17%) were The American Society of Breast Surgeons Official Proceedings
94 referred but did not complete an appointment. The vast majority of patients who saw a genetic counselor had genetic testing (92%), and 9.3% of those tested had pathologic mutations. Age was the only statistically significant difference in patients who were referred to genetic counseling, with the average age being 10 years younger than a nonreferred patient. Three hundred thirteen completed appointments, for a 77% appointment completion rate when referred. The 89 women referred to genetics who did not complete an appointment were surveyed: 14 stated they were too busy, 12 were not interested in testing, 8 had financial concerns, 4 did not know they were referred, 3 stated there was too much pre-appointment preparation, 3 stated that family history had become less worrisome once they obtained more information, 11 had other reasons, 21 patients were unable to be reached, and 2 patients were deceased. Conclusion: Multiple reasons were identified as barriers to genetic counseling in newly diagnosed breast cancer patients. The top reason was not being referred, and therefore provider education must be improved. To increase the rate of appointment completion, we should attempt to make appointments more convenient by coordinating them with other scheduled appointments. We should also provide information about cost and insurance coverage in the pre-appointment materials Triple-Negative Breast Cancer: Identifying an Unacceptable Time to Treatment Meghan Hansen 1, James Huth 1, Rachel Wooldridge 1, Monica DaSilva 1, Marilyn Leitch 1, Roshni Rao 1, Aeisha Rivers 1, Lynn Van Hooser 1, William Lodrigues 1 1 University of Texas Southwestern, Dallas, TX Objective: Acceptable interval times from diagnosis to treatment in cancer continue to be a source of controversy. Given the focus on quality outcomes within a background of healthcare network consolidation, acceptable time intervals need to be based on data rather than arbitrary administrative benchmarks. The aggressive behavior of triple-negative breast cancer (TNBC), which responds primarily to chemotherapy and has high rates of recurrence in a short time interval, allows for an assessment of the impact of a delay from diagnosis to treatment. This study evaluates the oncologic impact of increasing time intervals from diagnosis to treatment in TNBC. Methods: This study is a retrospective review of TNBC patients treated between January 2004 and August 2015 at an academic center. Data collected included demographics, pathologic factors, treatment, recurrence, and survival. Interval to initial treatment was defined as days from pathologic diagnosis to first local or systemic treatment. Statistical analysis included both a t test and Cox regression analyses to evaluate impact of time to treatment on overall survival and LRR. Variables, including stage, tumor size, age, race, and tumor proliferative rate, were also evaluated. Results: Median follow-up was 54 months for 301 TNBC patients. Mean interval to treatment was 46 +/ 2 days. Interval to treatment did not significantly impact overall survival (p = 0.22), although there was a trend toward worse survival with delays >90 days (p = 0.08). LRR was seen in 26 patients (9%). Median time to recurrence was 17.8 months, with time to treatment of 35 days seen in patients with an LRR, where a time to treatment of 47 days was seen in patients without a documented LRR. A shorter delay in time to treatment did not impact LRR. As expected, higher initial stage and tumor size impacted survival (p = <0.0001, P = ). There was no statistically significant difference observed with race, age, or tumor proliferative rates on either LRR or survival. There was a trend for higher LRR within patients less than 50 years of age (p = 0.1). Conclusion: With 4.5-year follow-up, a delay from time of pathologic diagnosis to time to initial treatment does not appear to adversely affect survival or LRR. This is consistent with our prior study revealing that a reasonable time from diagnosis to initial treatment is acceptable to allow for adequate workup and consultations to guide treatment decisions. The American Society of Breast Surgeons Official Proceedings
95 Margin Consensus Guideline Effect on Re-Excision Rates, Conversion to Mastectomy and Specimen Volumes Samantha Heidrich 1, Jack Rostas 2, Reiss Hollenbach 1, Robert Martin 1, Nicolas Ajkay 1 1 University of Louisville, Louisville, KY, Objective: The 2014 Society of Surgical Oncology American Society of Radiation Oncology consensus guideline on margins for breast conservation surgery defined no tumor on ink as an adequate margin for invasive carcinoma. Its purpose was to decrease unnecessary re-excisions and improve cosmetic outcomes. We sought to compare re-excision rates and specimen resection volumes before and after these guidelines were implemented at an academic institution. Methods: Data were gathered retrospectively from an IRB-approved, prospectively maintained database about patients with invasive carcinoma, stage I and II, who underwent partial mastectomy. Patients with DCIS only, diagnosed with excisional biopsy and receiving neoadjuvant chemotherapy, were excluded. The patients were split into 2 groups based on when they received treatment, before March 1, 2014 (pre-consensus [PC]) and after March 1, 2014 (post-consensus [PTC]), date of institutional guideline implementation. The groups were compared in a univariate analysis to investigate differences in re-excision rates, conversion to mastectomy, specimen volumes, use of selective resection margins, and selective resection margin volumes. Results: A total of 165 partial mastectomy patients were examined, with 124 in the PC group and 42 in the PTC group. The 2 groups were found to be different with regard to tumor grade and ER status (p = and 0.001, respectively). The PC group had a total of 40 (32%) patients return to the operating room, 27 having reexcisions and 11 were converted to mastectomy. Two patients had margin re-excisions followed by mastectomy conversion. In the PC group, 5 mastectomy and 12 partial mastectomy patients had no tumor on ink on initial evaluation. After release of the guidelines, the re-excision rates were significantly reduced to 1/42 (2.4%) (p < ), with no mastectomy conversions. The median resection volumes trended downward, 84.2 cm 3 and 55.9 cm 3 in the PC and PTC groups, respectively (p = 0.15). Selective margin resection was utilized more frequently in the PTC group (33/124 PC vs 24/41 PTC, p = ), but the PTC median selective margin resection volumes were significantly smaller (50 cm 3 vs 13.2 cm 3, p = 0.029). Patient Characteristics and Results Variable Pre-Consensus (n = 124) Post-Consensus (n = 42) p Value Median age, years (range) 60 (26-85) 60 (43-84) 0.48 Median tumor size, cm (range) 1.7 ( ) 1.4 ( ) 0.10 ER positive, n (%) 93 (75%) 41 (98%) PR positive, n (%) 83 (67%) 35 (85%) 0.07 Her-2 positive, n (%) 11 (10%) 2 (6%) 0.73 Tumor grade, n (%) Grade I 26 (22%) 17 (42%) Grade II 44 (37%) 16 (40%) Grade III 49 (41%) 7 (18%) Node positive, n (%) 32 (26%) 7 (17%) 0.29 Histologic type Invasive ductal, n (%) 98 (79%) 31 (77.5%) 0.68 Invasive lobular, n (%) 16 (13%) 4 (10%) Mixed, n (%) 4 (3%) 1 (2.5%) Other, n (%) 6 (5%) 4 (10%) The American Society of Breast Surgeons Official Proceedings
96 Re-excisions, n (%) 40 (32%) 1 (2%) < Partial mastectomies, n 27 1 Mastectomies, n 13 0 Operations with selective margin resection, n (%) Median selective margin volumes, cm3 (range) 33 (27%) 24 (57%) ( ) 13.2 ( ) Median total resection volume, cm 3 (range) 84.2 ( ) 55.9 ( ) 0.15 Conclusion: Institutional implementation of the 2014 margin guidelines resulted in a significant decrease in the number of re-excisions, conversions to mastectomy, and selective margin volume, and a trend toward smaller resection specimens. Smaller specimen and selective resection margin volumes may improve cosmetic outcomes SONIC-PBI A Novel Protocol to Complete Breast Cancer Surgery and Radiation Within 10 Days Tina Hieken 1, Robert Mutter 1, James Jakub 1, Judy Boughey 1, Amy Degnim 1, William Sukov 1, Stephanie Childs 1, Keith Furutani 1, Thomas Whitaker 1, Sean Park 1 1 Mayo Clinic, Rochester, MN Objective: Fifteen percent to 45% of patients do not receive the adjuvant radiotherapy recommended after breast-conserving cancer surgery. Whole- or partial-breast irradiation (PBI) typically is initiated 3 to 6 weeks after operation and administered over a 1- to 6-week period. We instituted a protocol for same-day operation and intraoperative catheter placement for PBI (SONIC-PBI). We hypothesized that with frozen-section assessment of margins and sentinel lymph nodes (SLN) all locoregional treatment could be completed within 10 days, with acceptable complication rates and cosmesis. Methods: Patients age 50 with clinical T1 ER+ SLN-negative invasive ductal cancer or pure DCIS were prospectively registered. Protocol treatment was operation and catheter placement, day 1; simulation and confirmation of final pathology, day 2; initiation of radiation, day 3. Cosmesis was assessed using photographs graded independently by 3 investigators with a 4-point validated scoring system in 51 patients with 6-month post-treatment photos. Results: From 10/2012 to 8/2015 we enrolled 123 patients; 110 (90%) underwent intraoperative placement of a strut-adjusted volume implant device (SAVI, Cianna Medical, Aliso Viejo, CA), while 13 did not, due to intraoperative pathology findings (6 SLN+, 7 extensive disease, 2 other). Eighty-two APBI patients (75%) were prescribed 34 Gy in 10 BID fractions/5 days, while 22 (20%) had 32 Gy/8 BID fractions/4 days, 5 (5%) had 21 Gy/3 QD fractions/3 days, and 1 received 8 Gy/2 fractions as a boost only (due to delayed +SLN). One hundred nine patients (99%) who had intraoperative catheter placement completed all locoregional therapy within 9 days. Patient, tumor features are summarized in the table. The 30-day complication rate was 7/110 (6%). The 1-year complication rate, evaluable in 81 patients, was 17% (14 patients): SSI in 5 (6%), symptomatic seroma in 5 (6%), other in 6 (7%) and correlated with device size (p = 0.05) but not tumor size or location. The ipsilateral breast local failure rate was 2%. Scored cosmesis was excellent in 27 (53%), good in 18 (35%), and fair in 6 (12%). The American Society of Breast Surgeons Official Proceedings
97 Variable Number (%) or Median (IQR) Age, mean, range, years 66, Presentation, abnormal mammogram 104/110 (95%) Pathologic tumor size, mm, mean, range (invasive) 11, Pathologic tumor size, mm, mean, range (DCIS) 9.4, 1 45 ER+ (DCIS) 20/21 (95%) ER+ (invasive cancers) 89/89 (100%) HER2+ (invasive cancers) 4/89 (4%) Ki67, median, IQR (invasive cancers) 9.1, Minimal tumor free margin, mm, median, IQR 5, 4 7 Number of margins re-excised intraoperatively PBI catheter size 6-1 mini /110 (53%) 30/110 (27%) 15/110 (14%) 7/110 (6%) 24 (22%) 66 (60%) 17 (15%) 3 (3%) Adjuvant hormonal therapy (ER+ patients) 70/109 (64%) Adjuvant chemotherapy 3/89 (3%) Conclusion: With the use of intraoperative frozen-section pathology, SONIC-PBI was successful in 99% of patients undergoing intraoperative brachytherapy catheter placement, substantially shortening locoregional treatment time. Our complication and recurrence rates were low, and cosmesis was good or excellent in most cases. This approach is efficient, allowing completion of definitive locoregional therapy within 9 days, and may enhance compliance with adjuvant radiotherapy. SONIC-PBI is an option for early-stage breast cancer in practices with low-margin positivity rates Radiographically Guided Shave Margins May Reduce Lumpectomy Re-Excision Rates: A Single-Surgeon Experience Priya Iyer 1, Alison Marko 2, Veeraj Jadeja 3, Debra Pratt 1 1 Cleveland Clinic, Cleveland, OH, 2 Northeast Ohio Medical University, Rootstown, OH, 3 Allergan, Elizabeth, NJ Objective: The principle of breast conservation balances adequate oncologic resection and ideal cosmesis. Strategies to minimize margin re-excision optimize patient care and health care costs. Using radiographic guidance allows for real-time re-evaluation of margins. We hypothesize that routinely using radiographically guided shave margins decreases re-excision rates. Methods: This is a single-surgeon, IRB-approved, HIPAA-compliant retrospective chart analysis of 182 patients who underwent breast conservation therapy from January 2013 to January In this timespan, a new technology was introduced to radiographically guided shave margins. The control group is thus defined as those who underwent traditional lumpectomy with selective shave margins. After performing the lumpectomy, orienting sutures were placed and the specimen radiographed. Based on proximity to each of 6 margins, additional shave margins were obtained. In addition, a new ultrasound probe, which allows directed intraoperative cavity sonography, was intermittently utilized in this timespan as well. Pathological factors and re-excision rates between the control arm and the radiographically guided (RG) arm were evaluated using chisquare analysis and Fischer exact test using SAS, JMP 1.1. The American Society of Breast Surgeons Official Proceedings
98 Results: Of the 182 patients studied, 93 patients were included in the control group and 89 in the RG arm. The re-excision rate was 18.3% in the control arm and 10% in the radiographically guided arm (p = 0.11). Pathology in the 182 cases included: 14.84% DCIS, 11.54% invasive mixed lobular-ductal, 8.79% invasive lobular, and 64.84% invasive ductal. Tumor type did not demonstrate statistical significance on re-excision rates (p = 0.22). Neoadjuvant chemotherapy was administered in 14.8% of cases with no statistically significant difference in re-excision rate (p = 0.24). A subset analysis was performed of the 89 patients in the RG arm to determine effect of intraoperative ultrasonography. In 29.21% no ultrasound was used, in 47.19% intracavitary ultrasound was used, and in 23.6% transcutaneous ultrasound was used. There is no statistically significant difference in re-excision rates (p = 0.38), however, the likelihood of type 1 error is high due to insufficient datapoints. In the subset of 64 patients in which no ultrasound was used, RG-shave margins were obtained in 40.63% of patients and selective shave margins in 59.38% with a resultant re-excision rate of 3.85% in the RG arm vs 21.05% in the traditional arm (p = 0.03). Conclusion: Radiographically guided shave margins best decrease re-excision rates in sonographically occult lesions. This new technique has the potential to not only reduce re-excision rates, but also decrease size of shave margins, and ultimately improve cosmetic outcomes while reducing health care costs. The American Society of Breast Surgeons Official Proceedings
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