Node-negative Invasive Breast Research Articles

Preoperative Dynamic Contrast-Enhanced and Diffusion-Weighted Breast Magnetic Resonance Imaging Findings for Prediction of Lymphovascular Invasion of the Lesions in Node-Negative Invasive Breast Cancer.

Purpose: Our single-centre retrospective study aimed to investigate the relationship between preoperative dynamic contrast-enhanced magnetic resonance imaging (DCE-MRI) findings and apparent diffusion coefficient (ADC) values and lymphovascular invasion (LVI) status of the lesions in patients with clinically-radiologically lymph node-negative invasive breast cancer. Methods: A total of 250 breast lesions diagnosed in preoperative magnetic resonance imaging were identified. All patients were divided into 2 subgroups: LVI-negative and LVI-positive according to the pathological findings of surgical specimens. The 2 groups' DCE-MRI findings, ADC values, and histopathological results of lesions were compared. Results: LVI was detected in 100 of 250 lesions. Younger age than 45 years and larger lesion size than 20 mm were found to be associated with the presence of LVI (P < .001). High histological and nuclear grade (P = .001), HER2-enriched molecular subtype (P = .001), and Ki-67 positivity (P = .016) were significantly associated with LVI. The LVI positivity rate was significantly higher in the lesions with medium-rapid initial phase kinetic curve and washout delayed phase kinetic curve (P = .001). The presence of LVI was significantly associated with the presence of peritumoural edema, sentinel lymph node metastasis, adjacent vessel sign, and increased whole breast vascularity (P < .001). When diffusion-weighted imaging findings were evaluated, it was determined that tumoural ADC values lower than 1068 × 10-6 mm2/second (P = .002) and peritumoural-tumoural ADC ratios higher than 1.5 (P = .001) statistically increased the probability of LVI. Conclusion: The patient's age, various histopathological and DCE-MRI findings, tumoural ADC value, and peritumoural-tumoural ADC ratio may be useful in the preoperative prediction of LVI status in breast cancer lesions.

Abstract P1-01-06: Predictor of sentinel node positivity in screen-detected invasive breast cancer

Abstract Introduction: Sentinel lymph node biopsy represents the standard of care for staging axilla in breast cancer patients who are clinically node negative. ACOSOG Z11 trial results questioned the importance of low burden nodal disease. Results from the SOUND trial on omission of axillary surgery in selected patients with early stage breast cancer are still awaited. Breast screening programs aim to detect cancers at an early stage and are expected to have low burden of nodal disease. The aim of our study was to determine predictors of sentinel node biopsy positivity in invasive breast cancers detected on screening mammography. Methods: This retrospective study included patients with node negative invasive breast cancer detected on screening mammogram performed between April 2018 and March 2020 and subsequently underwent curative surgery including sentinel node biopsy at breast care unit of Castle Hill Hospital, Cottingham, U.K. We looked at patient’s clinical, radiological and pre-operative pathological features and correlated them with histological results of sentinel node biopsy. Statistical analysis of the data was performed using SPSS version 22 and p-value of 0.05 was considered significant. Results: We identified 304 patients who met inclusion criteria. The mean age of these patients was 62.71 ± 7.2 years (range 47-78 years). Majority (88%) of women were postmenopausal. Overall, the sentinel node positivity rate was 11.76%. Women over the age of 55 years were less likely to be node positive compared to younger women (9.9% vs 22%, p=0.016). Tumours less than 10mm in size had node positive rate of 5.5% compared to tumour larger than 21mm (25%, p = 0.000). In comparison to grade 2and grade 3 tumours, grade 1 tumours had lower node positivity rate, (5% vs 14.4%) but the difference did not reach statistical significance (p= 0.073). All women with tubular and mucinous histological subtypes (n=13) were node negative. All women with grade 1 tumours less than 10mm in size (n=48) had a negative sentinel node biopsy compared to women with grade 2 tumors more than 20mm (9/32=28% positivity rate) and p-value of 0.000. There was no association between oestrogen, progesterone and HER2 receptor status with sentinel lymph node positivity rate. Conclusion: In selected screen detected patients including those above the age of 55 years, having grade 1 cancer, and less than 10 mm size on pre-treatment imaging, there might be scope for omission of axillary surgery. Citation Format: Raouef Ahmed Bichoo, Mohammed Bilal Elahi, Dorin Dumitru, Naila Bint Ihsan, Eiman Khalifa, Masuma Sarker, Tapan K Mahapatra, Brendan Paul Wooler, Peter Kneeshaw, Kartikae Grover. Predictor of sentinel node positivity in screen-detected invasive breast cancer [abstract]. In: Proceedings of the 2021 San Antonio Breast Cancer Symposium; 2021 Dec 7-10; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2022;82(4 Suppl):Abstract nr P1-01-06.

Comparative survival analysis of multiparametric tests\u2014when molecular tests disagree\u2014A TEAM Pathology study

Multiparametric assays for risk stratification are widely used in the management of both node negative and node positive hormone receptor positive invasive breast cancer. Recent data from multiple sources suggests that different tests may provide different risk estimates at the individual patient level. The TEAM pathology study consists of 3284 postmenopausal ER+ve breast cancers treated with endocrine therapy Using genes comprising the following multi-parametric tests OncotypeDx®, Prosigna™ and MammaPrint® signatures were trained to recapitulate true assay results. Patients were then classified into risk groups and survival assessed. Whilst likelihood χ2 ratios suggested limited value for combining tests, Kaplan–Meier and LogRank tests within risk groups suggested combinations of tests provided statistically significant stratification of potential clinical value. Paradoxically whilst Prosigna-trained results stratified Oncotype-trained subgroups across low and intermediate risk categories, only intermediate risk Prosigna-trained cases were further stratified by Oncotype-trained results. Both Oncotype-trained and Prosigna-trained results further stratified MammaPrint-trained low risk cases, and MammaPrint-trained results also stratified Oncotype-trained low and intermediate risk groups but not Prosigna-trained results. Comparisons between existing multiparametric tests are challenging, and evidence on discordance between tests in risk stratification presents further dilemmas. Detailed analysis of the TEAM pathology study suggests a complex inter-relationship between test results in the same patient cohorts which requires careful evaluation regarding test utility. Further prognostic improvement appears both desirable and achievable.

Determinants for non-sentinel node metastases in primary invasive breast cancer: a population-based cohort study of 602 consecutive patients with sentinel node metastases

BackgroundSentinel node biopsy (SNB) is the standard procedure for axillary staging in patients with clinically lymph node negative invasive breast cancer. Completion axillary lymph node dissection (c-ALND) may not be necessary for all patients as a significant number of patients have no further metastases in non-sentinel nodes (non-SN) and c-ALND may not improve survival. The first aim of our study is to identify clinicopathological determinants associated with non-SN metastases. The second aim is to determine the impact of the number of sentinel node (SN) with macro-metastases and the type of SN metastases on metastatic involvement in non-SN.MethodsThis is a retrospective study of 602 patients with primary invasive breast cancer operated on with SNB and c-ALND in Lund and Malmö during 2008–2013. All these patients had micro- and/or macro-metastases in SNs. Information was retrieved from the national Information Network for Cancer Care (INCA). The risk of metastases to non-SNs were analyzed in relation to clinicopathological determinants such as age, screening mammography, tumour size, tumour type, histological grade, estrogen status, progesterone status, HER2 status, multifocality and lymphovascular invasion. Additionally, we compared the association between the number of the SN and the type of metastases in SN with the risk of metastases to non-SNs. Binary logistic regression was used, yielding odds ratios (OR) with 95% confidence intervals (CI).ResultsWe found that 211 patients (35%) had metastases in non-SNs and 391 patients (65%) had no metastases in non-SNs. Lobular type (18%) of breast cancer (1.73; 1.0 1-2.97) and multifocal (31.3%) tumours (2.20; 1.41–3.44) had a high risk of non-SNs metastases. As compared to only micro-metastases, the presence of macro-metastases in SNs was associated with a high risk of metastases to non-SNs (4.91; 3.01–8.05). The number of SN with macro-metastases, regardless of the number of SNs removed by surgery, increases the risk of finding non-SNs with metastases. The total number of SN removed by surgery had no impact on diagnosis of metastases in non-SNs. No statistically significant associations were observed regarding other studied determinants.ConclusionWe conclude in the present study that lobular cancer and multifocal tumours were associated with a high risk of non-SN involvement. The presence of the macro-metastases in SNs and the number of SN with macro-metastases has a positive association with presence of metastases in non-SNs. The total number of SNs removed by surgery had no impact on finding metastases in non-SNs. These factors may be valuable considering whether or not to omit c-ALND.

Convolutional Neural Network Using a Breast MRI Tumor Dataset Can Predict Oncotype Dx Recurrence Score.

Oncotype Dx is a validated genetic analysis that provides a recurrence score (RS) to quantitatively predict outcomes in patients who meet the criteria of estrogen receptor positive / human epidermal growth factor receptor-2 negative (ER+/HER2-)/node negative invasive breast carcinoma. Although effective, the test is invasive and expensive, which has motivated this investigation to determine the potential role of radiomics. We hypothesized that convolutional neural network (CNN) can be used to predict Oncotype Dx RS using an MRI dataset. Institutional Review Board (IRB)-approved retrospective study from January 2010 to June 2016. In all, 134 patients with ER+/HER2- invasive ductal carcinoma who underwent both breast MRI and Oncotype Dx RS evaluation. Patients were classified into three groups: low risk (group 1, RS <18), intermediate risk (group 2, RS 18-30), and high risk (group 3, RS >30). 1.5T and 3.0T. Breast MRI, T1 postcontrast. Each breast tumor underwent 3D segmentation. In all, 1649 volumetric slices in 134 tumors (mean 12.3 slices/tumor) were evaluated. A CNN consisted of four convolutional layers and max-pooling layers. Dropout at 50% was applied to the second to last fully connected layer to prevent overfitting. Three-class prediction (group 1 vs. group 2 vs. group 3) and two-class prediction (group 1 vs. group 2/3) models were performed. A 5-fold crossvalidation test was performed using 80% training and 20% testing. Diagnostic accuracy, sensitivity, specificity, and receiver operating characteristic (ROC) area under the curve (AUC) were evaluated. The CNN achieved an overall accuracy of 81% (95% confidence interval [CI] ± 4%) in three-class prediction with specificity 90% (95% CI ± 5%), sensitivity 60% (95% CI ± 6%), and the area under the ROC curve was 0.92 (SD, 0.01). The CNN achieved an overall accuracy of 84% (95% CI ± 5%) in two-class prediction with specificity 81% (95% CI ± 4%), sensitivity 87% (95% CI ± 5%), and the area under the ROC curve was 0.92 (SD, 0.01). It is feasible for current deep CNN architecture to be trained to predict Oncotype DX RS. 4 Technical Efficacy: Stage 2 J. Magn. Reson. Imaging 2019;49:518-524.

Is there a role for 21-gene recurrence score in mucinous carcinoma of breast?

e12538Background: 21-gene recurrence score (RS) is widely used in hormone-receptor positive, lymph node negative invasive breast cancer to guide treatment. Many have expanded its use to patients wi...

Abstract P1-06-02: Comparative survival analysis of multiparametric tests in the TEAM pathology study: What to do when molecular tests disagree?

Abstract Multiparametric assays for risk are increasingly used in the management of node-negative and node-positive hormone receptor-positive invasive breast cancer. Data from multiple sources suggests different tests may provide different risk estimates at the individual patient level1. Analysis from the TEAM pathology study (Bayani and Yao et al npjBreast Cancer, 2017) allows direct comparison of prognostic information from gene signatures in a clinical trial cohort of postmenopausal patients. Risk classifications using genes comprising the following multi-parametric tests: OncotypeDx® (Genomic Health Inc.)2,3, Prosigna™(NanoString Technologies, Inc.)4-6, Mammaprint® (Agendia Inc.)7,8 were performed. For the OncotypeDX-Like Recurrence Score (RS), RNA abundance was processed to fit the measurement range as described2,3, with classification into high, intermediate or low risk groups based the derived RS and modeled for DRFS. For the Prosigna-Like Risk of Recurrence Score (ROR), samples were processed as previously outlined9, then modelled against DRFS. For the MammaPrint-Like Risk Score, samples were processed by published methods8 and modelled for DRFS. Comparing OncotypeDx-Like with Prosigna-Like showed that 45% of cases were classified identically by both (3.3% low risk, 20.9% intermediate, 20.7% high). Of 3370 cases, 353 (10.5%) had scores differing by more than 1 classification (i.e. hi/low or low/high). Almost all (343) of these were cases classified high risk by OncotypeDX-Like RS/low risk by Prosigna-Like ROR (Table 1). Univariate Cox regression analysis, using low/low cases as a reference (relative risk of distant metastasis =1.0), suggested that cases called low risk by Prosigna-Like ROR/High risk by OncotypeDx-Like RS did not perform differently from cases called low risk by both tests (Table 2). However, all cases called intermediate by one test and high risk by another appeared to be high risk (Table 2). Comparisons between Prosigna-Like ROR and MammaPrint-Like scores showed similar concordance between low/low and high/high (52.5% of cases with concordant results). In Prosigna-Like ROR intermediate risk cases, MammaPrint-Like results divided cases between low and high risk, as predicted. Comparisons between these tests is challenging, and evidence on their discordance in risk stratification presents further dilemmas. Preliminary analysis of TEAM suggests a complex inter-relationship between test results in the same patient cohorts requiring careful evaluation. Table 1OncotypeDX-Like RSLowInt.HighTotalLow1126163431071Prosigna-Like RORInt.1677046151486High10106697813Total289142616553370 Table 2OncotypeDX-Like RSLowInt.HighLowRef1.26 (0.57-2.79)1.13 (0.49-2.62)Prosigna-Like RORInt.1.2 (0.47-3.05)2.22 (1.03-4.78)4.27 (2.01-9.08)High6.10 (1.58-23.6)4.15 (1.79-9.59)4.92 (2.32-10.42) Citation Format: Bartlett JMS, Bayani J, Kornaga E, Piper T, Mallon E, Yao CQ, Boutros PC, Hasenburg A, Kieback DG, Markopoulos C, Dirix L, Seynaeve C, Can de Velde CJH, Rea DW. Comparative survival analysis of multiparametric tests in the TEAM pathology study: What to do when molecular tests disagree? [abstract]. In: Proceedings of the 2017 San Antonio Breast Cancer Symposium; 2017 Dec 5-9; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2018;78(4 Suppl):Abstract nr P1-06-02.

Racial Differences in 21-Gene Recurrence Scores Among Patients With Hormone Receptor-Positive, Node-Negative Breast Cancer.

Purpose The 21-gene recurrence score (RS) breast cancer assay is clinically used to quantify risk of 10-year distant recurrence by category (low, < 18; intermediate, 18 to 30; high, ≥ 31) for treatment management among women diagnosed with hormone receptor-positive, human epidermal growth factor receptor 2-negative, lymph node-negative breast cancer. Although non-Hispanic black (NHB) women have worse prognosis compared with non-Hispanic white (NHW) women, the equivalency of 21-gene RS across racial groups remains unknown. Patients and Methods Using the Metropolitan Detroit Cancer Surveillance System, we identified women who were diagnosed with hormone receptor-positive, human epidermal growth factor receptor 2-negative, lymph node-negative invasive breast cancer between 2010 and 2014. Multinomial logistic regression was used to quantify racial differences in 21-gene RS category. Results We identified 2,216 women (1,824 NHW and 392 NHB) with invasive breast cancer who met clinical guidelines for and underwent 21-gene RS testing. The mean RS was significantly higher in NHBs compared with NHWs (19.3 v 17.0, respectively; P = .0003), where NHBs were more likely to present with high-risk tumors compared with NHWs (14.8% v 8.3%, respectively; P = .0004). These differences were limited to patients younger than 65 years at diagnosis, among whom NHBs had significantly higher RS compared with NHWs (20 to 49 years: 23.6 v 17.3, respectively; P < .001 and 50 to 64 years: 19.6 v 17.4, respectively; P = .023). NHBs remained more likely to have high-risk tumors compared with NHWs after adjusting for age, clinical stage, tumor grade, and histology (odds ratio [OR], 1.75; 95% CI, 1.18 to 2.59). Conclusion NHBs who met clinical criteria for 21-gene RS testing had tumors with higher estimated risks of distant recurrence compared with NHWs. Further study is needed to elucidate whether differences in recurrence are observed for these women, which would have clinical implications for 21-gene RS calibration and treatment recommendations in NHB patients.

Survival of Node-negative Breast Cancer Patients Treated at the University Medical Centre Maribor in the Period 2000-2009.

IntroductionBreast cancer is increasingly diagnosed in the early stages without regional nodal involvement. The aim of the present study was to determine the 5-year overall (OS) and breast cancer specific survival (BCSS) for patients with node-negative breast cancer treated at the University Medical Centre Maribor, and compare it with survival at the national level.MethodsMedical records were searched for information on patients with lymph node-negative invasive breast cancer who received primary treatment at the University Medical Centre Maribor in the period 2000–2009. Information on all Slovenian node-negative breast cancer patients diagnosed in the same period was obtained from the Cancer Registry of Republic of Slovenia. Time trends in survival were assessed by comparing the periods 2000–2004 and 2005–2009.ResultsThe 5-year OS and BCSS of patients treated in Maribor in the period 2000–2009 were 92.3% (95% CI, 90.5%– 94.1%) and 96.4% (95% CI, 95.2%–97.6%), respectively, and did not differ from the corresponding OS and BCSS for Slovenian patients. Although the improvement in OS for patients from Maribor diagnosed in the period 2005–2009 compared to 2000–2004 did not reach statistical significance (HR 0.73; 95% CI, 0.51–1.05; p=0.086), BCSS significantly improved over the same time periods (HR 0.53; 95% CI, 0.30–0.94; p=0.028).ConclusionsSurvival of node-negative breast cancer patients treated at the University Medical Centre Maribor is comparable to survival of corresponding patients at the national level. The rising number of long-term breast cancer survivors places additional importance on survivorship care.

Can We Skip Intraoperative Evaluation of Sentinel Lymph Nodes? Nomogram Predicting Involvement of Three or More Axillary Lymph Nodes before Breast Cancer Surgery.

PurposeThe American College of Surgeons Oncology Group Z0011 trial reported that complete dissection of axillary lymph nodes (ALNs) may not be warranted in women with clinical T1-T2 tumors and one or two involved ALNs who were undergoing lumpectomy plus radiation followed by systemic therapy. The present study was conducted to identify preoperative imaging predictors of ≥ 3 ALNs.Materials and MethodsThe training set consisted of 1,917 patients with clinical T1-T2 and node negative invasive breast cancer. Factors associated with ≥ 3 involved ALNs were evaluated by logistic regression analysis. The validation set consisted of 378 independent patients. The nomogram was applied prospectively to 512 patients who met the Z0011 criteria.ResultsOf the 1,917 patients, 204 (10.6%) had ≥ 3 positive nodes. Multivariate analysis showed that involvement of ≥ 3 nodes was significantly associated with ultrasonographic and chest computed tomography findings of suspicious ALNs (p < 0.001 each). These two imaging criteria, plus patient age, were used to develop a nomogram calculating the probability of involvement of ≥ 3 ALNs. The areas under the receiver operating characteristic curve of the nomogram were 0.852 (95% confidence interval [CI], 0.820 to 0.883) for the training set and 0.896 (95% CI, 0.836 to 0.957) for the validation set. Prospective application of the nomogram showed that 60 of 512 patients (11.7%) had scores above the cut-off. Application of the nomogram reduced operation time and cost, with a very low re-operation rate (1.6%).ConclusionPatients likely to have ≥ 3 positive ALNs could be identified by preoperative imaging. The nomogram was helpful in selective intraoperative examination of sentinel lymph nodes.

Total tumor load assessed by one-step nucleic acid amplification assay as an intraoperative predictor for non-sentinel lymph node metastasis in breast cancer

BackgroundThis study aimed to determine the relationship between CK19 mRNA copy number in sentinel lymph nodes (SLN) assessed by one-step nucleic acid amplification (OSNA) technique, and non-sentinel lymph nodes (NSLN) metastization in invasive breast cancer. A model using total tumor load (TTL) obtained by OSNA technique was also constructed to evaluate its predictability. MethodsWe conducted an observational retrospective study including 598 patients with clinically T1-T3 and node negative invasive breast cancer. Of the 88 patients with positive SLN, 58 patients fulfill the inclusion criteria. ResultsIn the analyzed group 25.86% had at least one positive NSLN in axillary lymph node dissection. Univariate analysis showed that tumor size, TTL and number of SLN macrometastases were predictive factors for NSLN metastases. In multivariate analysis just the TTL was predictive for positive NSLN (OR 2.67; 95% CI 1.06–6.70; P = 0.036). The ROC curve for the model using TTL alone was obtained and an AUC of 0.805 (95% CI 0.69–0.92) was achieved. For TTL >1.9 × 105 copies/μL we got 73.3% sensitivity, 74.4% specificity and 88.9% negative predictive value to predict NSLN metastases. ConclusionWhen using OSNA technique to evaluate SLN, NSLN metastases can be predicted intraoperatively. This prediction tool could help in decision for axillary lymph node dissection.

Survival after Breast-Conserving Surgery with Whole Breast or Partial Breast Irradiation in Women with Early Stage Breast Cancer: A SEER Data-base Analysis.

Randomized clinical trials have demonstrated equivalency in survival outcomes for early stage breast cancer patients treated with either mastectomy or breast-conserving surgery (BCS) with radiation. Recent, state-level data confirm comparable survival outcomes. Using Surveillance Epidemiology and End Research (SEER) data, we sought to evaluate survival outcomes among patients with early stage breast cancer treated with mastectomy, BCS with whole breast irradiation (BCS + WBI), or BCS with accelerated partial breast irradiation (BCS + APBI). Data on women 50 years or older diagnosed with a node negative invasive breast cancer (≤3 cm in size) between 1995 and 2009 were extracted from the SEER data base. Women treated with mastectomy alone or BCS with radiation were eligible for analysis. Kaplan-Meier estimates and Cox proportional hazard models were used to compare overall survival (OS) and cancer-specific survival (CSS) among the treatment groups. 150,171 women fulfilled inclusion criteria. OS was significantly improved among women treated with BCS and WBI or BCS and APBI compared to mastectomy alone. Adjusted hazard ratios for death in BCS with WBI or APBI (versus mastectomy alone) were 0.73 (95% CI: 0.71, 0.76) and 0.68 (95% CI: 0.58, 0.79), respectively. Adjusted CSS was also significantly improved in patients treated with BCS and WBI (HR 0.80, 95% CI: 0.76, 0.85) as compared to mastectomy. BCS with radiation (WBI or APBI) was associated with significantly improved OS and CSS, versus mastectomy alone. These results support the use of BCS with WBI or APBI (in well selected patients) for the treatment of breast cancer.

Prognostic Role of HER2 Status and Adjuvant Trastuzumab Treatment in Lymph Node-Negative Breast Cancer Patients - a Retrospective Single Center Analysis

Background: The natural course of traditionally prognostically unfavorable human epidermal growth factor receptor 2 (HER2)-positive breast cancer has been changed by anti-HER2 therapy. It is not clear whether the prognosis for HER2-positive patients treated with adjuvant trastuzumab differs from that of HER2-negative patients. Methods: We performed a retrospective study including patients with lymph node-negative invasive breast cancer treated at our institution in the period 2000-2009. Disease-free (DFS) and overall survival (OS) were calculated using the Kaplan-Meier method. The Cox proportional hazards model was applied to control for other clinically important variables. Results: Median follow-up was 90-109 months. The 5-year DFS rates for HER2-negative patients, HER2-positive patients without adjuvant trastuzumab and trastuzumab-treated HER2-positive patients were 88.1% (95% confidence interval (CI) 85.6-90.6%), 73.1% (95% CI 64.3-81.9%) and 90.7% (95% CI 83.1-98.3%), respectively. No significant difference in DFS was observed between trastuzumab-treated HER2-positive patients and HER2-negative patients in multivariate analysis (hazard ratio 1.15; 95% CI 0.53-2.46; p = 0.728). There were no differences in OS among the 3 groups. Conclusion: Based on our results, the negative prognostic effect of HER2 positivity seen before targeted anti-HER2 treatment has completely disappeared in the era of routine trastuzumab administration in the adjuvant setting.

Sentinel Lymph Nodes for Breast Carcinoma: A Paradigm Shift.

-Sentinel lymph node biopsy has been established as the new standard of care for axillary staging in most patients with invasive breast carcinoma. Historically, all patients with a positive sentinel lymph node biopsy result underwent axillary lymph node dissection. Recent trials show that axillary lymph node dissection can be safely omitted in women with clinically node negative, T1 or T2 invasive breast cancer treated with breast-conserving surgery and whole-breast radiotherapy. This change in practice also has implications on the pathologic examination and reporting of sentinel lymph nodes. -To review recent clinical and pathologic studies of sentinel lymph nodes and explore how these findings influence the pathologic evaluation of sentinel lymph nodes. -Sources were published articles from peer-reviewed journals in PubMed (US National Library of Medicine) and published guidelines from the American Joint Committee on Cancer, the Union for International Cancer Control, the American Society of Clinical Oncology, and the National Comprehensive Cancer Network. -The main goal of sentinel lymph node examination should be to detect all macrometastases (>2 mm). Grossly sectioning sentinel lymph nodes at 2-mm intervals and evaluation of one hematoxylin-eosin-stained section from each block is the preferred method of pathologic evaluation. Axillary lymph node dissection can be safely omitted in clinically node-negative patients with negative sentinel lymph nodes, as well as in a selected group of patients with limited sentinel lymph node involvement. The pathologic features of the primary carcinoma and its sentinel lymph node metastases contribute to estimate the extent of non-sentinel lymph node involvement. This information is important to decide on further axillary treatment.

Abstract P5-15-01: Breast cancer specific survival in 38,568 patients with node negative hormone receptor positive invasive breast cancer and oncotype DX recurrence score results in the SEER database

Abstract Introduction: The SEER Program of the National Cancer Institute (NCI) is an authoritative source of cancer incidence and survival statistics, collecting population-based data for ∼28 percent of the US. As innovations in molecular testing are validated and recommended in guidelines, new genomic research models are needed to characterize their use and impact on patient outcomes in clinical practice. To that end, Genomic Health and SEER have collaborated to electronically supplement the SEER registries with Oncotype DX results. This first report characterizes breast cancer specific survival (BCSS) in node (N)- hormone receptor (HR)+ HER2- invasive breast cancer. Methods: The prospectively-defined population-biomarker-outcomes linkage had objectives, analysis cohort, standardized biomarker, and outcome defined prior to data linkage. Patients were eligible if N-, HR+, HER2- (by RT-PCR), had no prior malignancy, were 40-85 years of age, and were diagnosed between Jan 2004 (Oncotype DX available in Jan 2004) and Dec 2011 (SEER survival analysis complete through 2012). BCSS was defined as previously described and assessed rigorously (Howlader et al, JNCI 2010). Oncotype DX Recurrence Score results were provided to SEER as mandated by their registry operations. Analysis by treatment was interpreted in the context of the lack of randomization and well known limitations of registry reporting of chemotherapy (CT) treatment (Noone et al, Medical Care 2014). Results: Among 169,158 eligible patients, 38,568 (23%) had a Recurrence Score (RS), increasing from 2% of 2004 diagnoses to 35% of 2011 diagnoses. Patients with RS had median age of 57 yr, were 99.4% female, 84% white, 29% grade 1 and 54% grade 2, 25% 1cm or less and 53% between 1 and 2cm. Median follow-up was 39 mo with 8,239 patients having &amp;gt;5 yrs follow-up. Among low risk RS &amp;lt;18 (N=21,023), intermediate risk RS 18-30 (N=14,494) and high risk RS ≥31 (N=3,051) patients, chemotherapy use was reported in 7%, 34%, and 69%, respectively. 5-year BCSS (with 95%CI) are provided in Table. Continuous RS was significantly associated with BCSS unadjusted (p&amp;lt;0.001), and after adjusting for age, grade, and tumor size (p&amp;lt;0.001), and when stratified by treatment (p&amp;lt;0.001). Conclusions: 5 yr BCSS outcomes are excellent (99.6%) in the over 21,000 patients with low RS disease. As expected, high RS disease is associated with lower 5 yr survival despite addition of chemotherapy. More rigorous ascertainment of treatment is planned to draw conclusions regarding chemotherapy treatment benefit. Analyses that examine test utilization as well as annual survival updates to obtain longer term event rates will be important to gain additional insights into patient subgroup outcomes that can be characterized by large population-based genomic studies. RS&amp;lt;18RS 18-30RS≥31 NBCSS (95%CI)NBCSS (95%CI)NBCSS (95%CI)Analysis all pts2102399.6 (99.4-99.7)1449498.6 (98.3-98.9)305195.6 (94.4-96.6)Analysis by CT reported No/Unknown CT1955499.6 (99.5-99.7)957098.6 (98.2-98.9)93694.0 (91.1-96.0)Yes CT146999.3 (98.4-99.7)492498.6 (98.0-99.0)211596.4 (95.0-97.4) Citation Format: Shak S, Petkov VI, Miller DP, Howlader N, Gliner N, Howe W, Schussler N, Cronin K, Baehner FL, Penberthy L. Breast cancer specific survival in 38,568 patients with node negative hormone receptor positive invasive breast cancer and oncotype DX recurrence score results in the SEER database. [abstract]. In: Proceedings of the Thirty-Eighth Annual CTRC-AACR San Antonio Breast Cancer Symposium: 2015 Dec 8-12; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2016;76(4 Suppl):Abstract nr P5-15-01.

Abstract P3-07-18: Utilization and impact of oncotype DX 21- gene breast cancer assay in clinical practice across the US: 2010-2012 National cancer data base analysis

Abstract Oncotype DX (OD), initially used for early stage estrogen receptor-positive (ER+), node-negative (LN-) invasive breast cancers (BC) and later also for ER+ and 1-3 LN+BC, provides a low, intermediate or high 10-year risk recurrence score (LRS, IRS or HRS) for BC. Based on the score, the addition of adjuvant chemotherapy (AC) to endocrine therapy is recommended for HRS; no benefit for LRS, and unclear benefits for IRS. The test has been in use since 2004. Payment for OD was approved by the Centers for Medicare&amp;Medicaid Services in 2006. Patient selection for OD use remains unclear, and data on utilization and impact of the assay in clinical practice across the US are lacking. The utilization and impact of OD across the US is presented in a retrospective observational study of National Cancer Data Base (NCDB) patients (represents 75% of the US population) from 2010-2012. This time period encompasses the beginning of required recording of molecular assays and the latest data released by NCDB in 4/2015. Demographic and clinical variables of all patients that had OD results were analyzed using frequency statistics, chi-square and logistic regression analysis. 513080 patients had BC; 406525 were ER+. 86409 patients with known OD results were analyzed (23.7% of ER+). Patients age range from 19-90 (mean 58.8, median 59 years); 99.1% were females. Demographic and clinicopathologic characteristics of OD tested patientsCharacteristicsOD 86409=100%Age 18-403429=4%41-6455313=64%65-90+27667=32%Race White75749=87.7%Black6616=7.7%Other4044=4.6%Comorbidities 073901=85.5%110643=12.3%≥21865=2.2%Median Income Quartiles 2008-2012Missing 634=0.7%$&amp;lt;3800010430=12.1%$38000-4799917346=20.1%$48000-6299923273=26.9%$&amp;gt;6300034726=40.2%US geographic location CT MA ME NH RI VT5404=6.3%NJ NY PA15781=18.3%DC DE FL GA MD NC SC VA WV18984=22%IL IN MI OH WI16542=19.1%AL KY MS TN4704=5.4%IA KS MN MO ND NE SD7256=8.4%AR LA OK TX4342=5%AZ CO ID MT NM NV UT WY4757=5.5%AK CA HI OR WA8639=10%Urban vs ruralMissing 2264=2.6%Urban79642=92.2%Rural4503=5.2%ERMissing 190=0.2%ER+85018=98.4%ER-1181=1.4%ER borderline20=0.0002%Cancer stageUnknown 626=0.7%I58614=67.8%II25907=30%III1134=1.3%IV128=0.2%Tumor size (mm)Missing 723=0.8%1-52825=3.3%6-1017997=20.8%11-5063509=73.5%51-9001355=1.6%LN+Missing 2147=2.4%070165=81.2%110322=12%2-33113=3.6%4-39662=0.8%Histologic gradeUnknown 4178=4.8%G123142=26.8%G244451=51.4%G3&amp;G414638=17% 57.9% of tests followed National Comprehensive Network (NCCN)-defined intermediate risk guidelines (ER+/LN- tumors &amp;gt;1cm), while 15.5% of tests included N1 disease and 25.7% included T1a, T1b and T3 tumors. LRS had 90.1% negative predictive value (NPV) for no AC administration. IRS had 47.4% positive predictive value (PPV) and HRS had 88.9% PPV for AC administration. OD score and chemotherapy administration ChemotherapyChemotherapyTotalOD scoreNoYes LRS42600=90.1%4014=9.9%46614IRS12740=52.6%11520=47.4%7591HRS840=11.1%6751=88.9%78465 The OD is obtained in almost ¼ of ER+BC patients across the US. Its application across geographic and racial groups is fair. Factors influencing patient selection for OD test and AC administration upon obtaining IRS results require further study. Citation Format: Orucevic A, Heidel RE, Bell JL. Utilization and impact of oncotype DX 21- gene breast cancer assay in clinical practice across the US: 2010-2012 National cancer data base analysis. [abstract]. In: Proceedings of the Thirty-Eighth Annual CTRC-AACR San Antonio Breast Cancer Symposium: 2015 Dec 8-12; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2016;76(4 Suppl):Abstract nr P3-07-18.

Indocyanine green fluorescence mapping for sentinel lymph node biopsy in early breast cancer

IntroductionA recent feasibility study (ICG-10) has confirmed high sensitivity of ICG fluorescence mapping for sentinel SLN detection in early breast cancer with 95% of nodes both blue and fluorescent. This follow-on study has specifically evaluated a combination of ICG and blue dye for SLN localization. MethodsFifty consecutive patients (49 female; 1 male) with unilateral clinically node negative invasive (37) and non-invasive (13) breast cancer underwent SLN biopsy with blue dye and ICG. Median patient age was 48 years and median invasive tumour size 19 mm for primary surgical patients. All patients had a normal pre-operative axillary ultrasound. Nodal and procedural detection rates were calculated for ICG alone and in combination with blue dye. ResultsA total of 87 nodes were retrieved with an average nodal count of 1.8 per patient (range 1–4). Eighty four nodes were blue and fluorescent and 3 fluorescent only. Nodal detection rates for ICG alone and combined with blue dye were 100% (87/87) and 96% (84/87) respectively. Metastases were present in 18 nodes (all blue and fluorescent) with 10 patients node positive overall (20%). The procedural detection rate for blue dye and ICG was 96% (48/50) and 2 patients had fluorescent only nodes which were deemed sentinel (4%). ConclusionFluorescent imaging with ICG is a sensitive, valuable and safe method for SLN biopsy. A combination of blue dye and ICG is useful dual approach when radioisotope is unavailable. ICG has the potential to be a sole tracer agent with improved patient convenience and costs.

Abstract P3-04-11: Thyroid hormone up-regulates estrogenic and pro-carcinogenic signaling, inducing a basaloid and more motile phenotype in only steroid receptor positive breast cancer cells

Abstract Background: Co-morbidity of thyroid disease and breast cancer has been recognized for over a century. Up to two-thirds of women with breast cancer have clinical or occult thyroid disease, as compared to one fifth of unaffected females. Thyroid disease typically proceeds breast cancer by at least a decade, and many (nearly half) are on long term thyroid hormone supplementation at the time of diagnosis. The exogenous administration of thyroid hormone, for hypothyroidism or status post thyroidectomy for neoplasia, has been associated with an increased risk of breast cancer and in some studies, a worse prognosis. Causality, however, has been controversial. Results: We studied over 800 consecutive node negative invasive breast cancer patients diagnosed between 1976 and 1993 from a single institution. Of these, 92% were chemo-naive and only 14% received tamoxifen, reducing interactions with treatment for the study design. We showed untoward significant interactions with both univariate and multivariate analyses, between thyroid hormone supplementation, disease free and disease specific survival only in patients with steroid receptor positive tumors. These interactions were strongest in pre-menopausal, as compared to post-menopausal patients. We thus hypothesized that thyroid hormone (TH), either indirectly or directly, promoted carcinogenesis via the steroid receptors (SR) for estrogen and/or progesterone and have interrogated mechanisms of these interactions in vitro. Estrogen (E2) induce significant cellular proliferation, whereas TH alone (at concentrations of T4 1 x 10-6:T3 at 2.5 x 10-7 M) induced only mild cell proliferation in SR+ (MCF-7 andT47D), but not SR- breast cancer cell lines (MDA-MB-468 and SKBR3). In contrast, TH induced significant proliferation in SR + cells at significantly lower doses (down to T4 1 x 10-12: T3 2.5 x 10-13 M) if administered with low dose estrogen (E2: 1 x 10 -10). These mitogenic effects were demonstrated by MTS and DNA quantification assays, as well as flow cytometry, which revealed the induction of G2/M arrest and an increase in the percentage of cells in S phase with TH alone (at higher doses) or TH + E2 (at lower doses). Tamoxifen partially mitigated the pro-growth effects of TH + E2, whereas ICI 182,780 completely abrogated these effects. Using Western blots we have shown that that TH (with or without E2) upregulated ERa expression and activation, Cyclin A, B,D1, and E, E2F1, MAPK/ERK1/2 but not AKT signaling. TH +/- E2 also promoted clonogenicity, motility, a more basal phenotype (CD24+/CD44+) and mammosphere formation in cells grown under non-adherent conditions. Conclusions: We have demonstrated in Stage I breast cancer patients with minimal systemic treatment, that the administration of TH was associated with a significantly shortened disease free and disease specific survival, only in patients whose tumors expressed SR. TH administered to SR+ cell lines, particularly when co-administered with E2 at therapeutic/physiologic doses, upregulates and activates ER, cell proliferation, a more aggressive and motile basaloid phenotype. Citation Format: Ann D Thor, Zeying Fan, Reema Wahdan-Alaswad, Susan M Edgerton. Thyroid hormone up-regulates estrogenic and pro-carcinogenic signaling, inducing a basaloid and more motile phenotype in only steroid receptor positive breast cancer cells [abstract]. In: Proceedings of the Thirty-Seventh Annual CTRC-AACR San Antonio Breast Cancer Symposium: 2014 Dec 9-13; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2015;75(9 Suppl):Abstract nr P3-04-11.

The prognostic relevance of the mitotic activity index in axillary lymph node-negative breast cancer.

The aim of the present study is to look at the mitotic activity index (MAI) as a prognostic factor in a prospective population-based cohort of lymph node-negative invasive breast cancer patients. Analyses were based on 2,048 breast-conserving therapies in 1,971 patients, node-negative, and without any form of adjuvant systemic therapy with long-term follow-up. The 15-year distant metastases-free survival (DMFS) for women ≤55 years was 88.3 % for low MAI values (≤12) versus 73.4 % for high MAI values (>12); (HR 2.8; 95 % CI 1.8-4.4; p < 0.001). Multivariate analyses for DMFS showed significance for MAI. For MAI and Bloom-Richardson grading, by performing a likelihood ratio test, we showed the statistical significance for both. For women >55-years, the MAI was not an independent significant factor. We also confirmed the above findings for disease-specific survival. When multi-gene assays are not available, the MAI remains a robust prognostic marker in women younger than 55 years of age with early node-negative breast cancer.

Abstract 4372: MiR-449a promotes breast cancer progression by activating the NF-κB pathway

Abstract INTRODUCTION MicroRNAs (miRs) have been implicated in various human malignancies and are being developed as diagnostic, predictive, and prognostic biomarkers. Our previous global profiling studies found miR-449a to be over-expressed in archival lymph node-negative invasive ductal breast carcinoma samples (n=74) when compared to normal tissues. Furthermore, miR-449a expression level was significantly associated with relapse. The mechanism(s) by which miR-449a functions remains unknown, and the aim of the current study was therefore to elucidate the roles and mRNA targets of miR-449a in breast cancer. MATERIAL AND METHODS MiR-449a expression was evaluated in six human breast cancer cell lines (T47D, MDA-MB-468, MDA-MB-231, MCF-7, MDA-MB-453, and ZR75-1). Three of these cell lines, T47D, MMDA-MB-468, and MDA-MB-231, were selected and used to assess the biological effects of miR-449a on cell viability, clonogenicity, cell migration, and invasion. Downstream target genes were identified by combining in silico miRWalk prediction and cell line/patient sample microarray data. Targets were validated using qRT-PCR and luciferase reporter assays. RESULTS Consistent with our global profiling work, several (4/6) of the tested breast cancer cell lines over-expressed miR-449a. CDC20B, the miR-449a host gene and an essential regulator of cell division, was also over-expressed. Knockdown of miR-449a resulted in significantly decreased cell viability, clonogenic survival, migration, and invasion. MiR-449a candidate targets were then identified by integrating in silico prediction algorithms, cell line mRNA expression profiling (Affymetrix Human Genome U133 Plus 2.0), and clinical specimen mRNA expression data. Two genes, CRIP2 (Cysteine rich protein 2, a transcription factor) and PRKAG1 (Protein Kinase, AMP-Activated, Gamma 1 Non-Catalytic), were verified as miR-449a targets using qRT-PCR. Moreover, direct interactions between miR-449a and the 3′-UTRs of both CRIP2 and PRKAG1 were confirmed using luciferase reporter assays. Inhibition of CRIP2 by miR-449a allowed for NF-κB-induced transcription of survival, proliferation, and growth-related genes, providing further evidence for the role of miR-449a in breast cancer progression. CONCLUSIONS MiR-449a is over-expressed in breast cancer cells, promoting cellular proliferation, migration, and invasion. One mechanism by which miR-449a functions is to down-regulate CRIP2, leading to NF-kB activation and possible cancer progression. Further investigations into gene regulation by miR-449a may reveal other promising targets for the management of breast cancer. Citation Format: Wei Shi, Matthew Lee, Ryunosuke Kogo, Jeff Bruce, Christine How, Kenneth W. Yip, Fei-Fei Liu. MiR-449a promotes breast cancer progression by activating the NF-κB pathway. [abstract]. In: Proceedings of the 105th Annual Meeting of the American Association for Cancer Research; 2014 Apr 5-9; San Diego, CA. Philadelphia (PA): AACR; Cancer Res 2014;74(19 Suppl):Abstract nr 4372. doi:10.1158/1538-7445.AM2014-4372