Abstract Introduction: Neo adjuvant chemotherapy is increasingly being employed in breast cancer to reduce tumour size & down stage axilla. To reduce false negative rates in axillary lymph nodes after down staging with chemotherapy and to improve axillary conservation ultrasound guided clips were placed in involved axillary lymph nodes prior to commencement of NACT. The study aimed at whether preoperative lymph node clipping had any benefit in identification of lymph node after NACT.Methods: This is a single centre study of 55 patients (Mean age 53 years) with invasive breast cancer with biopsy proven involved lymph nodes (T1-3 N1) who underwent ultrasound guided axillary marker clip insertion before start of NACT. If Post chemotherapy imaging showed normal lymph nodes patients underwent SLNB with additional Lymph Nodes sampled to achieve a total of 4 lymph nodes. All sampled nodes were x rayed at the time of surgery to identify marker clip.Results: We had no procedure related complications with insertion of marker clip in any patients. The median number of nodes was 4.0. Average lymph nodes retrieved was 4.9. SLNB was identified in 47/55 patients (85.5%). Median number of sentinel nodes was 3.0 (Range 1-7) Marker was identified in 41/55 patients (74.5%) 30 (54.5%) patients had marker in sentinel node and 11 (20%) patients had marker in non-sentinel node. Histologically clip was reported in 21 (51.2%) patients. Overall pathological complete response (pCr) in axilla was seen 31/55 (56.45%). Tumours with Her2 over expression showed pCr in axilla 83% n=19/23 while triple negative tumours showed pCr in axilla 64% n=9/14. Er+ Her2- tumours showed low pCr rate 16.7% n=3/18. Completion axillary clearance was performed in 14/24 patients and 10/24 received radiotherapy to axilla.Conclusions: Clips in axillary lymph nodes are safe & relatively easy to deploy without any increased morbidity. Our clip identification rate (74.5%) co relates with other well-known publications (Caudel et al 80%, Z1071-76%). Our study findings validate that clip placement improves the identification of involved lymph nodes and hence improve the accuracy of limited axillary dissection in staging axilla. Citation Format: Mohammad Bilal Elahi, Raouef Ahmed Bichoo, Kartikae Grover, Eiman Khalifa, Naila Bint Ihsan, Peter J Kneeshaw, Brendan Paul Wooler, Dorin Dumitru, Ronjabati Roychaudhury, Ayesha Rahman, Tapan Kumar Mahapatra. Clipping of involved axillary lymph nodes before Neo adjuvant chemotherapy may improve in identification rates & staging of axilla in breast cancer [abstract]. In: Proceedings of the 2020 San Antonio Breast Cancer Virtual Symposium; 2020 Dec 8-11; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2021;81(4 Suppl):Abstract nr PS1-55.

Background Use of biological or synthetic mesh might improve outcomes of immediate implant-based breast reconstruction-breast reconstruction with implants or expanders at the time of mastectomy-but there is a lack of high-quality evidence to support the safety or effectiveness of the technique. We aimed to establish the short-term safety of immediate implant-based breast reconstruction performed with and without mesh, to inform the feasibility of undertaking a future randomised clinical trial comparing different breast reconstruction techniques. Methods In this prospective, multicentre cohort study, we consecutively recruited women aged 16 years or older who had any type of immediate implant-based breast reconstruction for malignancy or risk reduction, with any technique, at 81 participating breast and plastic surgical units in the UK. Data about patient demographics and operative, oncological, and complication details were collected before and after surgery. Outcomes of interest were implant loss (defined as unplanned removal of the expander or implant), infection requiring treatment with antibiotics or surgery, unplanned return to theatre, and unplanned re-admission to hospital for complications of reconstructive surgery, up to 3 months after reconstruction and assessed by clinical review or patient self-report. Follow-up is complete. The study is registered with the ISRCTN Registry, number ISRCTN37664281. Findings Between Feb 1, 2014, and June 30, 2016, 2108 patients had 2655 mastectomies with immediate implant-based breast reconstruction at 81 units across the UK. 1650 (78%) patients had planned single-stage reconstructions (including 12 patients who had a different technique per breast). 1376 (65%) patients had reconstruction with biological (1133 [54%]) or synthetic (243 [12%]) mesh, 181 (9%) had non-mesh submuscular or subfascial implants, 440 (21%) had dermal sling implants, 42 (2%) had pre-pectoral implants, and 79 (4%) had other or a combination of implants. 3-month outcome data were available for 2081 (99%) patients. Of these patients, 182 (9%, 95% CI 8-10) experienced implant loss, 372 (18%, 16-20) required re-admission to hospital, and 370 (18%, 16-20) required return to theatre for complications within 3 months of their initial surgery. 522 (25%, 95% CI 23-27) patients required treatment for an infection. The rates of all of these complications are higher than those in the National Quality Standards (< 5% for re-operation, re-admission, and implant loss, and < 10% for infection). Interpretation Complications after immediate implant-based breast reconstruction are higher than recommended by national standards. A randomised clinical trial is needed to establish the optimal approach to immediate implant-based breast reconstruction. Copyright (C) 2019 The Author(s). Published by Elsevier Ltd.

INTRODUCTION:The use of adjuvant radiotherapy is standard practice following breast conserving surgery and mastectomy in selected patients. Prospective clinical trials are currently being designed to assess the effect of omitting axillary lymph node clearance (ALNC) in selected patients. The aim of this study was to identify the percentage of patients understaged and not considered for postmastectomy radiotherapy (PMRT) and/or supraclavicular fossa radiotherapy (SCFRT) with positive sentinel lymph node (SLN) macrometastasis if the proposed prospective trial inclusion/exclusion protocols are followed.METHODS:A total of 38 women who were found negative for axillary metastases preoperatively but positive at SLN biopsy and who had ALNC were analysed. PMRT or SCFRT was offered to patients if ≥4 positive lymph nodes (including sentinel nodes) were positive for macrometastasis and/or a tumour size of ≥5cm was detected. Fisher's exact test was used to determine the statistical significance of omitting ALNC.RESULTS:The mean age of the 38 patients was 55 years. A fifth (21.1%) of patients had T1, 76.3% had T2 and 2.6% had T3 disease. The percentage of positive SLNs was 52.6% (1 node), 34.2% (2 nodes) and 13.1% (3 nodes). The number of positive nodes at clearance was 0-3. If the inclusion criteria for trials that consider omitting ALNC are followed (eg POSNOC trial), 23.7% of patients (p=0.0001) with ≥4 positive nodes (including SLNs) would not be offered SCFRT and PMRT. Similarly, if multicentric disease were to be excluded from the trial criteria, the proportion of undertreated patients would reduce by 15.7%.CONCLUSIONS:Our study has shown a significant risk of missing patients for PMRT or SCFRT if no ALNC is offered in the presence of SLN macrometastasis. Tumour multicentricity is an important factor in predicting high axillary nodal involvement. Consequently, exclusion of T2 tumours with multicentric involvement in trials considering omitting ALNC may be more appropriate.

Introduction: Mammography is performed in all symptomatic female breast referrals aged 40 years and over. If there is no palpable abnormality (P1) imaging is still performed which is effectively screening. Unlike the screening programme, there is no upper age limit for imaging these patients. The aim of this audit is to establish whether putting an upper limit of 75 years of age for patients with no clinical abnormality could have a detrimental effect on their care.

Introduction: Tamoxifen is an estrogen receptor modulator. IBIS study and European Institute of Oncology trials have shown a 2.3 fold increased risk of VTE in women treated with tamoxifen compared to placebo.

Introduction: Local recurrence in the mastectomy scar or chest wall occurs variably related to tumour and nodal factors. Routine histological analysis of all excised scars in patients who have had previous mastectomy has been a historical practice. Published reports have failed to provide any strong evidence in favour of such related practice.

Introduction: The NHSBSP target for re-operation rate after incomplete excision is 10% (NHSBSP and ABS at BASO). Reported figures vary between 9 - 40%. A UK national analysis reported re-excision rate of 19% (All Breast Cancer Report - NHS Screening). Intra-operative digital imaging of excised tissue can potentially improve surgical clearance.

Dynamic Contrast Enhanced Magnetic Resonance Imaging (DCE-MRI) is an effective diagnostic modality for symptomatic breast disease. However, its role in evaluating clinically occult disease associated with mammographically detected microcalcification remains unclear. Women recalled following screening mammography with microcalcification had DCE-MRI examination of the breast. The data were evaluated subjectively and objectively using both empirical and 2-compartment pharmacokinetic modelling techniques to evaluate signal intensity parameters. Eighty-eight patients aged 50-75 years (median 58) were recruited. Comparing malignant and benign lesions, the mean values in arbitrary units for the enhancement index at 1 min in the most enhancing 9-pixel square +/-1 standard deviation were 0.61+/-0.40 vs. 0.22+/-0.26 p=<0.001 with sensitivity, specificity, PPV, NPV and accuracy of 80.0%, 82.4%, 57.1%, 93.3% and 81.8%, respectively. The corresponding values attained by the radiologist were 75.0%, 89.7%, 68.2%, 92.4% and 86.4%. DCE-MRI is able to differentiate malignant from benign clinically occult lesions associated with microcalcification and may therefore offer an alternative to open surgical biopsy for women with equivocal findings following initial triple assessment for microcalcification in the breast.

Aims: The objectives of this study were to compare the efficacy of dynamic contrast-enhanced magnetic resonance imaging (DCE-MRI) in assessing the response of primary breast carcinoma to neoadjuvant chemotherapy compared to conventional imaging modalities, and to see how surgical outcome was influenced as a result of these findings.Methods: Thirty-four patients with locally advanced primary breast cancer underwent conventional imaging and DCE-MRI following six cycles of neoadjuvant chemotherapy prior to surgery. Changes in surgical management based on the post-chemotherapy DCE-MRI findings were recorded.Results: Prior to neoadjuvant chemotherapy, 22 of the 34 patients were assessed as requiring mastectomy and the remaining 12 were considered inoperable. Following chemotherapy two patients were still considered inoperable. In 11 of the 34 patients, the final decision to proceed to either mastectomy or non-surgical management was based primarily on pre-treatment disease status or patient choice. DCE-MRI findings, therefore, contributed to the operative decision in 21 of 34 patients. Two of these 21 patients were spared surgery as DCE-MRI demonstrated complete response to chemotherapy and one declined surgery. The remaining 18 were able to undergo wide local. excision, with only two patients subsequently requiring mastectomy for involved margins.Conclusions: DCE-MRI is able to accurately predict those patients suitable for breast conserving surgery following neoadjuvant chemotherapy and should be the imaging modality of choice in assessing the response of patients with primary breast carcinoma to neoadjuvant chemotherapy. (C) 2005 Elsevier Ltd. All rights reserved.

Sir, The recent review article by Kneeshaw et al (2003) in the British Journal of Cancer regarding advances made in breast imaging by magnetic resonance is very encouraging and its expedited entry into routine clinical practice should be supported. This is not only due to its anticipated enhanced sensitivity and usefulness, but potentially also for its safety, particularly as may apply to radiation hypersensitivities such as female carriers of ataxia telangiectasia (AT). Ataxia telangiectasia is a genetic cancer predisposition syndrome involving the overexpression of alpha-fetoprotein, immunosuppression of the host, advanced ageing, and a radiation hypersensitivity where AT homozygotes generally succumb to infection or to lymphoma before reaching adulthood (reviewed in Becker-Catania and Gatti, 2001). Female AT heterozygotes are at an increased risk of breast cancer, but this is usually detected after the age of 40 years (Swift et al, 1991; Swift, 2001,). The issue of safety of ionising radiation used for breast cancer screening has been previously raised for AT heterozygotes (Swift et al, 1991). About 1% of the population carries the genetic marker for AT, and 8–10% of all breast cancers appear to be AT heterozygotes (reviewed in Swift, 2001). This indicates the use of nonionising modes of breast imaging could make a significant impact on the incidence of breast cancers. However, other evidence suggests these potential benefits might also be extended into the general female population. A number of years ago while investigating the molecular biology of the AT radiation hypersensitivity, it was discovered that radioresistant DNA synthesis (RDS), the molecular signature of the radiation hypersensitivity of AT, could be modulated (Mirzayans et al, 1995; Mirzayans and Paterson, 2001). When c-myc and alpha-fetoprotein became implicated in the RDS phenotype (Laderoute, unpublished findings), oestrogen was tested for its ability to induce RDS in cells derived from normal individuals. As shown in Figure 1, RDS was induced by estradiol (E2) but not progesterone in a dose-responsive fashion in lymphoblastoid cell lines (LCLs) derived from normal individuals (panel A). The induction was specific to oestrogen as it was blocked in the presence of an excess of tamoxifen (panel C), an oestrogen antagonist (Laderoute, 1998). Furthermore, additional experiments showed the RDS assay could be geared to easily detect low dose ionising radiation exposures around 1 rad or less in radiation hypersensitive cells such as those from AT individuals or AT heterozygotes (Laderoute, 1998). These results raised the possibility that breast imaging techniques using low-dose ionising radiation may induce breast cancers or cause existing breast tumours to progress, if the circulating levels of oestrogen are elevated in women at the time of mammography exposure. This phenomenon might help explain the reduced benefits in the under 50 years age-at-entry group reported in mammogram clinical trials (Miller et al, 1992, 2002), the increased incidence of breast cancer with mammogram screening among 45- to 64- year olds not accountable by earlier detection (White et al, 1990), and the lack of impact of mammography screening for reducing breast-cancer mortality overall (Gotzsche and Olsen, 2000). Figure 1 Estrogen specifically induces RDS in cells from normal individuals. Radioresistant DNA synthesis (RDS) measures the relative failure of cells from AT individuals to inhibit DNA synthesis at 1 h following ionising radiation exposures when compared ... It remains to be seen if the incidence of breast cancer returns to the premammogram screening rates of the 1960 s and 1970 s, as ionising radiation-based breast imaging technologies are replaced by MR imaging and as women decline hormone replacement therapies. One might also expect survival to again correlate inversely with tumour size, which is why early breast cancer imaging methods were introduced in the first place.

The purpose of this work is to assess the additional benefit of MRI-based morphology and quantification of contrast enhancement in the differential diagnosis of sub-1cm breast lesions. Forty-three women with suspected breast cancer were examined using X-ray mammography, ultrasound mammography, and MRI. Dynamic contrast imaging was performed and relative enhancement at various time-points was calculated. The dynamic data was also processed using a two-compartment pharmacokinetic model. Radiological interpretation of high-resolution post-contrast images revealed a similar accuracy (69%) compared to X-ray mammography (69%) and ultrasound mammography (67%). The best individual parameter calculated from the dynamic images was found to be the exchange rate constant which revealed a diagnostic accuracy of 0.74±0.08. When information from the post-contrast images and dynamic data was combined in a logistic regression model a diagnostic accuracy of 0.92±0.03 was achieved. In conclusion, MR imaging of small breast lesions is feasible and the incorporation of quantitative MR derived parameters is beneficial.

Gynaecomastia is the commonest benign breast condition seen in men. It is well recognised that certain drugs that alter the normal sex hormonal profile in the body can induce gynaecomastia. Recently, an increasing use of androgenic-anabolic steroids among young men especially body-builders has increased the incidence of gynaecomastia. We report a case of a young weight-trainer who developed gynaecomastia due to oral intake of a herbal tablet which he used as a steroid alternative for body-building.

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