07.16 Outpatient vs. Inpatient Mastectomy: An Analysis of Patient Factors in U.S. Women with Breast Cancer

Posted on January 25, 2017

J. Yu1, M. Rendulic2, M. A. Olsen2, A. E. Cyr1, J. A. Margenthaler1  1Washington University,Surgery,St. Louis, MO, USA 2Washington University,Medicine,St. Louis, MO, USA

Introduction:
Despite advances in surgical technique and perioperative care, most women who undergo mastectomy for breast cancer are still commonly admitted as inpatients for pain control, perceived patient satisfaction, and closer monitoring for possible complications.  However, even one night of inpatient admission represents a substantial cost burden to the patient and has not been shown to reduce the odds of 30-day postoperative complications.  It is unclear which patients might be most suitable for same-day or outpatient mastectomy.  We sought to assess patient factors in relation to the utilization of outpatient vs. inpatient mastectomy in U.S. women with breast cancer.

Methods:
Using the Healthcare Cost and Utilization Project State Ambulatory Surgery and Services Databases and State Inpatient Databases for California and Florida from 2006-2011, we analyzed clinical and demographic factors in women over age 18 undergoing unilateral mastectomy for invasive breast cancer, breast cancer in situ, or history of breast cancer.  Clinical data assessment was performed using ICD-9 and CPT codes and the Elixhauser comorbidity index.  Descriptive statistics were performed to analyze the relationship between patient factors and admission status after mastectomy.

Results:
Of 71,619 women who underwent unilateral mastectomy, 23,503 (33%) were treated as an outpatient and 48,116 (67%) were admitted as inpatients postoperatively.  Significant geographic and temporal differences were clear: patients in Florida (9,440; 38%) were much more likely to have outpatient procedures compared to patients in California (14,063; 30%), and fewer outpatient mastectomy procedures were performed in 2010-2011 (6,350; 31%) compared to 2006-2009 (17,153; 33%).  Outpatients were more likely to undergo simple mastectomy (OR 1.61 [95% CI 1.56-1.66]) and less likely to undergo modified radical mastectomy (OR 0.65 [95% CI 0.63-0.67]) or to have simultaneous implant or expander reconstruction (OR 0.77 [95% CI 0.75-0.81]).  Women undergoing mastectomy as outpatients were also more likely to be younger (≤50 years), have private insurance, be Caucasian, and have fewer comorbidities (p<0.05). 

Conclusion:
The utilization of outpatient mastectomy varies widely based on clinical and geographic factors.  Patients with private insurance, fewer comorbidities, and limited disease who do not undergo immediate reconstruction are more likely to undergo mastectomy without inpatient admission.  Assessment of short- and long-term patient outcomes may provide additional evidence to support outpatient mastectomy as a patient-centered and cost-effective approach for certain breast cancer patients.
 

07.06 Directed Shave Margins in Breast-Conserving Surgery: Accuracy of Intraoperative Surgeon Assessment

Posted on January 25, 2017

J. Yu1, J. Yu1, L. C. Elmore1, A. E. Cyr1, J. A. Margenthaler1  1Washington University,Surgery,St. Louis, MO, USA

Introduction:
During breast-conserving surgery (BCS), additional cavity shave margins may be excised after removal of the primary specimen at the discretion of the surgeon to reduce rates of positive margins. We sought to evaluate the concordance of directed shave margins with disease on pathology and to assess the accuracy of surgeon judgment. 

Methods:
Utilizing a prospectively-maintained institutional database, we reviewed all women undergoing re-excision following breast-conserving surgery for invasive breast cancer or ductal carcinoma in situ (DCIS) from 2010-2013.  We then identified all patients who had directed shave margins taken due to clinical or radiographic suspicion during the index procedure.  Surgeon judgment was considered concordant when the shave margin that was taken corresponded to a positive or close margin on the primary tumor specimen. Positive margins were defined as invasive disease or DCIS touching the edge of the specimen, and close margins were defined as disease within 2 mm of the edge. Descriptive statistics were used in data analysis.

Results:
Of the 384 women undergoing re-excision, 99 patients had additional shave margins taken during their index procedures.  18 (18.2%) patients had invasive carcinoma alone, 27 (27.3%) had DCIS alone, and 54 (54.5%) had both. Of 191 total shave margins, an average of 1.9±0.9 shave margins were taken per patient, and the mean shave margin volume was 10.43 cm3.  Ninety-six (50.3%) shave margins were positive for invasive disease or DCIS. However, only 74 (38.7%) shave margins were taken when the corresponding primary tumor margin was positive or close. There was no difference in concordance when the shave was taken for clinical or radiographic suspicion (38.2% vs. 36.6%, p>0.05). Forty-six (24%) shave margins were positive for disease when the corresponding primary tumor margin was negative. On re-excision histology, 66 (66.7%) patients had no disease, 25 (25.2%) had DCIS, 7 (7.1%) had invasive disease and one had both (1.0%). 

Conclusion:
Surgeons are limited in their ability to accurately assess margin status intraoperatively which leads to imprecise use of directed shave margins. Implementation of routine shave margins or alternative margin assessment methods may be more likely to reduce the rates of positive margins following BCS, and further research is necessary to define the best standard of practice. 

06.07 The Prognostic Significance of Adrenocortical Carcinomas Identified Incidentally

Posted on January 25, 2017

K. K. Rossfeld1, N. Saunders2, T. Tran13, Q. Duh9, J. Mansour8, S. Maithel2, C. Solorzano10, T. Wang4, J. Glenn4, E. Levine11, S. Weber6, A. Salem6, R. Fields5, G. Poultsides13, T. Pawlik1, J. Phay1, L. A. Shirley1  1Ohio State University,Department Of Surgery,Columbus, OH, USA 2Emory University School Of Medicine,Department Of Surgery,Atlanta, GA, USA 3Johns Hopkins University School Of Medicine,Department Of Surgery,Baltimore, MD, USA 4Medical College Of Wisconsin,Department Of Surgery,Milwaukee, WI, USA 5Washington University,Department Of Surgery,St. Louis, MO, USA 6University Of Wisconsin,Department Of Surgery,Madison, WI, USA 7University Of California – San Diego,Department Of Surgery,San Diego, CA, USA 8University Of Texas Southwestern Medical Center,Department Of Surgery,Dallas, TX, USA 9University Of California – San Francisco,Department Of Surgery,San Francisco, CA, USA 10Vanderbilt University Medical Center,Department Of Surgery,Nashville, TN, USA 11Wake Forest University School Of Medicine,Department Of Surgery,Winston-Salem, NC, USA 12New York University School Of Medicine,Department Of Surgery,New York, NY, USA 13Stanford University,Department Of Surgery,Palo Alto, CA, USA

Introduction:
Adrenal tumors, including adrenocortical carcinomas (ACC), are often identified incidentally on imaging, being diagnosed as an “incidentaloma”.   Little is known regarding the difference in prognosis among patients who have an incidental ACC versus those patients with ACC who present with signs or symptoms.

Methods:
Patients who underwent resection of ACC at one of 13 institutions between January 1993 and December 2014 were identified.  ACC tumors were categorized as incidentalomas versus symptomatic adrenal tumors.  Patients without data fields needed for the current study were excluded.  Data on patient age, gender, race, body mass index (BMI), tumor size, tumor weight, presence of metastases, and margin status were collected and analyzed according to incidental versus non-incidental ACC category.  Clinical variables were analyzed using Chi-square, Fisher Exact, or independent T-test as appropriate.  Kaplan-Meier curves for overall (OS) and recurrence-free survival (RFS) were analyzed using log-rank testing.  Cox regression was utilized to analyze potential differences in OS and RFS among relevant clinical variables.

Results:
Among 232 evaluable patients with ACC, 100 (43.1%) were diagnosed with an incidental ACC while 132 (56.9%) patients presented with symptoms/signs.  Clinical and pathological features including age, gender, race, BMI, nodal status, tumor size, tumor weight, and surgical margin status were all comparable among incidental versus non-incidental ACC patients (all p>0.05). However, patients with incidentalomas were more likely to have a T1/T2 tumor (55.8% vs. 33.9%, p<0.01) and were less likely to have metastatic disease at presentation (13.1 % vs. 23.6%, p=0.031).  Patients with an incidental ACC had a better median RFS (29.4 months) compared with patients with a non-incidental ACC (12.5 months, p=0.020).  The improved RFS among patients with incidental ACC tumors persisted when RFS was stratified by the presence of metastasis (p=0.034), but not by T stage (p= 0.29).  Among patients who initially presented with an incidentaloma, those who had tumors that were later noted to be hormonally active on further work-up had a shorter RFS compared with patients with non-functional tumors (8.8 vs. 47.9 months, p=0.002). 

Conclusion:
Patients with resected ACC who had tumors that were identified incidentally had an improved RFS compared with patients who presented with symptoms or signs.  This difference in RFS was likely related to a lower T-stage on presentation.  Patients with incidentalomas that were hormonally active had a shorter RFS than those with non-functional incidentalomas, highlighting potential prognostic importance of evaluating hormonal secretion in asymptomatic patients.
 

04.20 Effects of CD47mAb Treatment on VEGF Signaling in the Huh-7 Hepatocellular Carcinoma Cell Line

Posted on January 25, 2017

D. Chirumbole1, M. Xu1, X. Wang1, G. A. Upadhya1, Y. Lin1, W. C. Chapman1  1Washington University,Transplant Section, General Surgery,St. Louis, MO, USA

Introduction:
Hepatocellular carcinoma (HCC) is the most common primary liver malignancy, and studies suggest that CD47mAb immunotherapy could be an effective therapeutic option. CD47 ligation has also been shown to inhibit vascular endothelial growth factor (VEGF) signaling in various cell types. However, few studies have considered the effects of CD47mAb treatment on VEGF signaling and tumor progression in HCC. The purpose of this study is to investigate the effects of CD47mAb treatment on VEGF signaling in the Huh-7 HCC cell line.  

Methods:
The Huh-7 HCC cell line was treated with Control IgG, CD47mAb1 (VX1000R), or CD47mAb2 (VX1004R) at a concentration of 10 µg/mL for 24 hours. Cells were then collected for study. ELISA, qRT-PCR, Western blot, and immunofluorescent staining analyses were performed to investigate the expression of VEGFs, VEGFRs, epidermal growth factor receptor (EGFR), and downstream markers related to cell growth and proliferation at the mRNA or protein level. 

Results:
VEGFR-1 and -2 expression was significantly reduced in VX1004R-treated cells compared to control in terms of relative density to β-actin (VEGFR-1: 0.181±0.105 vs. 0.618±0.064, p=0.004; VEGFR-2: 0.127±0.071 vs. 0.259±0.038, p=0.048). Phosphorylated ERK1/2 and total p38 MAPK were also significantly reduced after VX1004R treatment (phospho-ERK1/2: 0.582±0.020 vs. 0.736±0.088, p=0.042; p38 MAPK: 0.857±0.077 vs. 1.120±0.014, p=0.004), as was the expression of proliferating cell nuclear antigen (PCNA) (0.457±0.044 vs. 0.546±0.003, p=0.047). On the other hand, there was no significant change in phosphorylated p38 MAPK expression after treatment. VX1000R-treated cells showed a trend toward decreased expression of most markers, but there were no significant differences at p<0.05. Expression of vegf-a mRNA was significantly reduced in both CD47mAb-treated groups (VX1004R: fold change=0.593±0.061, p=0.002; VX1000R: fold change=0.775±0.046, p=0.010). Expression of vegf-b mRNA was reduced in VX1004R-treated cells only (fold change=0.693±0.083, p=0.010). There was a non-significant trend toward decreased EGFR expression in both CD47mAb-treated groups. 

Conclusion:
The results of this study suggest that CD47mAb treatment may inhibit VEGF signaling, downstream kinase activation, and cell proliferation in the Huh-7 cell line and therefore could inhibit tumor progression. VX1004R appears to be a more effective treatment than VX1000R. Further study is needed to investigate the effects of CD47mAb treatment on VEGF signaling in other HCC cell lines and in an in vivo system.   
 

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