Level II Oncoplastic Surgery Cadaveric Workshop

8-9 October 2014MERF AND HOLY SPIRIT NORTHSIDE PRIVATE HOSPITAL, BRISBANE, AUSTRALIA.

H O S T E D I N PA R T N E R S H I P B Y

AND

Australasian Breast Congress9-11 October 2014SURFERS PARADISE MARRIOTT RESORT, GOLD COAST

AustralasianSociety forBreast Disease

HANDBOOK AND ABSTRACTS

CONTENTS

SECTION I

Welcome 5

OrganisingCommittee 5

Sponsors 6

TradeExhibitors 6

UsefulInformation 6

SocialProgram 7

KeynoteSpeakers 8

LocalFaculty 11

Presenters–ProfferedPapers 15

ScientificProgram 19

SECTION II

Abstracts 24

Section1Handbook

SURFERS PARADISE MARRIOT RESORT - FLOOR PLAN

PLENARY SESSIONS(ELSTON ROOM)

WELCOMEOn behalf of Australasian Society for Breast Diseaseand BreastSurgANZ, we warmly welcome you to theAustralasianBreastCongress.

The Congress will have an emphasis on the role ofloco-regionaltherapyinprovidingoptimalbreastcancertreatment. The program includes two communicationworkshops and an income maximisation workshop,with session topics covering areas such as oncoplasticsurgery, immediate breast reconstruction, partialradiotherapy, axilla management and neoadjuvanttreatment. The noted international speakers and localexpertfacultywilltogetherprovideplentyofinterestandwhilsttheslantislargelysurgical,theCongresswillbeofgreatvaluetoalldisciplines.

The Level II Oncoplastic Surgery Cadaveric WorkshopwillbeheldattheHolySpiritNorthsidePrivateHospitalEducation Centre and Medical Engineering ResearchFacility (MERF) in Brisbane. Miss Anne Tansley andMr Richard Sutton from the UK will run the workshopassistedbylocalfaculty.

OursincerethanksgotooursponsorsJohnson&JohnsonMedical,DeviceTechnologies,Allergan,RocheProducts,AstraZeneca Oncology, Medical Specialties Australia,Specialised Therapeutics, Bongiorno National NetworkandtheNationalBreastCancerFoundation.Wealsothankall thetradeexhibitorsfortheirsupport. ItwouldnotbepossibletoholdthisCongresswithoutthissupport.Thus,itisisimportantforyoualltotaketimetomeetwiththerepresentativesoftheparticipatingcompanies.

To help us in our future planning, we would greatlyappreciate it if you took the time to complete the briefquestionnaire provided in your satchel and drop it intotheboxplacedintheCongressOffice.

Wehopeyouwillenjoytheprogramaswellasthesocialinteractionwithyourcolleagues.

Yourssincerely

Daniel de Viana Andrew SpillanePresident PresidentAustralasianSocietyfor BreastSurgANZBreastDisease

ORGANISING COMMITTEEDrDavidLittlejohn DrChristopherPykeDrDanieldeViana MrDavidWaltersDrYvonneZissiadis MsSoleiGibbs

ABOUT THE AUSTRALASIAN SOCIETY FOR BREAST DISEASETheAustralasianSocietyforBreastDiseasewasconstitutedin 1997. Its primary goal is to promote multidisciplinaryunderstanding and practice in the prevention, detection,diagnosisandmanagementofbreastdiseaseandresearchintothisareaofmedicine.TheSociety’sExecutiveprovidesforbroadmultidisciplinaryrepresentation.

The Society thanks current members for their supportand involvement and welcomes new members from alldisciplines involved intheareaofbreastdisease.Youcandownloadamembershipapplicationformfromourwebsite:www.asbd.org.auorcontacttheSecretariat.

CONTACT DETAILSAustralasian Society for Breast DiseasePOBox1124,CoorparooDCQld4151T: +61738471946F:+61738477563E:info@asbd.org.auW:www.asbd.org.au

ABOUT BREASTSURGANZBreast Surgeons of Australia and New ZealandIncorporated (BreastSurgANZ) is the primary group ofsurgeons treating patients with breast disease, benignand malignant, in Australia and New Zealand. The careprovided by our members is totally patient centred. TheSociety is committed to improving patient care throughteaching,research,andthedevelopmentofevidence-basedstrategies.Individualmembers’surgicalperformanceandoutcomes is continuously monitored through assessmentviatheBreastSurgANZQualityAudit(formerlytheNationalBreastCancerAudit.)

CONTACT DETAILSBreastSurgANZPOBox1207RandwickNSW2031E:media@breastsurganz.comE:members@breastsurganz.comE:partners@breastsurganz.comW:www.breastsurganz.com

SECTION 1 I P5

SPONSORSThankyoutoallthesponsorsandexhbitorsfortheirsupport.

TRADE ExHIBITIONBooth no. Company

1 AstraZenecaOncology

2 GEHealthcare

3 SpecialisedTherapeutics

4 CookMedical

5 AuroraBioscience

6 Sonologic

7&8 MedicalSpecialtiesAustralia

9&10 Roche

11 ZEISSAustralia

12&13 DeviceTechnologies

14&15 Johnson&JohnsonMedical

16 FujifilmSonoSite

17 Allergan

18 BongiornoNationalNetwork

19 MatrixSurgical

20 Bard

21 Covidien

22 NovartisOncology

23 Medtronic

24 Mammagard

25 Riancorp

USEFUL INFORMATION

VENUESurfers Paradise Marriott Resort & Spa158FernyAvenueSurfersParadiseQld4217AustraliaT:+61755929800F:+61755929888

CONGRESS OFFICETheCongressOfficewillbeopenduringthefollowingtimes:

Thursday9October2014 08:00-19:00hoursFriday10October2014 07:30-17:30hoursSaturday11October2014 07:30-15:00hours

SPEAKERS’ AUDIOVISUAL TESTING ROOMSpeakers’ Audiovisual Testing will be available in Terraceroom2duringthefollowingtimes:

Thursday9October2014 15:00-18:30hoursFriday10October2014 08:00-16:00hoursSaturday11October2014 08:00-13:00hours

NAMEBADGESPlease wear your namebadge at all times. It is youradmission pass to sessions and morning and afternoonteas. If you misplace your namebadge, please contact theCongressOffice.

TICKETSAttendance at workshops and social functions is by ticketonly.Ticketsareenclosedinyourregistrationenvelopewithyour namebadge, according to your attendance indicationon the registration form. If you misplace any tickets or donothaveticketstotheactivitiesyouwishtoattend,pleasecontacttheCongressOffice.

SPECIAL DIETSIf youhavemadeaspecialdietary request,please identifyyourselftoservingstaffatfunctions.

MESSAGESAmessageboardislocatedneartheCongressoffice.PleaseadvisepotentialcallerstocontactSurfersParadieMarriottResort(seedetailsabove)andaskfortheAustralasianBreastCongress Office. Please check the board for messages aspersonaldeliveryofmessagescannotbeguaranteed.

DRESSSmartcasualattireisappropriateforCongressandworkshopsessions.Ajacketmaybeneededforairconditionedmeetingrooms. Dress for Congress dinner is cocktail (with somesparkle!).

SOCIAL PROGRAM

LUNCHESLunches will be served in the Garden Terrace Room andTradeExhibitionarea.Lunchserviceisbyticketonly.Pleaseensureyouhavethecorrecttickets.Additionalticketsareavailableat$45perperson.

WELCOME RECEPTIONThursday 9 October 2014, 18:00 - 19:30 hoursMeetyourfellowdelegatesfordrinksbytheMarriottpool.Includedforfulltimedelegatesandregisteredpartners.Additionalticketscost$60perperson.

NETWORKING DRINKSFriday 10 October 2014, 17:00 - 18:00 hoursFollowingthe lastsession for theday,catchupwithyourcolleaguesatdrinksintheTradeExhibitionarea.Includedfor fulltime and Friday delegates and registered partnersonly.Noadditionaltickets.

MEETING DINNER Saturday 11 October 2014, 19:30 - 23:00 hoursBetransportedtoaneveningofsparkleandglamourasfinebubblesmeldwithcrystalblingtogethertomaketheperfectcocktail! Dinner will include pre dinner refreshments,dinneranddrinks,andentertainment.Includedforfulltimedelegatesandregisteredpartners.Additionaltickets:$130perperson.

ANNUAL GENERAL MEETING

The Annual General Meeting of the Australasian Societyfor Breast Disease will be held at 7.30am on Saturday11 October 2014. As breakfast will be served during theMeeting,pleaseconfirmyourattendance/nonattendance.Admissionisfreetomembersonly.

CONTINUING PROFESSIONAL DEVELOPMENT

RACSThiseducationalactivityhasbeensubmitted to theRoyalAustralasianCollegeofSurgeons’ContinuingProfessionalDevelopment(CPD)Program(1pointperhour,Category4:MaintenanceofClinicalKnowledgeandSkillstowards2014CPDtotals).

RANZCRThe allocation of points in Royal Australian and NewZealand College of Radiologists Continuing ProfessionalDevelopment(CPD)Programasfollows:• 6 pointsmaybeclaimedforattendanceatthe“Australasian

BreastCongress”tobeheldon10October2014.• 6 pointsmaybeclaimedforattendanceatthe“Australasian

BreastCongresstobeheldon11October2014.• A total of 12 pointsmaybeclaimedforattendanceatthe

“AustralasianBreastCongress” tobeheld from9to11October2014.

• A total of 3.25 points may be claimed for attendanceat the “Communications Workshop” to be held on9October2014.

• Foranyonewhoattendsonlypartofthismeeting,pointsmaybeclaimedprorataat1 point per hour.

RACGPBreastPhysiciansandGeneralPractitionerscanaccesstheRACGPwebsitewww.racgp.org.autodeterminetheQApointsonanindividualbasis(Category2)forMeetingattendance.

SECTION 1 I P7

The Foundation for Breast Cancer Care is beinglaunchedon10October2014.Thefoundationwasrecently established by senior breast surgeonsand policy makers in this arena. Its aim is topartnerwiththeBreastSurgANZsocietytodevelopstrategiesandprograms for implementingbreastcancereducation,training,research,development,management and prevention. It has a uniquefocus for innovation in breast cancer treatment,by promoting excellence in breast surgery andresearch. BreastSurgANZ already has a strongtrack record in quantifying its work. Working toidentify and support marginalised communities,theFoundationintendstofocusonclosingthegapinbreastcancercare. Forfurtherenquiriesortojoinusonthe10th(ticketsarestillavailable)atthelaunch dinner, please contact, Karen Littlejohn -breastcancercarefoundation@gmail.com.

LEVEL II ONCOPLASTIC SURGERY CADAVERIC WORKSHOP

8-9 October 2014, Merf And Holy Spirit Northside Education Centre, Brisbane

UK Faculty: AnneTansley RichardSutton

Australasian Faculty: DavidLittlejohn JamesKollias ElisabethElder RichardMartin DanieldeViana JamesFrench MelissaBochner CindyMak AndrewSpillane LeeJackson

KEYNOTE SPEAKERS

Prof Hiram (Chip) S. Cody III MD, FACSHiram Cody is a graduate of Dartmouth College and theColumbia University College of Physicians and Surgeons.He completed Surgical Residency at The RooseveltHospital inNewYork,andaSurgicalOncologyFellowshipat Memorial Sloan-Kettering Cancer Center, where he iscurrently Attending Surgeon (Breast Service, DepartmentofSurgery),Member(MemorialHospital),andProfessorofClinicalSurgery(WeillCornellMedicalCollege).Hisclinicalresearch over the last 15 years has focused on sentinellymphnodebiopsy.HeisPresidentoftheAmericanSocietyof Breast Surgeons, and is Past-President of the NewYork Metropolitan Breast Cancer Group. He is Editor ofthejournalBreast Diseasesandthemulti-authortextbookSentinel Lymph Node Biopsy. He serves on numerouseditorial boards, reviews and lectures widely, and is theauthorofmorethan200peer-reviewedpapers,editorials,bookchaptersandreviews.

Mr Richard Sutton MBBS, FRCS, FRCS Richard Sutton is a Consultant General Surgeon with aspecial interest inBreastSurgery, inparticularcosmetic,oncoplastic and breast reconstructive surgery. He is theDirectoroftheBreastUnitattheRoyalUnitedhospital inBath,UK.

The UK is fortunate in having a very well developedtraining programme in oncoplastic and reconstructivebreast surgery. Mr Sutton is actively involved in thistraining programme being the Director for the SpecialtySkills Course in Breast Surgery (Principles in BreastReconstruction-level1)attheRoyalCollegeofSurgeonsofEnglandaswellasatutorandexaminerfortheUKNationalMastersofSurgerycourseinOncoplasticBreastSurgery.

Miss Anne Tansley MBChB, FRCS(Ed), FRCSAnne Tansley has been a Specialist Consultant BreastSurgeonatTheRoyalLiverpoolUniversityHospitalsince2006. After qualifying in 1992 at the Liverpool MedicalSchool she spent time training at Concord HospitalSydney,Australia,completingher training in theMerseyRegion until taking up specialist breast practice as aconsultant surgeon. She was later appointed to theNational Oncoplastic Fellowship Training program andspent a year working in the Whiston NHS Plastics UnitandtheRoyalLiverpoolUniversityHospitalastheBreastFellow working out of the Linda McCartney Breast Unit.As the RCS Breast Tutor she is involved in organising asuccessful National Teaching Program for surgeons andtrainees.MissTansley’sspecialclinical interests includediagnosticaspectssuchasbreastassessmentclinicsandsurgical management in Breast Screening; all aspectsof oncoplastic breast surgery including therapeuticmammaplasty,implant based breast reconstruction anduse of Acellular Dermal Matrices; and symmetrizationtechniquesincludingbreastaugmentation;breastliftandreduction.Herresearchinterestsare:lumpectomy(breastconserving surgery including breast reduction surgeryfor breast cancer treatment and surgical training in thespecialtyofbreastsurgery.

FACULTY MEMBERS

Johnson & Johnson Medical Pty Ltd. Telephone: 1800 338 160 or +61 2 9815 3680 | Address: 1-5 Khartoum Road, North Ryde, NSW 2113 | Email: mentorcustserv@its.jnj.com

Johnson & Johnson Medical Pty Ltd. ABN 85 000 160 403 | Mentor is a business unit of Johnson & Johnson Medical Pty Ltd.

FR5523 Sept 14 E000000_000

We welcome you to come visit us on Stand 14 & 15 to learn more about our product range for reconstructive breast surgery.

MENTOR is proud to be a Major Sponsor of the

Australasian Breast Congress 2014.

LOCAL FACULTY

Dr Melissa Bochner FRACS, MS, MBBSMelissa Bochner trained in General Surgery in NSWand attained her FRACS in 1995. She has a Master ofSurgeryfromtheUniversityofSydneyandcompletedpostFellowshiptraininginBreastandEndocrineSurgeryattheRoyal Adelaide Hospital and the Edinburgh Breast Unit.DrBochnerhasappointmentsasaBreastandEndocrineSurgeonattheRoyalAdelaideHospital,StAndrewsPrivateHospital,andattheWomen’sandChildren’sHospital,andisaclinicaltitleholderattheUniversityofAdelaide.

Dr Meagan Brennan BMed, FRACGP, FASBPMeagan Brennan is a Staff Specialist Breast Physicianat theWestmeadBreastCancer Instituteandsheworksin private practice at the Poche Centre in North Sydney.Herclinicalinterestsincludethemanagementofwomenat high genetic risk of cancer and the management ofbenign breast disease. Dr Brennan is currently involvedin research projects in the areas of survivorship careplanning, breast MRI and factors affecting the choice ofbreast reconstruction in women with breast cancer. Sheis a Clinical Senior Lecturer at Sydney Medical School,University of Sydney where she teaches evidence basedmedicine and clinical skills to students at the NorthernandWesternClinicalSchools.

Dr Elisabeth E ElderMBBS, PhD, FRACSElisabeth Elder graduated from the Karolinska Institute inStockholm,Swedenin1992,whereshealsocompletedhersurgical training together with a PhD in tumour biology in2002.ShegainedherAustralianFRACSin2008andisnowastaffspecialistinbreastsurgeryattheWestmeadBreastCancerInstituteandclinicalseniorlecturerattheUniversityof Sydney. She is the incoming chair of the oncoplasticsubcommitteeofBreastSurgANZ.

Dr Marie-Frances Burke MBBS, FRANZCRMarieBurkeistheDirectorofMedicalServicesatGenesisCancercare Queensland (formerly Premion), the largestprovider of private Radiation Oncology services in thestate. She qualified in medicine from the University ofQueensland in 1982, and was awarded the Fellowshipof the Royal Australian and New Zealand College ofRadiologists in 1989. Dr Burke commenced in privatepractice in radiation oncology at the Wesley in 1995 andnowconsultsthere,aswellasattheGenesisCancerCare

Queensland’s Chermside and Nambour centres. Herspecialties include breast cancer, gynaecologic cancerandskincancer.SheiscurrentlyontheRANZCRFacultyofRadiationOncologyCouncil,andtheRANZCREconomicsandWorkforceCommittee, isapastSecretary/Treasurerfor theAustralasianSocietyofBreastDiseaseand isontheboardof theBreastandProstateCancerAssociationof Queensland. She has recently chaired the nationalcommittee on “Guidelines for Hypofractionated BreastRadiation”forCancerAustralia.

A/Prof Gelarah Fashid MBBS, MD, MPH, FRCPA, FFSc(RCPA)Gelareh Farshid serves as the Clinical Director ofBreastScreen South Australia and as a senior consultantpathologist at SA Pathology. She has a long standingprofessional and research interest in the diseasesof the breast. Breast cancer screening and breastpathology are among her areas of expertise. Among hervarious contributions, Dr Farshid is the secretary of theInternationalSocietyofBreastPathology,andChairoftheAustralasianBreastPathologyQualityAssuranceProgram.She represents the Royal College of Pathologists ofAustralasiaontheBreastScreenAustraliaNationalQualityManagementCommittee.

Dr Susan Fraser MBBS, FASBPSusan Fraser has worked as a Breast Physician for 24years.Shehasworkedinrolesincludingdiagnosticbreastassessment, BreastScreen reading and assessment,breastsurgicalassistingandpostcancerfollowupcare.She is the current President of the Australasian SocietyofBreastPhysicians.DrFrasercurrentlyworksbteweenCairns,herhomeandBreastcareon theGoldCoastandcontinuestoreadandassessforBreastScreenQueenslandandNSW.

Dr Michael Gattas MBBS, FRACP MichaelGattasisagraduateofSydneyUniversity.HeisaPhysician who works full time as a Clinical Geneticist inBrisbane.HehasbeenastaffspecialistattheQueenslandClinical Genetics Service since 1996. Dr Gattas wasmainly responsibility for familial cancer patients in thisserviceuntilhestartedhisprivatepractice in2004.He isa regular attendee at the multidisciplinary breast cancermeeting held at the Wesley Hospital in Brisbane. He hasanactiveinterestindeliveringclinicalgeneticsservicesbyvideoconferencetechnology.DrGattashaspreviouslybeenamemberoftheEthicsCommitteeoftheRoyalChildren’sHospitalinBrisbane.

SECTION 1 I P11

A/Professor Bruno Giuffrè MBBS, FRANZCRAssociate Professor Bruno Giuffrè is a Senior StaffSpecialist Radiologist in Radiology Department atRoyal North Shore Hospital and North Shore PrivateHospital. His areas of clinical and research interest areBreast and Musculoskeletal Imaging and he has beeninstrumental in developing and supervising techniquesand protocols for these disciplines at RNSH. He is alsoinvolved in many aspects of medical Informatics. HiscurrentprojectsincludecorrelationofhistopathologywithMRI abnormalities of breast lesions and the correlationbetweenMRIandUltrasoundabnormalitiesofjointswithoperativefindings.Hehasextensiveteachingexperiencewithawidevarietyofaudiencesfrommedicalstudentstoclinicalcolleagues.

Dr Janet GrayMBBS, FRANZCRJanetGrayisagraduateofUniversityofQldwhotrainedinRadiology at Royal Brisbane Hospital. She was a partnerin Drs Masel and Casey and then QDI for many years,specialising in Women’s imaging. During this periodBreastScreenAustraliabeganapilotstudyatRoyalWomen’sHospitalandDrGraywasamemberofthissuccessfultrial.She continued working in BreastScreen and the privatesectoruntil2013.SincethattimeshehasworkedforTheQld Health department as the State Radiologist for theBreastScreenProgramme.

A/Prof Sandi Hayes PhDSandiHayesisanExercisePhysiologist,PrincipalResearchFellow and co-leader of a cancer survivorship researchprogram(ihop)withintheInstituteofHealthandBiomedicalInnovation,QueenslandUniversityofTechnology,Australia.Herprogramofresearchdrawsonexperiencesandtrainingin exercise science, epidemiology and public health andfocuses on understanding the physical and psychosocialconcernsfacedfollowingcancerandtheroleofexerciseincancer recovery. Her work has involved the development,conduct and successful completion of randomised,controlled trials as well as population-based, prospective,longitudinal cohort studies that have included over 1,000cancersurvivors.

Dr Brigid Hickey MBBS, RANZCRBrigid Hickey is a University of Queensland medicalgraduate who trained in Radiation Oncology in Brisbane.Shewasthe1997WindeyerFellow(MtVernonUK)andhasworkedinTownsvilleandChristchurch,NewZealandbeforesettlinginBrisbane.SheistheActingDirectorofRadiation

Oncology, Mater Service. She has truly returned to herroots; her office is directly across the road from whereshe was born! Dr Hickey has had a long association withtheCochraneCollaboration,publishingherfirstCochraneSystematic review in 2000. She is currently a CochraneBreast Cancer Group Editor and has published Cochranesystematicreviewsoncolorectalandprostatecancer.

Dr James Kollias MD, FRACS, MBBSJamesKolliasisaspecialistbreastsurgeonattheRoyalAdelaideHospitalandatBreastscreenSA.He isapastExecutiveMemberofASBD,pastChairmanoftheRACSBreast Section, Founding President of BreastSurgANZandpastChairmanoftheBreastSurgANZBreastQualityAudit. He has served as an adviser for a number ofbreast cancer working parties for Cancer Australia /National Breast and Ovarian Cancer Centre. Dr Kolliashaspublishedover90manuscriptsinrefereedscientificjournals and is a senior lecturer with the University ofAdelaideDepartmentofSurgery.

A/Prof Margo LehmanMBBS, FRANZCR, GDPMargot Lehman is a graduate of the University ofQueensland. She is currently working as a Senior StaffSpecialistintheDepartmentofRadiationOncologyPrincessAlexandra Hospital where she is a member of the breastcancer multi-disciplinary team. She is the co-author ofCochranesystematicreviewsevaluatingacceleratedpartialbreastirradiation,radiationfractionsize,thesequencingofchemotherapyandradiationtherapyandtheroleofregionalnodalirradiationinbreastcancermanagement.

Dr David LittlejohnMBBS, FRACSDavidLittlejohnisaspecialistbreastoncoplasticsurgeonperforming the full range of breast cancer surgeryincludingbreastoncoplasticproceduressuchaslatissimusdorsi miniflap and therapeutic mammoplasty as well asimmediate and delayed breast reconstruction utilisingTRAM and LD flaps. Dr Littlejohn as been practisingoncoplasticbreastsurgery inWaggaWagga for14yearsandisthesecretaryandtreasureroftheBreastSectionoftheRoyalAustralianCollegeofSurgeonsandafoundingmemberofBreastSurgeonsNSWandBreastSurgANZandistheoutgoingchairmanoftheoncoplasticcommittee.

Prof Bruce MannMBBS, PhD, FRACSBruceMannisDirectorofTheBreastServiceattheRoyalMelbourne and Royal Women’s Hospital in Melbourne.He completed Surgical training at The Royal Melbourne

SECTION 1 I P13

Hospital and Fellowship training at Memorial SloanKettering Cancer Centre. He has been involved in manyclinicaltrialsandmuchclinicalandtranslationalresearch,withhismainresearchinterestbeingtailoringtreatmenttothediseaseandthepatient.Dr Kerry McMahonMBBS, FRANZCRKerry McMahon is a radiologist with Queensland X-RayinBrisbanewhereshehasaspecialinterestinWomen’simaging. This includes mammography and Breast MRI,obstetricandgynaecologicultrasoundandbonemineraldensitometry, and Pelvic/Gynaecology MRI. She is agraduate from the University of Qld, completing herradiology training at the Royal Brisbane Hospital and afellowship year in Women’s Imaging at the EdinburghRoyal Infirmary, Scotland. She has currently been inprivate practice with Qld X-Ray since 1999, and is avisitingconsultanttoBreastScreenQld.

The Hon Maxine Morand BA, MA PrelimMaxine Morand has a background in health, research andpolitics. She began her career as a general nurse thencompleted an Arts Degree and a Masters Preliminary inSociology, which led to a research role at the Centre forBehaviouralResearch inCanceratCancerCouncilVictoria.Ms Morand worked as an advisor to the Victorian Ministerfor Health before being elected to the Victorian LegislativeAssemblyin2002.AneightyearcareerinParliamentincludedseniorgovernmentappointmentsofParliamentarySecretaryfor Health and Minister for Children and Early ChildhoodDevelopment, and Minister for Women’s Affairs. MaxineMorandiscurrentlyCEOofBreastCancerNetworkAustraliaandisontheCancerAustraliaBreastCancerAdvisoryGroup.Shewasdiagnosedwithbreastcancerin2010.

Dr M Teresa Nano MBBS, FRACSTeresa Nano graduated from Queensland Universityand gained her FRACS with the Australasian College ofSurgeonsin1999.ShesubsequentlycompletedatwoyearBreast and Endocrine Surgical Fellowship at the RoyalAdelaide with research work in breast reconstruction.DrNanocurrentlyworksatGreenslopesPrivateHospital,BreastScreenQueenslandandWesleyBreastClinic.

A/Prof Nirmala Pathmanathan BScMed, MBBS, FRCPA, MIACNirmala Pathmanathan is the Executive Director of theWestmeadBreastCancerInstituteinSydney,andaSeniorStaff Specialist, Anatomical Pathologist, at the InstituteofClinicalPathologyandMedicalResearchatWestmead

Hospital. She has also worked as a Senior ResearchFellow at Westmead Millennium Institute in BreastCancerResearch.SheistheDesignated/LeadPathologistfor BreastScreen, Sydney West. Dr Pathmanathan haslecturedextensivelylocallyandinternationallyinthefieldofbreastcancerandhaspublishedanumberofarticlesinpeer-reviewed journals.She is therecipientandchiefinvestigator in several grant funded research projectsincludingtheBreastCancerTumourBankinSydney.Sheis a Member of NBOCC Sentinel Node Biopsy Subgroupandwasinvolvedinthedevelopmentofrecommendationsfor use of Sentinel Node Biopsy in Breast Cancer.Recently, she has been a steering committee memberin the development and presentation of breast cancerworkshopsaimedatimprovingthequalityofbreastcancerpathology and HER2 testing in several countries acrosstheAsiaPacificRegion.

A/Prof Christopher Pyke MBBS, FRACS, FACS, PhDChris Pyke is an Associate Professor in Surgery at theUniversityofQueensland,theChairmanoftheFoundationforBreastCancerCareandtheImmediatePastPresidentof BreastSurgANZ. After completing his surgical trainingat Mater, Dr Pyke undertook surgical fellowships at theNottingham Breast Unit in the United Kingdom and theMayoClinicintheUnitedStatesofAmerica.OnhisreturntoAustralia,DrPyketookupapositionasseniorlecturerattheMaterHospitalinBrisbaneandcompletedaPhDinbreastcancerriskquantification.

Winthrop Prof Christobel Saunders MBBS (Lond), FRCS, FRACSChristobel Saunders is Winthrop Professor of SurgicalOncology (since 2002), academic surgeon, cancerresearcherandteacherofsurgeryattheSchoolofSurgery,TheUniversityofWesternAustralia.Shehasbeencloselyinvolved in strategic planning and management of healthcancer services in Australia for the last decade as BoardmemberandAdvisoryCouncilmemberofCancerAustralia,pastPresidentoftheCancerCouncilWA(2009-2013),andlocallyasauthoroftheWAHealthCancerServicesFramework(www.clinicalnetworks.health.wa.gov.au/cancer/docs)andfirstA/DirectorState-wideCancerandPalliativeCareNetwork.Shehassubstantiallycontributedtomanyclinicalaspectsofbreastcancerresearch includingclinical trialsofnewtreatments,psychosocial, translationalandhealthservicesresearch.WinthropProfessorChristobelSaundersis active in several areas of surgical oncology cancerresearch, with a particular emphasis on breast cancer.Areasofcurrentresearchfocusinclude:Minimallyinvasivediagnosis and treatment of breast cancer; Translationalcancer research; Familial breast cancer; Endocrine

treatments in breast cancer; Exogenous and endogenoushormonesandbreastcancer;CancerserviceresearchandPsycho-oncology.

Dr Raja SawhneyRaja Sawhney was born in London, UK and attained hisprimarymedicaldegreefromGuy’s&St.Thomas’HospitalsinLondon.HemovedtoAustralia in1998andpursuedhiscareerinsurgicalspecialtiesbeforecommencingadvancedtraininginPlastic&ReconstructiveSurgerypredominantlyinQueensland.Sincecompletinghisadvancedtraining,hehasbeenworkingasafull-timestaffspecialistintheGoldCoastHealth district expanding public reconstructive services,especially for breast reconstruction. He works in closecollaboration with the Oncologic and Oncoplastic Breastsurgeonswithin the public and private sectors here in theGoldCoast.HeistheDirectorofPlasticandReconstructiveSurgeryatGoldCoastUniversityandRobinaHospitals.

Dr Catherine Shannon MBBS (Hons), FRACPCatherineShannon isdirectorofMedicalOncologyat theMater Adult Hospital Brisbane. She is a member of theexecutiveoftheAustralasianSocietyforBreastDiseaseandthebreastcanceradvisorycommitteeforCancerAustralia.She has a special interest in breast and gynecologicalmalignancy.She is thedirectorof theoncologytrialsunitforMaterHealthServicesandhonoraryseniorinvestigatorfor Mater Research. She is the principal investigator ona number of clinical trials in breast and gynecologicalmalignancyandamemberoftheAustralasiancollaborativeresearch groups for Breast, gynecological and lungmalignancies. Catherine has extensive experience withclinicaltrialsofnewdrugsforthetreatmentofmalignancy.Her special interests include the management of breastcancerinyoungwomenandpregnantwomenandshehaspublishedinthisfield.

Ms Vicki ShepherdVickiShepherdhasbeenaBCNAConsumerRepresentativesince 2006. She was diagnosed with early breast cancerin 2003 and underwent a lumpectomy, followed bychemotherapy, radiotherapy and hormone therapy. Sinceundergoing BCNA’s Science and Advocacy Training,MsShepherdhasprovidedconsumerinputonavarietyofcommitteesandresearchprojects,includingastudylookingatthesurgicaloutcomesinAustraliaforwomendiagnosedwithearlybreastcancer.ShewasalsotheBCNAConsumerRepresentative on the Cancer Australia working groupdeveloping a resource on issues of sexuality for womenwithbreastcancer.ShelivesinBrisbaneandispassionateabout improving outcomes for women diagnosed withbreastcancer.

A/Prof Andrew Spillane MD, FRACS, BMBSAndrew Spillane is the President of BreastSurgANZ.He is Associate Professor of Surgical Oncology at TheUniversity of Sydney, Northern Clinical School. Hespecialises in the surgical management of melanoma,breast cancer and soft tissue tumours. Dr Spillane iscurrently a senior surgeon with Melanoma InstituteAustralia (MIA), and a VMO at the Mater, Royal NorthShoreandNorthShorePrivateHospitals.

A/Prof Donna Taylor MBBS, FRANZCR, FRCP(C)Donna Taylor is a Consultant Radiologist at the RoyalPerth Hospital, Screen Reader at BreastScreen WesternAustraliaandClinicalAssociateProfessorattheSchoolofSurgery,UniversityofWesternAustralia.Shehasextensiveexperience in breast imaging and intervention and is apassionate advocate for multidisciplinary breast cancerresearch.Hercurrentprojects includeanRCTcomparinglowdoseiodine125seedswithhook-wiresforlocalisationofbreastcancers,useofsonographicallyvisiblebreastbiopsymarkers, quantifying breast tissue composition with non-contrast breast MRI and a non-inferiority trial comparingcontrast enhanced mammography with MRI for breastcancerstaging.DrTaylorisaFRANZCRpart2examiner,amemberoftheRANZCRRadiologyandRadiationOncologyResearch Committees and an Associate Editor for theJournal of Medical Imaging and Radiation Oncology.

A/Prof Jane Turner MBBS, FRANZCP, PhDJaneTurnerisaconsultation-liaisonpsychiatristwhohasworkedfor25yearsinOncology.Shehasbeenextensivelyinvolvedinthedevelopmentofclinicalpracticeguidelines,including psychosocial clinical practice guidelines, andhasexperienceincommunicationskillstrainingforhealthprofessionals from a range of clinical disciplines. She iscurrently engaged in research evaluating a structuredintervention for fear of cancer recurrence in women withbreast cancer, and is leading a trial of a nurse-deliveredsurvivorshipinterventionforpatientswhohavecompletedtreatmentforheadandneckcancer.

Dr Daniel de Viana MBBS, FRACSDanieldeVianaisamedicalgraduatefromtheQueenslandUniversity, who completed his general surgery trainingthrough Princess Alexandra Hospital, Brisbane. Heundertook postgraduate training in breast surgery andcancer management in the United Kingdom. He settledontheGoldCoastin1999,initiallyworkingasStaffBreastSurgeon at the Gold Coast Hospital, and commenced

private practice in 2000. Dr de Viana is a consultant atBreastScreenSouthport,memberofsurgicalreviewpanelofBreastScreenQueensland,PresidentoftheAustralasianSocietyforBreastDisease,memberofRoyalAustralasianCollege of Surgeons Breast Section, and member of theInternationalSocietyofBreastDisease.

Mr David Walters MBBS (Adel), FRACS, DDU, GIACDDavidWaltersisaSeniorConsultantBreastandEndocrineSurgeon at The Queen Elizabeth Hospital and SeniorLecturerwiththeUniversityofAdelaide.HeisalsoVisitingConsultantSurgeonatBreastScreenSAandFoundingandcurrent executive member BreastSurgANZ. Mr Walters isChairofBreastSurgANZQualityAuditSteeringCommittee,ViceChairofSAStateCommitteeforRACS,andDirectoratSt.AndrewsHospital.

Dr Yvonne Zissiadis MBBS,FRANZCRYvonneZissiadis isaRadiationOncologistwithaspecialinterest in breast cancer. She completed her RadiationOncology training at Peter MaCallum Cancer InstitutefollowingwhichshetookupaResearchFellowshipattheBreastCancerInstituteinNSW.FollowingthatDrZissiadiswas appointed Consultant Radiation Oncologist at thePrince of Wales Hospital, Sydney. She then undertook asecondfellowshipattheMassachusettsGeneralHospital,Boston before returning to her home state of Perth totakeupaRadiationOncologyconsultantpositionatRoyalPerth Hospital. She now works for Genesiscancercare,both privately and at Royal Perth Hospital. Dr Zissiadishas been an active member of the Trans TasmanRadiation Oncology Group participating in many of theirbreastcancertrials.SheiscurrentlytheChairoftheWAGCC Research committee as well as a member of theBreastCancerResearchCentre’sresearchcommittee.Inaddition,shehasalectureshipatEdithCowenUniversityandtheUniversityofWA,withwhomsheiscollaboratingonexerciseinbreastcancertrials.

PRESENTERS - PROFFERED PAPERS

Dr Verity Ahern FRANZCR Director,SydneyWestRadiationOncologyNetwork,CrownPrincessMaryCancerCentre,WestmeadHospital,Sydney

Dr Su Ang MBBS Breastregistrar,RoyalPrinceAlfredHospital,Sydney

A/Prof Peter Graham MBBS, FRANZCR, Cert Bioeth, GradDipMedStatActingDirectorRadiationOncology,DirectorClinicalTrialsUnit,CancerCareCentre,StGeorgeHospital,Sydney

Ms Louise Koelmeyer B. App ScOccupational therapist; Development Manager, Life AfterCancerExperience(LACE)MacquarieUniversityCancerInstitute,Sydney

Dr Caitlin Lim MBBS FRACSSeniorSurgicalRegistrar,BankstownHospital

Dr Farid Meybodi MBBS, FRACSStaffSpecialist,WestmeadBreastCancerInstitute,Sydney

Dr Kowsi MurugappanFRACSBreastandEndocrineSurgicalFellowChristchurchHospital

A/Prof Donna Taylor MBBS, FRANZCR, FRCP(C)Consultant Radiologist, Royal Perth Hospital; ScreenReader,BreastScreenWesternAustraliaClinicalAssociateProfessor,SchoolofSurgery,UniversityofWesternAustralia

SECTION 1 I P15

VENUES

LEVEL II ONCOPLASTIC SURGERY CADAVERIC WORKSHOP8-9 October 2014, MERF and Holy Spirit Northside Education Centre, Brisbane

THURSDAY 9 OCTOBER 2014

08:00-18:00 Registration Venue:CongressOffice,TerraceRoom1

18:00-19:00 Speakers’ audiovisual testing Venue:TerraceRoom2

09:00-12:30Workshop: Communication Venue:HinterlandRoom1

12:30-16:30Workshop: Maximising Your Earnings in Private Practice Venue:HinterlandRoom2

14:30-18:00Workshop: Communication Venue:Venue:HinterlandRoom1

18:00-19:30 Welcome reception Venue:Marriottpoolside

FRIDAY 10 OCTOBER 2014

07.30-17.30 Registration Venue:CongressOffice,TerraceRoom1

07:00-08:45 Educational Breakfast: Gene Expression Assays for Breast Cancer and Their Use in The “Real’ World Venue:HinterlandRoom

07:30-16:00 Speakers’ audiovisual testing Venue:TerraceRoom2

17:00-18:00 Networking drinks TradeExhibitionarea SATURDAY 11 OCTOBER 2014

07:30-15:00 Registration Venue:CongressOffice,TerraceRoom1

07:30-08:45 Australasian Society for Breast Disease Annual General Meeting Venue:VerandahRoom

07:30-13:00 Speakers’ audiovisual testing Venue:TerraceRoom2

19:30-23:00 Meeting dinner Venue:MarriottBallroom

ThevenueforallscientificprogramplenarysessionsistheElstonRoom.

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SECTION 1 I P19

PROGRAM

Pleasenotethattheprogramissubjecttochange.

THURSDAY 9 OCTOBER 2014

08:00-18:00 Registration

09:00-12:30 Workshop: Communication JaneTurner

10:00-12:00 Workshop: Maximising Your Earnings in Private Practice MichaelWaycottandSimonFarmer Sponsored by Bongiorno National Network14:00-17:30 Workshop: Communication JaneTurner

18:00-19:30 Welcome reception

FRIDAY 10 OCTOBER 2014

07:00-08:45 Educational breakfast session: Gene Expression Assays RicharddeBoerandBruceMann for Breast Cancer and Their Use in the ‘Real’ World Sponsored by Specialised Therapeutics 09:00-10:30 Session 1: Screening and Diagnostics Chair:JanetGrayandMaxineMorand

Welcome DanieldeVianaandAndrewSpillane

AdvancesinBreastImaging KerryMcMahon

What’swrongwithBreastScreenscreening?(andwhat’sright?) MeaganBrennan

ExpandingtheindicationsforMRI:Whatisbestpractice? ChristobelSaunders

ConfessionsofaMRIsceptic HiramCody

Discussion/questions Faculty

10:30-11:00 Morning break

11:00-12:30 Session 2: Oncoplastic Techniques Sponsored by Allergan Chair:DanieldeViana

Singlestagereconstruction AnneTansley

Breastcancerlocalisation,a2014update DonnaTaylor

Newtechniquesandtechnologiesinreconstruction RajaSawhney

Therapeuticmammoplasty RichardSutton

Discussion/questions Faculty

12:30-13:30 Lunch13:30-15:00 Session 3: Axillary Surgery and Proffered Papers Chair:AndrewSpillane

Keynote:ThemanagementoftheaxillapostZ0011 HiramCody Discussion/questions

Liposuctionforadvanced-Impactofliposuctiononlimbvolumes. SurgicaltreatmentresultsfromAustralia LouiseKoelmeyer

Whatshouldbeusedforlowerpolecoverageinimmediate two-stageexpander/implantbasedbreastreconstruction? FaridMeybodi

Canthecontentofseromafluidfrommastectomyoraxillary clearancewoundspredictclinicalcourse? CaitlinLim

Positiveanteriormarginsinbreastconservingsurgery: Doesitmatter?Asystematicreview–theliterature SuAng

“ROLLIS”RadioguidedOccultLesionLocalisationusing Iodine-125(I-125)Seedsforremovalofimpalpablebreastlesions: firstAustralianresults DonnaTaylor

15:00-15:30 Afternoon break

15:30-17:00 Session 4A: Radiotherapy and Reconstruction Chair:YvonneZissiadis

Acceleratedpartialbreastirradiation–Cochranereview BrigidHickey

Partialbreastirradiation:MSKCCexperience HiramCody

Issuesintreatingpatientswithreconstruction MarieBurke

Reconstructiveoptionsinthehighriskpatient RajaSawhney

Discussion/questions Faculty

15:30-17:00 Session 4B: Survivorship: Optimising Life After Breast Cancer Chair:ChristobelSaunders

Physicalhealthandqualityoflifeinbreastcancersurvivors SandiHayes

Psychosexualhealth JaneTurner

AninteractivepanelQ&Asessionaddressingtheimportantissues facingbreastcancersurvivors Panel Surgeon: MelissaBochner Breastphysician: SusanFraser Geneticist: MichaelGattas Medicaloncologist: CatherineShannon BCNArepresentative: VickiShepherd BreastCareNurse: TBA

17:00-18:00 Networking drinks

FRIDAY 10 OCTOBER 2014 - CONTINUED

SATURDAY 11 OCTOBER 2014

07:30-08:45 ASBD Annual General Meeting

09:00-10:30 Session 5: Neoadjuvant Therapy Update Sponsored by Roche Chair:BruceMann

Neoadjuvantchemotherapy–expandingtheindications AndrewSpillane

Neoadjuvanttherapyandaxillarystaging HiramCody

Interpretingpathologyduringandafterneoadjuvanttherapy GelarahFashid

Neoadjuvanttherapyforbreastcancer–currenttrialsandfuturedirections CatherineShannon

Discussion/questions Faculty

10:30-11:00 Morning break

11:00-12:30 Session 6: Genetics Keynote and Proffered Papers Sponsored by AstraZeneca Oncology Chair:DavidWalters

Breastcancerbiology:Prognosticandpredictivefactors incurrentclinicalpractice NirmalaPathmanathan Discussion

ComparativeevaluationofContrastEnhancedSpectralMammography (CESM)andContrastEnhancedMagneticResonanceImaging(CEMRI) forlocalstagingofbreastcancer:InterimresultsfromtheCESMVstudy DonnaTaylor

Predictorsofresponsesandsexualfunctionforwomen intheStGeorgeBreastBoostRandomizedTrial(StGBBT) PeterGraham

Whatisthevalueofaxillarystaginginelderlywomenwithbreastcancer? Reviewoffouryearsprospectiveseriesfromasingleinstitution KowslyaMurugappan

PETScansforlocallyadvancedbreastcanceranddiagnostic MRItodeterminetheextentofoperationandradiotherapy (PETLABRADOR);TROG12.02 VerityAhern

12:30-13:30 Lunch13:30-15:00 Session 7: Multidisciplinary Meeting Case Review Chair/Moderator:JamesKollias

Panel Surgeons: HiramCody,AnneTansley,ElisabethElder Radiationoncologist: MarieBurke Medicaloncologists: CatherineShannonandNatashaWoodward Geneticist: MichaelGattas Pathologist: GelarahFashid Radiologist: BrunoGiuffre BreastCareNurse: TBA

15:00-15:30 Afternoon break

15:30-17:00 Session 8: Great Debates in Breast Cancer Chair:ChristopherPyke

“Theaxillaistheresponsibilityofthesurgeonnotthe radiationoncologist” TeresaNanoandMargotLehman

“Oncoplasticsurgeryservestwomasterspoorly: oncologyandplastics” HiramCodyandRichardSutton

Closingcomments19:30–23:00 Congress dinner Awardsforbestprofferedpaperandbestposter

SECTION 1 I P21

Section2Abstracts

WORKSHOP:COMMUNICATION

Jane Turner

Theworkshopwillprovideabriefoverviewofkeycommunicationtechniquesincludingbarrierstogoodcommunication.Inadditiontherewillbediscussionaboutchallengingencounterssuchasrespondingtopatientswhoareangryordepressed,orsituationsof familyconflict.Embedded in theworkshop isattention to thepersonal impactofthesechallengingencounters.Theaimoftheworkshopistoenhancetheconfidenceofparticipantsintheirclinicalcommunicationthroughtheuseofbriefrole-playsalignedwiththespecificneedsoftheindividualclinicians.

NOTES

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Register4 was established with seed funding from the National Breast Cancer Foundation.

NOTES

SECTION 2 I P27

SESSION 1:SCREENING AND DIAGNOSTICS

ADVANCES IN BREAST IMAGING Kerry McMahon Radiologist,QldX-Ray,Brisbane

Mammography has formed the basis of breast screening programs throughout theworldsincethe1980’s,andhascontributedtoasignificantreductioninbreastcancermortality. For over 20 years, little change or advance in mammography techniquesoccurred until more recently with the introduction of digital imaging, initially in theformofCRmammographyandfullfielddigitalmammography.In2005theDMISTtrialwasreleased,showingimprovementsinconspicuityofmicrocalcificationandimprovedpenetrancewithinthe“densebreast”,withanincreaseindetectionrateofDCIS,howevertheincreaseinthedetectionrateofsmallbreastcancerwaslesspronounced.

Theadventof fullfielddigitalmammographyhashowever lead todevelopmentofDigital Tomosynthesis Mammography, and this has the potential to significantlyimprovethedetectionrateofbreastcancerandreducethefalsepositiverecallrate.MuchresearchisstillongoinghoweverpreliminaryresultsfromtheOsloTrialandSTORMtrialareextremelyencouraging.DigitalBreast tomosynthesisenables thebreasttissuetobereprocessedin1mmslices,increasingtheconspicuityofspiculatedlesions, frequently obscured by superimposed tissue on a standard 2D image. Atthis stage, digital tomosynthesis is generally performed in addition to standard4 view 2D images, which does involve slightly increased radiation dose, thoughwellwithinacceptablelimits.Synthesized2DImaging,knownas“C-View”,createsa synthesized 2D from the 3D datasets, and eliminates the need for an additionalconventional2Dexposure.Thishasthepotentialtoreducetheradiationdose,andcomparesextremelyfavourably,potentiallyevenbetterthanstandard2Dexposures.The advent of full field digital mammography also enables remote reporting andimprovedreportingtimestoruralandremoteregions,andimprovementsinserviceprovidertoremoteregionsofAustralia.

MRI continues to be advantageous in characterization of mammographically occultdisease,andscreeningofhigh-riskyoungwomen.Developmentsinmolecularimaginghoweverarelikelytoformthebasisofsignificantadvancesinimagingoverthenext10 years. Molecular imaging incorporates MRI with spectroscopy, nuclear medicinetechniques such as PET imaging and Breast specific Sestamibi imaging, and thenewfieldofphotoacousticimaging.Thistogetherwiththedevelopmentofindividualrisk-profilesforwomenmaypotentiallychangethemethodofscreening,particularlyinofferingprogramstailoredtoindividualriskandbreasttissuedensity.

Useful References: 1 DiagnosticPerformanceofDigitalversusFilmMammographyforBreastCancer

Screening: Digital Mammographic Imaging Screening Trial Investigators Group;N Engl J Med2005,353;17:1773-83.

2 Breast Screening using 2D-mammography or integrating digital breasttomosynthesis (3D-mammography) for single-reading or double-reading –Evidencetoguidefuturescreeningstrategies.Houssamietal:Eur J Cancer(2014)50,1799-1807.

3. Comparison of Digital Mammography Alone and Digital Mammography plusTomosynthesisinapopulationbasedscreeningprogram.Skaaneetal.Radiology(2013)267:47-56.

NOTES 4. Advancesinmolecularimagingforbreastcancerdetectionandcharacterization.Spechtetal.Breast Cancer Research2012,14:206.

5. Light In and Sound Out: Emerging Translational Strategies for PhotoacousticImaging.Zackrissonetal.2014.AmericanAssociationforCancerResearch.

6. FDGPET,PET/CTandBreastCancerImaging:Rosenetal.Radiographics2007;27:S215-S229.

WHAT’S WRONG WITH BREASTSCREEN SCREENING? (AND WHAT’S RIGHT?)Meagan Brennan

ThepresentationwilldiscusstheroleofBreastScreen23yearsafteritsestablishmentin 1991. The evolution of BreastScreen and its current National AccreditationStandards (including participation and re-screening rates) will be reviewed and theresultsofthe2009EvaluationReportwillberevisited.ThepresentationwilldiscusshowBreastScreenaddressestheneedsofmultidisciplinarybreastcancertreatmentteams. Future directions will be proposed, including the need for a more tailoredapproachtoscreeningbasedonbreastcancerrisk.

ExPANDING THE INDICATIONS FOR MRI: WHAT IS BEST PRACTICE? Christobel Saunders

Annual MRI screening for women under 50 years at high-risk of breast cancer(including those at high risk due to previous chest wall irradiation), in conjunctionwithasurveillanceprogrammethatincludesmammography,clinicalexaminationandriskreductionadviceandfollowupofsuspiciouslesions,isnowacceptedpracticeinAustralia, with a Medicare rebate available. This is based on international evidencethatsuggestssucharesultsindetectionoflowerstagecancersthanmammographyalone, but important drawbacks include its cost and higher recall rates than seenwithmammographyalone.AnumberofunansweredquestionsremaintoensuretheoptimalfunctionandapplicationofMRIscreening,itsavailabilitytowomenwhomostneeditandtoensureaccesstothenecessaryfollowupinvestigationstoprovideafinaldiagnosis,andfurtherresearchinthisareaisplannedinthe“realworld”setting.

NOTES

SECTION 2 I P29

CONFESSIONS OF AN MRI SCEPTIC Hiram S Cody III MDAttendingSurgeon,BreastService,DepartmentofSurgery,MemorialSloan-KetteringCancerCenterProfessorofClinicalSurgery,WeillCornellMedicalCollege,NewYork,USA

The promise of breast MRI, our most sensitive imaging modality for the detection ofbreastcancer,issubstantialbuttheresultsofbreastMRIinpractice,especiallyfromasurgicalperspective,havebeenmixed.Here,categorizedas“yes”,“maybe”and“no”,aremyownindicationsforbreastMRI.

“Yes”1) Detection of an occult primary breast cancer. These comprise ≤1% of all breast

cancers and were historically treated by modified radical mastectomy, with thedisconcerting result that in about 30% of cases no primary was found in thebreast.MRIidentifiesabreastabnormalityinabout70%ofthesepatients,mostlyT1cancers,andanegativeMRIimpliessufficientlylowtumorburdenthatwholebreastRTwillsufficeforlocalcontrol1.

2) Highest risk screening.Measuredbysensitivityandstageatdiagnosis,thebenefitofMRIovermammographyinscreeningpatientswithprovenorsuspectedBRCAmutations is well-established2-4. MRI screening seems appropriate for otherhighest-riskgroupsincludingpatientswhohavereceivedmantleRTforlymphoma,buttheevidenceisinsufficient.

3) Response to neoadjuvant chemotherapy. Neoadjuvant chemotherapy will allowbreastconservationforsomepatientsinwhomitwouldnototherwisebepossible,andMRIhelpstodeterminethepatternofresponseandthusthefeasibilityandextentofbreastconservingsurgery.Inmeta-analysisof44studies(2050patients)5thesensitivityofMRIinidentifyingresidualdiseasewas92%andtheaccuracyofpredictingapCRwas60%;inanotherlargemulticenterstudy(770patients)6theaccuracyofMRIinpredictingapCRvariedbytumorsubtypebutwas74%overall.

4) Problem solving.MRIcanbeparticularlyusefulforanyclinicalsituationinwhichthe results of physical exam, mammography and ultrasound are ambiguous ordiscordant,andonemustchoosebetweenfurther intervention(biopsy,surgery)vs.observation.ThismustbetakenasanecdoteasIhavenodatatosupportit.

“Maybe”1) Higher-than-normal risk screening.MRImayhavearoleinscreeningpatientswith

BRCAmutationsofuncertainsignificanceorwhohavehighriskfamilyhistoriesandtestnegativeforBRCAmutations.AlthoughscreeningMRIisoftenrecommendedforpatientswithalifetimebreastcancerriskexceeding20%,MRIisnotofprovenbenefitforLCIS(lifetimerisk~30%)oratypicalhyperplasias(lifetimerisk~20%)7.

“No”1) Routine preoperative evaluation for breast conservation or post-operative follow-up.

BreastMRIhasbeenpresumedbeneficial forpatientswith lobularcancersbutthereisnoevidencethatMRIismoreusefulforlobularthanforductcancers.Thereisnoevidence thatpreoperativeMRIalters the ratesof re-excision,conversionto mastectomy, ipsilateral local recurrence, or contralateral breast cancer8-12.Finally,thereisnoevidencethatMRIisofbenefitforpostoperativefollowup.

2) Moderate risk screening. There is no evidence of benefit for MRI screening inwomenwhoselifetimebreastcancerriskis<20%.

3) “MRI is suggested”. There is no evidence that MRI is of benefit in women withyoungerage,difficultmammography,densebreasts,non-high-riskfamilyhistory,benignbreastbiopsies,personalhistoryofbreastcancer,breastpain,oranxiety.

NOTES References1. de Bresser J, de Vos B, van der Ent F, et al. Breast MRI in clinically and

mammographicallyoccultbreastcancerpresentingwithanaxillarymetastasis:asystematicreview. Eur J Surg Oncol2010;36(2):114-9.

2. Warner E, Messersmith H, Causer P, et al. Systematic review: using magneticresonanceimagingtoscreenwomenathighriskforbreastcancer.Ann Intern Med2008;148(9):671-9.

3. Warner E, Hill K, Causer P, et al. Prospective study of breast cancer incidenceinwomenwithaBRCA1orBRCA2mutationundersurveillancewithandwithoutmagneticresonanceimaging.J Clin Oncol2011;29(13):1664-9.

4. Rijnsburger AJ, Obdeijn IM, Kaas R, et al. BRCA1-associated breast cancerspresentdifferentlyfromBRCA2-associatedandfamilialcases:long-termfollow-upoftheDutchMRISCScreeningStudy.J ClinOncol2010;28(36):5265-73.

5. Marinovich ML, Houssami N, Macaskill P, et al. Meta-analysis of magneticresonanceimagingindetectingresidualbreastcancerafterneoadjuvanttherapy.JNatlCancerInst2013;105(5):321-33.

6. DeLosSantosJF,CantorA,AmosKD,etal.Magneticresonance imagingasapredictor of pathologic response in patients treated with neoadjuvant systemictreatment for operable breast cancer. Translational Breast Cancer ResearchConsortiumtrial017.Cancer2013;119(10):1776-83.

7. PilewskieM,MorrowM.Applicationsforbreastmagneticresonanceimaging.SurgOncolClinNAm2014;23(3):431-49.

8. PetersNH,vanEsserS,vandenBoschMA,etal.PreoperativeMRIandsurgicalmanagementinpatientswithnonpalpablebreastcancer:theMONET-randomisedcontrolledtrial.EurJCancer2011;47(6):879-86.

9. TurnbullL,BrownS,HarveyI,etal.ComparativeeffectivenessofMRI inbreastcancer(COMICE)trial:arandomisedcontrolledtrial.Lancet2010;375(9714):

563-71.10. HoussamiN,TurnerR,MorrowM.Preoperativemagneticresonanceimagingin

breastcancer:meta-analysisofsurgicaloutcomes.AnnSurg2013;257(2):249-55.11. BrennanME,HoussamiN,LordS,etal.Magneticresonanceimagingscreeningof

thecontralateralbreastinwomenwithnewlydiagnosedbreastcancer:systematicreviewandmeta-analysisofincrementalcancerdetectionandimpactonsurgicalmanagement.JClinOncol2009;27(33):5640-5649.

12. Pilewskie M, King TA. Magnetic resonance imaging in patients with newlydiagnosedbreastcancer:Areviewoftheliterature.Cancer2014;120(14):2080-9.

NOTES

NOTESSESSION 2:ONCOPLASTIC TECHNIqUESSponsored by Allergan

SINGLE STAGE RECONSTRUCTION Anne Tansley

BREAST CANCER LOCALISATION, A 2014 UPDATE Donna TaylorDepartment of Radiology, Royal Perth Hospital and School of Surgery, University ofWesternAustralia

IntroductionMammographic screening has led to an increasing number of impalpable breastcancersthatrequirelocalisationforbreastconservingsurgery(BCS).Theaimsofsurgeryare:• Completelesionexcisioninoneoperation.Acceptablepathologicalmarginsvary

(SSOguidelinenotumouratink1,inAustralia,2-5mm)• Goodcosmeticoutcome(relatedtotissuevolumeexcised2)

Ideal features of currently available techniques for pre/intra-operative lesionlocalisationarelistedinTable1.

SECTION 2 I P31

NOTES Table 1: Features of currently available preoperative lesion localisation techniques

X=Disadvantage,3=Advantage,*=granulomascanoccurifnotexcised,ROLL=Radio-occultlesionlocalisation,MG=mammogram,US=ultrasound,IOUS=intra-operativeultrasound, SNB= sentinel node, **SNOLL:=SNB+ROLL may interfere, ***ROLL:liquidcandisperse intoadjacent tissues,****ROLLIS:sealedsource,NDA=NoDataAvailable,T1/2=half-life,*****US:canonlybeusedforUSvisiblelesions(68%)5.

Patterns of use of lesion localisation techniquesThere is no published data. In a recent online survey of the 279 members of theBreastSurgANZ,themostfrequentlyusedpre-operativelesionlocalisationtechniquewas HWL (71/79 respondents, 89.87%). IOUS was the next most commonly usedmethod(30/79surgeons,37.97%),apromisingincreasefromthe17%figurenoteda2010surveypublishedbyLawetal6.

WhiletheuseofacarbontrackispopularinsomeAustraliancentres,responsestooursurveyindicatethatoverall,thistechniqueisinfrequentlyusedbyANZsurgeons(12/79respondents,15.19%).Radio-guidedtechniques(liquidTc99mMAAandsolidiodine125seeds)arecurrentlyrarelyused3/79(3.80%).

The choice of lesion localisation technique will depend upon• Availabilityoflocalexpertiseandequipment.• Characteristics of the lesion: size/shape/orientation / location in breast.

“Bracketing” should be considered for lesions >25mm in size, with elongatedshapeinsupero-inferiorormedio-lateralorientation.

• Needtocorrectformigrationofbiopsymarker• Sonographicvisibilityof lesion/biopsymarker.US>mammographicguidance

for pre-operative lesion localisation in terms of ease, speed, accuracy andpatientcomfort.

Ideal Feature Localisation technique

HWL CarbonTrack

ROLL IOUS ROLLIS(I-125seed)

Lowcost 3 3 3 x 3

Flexibilitywithscheduling x 3 x 3 3

SuitableforUSandMGvisiblelesions

3 3 3 x 3

Nomovement/migration x NDA x 3 33

Bracketingavailable 3 NDA x 3 3

Minimaltrainingrequired 3 3 3 x 3

Usesexistingequipment 3 3 3 x 3

NoinferencewithSNB 3 3 3** 3 3

Noradiationdose x x x 3 x

Noriskofspill/contamination

3 x* x*** 3 3****

Shorttheatretime x NDA NDA x 34

Surgeoncanchoosesurgicalapproach

x x 3 3 3

Cosmesis NDA NDA NDA NDA NDA

NOTES

SECTION 2 I P33

• UseofIOUSavoidsneedforseparatepre-operativelocalisationprocedure,givesimmediatefeedbackastoadequacyoflesionexcisionandimproveslikelihoodofobtainingclearmargins7.

Specimen imaging important toconfirmexcisionof lesion/biopsymarker/seed,andneedforintra-operativere-excisionforclosemargins.

Goodcommunicationbetweenradiologist/nuclearmedicinephysicianandsurgeonisakeyfeatureinobtainingthebestoutcome.

References1 MoranMS,SchnittSJ,GiulianoAE,etal.SocietyofSurgicalOncology–American

Society for Radiation Oncology consensus guideline on margins for breast-conservingsurgerywithwhole-breastirradiationinstagesIandIIinvasivebreastcancer.Int J Radiat Oncol* Biol* Phys.2014;88:553-64.

2 Cochrane RA, Valasiadou P, Wilson AR, Al-Ghazal SK, Macmillan RD. Cosmesisandsatisfactionafterbreast-conservingsurgerycorrelateswiththepercentageofbreastvolumeexcised.Br J Surg.2003;90:1505-9.

3 van Riet YE, Maaskant AJ, Creemers GJ, et al. Identification of residual breasttumour localization after neo-adjuvant chemotherapy using a radioactive 125Iodineseed.Eur J Surg Oncol.2010;36:164-9.

4 Lovrics PJ, Goldsmith CH, Hodgson N, et al. A multicentered, randomized,controlled trial comparing radioguided seed localization to standard wirelocalization for nonpalpable, invasive and in situ breast carcinomas. Ann SurgOncol.2011;18:3407-14.

5 Gray RJ, Pockaj BA, Karstaedt PJ, Roarke MC. Radioactive seed localization ofnonpalpablebreastlesionsisbetterthanwirelocalization.AmJSurg.2004;188:37780.

6 Law MT, Kollias J, Bennett I. Evaluation of office ultrasound usage amongAustralianandNewZealandbreastsurgeons.WorldJSurg.2013;37:2148-54.

7 KrekelNM,ZonderhuisBM,StockmannHB,etal.Acomparisonofthreemethodsfornonpalpablebreastcancerexcision.EurJ SurgOncol.2011;37:109-15.

NOTESNOTES NEW TECHNIqUES AND TECHNOLOGIES IN RECONSTRUCTIONRaja Sawhney

Patientsconsideringbreastreconstructionrepresentadiversegroupofpatientswithregard to disease profile, surgical intervention for cancer extirpation and adjuvanttherapy.Thegoalsofreconstructionareeffectedbypatientdesire,age,comorbidities,expectations,psychosocialissuesandbodyspecificstonameafew.Optionsavailablealso depend on surgeon training, experience and available resources. A tailoredapproachisusuallyrequiredtoindividualiseamulti-stagereconstructionplan.Beyondthis a certain amount of fluidity is required as you may be required to modify yourplan in between stages. Patient education can be overwhelming and confusing forthepatientandmultipleconsultsareoftenrequiredtohelpthemattainareasonableunderstandingofoptionstobasetheirdecisionupon.

NoothersubspecialtyinPlastic&ReconstructiveSurgerybringstogetherformandfunction quite like breast reconstruction as aesthetics of the reconstructed breastareintegraltoit’sfunction.Thecomplexitiesandadvancesintreatmentregimessetthesceneforinnovation,useofnewtechniquesandnewtechnologyinthesearchforbetteroutcomesandreduceddonorsitemorbidity.

Wewilldiscuss• Avoidingskinislandsand“patchwork”inbreastreconstruction

o Pre-expansionfordelayedautologousreconstructiono SequentialexpansionandreductionofskinislandsfrompedicledLatissimus

Dorsireconstructions• Manipulatingmastectomyscarsindelayedreconstruction• Nipple-sparing mastectomy through Inframammary approach with immediate

reconstruction• UseofAcellularDermalMatricesinExpander/implantbasedreconstruction• AutologousFatTransferandtheBRAVAexternalexpansiondevice.

THERAPEUTIC MAMMOPLASTYRichard Sutton

NOTES

SECTION 2 I P35

SESSION 3:AxILLARY SURGERY KEYNOTE AND PROFFERED PAPERS

KEYNOTE ADDRESS: MANAGEMENT OF THE AxILLA POST-Z0011Hiram S Cody IIIMDBreastService,DepartmentofSurgery,MemorialSloan-KetteringCancerCenter;WeillCornellMedicalCollege

The widespread adoption of sentinel lymph node (SLN) biopsy as standard carefor axillary staging in cN0 breast cancer is supported by the results of at least 69observationalstudies1,7randomizedtrials2,3meta-analyses2-4,anASCOGuideline5,and an extensive literature covering all aspects of the procedure. These studiesestablish that patients with negative SLN do not require axillary dissection (ALND),that axillary local recurrence (LR) after a negative SLN biopsy is rare (0.3%)6, thatdisease-free (DFS)andoverallsurvival (OS)areunaffectedby theadditionofALNDtoSLNbiopsy,and that themorbidityofSLNbiopsy is less than thatofALND.Thelogicalnextquestion in theevolutionofaxillarystaging is toaskwhether thereareSLN-positivepatientswhocanavoidALND,andit isclearthatthereare:30-50%ofSLN-positivepatientshavediseaselimitedtotheSLN1.

Bilimoriaetal.7 reportpatternsofcarein97,314SLN-positivepatients(1998-2006)fromtheNationalCancerDataBase;23%withSLNmacrometastases(>2mm,pN1)and36%withSLNmicrometastases(0.2-2mm,pN1mi)didnothaveALND,yetaxillarylocalrecurrenceand5yearrelativesurvivalwereunaffected.Yietal.8reporton26,986SLN-positive patients (1998-2004) from the SEER database; they find that 11% ofthosewithSLNmacrometastasesand33%of thosewithSLNmicrometastasesdidnot haveALND,and OSat50monthswasunaffected.Both studies reportastrongtrendovertimeawayfromALNDforpatientswithSLNmicrometastases.Ninesmallerretrospectivestudies9comprising1035patientswithpositiveSLNandnoALNDreportlowratesofaxillaryLR,mostintherangeof0-2%,at28-82months’follow-up.

The most definitive data are from ACOSOG Z001110,11, a prospective randomized trialin which 813 SLN-positive patients with clinical stage T1-2N0 breast cancer wererandomized to ALND vs no further surgery. All were SLN-positive by routine H&Estainingandallhadbreastconservationincludingwhole-breastRT.Patientswith3ormorepositiveSLN(orwithmattednodes)wereexcludedandaxillary-specificRTwasnotallowed.Additionalpositivenodeswerefoundin27%ofthepatientswhohadALND,butat6years’follow-uptherewerenodifferencesbetweentheALNDandno-ALNDarmsinlocal(3.6%vs1.9%),regional(0.5%vs0.9%),oroveralllocoregionalrecurrence(4.1%vs2.8%)10,norwerethereanydifferencesindisease-freeoroverallsurvival11.CriticsofZ0011havefocusedonissuesofcaseselection(arguingthatyoungwomenandthosewithER-negativetumorswereunder-represented),followup(arguingthat6.3 years is inadequate), and statistical power (arguing that Z0011 did not meet itsplannedaccrualorstatisticalendpoints).Inresponse,MorrowandGiuliano12argueasfollows:1)youngerageisassociatedwithhigherratesofrecurrenceintheipsilateralbreast, but not in regional nodes, 2) ER-negative tumors are associated with earlyrelapsebutnotwithhigherratesofaxillarynodeinvolvement,3)mostwomenwithintheZ0011selectioncriteriaarepostmenopausalandER-positive,4)axillaryrecurrenceisanearlyevent(virtuallyalloccurwithinthefirst5years),and5)Z0011closedearly(based on slow accrual and a lower-than-expected rate of events) but achieved itspredefinedgoal,showingwithahighlevelofsignificancethatSLNbiopsyalonewasnotinferiortoALND.

NOTES The principal implications of Z0011 are surgical, and over the last 2 years manyinstitutionsandsurgeonsintheUS(andtoalesserextentworldwide)havefoundtheresults to be persuasive and practice-changing, incorporating into their treatmentguidelines a policy of “no-ALND” for SLN-positive patients who meet the Z0011selectioncriteria.Atourinstitutionwehavedonesosince2010and84%ofourZ0011-eligiblepatientshavebeenabletoavoidALND13.

WhataretheimplicationsofZ0011forbreastimagers?Preoperativeaxillaryultrasound(US) and US-guided needle biopsy were not part of Z0011 but are well-establishedworldwide14andhaveallowed the triageofnode-positivepatientsdirectly toALND.ForcN0patientswhomeettheZ0011entrycriteriawehavelargelyabandonedaxillaryUSandUSneedlebiopsy.AmongrecentZ0011-eligiblepatientstreatedwithoutaxillaryUS,about85%haveavoidedALND.EvenamongcN0patientswithapositiveUSneedlebiopsyabout70%haveavoidedALND(M.Pilewskie,unpublisheddata).

Whatare the implicationsofZ0011 for themedicaloncologist?Montemurroetal.15useposthoccasereviewtoarguethattheinformationgainedfromcompletionALNDcould change the indication for systemic chemotherapy in 16% of their patients.Reassuringly, two large trials which randomized SLN-positive patients to ALND vsno-ALND (ACOSOG Z001111) and ALND vs axillary RT (EORTC AMAROS16) found nodifferences in the usage of chemotherapy, hormonal therapy, or RT based on theperformanceofALND.

WhataretheimplicationsofZ0011fortheradiationoncologist?Positiveaxillarynodeswere presumably left behind in 27% of the no-ALND Z0011 patients but only 0.9%developedaxillaryLR.ModernCT-guidedtreatmentplanningallowstreatmentofatleastpartoftheaxillabyadjustingthesuperioranddeeptangentborders.AlthoughZ0011 did not allow supraclavicular or axillary fields, Haffty et al.17 suggest thatirradiation of the lower axillary nodes with “high tangents” to the breast may havecontributedtoalowrateofaxillaryLR,andRezniketal.18estimatethat“hightangents”treataxillarylevelsI,IIandIIIwith86%,71%and73%,respectively,oftheprescriptiondose.AnauditofZ0011isaskingwhetherparticipatingradiationoncologistsadjustedtheirtangentfieldsbasedontumorcharacteristicsandtheextentofaxillarysurgery.

Can the success of Z0011 be extended to Z0011-ineligible patients, specificallythosetreatedbya)mastectomywithoutRT,b)partialbreastirradiation(PBI),andc)neoadjuvantchemotherapy(NAC)?Regardingmastectomy,wehaverecentlyreported19on535SLN-positivepatientsfromthepre-Z0011erawhohadeithermastectomyorbreastconservationwithoutotheraxillary-specifictreatment:among234withN1miorN1disease,therewerenodifferencesat4yearsinregionalnoderecurrencebetweenmastectomy (97 patients, 2.5%) and breast conservation (134 patients, 1.5%). Thisloweventrateisencouragingbutrequireswiderconfirmationinprospectivestudiesspecifictomastectomy.RegardingPBI,theMammoSiteRegistryTrial(inwhichPBIisdeliveredthroughanintracavitaryballoon)hasreported5-yearaxillaryLRof0.8%inSLN-negativepatients20,aresultquitesimilartothatofnegativeSLNbiopsyingeneral(0.3%).TheTARGITTrial21,aninternationalmulticenterrandomizationofPBIgivenasasingleintraoperativedosetothetumorsite(n=1113)vsconventionalwhole-breastRT(n=1119)reportsnodifferencein4yearLR(1.20%vs.0.95%,p=0.41),orinaxillaryLR (J.S. Vaidya, personal communication). Both studies suggest that the effect ofwhole-breastRTonaxillaryLRinSLN-negativepatientsismodestatbest.NostudiesaddressSLN-positivepatientstreatedwithPBIandwithoutALND,butitisreasonabletoassumethattheresultswouldbeatleastasgoodasformastectomyand,totheextentthatthePBIpatientshaveearlier-stagedisease,probablybetter.

NOTES

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Regarding neoadjuvant chemotherapy (NAC), the false-negative rate of SLN biopsyafter NAC (in 27 studies comprising 2148 patients) is roughly comparable to thatof SLN biopsy in general, 10.5%22. The performance of SLN biopsy following NACin patients with biopsy-proven nodal metastases is the subject of two prospectiveobservational trials, ACOSOG 107123 and SENTINA24, which report false-negativeratesof12.8%(n=607)and14%(n=592),slightlyhigherthanforSLNbiopsyingeneral.Mamounas25 has recently reported on pattern of 10-year patterns of locoregionalrecurrence after NAC in NSABP B-18 and B-27; the highest rates of regional noderecurrencewereinclinicallynode-positivepatientswhosenodesremainedpositiveafterNAC.Twonewrandomizedtrialsaimtoclarifymanagementoftheaxillainnode-positivepatientsafterNAC.NSABPB-51/RTOG1304(www.nsabp.pitt.edu/)comprisespatientswhoseSLNbecomenegativeafterNAC,randomizingtoaxillaryRTvsnoRT,andAlliance11202(www.allianceforclinicaltrialsinoncology.org/)comprisesthosewhoseSLNremainpositive,randomizingtoALNDvsnofurthersurgery.EachpromisesamoreconservativeapproachtotheaxillafollowingNACinpatientswithnodalmetastases.

Looking furtherahead,wemustaskwhetheraxillarystaging isnecessaryatall.Weliveinanexcitingerawherepredictionincreasinglytrumpsprognostication,andwheremolecularclassificationincreasinglytrumpsconventionalhistopathology.The21-generecurrence score can predict chemotherapy benefit for node-negative26 and possiblyfor node-positive patients27, sparing them treatment from which they cannot benefit,andisthesubjectoflargerandomizedtrials(TailoRx28andRxPONDER(www.swog.org/rxponder)).Inthissetting,theroleoflymphnodestagingforbreastcancerisindecline.OurnextgenerationofclinicaltrialswillcompareSLNbiopsytonoaxillarystaging,andALNDwillincreasinglybeusedforsalvageratherthanpreventionoflocalrecurrence.

References1 KimT,GiulianoAE,LymanGH.Lymphaticmappingandsentinellymphnodebiopsy

inearly-stagebreastcarcinoma.Cancer2006;106(1):4-16.2 KellM,BurkeJ,BarryM,etal.Outcomeofaxillarystaginginearlybreastcancer:

ameta-analysis.Breast Cancer Res Treat2010;120(2):441-447.3 Wang Z, Wu LC, Chen JQ. Sentinel lymph node biopsy compared with axillary

lymphnodedissectioninearlybreastcancer:ameta-analysis.BreastCancerResTreat.2011;129(3):675-689.

4 Pesek S, Ashikaga T, Krag LE, et al. The false-negative rate of sentinel nodebiopsyinpatientswithbreastcancer:ameta-analysis.WorldJSurg.2012;36(9):2239-2251.

5 LymanGH,TeminS,EdgeSB,etal.Sentinellymphnodebiopsyforpatientswithearly-stagebreastcancer:AmericanSocietyofClinicalOncologyclinicalpracticeguidelineupdate.J Clin Oncol2014;32(13):1365-83.

6 vanderPloegIM,NiewegOE,vanRijkMC,etal.Axillaryrecurrenceafteratumour-negativesentinelnodebiopsyinbreastcancerpatients:Asystematicreviewandmeta-analysisoftheliterature.Eur J SurgOncol.2008;34(12):1277-1284.

7 BilimoriaKY,BentremDJ,HansenNM,etal.ComparisonofSentinelLymphNodeBiopsyAloneandCompletionAxillaryLymphNodeDissectionforNode-PositiveBreastCancer.J Clin Oncol2009:JCO.

8 YiM,GiordanoSH,Meric-BernstamF,etal.Trendsinandoutcomesfromsentinellymphnodebiopsy(SLNB)alonevs.SLNBwithaxillarylymphnodedissectionfornode-positivebreastcancerpatients:experience fromtheSEERdatabase. Ann.Surg.Oncol. 2010;17Suppl3:343-351.

9 CyrA,GaoF,GillandersWE,etal.Diseaserecurrenceinsentinelnode-positivebreast cancer patients forgoing axillary lymph node dissection. Ann Surg Oncol.2012;19(10):3185-3191.

NOTESNOTES10 GiulianoAE,McCallLM,BeitschPD,etal.ACOSOGZ0011:Arandomizedtrialof

axillarynodedissectioninwomenwithclinicalT1-2N0M0breastcancerwhohaveapositivesentinelnode.ASCOMeetingAbstracts2010;28(18_suppl):CRA506.

11 GiulianoAE,HuntKK,BallmanKV,etal.Axillarydissectionvsnoaxillarydissectioninwomenwithinvasivebreastcancerandsentinelnodemetastasis:arandomizedclinicaltrial.JAMA2011;305(6):569-575.

12 MorrowM,GiulianoA.ToCutIstoCure:CanWeReallyApplyZ11inPractice?Ann Surg Oncol2011;18(9):2413-2415.

13 DengelLT,VanZeeKJ,KingTA,etal.Axillarydissectioncanbeavoided in themajority of clinically node-negative patients undergoing breast-conservingtherapy.Ann Surg Oncol2014;21(1):22-7.

14 Houssami N, Ciatto S, Turner RM, et al. Preoperative ultrasound-guided needlebiopsyofaxillarynodesininvasivebreastcancer:meta-analysisofitsaccuracyandutilityinstagingtheaxilla.Ann Surg.2011;254(2):243-251.

15 MontemurroF,MaggiorottoF,ValabregaG,etal.OmissionofAxillaryDissectionafteraPositiveSentinelNodeDissectionmayInfluenceAdjuvantChemotherapyIndications in Operable Breast Cancer Patients. Ann Surg Oncol. 2012; 19(12):3755-3761.

16 Straver ME, Meijnen P, van TG, et al. Role of axillary clearance after a tumor-positive sentinel node in the administration of adjuvant therapy in early breastcancer.J Clin Oncol.2010;28(5):731-737.

17 Haffty BG, Hunt KK, Harris JR, et al. Positive sentinel nodes without axillarydissection: implications for the radiation oncologist. J Clin Oncol. 2011; 29(34):4479-4481.

18 Reznik J, Cicchetti MG, Degaspe B, et al. Analysis of axillary coverage duringtangential radiation therapy to the breast. Int J Radiat Oncol Biol Phys. 2005;61(1):163-168.

19 MilgromS,CodyH,TanL,etal.CharacteristicsandOutcomesofSentinelNode-PositiveBreastCancerPatientsafterTotalMastectomywithoutAxillary-SpecificTreatment.Ann Surg Oncol.2012;19(12):3762-3770.

20 Aburabia M, Roses RE, Kuerer HM, et al. Axillary failure in patients treatedwith MammoSite accelerated partial breast irradiation. Ann Surg Oncol. 2011;18(12):3415-3421.

21 VaidyaJS,JosephDJ,TobiasJS,etal.Targetedintraoperativeradiotherapyversuswhole breast radiotherapy for breast cancer (TARGIT-A trial): an international,prospective, randomised, non-inferiority phase 3 trial. Lancet 2010; 376(9735):91-102.

22 van Deurzen CH, Vriens BE, Tjan-Heijnen VC, et al. Accuracy of sentinel nodebiopsy after neoadjuvant chemotherapy in breast cancer patients: a systematicreview.Eur J Cancer2009;45(18):3124-3130.

23 Boughey JC, Suman VJ, Mittendorf EA, et al. Sentinel lymph node surgery afterneoadjuvantchemotherapyinpatientswithnode-positivebreastcancer:theACOSOGZ1071(Alliance)clinicaltrial.JAMA2013;310(14):1455-1461.

24 KuehnT,Bauerfeind I,FehmT,etal.Sentinel-lymph-nodebiopsy inpatientswithbreastcancerbeforeandafterneoadjuvantchemotherapy(SENTINA):aprospective,multicentrecohortstudy.Lancet Oncol.2013;14(7):609-618.

25 Mamounas EP, Anderson SJ, Dignam JJ, et al. Predictors of locoregionalrecurrenceafterneoadjuvantchemotherapy: results fromcombinedanalysisofNationalSurgicalAdjuvantBreastandBowelProjectB-18andB-27.J Clin Oncol.2012;30(32):3960-3966.

26 Paik S, Tang G, Shak S, et al. Gene expression and benefit of chemotherapy inwomenwithnode-negative,estrogenreceptor-positivebreastcancer.

J Clin Oncol 2006;24(23):3726-3734.27 AlbainKS,BarlowWE,ShakS,etal.Prognosticandpredictivevalueofthe21-gene

recurrence score assay in postmenopausal women with node-positive, oestrogen-receptor-positive breast cancer on chemotherapy: a retrospective analysis of arandomisedtrial.Lancet Oncol.2010;11(1):55-65.

28 SparanoJA.TAILORx:trialassigningindividualizedoptionsfortreatment(Rx).Clin Breast Cancer2006;7(4):347-350.

NOTESLIPOSUCTION FOR ADVANCED LYMPHOEDEMA – IMPACT OF LIPOSUCTION ON LIMB VOLUMES. SURGICAL TREATMENT RESULTS FROM AUSTRALIAKoelmeyer L.A1, Kastanias K1, Sedger L.M1, Lam T.C2, Ngo q.D2, Heydon-White A3, Sherman K.A4, Winch C1, Magnussen J.S5, Munnoch A6, Mackie H2, Boyages J1,2

1MacquarieUniversityCancerInstitute,MacquarieUniversity,Australia2MacquarieUniversityHospital,MacquarieUniversity,Australia3TheClinicPhysiotherapy,MacquarieUniversityHospital,MacquarieUniversity,

Australia4DepartmentofPsychology,MacquarieUniversity,Australia5MacquarieMedicalImaging,MacquarieUniversityHospital,MacquarieUniversity,

Australia6DepartmentofPlasticSurgery,NinewellsHospital,Dundee,UnitedKingdom

BackgroundAlthoughliposuctionhasbeenestablishedasatreatmentforadvancedlymphoedemain Europe and Scandinavia, determining its effectiveness in a hotter country likeAustraliaisimportant.

MethodsAprospectiveanalysisonpatientswithunilateral,non-pitting,primaryorsecondaryadvanced (ISL stage ll or lll) lymphoedema, with a calculated limb volumedifferencegreaterthan25%,andforwhomconservativetherapieswerenolongereffective,wascarriedout.EligiblepatientsattendedthemultidisciplinaryAdvancedLymphoedemaAssessmentClinic (ALAC),ofwhom37%travelledfrominterstateor New Zealand. Liposuction was performed under general anaesthesia andappropriatecompressiongarmentsorReadyWrapswereappliedintra-operativelyandcontinued throughout follow-up.Followingsurgery,patientsweremonitoredat6weeks,3,6,9,12,18and24monthswithbioimpedancespectroscopy(L-Dex),volume differences using circumferential measurements, Magnetic ResonanceImaging(MRI)andfunctionalassessments.

ResultsBetweenMay2012andJune2014,106patientsattendedALAC,57 (55.7%)aged55±11.6yearswereeligible for liposuctionsurgery.Twenty-fourpatients (40.7%)whohaveundergonesurgery(ofwhom66.6%hadapreviousdiagnosisofbreastcancer)hadameanpre-surgicalpercentagelimbvolumedifferenceof43.6%(range,23-83).At six-week post-surgery mean limb difference reduced to 12.4% (range, -2-24),(t(23)=10.29, p<0.001). With continued compression at 6-month post-surgery, meanlimb volume further reduced to 3.8%, an 89.6% reduction of pre-surgical volume(t(18)=9.17,p<.001).By12monthspost-surgerywithareductionof97.2%(t(9)6.54,p<.001), equal volume was nearly obtained. For those who had an eighteen-monthpost-surgery assessment (n=3), affected limb was now smaller than unaffectedlimbwithamean limbexcessvolumeof -5.3% (p=.042).Therehavebeennomajorcomplicationsfromthesurgery.

ConclusionLiposuction isasafeandeffectiveoptionforcarefullyselectedAustralianpatientswithadvancedlymphoedemaassessedandtreatedbyamultidisciplinaryteam.

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NOTES WHAT SHOULD BE USED FOR LOWER POLE COVERAGE IN IMMEDIATE TWO-STAGE ExPANDER / IMPLANT BASED BREAST RECONSTRUCTION? Farid Meybodi*, Ines Prasidha, James French, Jeremy Hsu, Elisabeth ElderWestmeadBreastCancerInstitute,Australia

Background and purposeImplant-basedreconstructionisthemostcommontypeofpostmastectomyimmediatebreast reconstruction. This can be performed either with a single-stage, direct toimplantmethodorasatwo-stageinsertionoftissueexpanderfollowedbyadelayedexchangetoapermanentgelimplant.Acommoncriticismofthetwo-stagedtechniqueisthelackoflowerpoleprojection.Whiletheuseofdifferentmaterialstoprovidelowerpolecoverageiswellestablishedindirecttoimplantreconstruction,thebestmethodforcoverageintwo-stagereconstructionsremainsunclear.

MethodsFromNovember2013toJuly2014,24breastsin20patientswerereconstructedwithanatomicaltissueexpandersandassessedduringthecourseoftheirexpansionusingthree-dimensionalphotography(3-D).Fourdifferenttechniquesincludinglipodermalflap(LF),biologicmesh(BM),serratusanterioradvancementflap(SA)andsyntheticmesh(SM)wereusedtoachievelowerpolecoverage.

3-DphotographywasperformedusingtheCanfieldVectrasystembeforeandafter55expansions,andattheendofexpansionprocess.Distributionofaddedvolumeintheupperandlowerpoleofthebreastswerecalculatedandcomparedbetweengroups.

ResultsLowerpolecoveragewasachievedusingaLF in12/24 (50%),BM in5/24 (21%),SAin 3/24 (13%) and SM in 4/24(17%). Volume distribution immediately after eachexpansion (50-200 ml per session) was not significantly different between groups.ThemeanproportionoffinallowerpoleexpansionwassignificantlyhigherinLFandBMcomparedtoSAandSM(47±10%versus36±8%;p<0.05).

ConclusionBetter lowerpoleexpansionwasachievedusinga lipodermalflaporbiologicmeshwhencomparedtototalmusclecoverageorsyntheticmesh.

NOTES

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CAN THE CONTENT OF SEROMA FLUID FROM MASTECTOMY OR AxILLARY CLEARANCE WOUNDS PREDICT CLINICAL COURSE?Lim C,* Akra R, Yarrow S, Segara D, Soon PDeptofGeneralSurgery,Bankstown-LidcombeHospital,NSWAustralia

Background and purposeDependingon themethodofdetection, the incidenceofseromaaftermastectomyoraxillary dissection varies from 10-85%. After mastectomy or axillary clearance, itis standardpractice toplaceasuctiondrain to remove theseromafluid.Becauseofthepotentialriskofinfection,thesuctiondrainisoftenremovedafteraweekwiththeresultantneedforsubsequentwoundaspiration.

The purpose of this study is to determine whether the content of seroma fluid aftermastectomyoraxillaryclearanceforbreastcancerisabletopredicttheclinicalcourseofseromaproductionandhenceaffectclinicaldecision-making.

MethodsAllpatientsundergoingmastectomyand/oraxillaryclearanceatBankstownHospitalfromMay2013toMay2014whoareabletoprovideinformedconsentwererecruited.Drain fluid was sent for microscopy for cell count and biochemical analysis forferritin,sodium,potassium,protein,albuminandcalciumlevelsonD2andD7postop.Total seroma output was documented from the patient’s clinical notes.StatisticalanalyseswasperformedusingPearson’srankcorrelationonSPSS.

Results37subjectswererecruitedforthepurposeofthestudy.(26IDC,4ILC,4DCIS,3others).Themeantumoursizewas35mmandthemeantotalseromavolumewas762mlswithanincreaseinthetumoursizecorrespondingwithincreasedseromaoutput.(p=0.017).

Therewasasignificantincreaseintheferritinlevelofseromafluidfrom937to1343overD2toD7.(P<0.001)CorrelationexistsbetweentheD7proteinandalbuminlevelsandthetotalseromavolumewithlowproteinandalbuminlevelsfavouringanincreasedseromaoutput.(p=0.002,p=0.001).

ConclusionThisstudysuggests thatanalysisofseromafluid forproteinandalbumin levelsonD7 may be useful in predicting total seroma volume and hence influence clinicaldecision-makingregardingdrainremoval.

ReferenceDivino CM, Kuerer HM, Tartter PI: Drains Prevent Seromas Following LumpectomywithAxillaryDissection.Breast J6:31-33,2000.

NOTES POSITIVE ANTERIOR MARGINS IN BREAST CONSERVING SURGERY: DOES IT MATTER?: A SYSTEMATIC REVIEW OF THE LITERATUREAng S.C*1, Tapia G2, Davidson E.J3, Kahramangil B4, Mak C3, Carmalt H3, Warrier, S3

1 Department of General Surgery, Royal Prince Alfred Hospital, Sydney, New SouthWales,Australia

2BreastSurgeryResearcher,RoyalPrinceAlfredHospital,Sydney,NewSouthWales,Australia

3 Department of Breast Surgery, Royal Prince Alfred Hospital, Sydney, New SouthWales,Australia

4HacettepeUniversityFacultyofMedicine,Ankara,Turkey

Background and purpose Arecentconsensusguidelineforbreastconservingsurgery(BCS)reportedthatpositivemarginsareassociatedwithanincreasedriskofipsilateralbreasttumorrecurrence(IBTR)1. Ithasbeenreported that involvementofanatomicallynon-breastmargins,suchasanteriormargins,isassociatedwithlowerriskofIBTRthanradialmargins.Although it is common practice among breast surgeons not to re-excise positiveanteriormargins(PAM);thereisnoconsensusregardingthispractice.Thepurposeofthissystematicreviewistofindevidencethatassessesthispractice.

MethodsAsystemicliteraturereviewwasperformedthroughnineelectronicdatabasesfromJanuary1995toJuly2014.Relevantstudiesincludedthosethatdiscussedanatomicallocation of involved margins in BCS. Studies were selected independently by threereviewersaccordingtopredefinedselectioncriteria.

ResultsOf 677 articles, five studies were identified evaluating PAM. A retrospective studyexamined re-excision rates and percentage of residual disease in PAM, but did notreportIBTRrates.Anotherstudyreported2,5%ofIBTRinpatientswithnonnegativemargin treated by radiation (23% corresponded to anterior margin)2. An Americansurveyshowedthat47%ofsurgeonswouldnotre-exciseaPAM,whileaBritishsurveyshowedthat71%ofsurgeonswouldnotre-exciseaPAMof1mm.AlatersurveyintheUKreported that43.8%surgeonswouldnot re-exciseaPAM inDCIS,whilst29.2%wouldnotforinvasivecarcinoma.

ConclusionCommonsurgicalpracticestonotre-exciseaPAMcontradictcurrentguidelinesthatrecommend obtaining negative margins to reduce the risk of IBTR. However, thereisscarceevidenceoftherelationshipbetweenIBTRandPAMinBCS.Somestudiesindicatethatre-excisionofPAMhaslimitedbenefitduetoalowresidualdiseaseafterre-excision.Furtherstudiesarerequiredtoevaluatethistopic.

References1 J Clin Oncol32:1507-1515.Moranetal.2 Am J Clin Oncol2007;30:146–151.McIntosh.

NOTES

NOTESROLLIS” RADIOGUIDED OCCULT LESION LOCALISATION USING IODINE-125 (I-125) SEEDS FOR REMOVAL OF IMPALPABLE BREAST LESIONS: FIRST AUSTRALIAN RESULTS Taylor D*1,2, Bourke A2,3, Hobbs M1,2, Westcott E4, Saunders C1,2

1 DepartmentofRadiology,RoyalPerthHospital2 SchoolofSurgery,UniversityofWesternAustralia3 DepartmentofRadiology,SirCharlesGairdnerHospital4 DepartmentofMedicalTechnologyandPhysics,SirCharlesGairdnerHospital

BackgroundApproximately one third of breast cancers are impalpable, requiring pre-operativelocalisation1. Current techniques, including hookwire (HWL), carbon tracks andultrasound, have disadvantages. Low activity radioactive iodine-125 seeds are apromisingalternativeused in theUSandNetherlands.ThesepilotstudiesdescribethefirstuseofthisinAustralia.

MethodsAtotalof120participants(ROLLISpilotandpilotextensionstudies)underwentROLLISwithHWLforback-up. If indicated,sentinelnode(SN)biopsywasundertakenusingtechnetium-99(Tc-99m)colloidandahand-heldgammaprobe.Eligibilitycriteriaforbothstudiesaresummarised:

Outcomesmeasuredincludedeaseofhook-wireandseedinsertion,dependenceonROLLISvsHWLduringsurgery,histopathologyincludingsizeofradialmargins,easeofseedretrievalbypathology,safetyincludingreturnofseedsfordisposal,learningcurvewithROLLIS,andre-excisionratecomparedtohistoricalinstitutionaldata.

Results• Allseedsandlesionswereremoved• Nocasesofseedmigration• Learningcurvewasshort–2cases• Surgeons/radiologistspreferredROLLIS• SNbiopsywassuccessfulwhereindicated• Re-excisionrateforgroupB(extensionstudy):17.11%

ROLLISpilotextensionstudyn=99 ROLLISpilotstudyn=21

Inclusion criteria•Informedconsent•Female≥40years•Impalpablelesion•Pre-operativecorebiopsy•Candidateforbreastconservingsurgery(BCS)

•GroupA:benign/indeterminatelesions•GroupB:malignantlesions

•Solitarymalignantlesion

Exclusion Criteria•Pregnancy/lactation•BCScontraindicated•RecentNuclearMedicineorPETradioisotopeadministrationthatmayadverselyaffecttheprocedure(isotopeswithlonghalflifeeggallium-67,thallium-201)

•Periaraeolarlesion(ifSNmappingrequired)

•Intraductallesion•Peri-areolarlesion

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NOTESNOTES Lessons• Radiologistsshoulddeployseedbeforewire,placeseedondeepsurfaceof the

lesionandavoidantero-posteriorbracketing.• Surgeonsshouldfamiliarisethemselveswithcorrectgammaprobesettingsand

removesentinelnodebeforethebreastlesion.

ConclusionROLLISisaneasilylearnt,safeandeffectivealternativetechniquetostandardHWL.

Reference1 AhmedM,DouekM.Radioactiveseedlocalisation(RSL)inthetreatmentofnon-

palpablebreastcancers:Systematicreviewandmeta-analysis.The Breast.20138//;22(4):383-8.

NOTES

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SESSION 4A:RADIOTHERAPY AND RECONSTRUCTION

ACCELERATED PARTIAL BREAST IRRADIATION – COCHRANE REVIEW Brigid HickeyRadiationOncology,MaterService,Brisbane

Breastconservingtherapyforwomenwithbreastcancerconsistsoflocalexcisionofthetumour(achievingclearmargins)followedbyradiationtherapy(RT).RTisgiventosterilizetumourcellsthatmayremainaftersurgerytodecreasetheriskof localtumourrecurrence.Mosttruerecurrencesoccurinthesamequadrantastheoriginaltumour.WholebreastRTmaynotprotectagainstthedevelopmentofanewprimarycancer developing in other quadrants of the breast. In this Cochrane Review, weinvestigatedtheroleofdeliveringradiationtoalimitedvolumeofthebreastaroundthetumourbed(partialbreastirradiation:PBI)sometimeswithashortenedtreatmentduration(acceleratedpartialbreastirradiation:APBI).

ObjectivesTo determine whether PBI/APBI is equivalent to or better than conventionalor hypofractionated WBRT after breast conservation therapy for early-stagebreastcancer.

Search methodsWesearchedtheCochraneBreastCancerGroupSpecialisedRegister(07November2013),CENTRAL(2014,Issue3),MEDLINE(January1966to11April2014),EMBASE(1980to11April2014),CINAHL(11April2014)andCurrentContents(11April2014).Wesearchedthe InternationalStandardRandomisedControlledTrialNumberRegister,the World Health Organization’s International Clinical Trials Registry Platform (07November 2013) and US clinical trials registry (www.clinicaltrials.gov) (22 April2014).WesearchedOpenGrey(23April2014),referencelistsofarticles,conferenceproceedingsandpublishedabstracts,nolanguagerestrictionswereapplied.

Selection criteriaRandomised controlled trials (RCTs) without confounding, evaluating conservativesurgeryplusPBI/APBIversusconservativesurgerypluswholebreastRT.Weincludedpublishedandunpublishedtrials.

Data collection and analysisThreereviewauthors (ML,DFandBH)extracteddata.Weentereddata intoReviewManager for analysis. BH and ML assessed trials and graded the methodologicalquality.Anydisagreementswereresolvedthroughdiscussion.

Main resultsWeincludedfiveRCTs(3558women).TwooldertrialsexaminedRTtechniqueswhichdonot reflectcurrentpracticeandone trialhadashort follow-up.Wedowngradedthe quality of the evidence for key outcomes due to risk of bias. Following GRADErecommendations,thequalityofevidenceforouroutcomeswasverylowtolow.Forthecomparisonofpartialbreastirradiation/acceleratedbreastirradiation(PBI/APBI)withwholebreastirradiation(WBRT),localrecurrence-freesurvivalappearedworse(Hazard Ratio (HR) 1.98, 95% confidence interval (CI) 1.43 to 2.75; four trials, 2445participants,verylowqualityevidence).CosmesisappearedimprovedwithPBI/APBIinasingletrial(OR0.40,95%CI0.23to0.72;onetrial,241participants,verylowqualityevidence),butlatetoxicity(telangiectasiaOR4.41,95%CI3.21to6.05;verylowqualityevidence,708participants)andsubcutaneousfibrosis(OR4.27,95%CI3.04to6.01;

NOTES onetrial,710participants,verylowqualityevidence)appearedincreasedinanothertrial.WefoundnoclearevidenceofadifferenceforthecomparisonofPBI/APBIversusWBRTfortheoutcomesof:overallsurvival (HR1.0,95%CI0.85to1.18; fourtrials,2445participants,verylowqualityevidence),cause-specificsurvival(HR0.98,95%CI0.78to1.24;threetrials,966participants,lowevidencequality),distantmetastasis-freesurvival (HR1.01,95%CI0.82 to1.24;1140participants, lowqualityevidence),subsequentmastectomyrate(OR0.20,95%CI0.01to4.21;258participants,lowqualityevidence)andrelapse-freesurvival(HR0.99,95%CI0.53to1.85;258participants,lowqualityevidence).Newipsi-lateralprimariesappeared increasedwithAPBI/PBI (OR29.77,95%CI1.77to500.15;1305participants,onestudy).Wefoundnodatafortheoutcomesofacutetoxicity,costs,qualityoflifeorconsumerpreference.

Authors’ conclusionsThe limitationsof thedatacurrentlyavailablemean thatwecannotmakedefinitiveconclusions about the efficacy and safety or ways to deliver of PBI/APBI. We awaitcompletionofongoingtrials.

ReferencesDodwellDJ,DykerK,BrownJ,HawkinsK,CohenD,SteadM,etal.Arandomisedstudyofwhole-breastvstumour-bedirradiationafterlocalexcisionandaxillarydissectionforearlybreastcancer.Clinl Oncol2005;17(8):618-22.LehmanM,HickeyBE,FrancisDP,SeeAM.Partialbreastirradiationforearlybreastcancer.CochraneDatabaseofSystematicReviews2014,Issue6.Art.No.:CD007077.DOI:10.1002/14651858.CD007077.pub2.Polgár C, Fodor J, Major T, Sulyok A, Kásler M. Breast-conserving therapy withpartialorwholebreastirradiation:ten-yearresultsoftheBudapestrandomizedtrial.Radiotherapy and Oncology2013;108(2):197-202.RibeiroGG,MageeB,SwindellR,HarrisM,BanerjeeSS.TheChristieHospitalbreastconservationtrial:anupdateat8yearsfrominception.Clin Oncol 1993;5(5):278-83.VaidyaJS,WenzF,BulsaraM,TobiasJS,JosephDJ,KeshtgarM,etal.Risk-adaptedtargeted intraoperative radiotherapy versus whole-breast radiotherapy for breastcancer: 5-year results for local control and overall survival from the TARGIT-Arandomisedtrial. Lancet 2013;383(9917):603.Veronesi U, Orecchia R, Maisonneuve P, Rotmensz N, Sangelli C, Luini A, et al.Intraoperative radiotherapy versus external radiotherapy for early breast cancer(ELIOT):arandomisedequivalencetrial. Lancet Oncol 2013;14(13):1269-77.

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PARTIAL BREAST IRRADIATION: MSKCC ExPERIENCEHiram S Cody IIIMDBreastService,DepartmentofSurgery,MemorialSloan-KetteringCancerCenter;WeillCornellMedicalCollege,NewYor,USA

Following breast-conserving surgery, accelerated partial breast irradiation (APBI)appearstobeareasonablealternativetoconventionalwhole-breastRT(WBRT),andinproperlyselectedpatientstoachievecomparableoutcomes.APBIhasthehypotheticaladvantagesoftreatingthatportionofthebreastatgreatestriskforlocalrecurrenceandofpreservingtheoptionforwhole-breastRTinthefuture;APBIalsohasthepracticaladvantagesofshortenedtreatmenttimeandpatientconvenience.APBIisappropriatefor breast cancer patients with early-stage disease at low risk for ipsilateral breasttumorrecurrence(IBTR),andtheASTROselectioncriteriaarerepresentative:age>60,unicentric,T1ductal(orfavorablesubtype)cancer,ER-positive,node-negative,marginsnegative,andnon-extensiveDCIScomponent1.

TheAmericanSocietyofBreastSurgeonsMammositeRegistryhasreportedexcellent5-yearresultsforAPBIdeliveredbyintracavitaryballoon(35Gyin10fractionsover5days)in1449patients,withsurvivalandlocalcontrolcomparabletothoseofWBRT2.IntheTARGITrandomizedtrialcomparingsingle-doseintraoperativeRT(IORT)withconventionalWBRT3,theauthorsobserved2%moreIBTRbutfewernon-breastcancermortalities in the IORT arm, with no differences in breast cancer specific survival.NASBPB-39,arandomizationbetweenPBI(deliveredbyintracavitaryballoon,catheterbrachytherapy, or external beam) and conventional WBRT, has completed accrualbutnotyetreportedresults.OurownexperiencewithIORTislimited;in52patientstreatedwithsingle-doseIORTusingaHammapplicatorandfollowedfor1year,wehaveobservedbettercosmeticoutcomesatadoseof18Gy(patients#19-52)thanwithourinitialdoseof20Gy(patients#1-18)4.

OurinterestinIORThasdiminishedsignificantlyovertime,basedontheobservationthatmanypatientswhomeettheselectioncriteriaforPBImaynotrequireRTatall.Hughesetal.5haverecentlyreported10yearresultsofCALGB9343,arandomizationof 636 women >70 with cT1N0 ER+ breast cancers to lumpectomy followed by RTplus tamoxifen vs tamoxifen alone. Locoregional recurrence was less frequent withRT(2%vs10%)butthisdidnottranslateinanysignificantdifferencesintherateofmastectomy(2%vs4%),timetomastectomy,timetodistantmetastasis,breastcancerspecificsurvivaloroverallsurvival.

1 SmithBD,ArthurDW,BuchholzTA,etal.Acceleratedpartialbreast irradiationconsensusstatementfromtheAmericanSocietyforRadiationOncology(ASTRO).Int J Radiat Oncol Biol Phys.2009;74(4):987-1001.

2 Vicini F, Beitsch P, Quiet C, et al. Five-Year Analysis of Treatment Efficacy andCosmesis by the American Society of Breast Surgeons Mammosite BreastBrachytherapyRegistryTrialinPatientsTreatedwithAcceleratedPartialBreastIrradiation. Int J Radiat Oncol Biol Phys.2010.

3 VaidyaJS,JosephDJ,TobiasJS,etal.Targetedintraoperativeradiotherapyversuswhole breast radiotherapy for breast cancer (TARGIT-A trial): an international,prospective, randomised, non-inferiority phase 3 trial. Lancet 2010; 376(9735):91-102.

4 SacchiniV,BealK,GoldbergJ,etal.Studyofquadranthigh-doseintraoperativeradiationtherapyforearly-stagebreastcancer.Br J Surg 2008;95(9):1105-10.

5 Hughes KS, Schnaper LA, Bellon JR, et al. Lumpectomy plus tamoxifen withorwithout irradiation inwomenage70yearsorolderwithearlybreastcancer:long-termfollow-upofCALGB9343.J Clin Oncol 2013;31(19):2382-7.

NOTES ISSUES IN TREATING PATIENTS WITH RECONSTRUCTIONMarie-Frances BurkeGenesisCancerCareQueensland

Formanywomenwithbreastcancer,radiationtreatmentcanhaveanimportantroletoplayaftermodifiedradicalmastectomy.Post-mastectomyradiationcanbegiventoreducetheriskoflocalrecurrence,andcanalsoimprovesurvivalinselectedpatients.Typically,thesearewomenwith4ormorepositivelymphnodes,tumourslargerthan5cmorwithpositivesurgicalmargins.Currently,thereareworldwidetrialsgoingontoassessthebenefitofpost-mastectomyradiationinwomenwith1-3positivenodes.Outsideofthesetrialsitisnotunusualforwomentobeconsideredforpost-mastectomyradiationinlightofotheradversefactors,suchas,lymphovascularinvasion,youngageand multifocality. So potentially the use of post-mastectomy radiation will increaseovertime.

With advances in plastic surgical techniques, immediate breast reconstruction isnowanoptionformanypatientswhoundergomastectomy,andfromapsycho-socialand sexual standpoint, breast reconstruction plays a highly important role in themanagementofpatientswithbreastcancer.Concernaboutimmediatereconstructionthough exists when a patient is likely to need chest wall radiation. These concernshave included an increased incidence of complications, poorer cosmetic outcomeandtechnicalproblemsintheadministrationofradiation.Theratesofcomplications,as well as the aesthetic outcomes, vary depending on the timing of the radiationtreatmentinrelationtothereconstruction,aswellasthetypeofreconstructionused.Hence, a multidisciplinary collaboration is warranted in which the breast surgeon,plasticsurgeonandradiationoncologistconferwithoneanotherandwiththepatient,to ensure the best cosmetic outcome without compromising the proven benefits oftimelypost-mastectomyradiationtreatment.

In the setting of breast reconstruction, the effects of radiotherapy are potentiallytwofold,withconsiderationrequiredontheimpactofimmediatebreastreconstructionontheadministrationofandtheinitiationofradiationtherapy,aswellastheeffectsofradiotherapyonoperativecomplicationsandcosmeticoutcomefollowingimmediatebreastreconstruction.

Breast reconstruction may impact on the delivery of radiotherapy, by altering thecontour of the chest wall and making the design of the radiotherapy fields morechallenging.Modernadjuvantradiationtreatmentfieldsmay includethechestwall,internalmammarynodes,supraclavicularnodesandtheapexoftheaxilla.Distortingtheanatomywithabreast reconstructionmay lead tocompromises infielddesign,diminish the radiation dose available in some areas, or dictate the need for widerradiationfieldswithmorenormaltissuebeingirradiated1.

The impact of breast reconstruction on delaying the administration of radiotherapyhas been explored in only a few studies, despite the fact that there may be pooreroncological outcomes with treatment delays. Those studies that have addressedtheissuehaveallbeenrelativelysmall innumbersandbasedatsingleinstitutions.Theyhavenotshownadelayincommencementofadjuvantradiationtreatmentthough,inpatientsundergoingimmediatebreastreconstruction2.

Post-mastectomyradiationtreatmentcanresultinhighratesofcontracture,fibrosis,poorer wound healing and poor cosmesis in both implant based reconstructionsand autologous reconstructions. There is no consensus in the literature however,astowhich istheoptimalmethodwhenpost-mastectomyradiation isplanned.Theeffectsofradiotherapyonareconstructedbreastmayhoweverbelessthanpreviouslysuggested,assomeofthestudiesshowingsevereeffectswereassociatedwitholder

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regimes and modes of administration of radiotherapy, and more recent techniquessuch as Intensity Modulated Radiation Treatment and Tomotherapy may improveoutcomesinthesettingofbreastreconstruction3,4.

Immediate breast reconstruction can be successfully performed in the setting ofpost-mastectomyradiationinmostpatients,butfurtherstudyisneededintooptimalmethodsandtiming,andoptimalradiationtreatmenttechniques.Anyrecommendationmadetoanindividualpatientmustbedoneinacollaborativefashionbetweenbreastsurgeons,plasticsurgeonsandradiationoncologists.

References1 Motwani S, Strom E, Schechter N, et al. The impact of immediate breast

reconstruction on the technical delivery of postmastectomy radiotherapy. Int J Radiat Oncol Biol Phys.2006;66:76-82.

2 SalhabM,AlSarakbiW,JosephA,etal.Skin-sparingmastectomyandimmediatebreastreconstruction:patientsatisfactionandclinicaloutcome. Intl J Clin Oncol2006;11:51-4.

3 Massabeau C, Fournier-Bidoz N, Wakil G, et al. Implant breast reconstructionfollowedbyradiotherapy:Canhelicaltomotherapybecomeastandardirradiationtreatment?Medical Dosimetry2012;37:425-431.

4 KoutcherL,BallangrudA,CordeiroPG,etal.Postmastectomyintensitymodulatedradiation therapy following immediate expander-implant reconstruction.Radiotherapy and Oncology2010;94(3):319-323.

NOTES RECONSTRUCTIVE OPTIONS IN THE HIGH RISK PATIENT Raja Sawhney

Highriskpatientsforreconstructioncanbedividedintothosewhohavehighriskfordiseaserecurrenceandthoseathigherriskofcomplicationsorfailurerelatedtoreconstruction.

High risk disease encompasses those with advanced local tumours in the breast,nodaldiseaseandevenmetastaticdisease.Haltingreconstructioneffortsuntilhighrecurrenceriskperiodshavepastissensibleandshouldremainthemainstay.Itdoeshoweverleavesomeofthesepatientsindespairinwhatmayevenbetheirlastyearsof life. Furthermore, disease is unpredictable and many high risk patients do notrecur and some live with metastatic disease for lengthy periods. High risk diseasedoes have implications on reconstruction efforts. Utilising less invasive options ina definitive or temporising manner may plausible in the patient who would like topursuereconstructionatanearlystageratherthanwaittosatisfydiseasefreesurvivalcriteria.Issuestoconsiderincludebudgetsandresourcemanagement.Decisionsherearedifficultwithsomephilosophicalcontroversies.

High riskpatients for reconstructionagainhaveawidearray.Radiotherapy is themajortreatmentfactorfollowedbychemotherapythateffecttissuecharacteristicsandvascularity.Tissuesbecomerestrictiveandhealpoorlychallengingreconstructiveefforts.Radiotherapyisoftenunilateralsoachievingsymmetrytoanativeornon-irradiated contralateral reconstruction can invite complexity. Couple this with co-morbidities,overweightbodyhabitusandhighexpectationsand theplot thickens.Nevertheless,wehavesomewelltravelledroadsandsomenewlesstravelledonestoleadustoourdestination.Generallyspeakingwetendtofavournewvascularisedtissue import as at least part of the reconstruction in radiotherapied patients.That said in the select patient with less effected tissues expander/implant basedreconstructionscanstillachievereasonableresultsalbeitwithahighercomplicationriskprofile.Autologousfattransfercanimprovetissueeffectsfromradiotherapybutnotreversethemcompletely.Ontheotherhand,olderpatientswithcomorbiditiesgenerallysuitlessinvasiveproceduresandtheaimsofreconstructionmaybeinlinewithlowerexpectations.

Hottopics• Immediate expansion in pts likely to need adjuvant therapy to maintain skin

envelopefordelayeddefinitivereconstruction• Neoadjuvantradiotherapyfollowedbymastectomyandimmediatereconstruction• Composite reconstruction with autologous fat transfer and implants after

radiotherapy• One-stagehybridexpandersforolder,co-morbidandhighriskdiseasepatients

NOTESSESSION 4B:SURVIVORSHIP: OPTIMISING LIFE AFTER CANCER

PHYSICAL HEALTH AND qUALITY OF LIFE IN BREAST CANCER SURVIVORSSandi HayesInstituteofHealthandBiomedicalInnovation,QueenslandUniversityofTechnology

Approximately13,000Australianwomenarediagnosedwithbreastcancereachyear,representingthemostcommoncanceramongwomenandaccountingfornearlyone-thirdofallcancerdiagnoses.Whilethevastmajorityofwomendiagnosedwithbreastcancerwillnotdiefromthedisease(5-yearsurvival,88%),breastcancerisaleadingcancer cause of burden, contributing to significant number of ‘healthy life years’lost. Thecurrentmodelofcancercareisfocusedondiseasetreatmentfollowedbyongoingcancerrecurrencesurveillance.However,asbreastcancersurvivalcontinuesto increase among Australian women, so too does our need to understand theirtreatment-relatedconcerns,andtoidentifysafe,effective,evidence-basedstrategiestoimprovethequalityandquantityoftheirsurvival.

Breastcanceranditsassociatedtreatmentareassociatedwithamyriadofadversephysicalandpsychosocialeffects.Despitemajoradvancesinbreastcancertreatmentthathavecontributedtoless-invasiveandmoretargetedtreatment,treatment-relatedimpairmentsremaincommonandpersistintolonger-termsurvivorship.Themajority(>65%) of breast cancer survivors experience at least one impairment. As such,womentypicallysufferfromtheaggregateburdenofimpairments,presenceofotherco-morbidities and disease treatment. Unfortunately, it is not uncommon for theseimpairmentstogounrecognizedanduntreateduntiltheyreachlevelsthatsignificantlyinfluencefunction,qualityoflifeandpotentiallysurvival.

Evidence is overwhelming and compelling for the benefits of exercise following thediagnosisofbreastcancer.Exercisereducesthenumberandseverityoftreatment-relatedimpairmentsduringtreatment,andoptimisesfunctionandqualityoflifeduringandbeyondthecancertreatmentperiod.Exercisealsoreducesriskoffuturechronicdiseaseandhasbeenlinkedwithreducedriskofcancerrecurrenceandimprovedoverall-andcancerspecific-survival. Exercise is considered safe and participating in regular exerciseduringtreatmentisfeasible,evenwhentreatment-relatedimpairmentsarepresent.Yet,themajorityofbreastcancersurvivorsareeithersedentaryorinsufficientlyactiveduringtreatmentandaremorelikelytoreducetheirexerciselevelsfollowingacancerdiagnosis,comparedwithinitiatingormaintaininganexerciseregime.

Throughout the course of this presentation, the presence of treatment-related sideeffects,theirrelationshipwithfunctionandqualityoflifeandthepotentialsbenefitsofexercisingduringandfollowingbreastcancertreatmentinoptimisingfunction,qualityof lifeandpotentiallysurvivalwillbediscussed. Thequestionisnolongerwhetherwomenwithbreastcancershouldbeactiveduringandfollowingtheirtreatment,butishowdotheybecomeand/orstayactiveinanendeavourtolivehealthylivesbeyondtheirbreastcancerexperience.

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NOTES PSYCHOSExUAL HEALTH Jane TurnerSOMCentral - Psychiatry - RBWH, Faculty of Medicine and Biomedical Sciences,UniversityofQueensland

Itisself-evidentthatthediagnosisandtreatmentofbreastcancerposesachallengeforthewomanandherfamily.Theinitialphaseofadjustmentafterdiagnosistypicallyfocusesonmakingtreatmentchoicesandcopingwithtreatment.Howevercompletionofactivetreatment,whilstoftenanticipatedwithrelief,canbeadifficultphaseinwhichthewomanconfrontsthelonger-termimpactofthediagnosis.Formanywomen,thisis the time when they reflect more deeply about the effect on confidence and self-esteem,onbody imageandsexuality,andchanges inrolesandrelationships.Manyhealth professionals lack confidence about raising issues related to psychosexualhealthbecauseofconcernsaboutlackofspecifictraining,andassumethatthesearepersonalissueswhichthewomanmightaddresselsewhere.Therealityisthatmanywomenfeelreluctanttoraisetheseissuesbecausetheyfeelguiltyandembarrassedorconvincedthatlittlecanbedonetohelp.

Thispresentationoutlinessomeofthecommonpsychosexualdifficultiesexperiencedby women after treatment for breast cancer including changes in libido, vaginaldrynessandhotflushes,anddescribesevidence-basedrecommendationstoassist.The presentation includes discussion of the complex psychosocial contributionsto concerns about sexuality and provides practical suggestions to assist healthprofessionalstoinitiatediscussionandprovideinformation,supportandguidance.

Chair: ChristobelSaunders

PanelSurgeon: MelissaBochnerBreastphysician: SusanFraserGeneticist: MichaelGattasMedicalOncologist: CatherineShannonBCNArepresentative: VickiShepherdBreastCareNurse: TBA

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SESSION 5: NEOADJUVANT THERAPY UPDATESponsored by Roche

NEOADJUVANT CHEMOTHERAPY – ExPANDING THE INDICATIONSAndrew SpillaneThe University of Sydney, Northern Clinical School; Melanoma Institute Australia(MIA);Mater,RoyalNorthShoreandNorthShorePrivateHospitals

Neoadjuvantchemotherapy(NAC)isusedinapproximately3%ofthecasesregisteredintheBreastSurgANZQualityAudit.NACiswelldocumentedashavingthesamelong-termsurvivalasadjuvant therapywith thebenefitof improvingbreastconservationrates1.Inaddition,itisalsonowclearthatinabroadersenseNACisafacilitatorofmore conservative and oncologically safe surgical procedures. NAC can be used todown-stagethebreastandaxilla,tofacilitatebettercosmesiswithBCS,increasetherateofimmediatebreastreconstructioninwomenrequiringmastectomy,andenabletimeforunderstandingcomplexsurgicaldecision-makingortimeforgenetictestingforthoseathighriskforaBRCAmutation.Withpatientselectionbasedonmolecularphenotype recognition predictable high complete pathological response rates areachievedespeciallyinTripleNegativeBreastCancerandHer2enhancedbreastcancerwhilst rates of progression on NAC are <3%2. New oncoplastic and reconstructivetechniquesarebroadeningtherangeofsurgicaloptionsforwomenandtheevolvingparadigmforsurgicalmanagementofbreastcancerofanexpectationofbothexcellentoncologicalmanagementandaestheticoutcomesisenhancedinmanysituationsbytheuseofNAC.TheseadvantagessuggestNACshouldbeofferedtoallwomenwhopresentwithapresentationwherebyitisclearchemotherapywillbeanessentialpartoftheirtreatment3.1 Mauri D , Pavlidis N, Ioannidis JPA. Neoadjuvant Versus Adjuvant Systemic

TreatmentinBreastCancer:AMeta-Analysis.JNCI2005;97;3:189-194.2 CaudleAS,Gonzalez-AnguloAM,HuntKK,etal.PredictorsofTumorProgression

During Neoadjuvant Chemotherapy in Breast Cancer. J Clin Oncol. 2010; 28;11:1821-1828.

3 Kaufmann M, von Minckwitz G, Mamounas EP et al. Recommendations froman International Consensus Conference on the Current Status and Futureof Neoadjuvant Systemic Therapy in Primary Breast Cancer. Ann Surg Oncol.2012;19:1508–16.

NOTES NEOADJUVANT THERAPY AND AxILLARY STAGINGHiram S Cody III MDBreastService,DepartmentofSurgery,MemorialSloan-KetteringCancerCenterandWeillCornellMedicalCollege,NewYork,US

Neoadjuvant chemotherapy (NAC) for breast cancer is well-established, andin multiple randomized trials has been associated a modestly increasedrate of breast conservation, variation in response by biologic subtype, andsurvival comparable to that of postoperative adjuvant chemotherapy1-3. Withcurrent regimens of NAC, about 40% of axillary node-positive patients becomenode-negative.

SentinellymphnodebiopsyhasbecomestandardcareforaxillarystaginginvirtuallyallpatientswithcN0operablebreastcancerandhasbeenlogicallyextendedtotheneoadjuvantsetting,whereitcanbedonebeforeorafterNAC.Theargumentsinfavorof“SLNupfront”arethat:

1) axillarystagingismoreaccurate,2) SLN-negativepatientsrequirenofurtheraxillarysurgery,3) SLN-positivepatientscanproceeddirectlytoALNDpost-NAC.

Theargumentsinfavorof“SLNpost-NAC”arethat:1) upfrontaxillarystagingupfrontisirrelevant(chemotherapyisgivenregardless),2) everypatientmusthavetwooperations,3) 40% of node-positive patients achieve a pathologic CR and may not require ALND.

IntheUS,theemergingconsensusfavorsSLNpost-NAC,and27retrospectivestudies(inwhichSLNbiopsywithabackupALNDwasdoneafterNAC)4showthatthesuccessrateisslightlylower(91%)andthefalse-negativeratewasroughlycomparable(10.5%)tothatofSLNbiopsyingeneral.

ThesestudiesdonotaddresstheperformanceofSLNbiopsyinpatientswithprovenaxillary node metastases but two recent prospective observational studies have.In ACOSOG 10715, 607 patients with cT0-4, pN1-2 breast cancers had SLN biopsyand ALND after NAC, with success and false-negative rates of 92.5% and 12.6%,respectively.InSENTINA6,among592comparablepatients,theauthorsobserved80%successand14%false-negatives.Takentogether,thesetrialsshowthatthetechniqueofSLNbiopsymatters: false-negativeswereminimizedbytheremovalofat least2SLN,byusingdualagentmapping(dyeplusisotope),andbytheperformanceofSLNbiopsyonce,afterNAC(ratherthantwice,beforeandafterNAC).

Onacautionarynote,Mamounas7hasrecentlyreportedonpatternof10-yearpatternsoflocoregionalrecurrenceafterNACinNSABPB-18andB-27;thehighestratesofregionalnoderecurrencewereinclinically node-positive patients whose nodes remained positiveafterNAC.Twonewrandomizedtrialsaimtoclarifymanagementoftheaxillainnode-positivepatientsafterNAC.NSABPB-51/RTOG1304(www.nsabp.pitt.edu/)comprisespatientswhoseSLNbecomenegativeafterNAC,randomizingtoaxillaryRTvsnoRT,andAlliance 11202 (www.allianceforclinicaltrialsinoncology.org/) comprises those whoseSLNremainpositive,randomizingtoALNDvsnofurthersurgery.EachpromisesamoreconservativeapproachtotheaxillafollowingNACinpatientswithnodalmetastases.

References1 Mauri D, Pavlidis N, Ioannidis JPA. Neoadjuvant Versus Adjuvant Systemic

Treatment in Breast Cancer: A Meta-Analysis. JNCI Cancer Spectrum 2005;97(3):188-194.

2 RastogiP,AndersonSJ,BearHD,etal.PreoperativeChemotherapy:UpdatesofNational Surgical Adjuvant Breast and Bowel Project Protocols B-18 and B-27.J Clin Oncol2008;26(5):778-785.

NOTES3 HoussamiN,MacaskillP,vonMG,etal.Meta-analysisoftheassociationofbreast

cancersubtypeandpathologiccompleteresponsetoneoadjuvantchemotherapy.Eur J Cancer2012;48(18):3342-3354.

4 van Deurzen CH, Vriens BE, Tjan-Heijnen VC, et al. Accuracy of sentinel nodebiopsy after neoadjuvant chemotherapy in breast cancer patients: a systematicreview.Eur J Cancer2009;45(18):3124-3130.

5 BougheyJC,SumanVJ,MittendorfEA,etal.Sentinel lymphnodesurgeryafterneoadjuvant chemotherapy in patients with node-positive breast cancer: theACOSOGZ1071(Alliance)clinicaltrial.JAMA2013;310(14):1455-1461.

6 Kuehn T, Bauerfeind I, Fehm T, et al. Sentinel-lymph-node biopsy in patientswith breast cancer before and after neoadjuvant chemotherapy (SENTINA): aprospective,multicentrecohortstudy. Lancet Oncol.2013;14(7):609-618.

7 Mamounas EP, Anderson SJ, Dignam JJ, et al. Predictors of locoregionalrecurrenceafterneoadjuvantchemotherapy: results fromcombinedanalysisofNationalSurgicalAdjuvantBreastandBowelProjectB-18andB-27.J Clin Oncol 2012;30(32):3960-6.

INTERPRETING PATHOLOGY DURING AND AFTER NEOADJUVANT THERAPY Gelarah Fashid

NEOADJUVANT THERAPY FOR BREAST CANCER – CURRENT TRIALS AND FUTURE DIRECTIONS Catherine ShannonDirector,MedicalOncologyMaterCancerCareCentre,Brisbane

Neo-adjuvant therapy has become standard of care for locally advanced andinflammatory breast cancer. Pathological complete response (pCR) is a robustpredictor of long term outcome but occurs in only a subset of patients. Theneo-adjuvanttherapyparadigmallowsearlyassessmentoftheadditionofnewdrugsto therapy in patients with high risk disease as well as opportunities for predictivebio-markerdiscoveryandassessmentofimagingmodalitieswhichmightidentifyearlyresponse. There are currently 4 neo-adjuvant studies recruiting in Australian siteswith2moretoopeninthenearfuture.Thedevelopmentofsophisticatedpathologicalmethodsofquantifyingresidualcancerburden(RCB)hasallowedforstratificationofpatientswithworseoutcomesintotrialsofmoreintensivetreatmentwithnewagents.The2013FDAapprovalofPertuzumabfortheneo-adjuvanttherapyofHER-2positivebreastcancersignalledaneweraforneo-adjuvanttrialdesign.TheuseofadaptivetrialdesignssuchastheI-SPYcollaborativeishopedtoleadtoacceleratedapprovalofnewdrugsandmoreimportantlytheidentificationofsubsetsofbreastcancerswhichrespondtoparticulartargetedtherapy.

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NOTES SESSION 6: GENETICS KEYNOTE AND PROFFERED PAPERSSponsored by AstraZeneca Oncology

BREAST CANCER BIOLOGY: PROGNOSTIC AND PREDICTIVE FACTORS IN CURRENT CLINICAL PRACTICENirmala Pathmanathan

Ingeneral, timedependantprognostic factorssuchastumoursizeand lymphnodemetastasis may not declare their associated risk at the time of diagnosis. Thisis especially relevant in early breast cancer and in a setting of population-basedmammographic screening. In this regard, the biological/molecular characteristicsof breast cancer assume even greater significance. Currently breast cancerprognosticationandtreatmentselection isreliantontheassessmentofclinicalandpathologicalcharacteristicsofbreasttumours.Thisinformationcanbeintegratedintointernet-basedtoolstoassistwithpredictionofoutcomeandchemotherapybenefit.

Inthelastdecadegeneexpressionprofilingusingmicroarraytechnologieshasemergedasapotentialcandidatefortherefinementofbreastcancerprognosisandpredictionofsystemictreatmentresponse.Thesestudieshaveservedtoemphasisetheunderlyingheterogeneity in breast cancers, and this is reflected clinically in terms of prognosisandtreatmentresponse.Theclassificationofbreastcancersintoclinicallymeaningfulsubgroupsonthebasisofthesegeneexpressionprofilesisrelevanttocontemporaryoncologypractice,withtheneedforfurtherdefinitionandrefinementsintheprognosticandpredictiveassessmentofbreastcancerwiththeultimategoalofidentifyingmoretailoredtherapeuticregimensandimportantlytoidentifythosepatientsinwhomadjuvanttherapymaybesafelyavoided.Consequentlytherehavebeenanumberofcommerciallyavailableandthereisconsiderableinterestinapplicationofthesetechniquesintoroutinepractice.Significantly,whencomparingvariousgeneplatforms,thereislittleoverlapintermsofindividualgenesinmostoftheseassays;notably,however,proliferationrelatedgenesappeartobeacommondiscriminatorycomponentacrossallarrayplatforms.

Thefirstgenerationofthesemultigeneprognosticclassifiers(“genesignatures”)havebeen shown to outperform traditional clinicopathological features in retrospectivedatasets.Twoofthesearecurrentlybeingtestedinprospectivemulticentrerandomisedclinicaltrialsandtheseareexpectedtoreportinthenearfuture.Secondgenerationmultigeneassayshavefocussedonidentificationofintrinsicsubtypeaswellasariskscorewhichincorporatesclinicalinformation.

The contribution of microarray-based gene expression profiling has certainlycontributed to the understanding of the heterogeneity and complexity of breastcancers.Incorporationofthisinformationintoroutineclinicalpracticeisachallengingandevolvingarea.Clearlythisshouldbeinthecontextofamultidisciplinarysettingandinclosecollaborationandcommunicationwiththepatient.

NOTESCOMPARATIVE EVALUATION OF CONTRAST ENHANCED SPECTRAL MAMMOGRAPHY (CESM) AND CONTRAST ENHANCED MAGNETIC RESONANCE IMAGING (CEMRI) FOR LOCAL STAGING OF BREAST CANCER: INTERIM RESULTS FROM THE CESM V STUDYDonna B. Taylor*1,2; Max Hobbs1,2

1 DepartmentofRadiology,RoyalPerthHospital2 SchoolofSurgery,UniversityofWesternAustralia

BackgroundOptimaltreatmentofbreastcancerrequiresaccuratelocalstaging.Standardimaging(mammographyandultrasound)haslimitations.Newdiagnostictechniqueswhichuseintravenouscontrast increaseourability todetectbreastcancerbyshowingcontrastuptake associated with tumour neo-angiogenesis1. Contrast Enhanced MagneticResonanceImaging(CEMRI)iscurrentlythemostsensitiveimagingtechniqueforbreastcancerdetection;however,itsuffersfrommanydrawbacksincludinghighcost,timelyaccessibility,patientcontraindicationsandlowspecificity.Previousstudieshaveshownthat contrast enhanced spectral mammography (CESM) may have similar diagnosticcapabilitytoCEMRIwithouttheseassociatedcosts2.

MethodsThestudyincludedpatientswithbiopsyprovenbreastcanceraged≥21years,fitforsurgery, and excluded patients with contra-indications to intravenous contrast orCEMRI,candidatesforneo-adjuvantchemotherapy,orwhohadpureinsitucarcinoma.ParticipantsunderwentbothCESMandCEMRI.Studieswereindependentlydoublereadandresultsbenchmarkedagainstthefinalsurgicalhistopathology,corebiopsyhistology or one year follow-up imaging. CESM and CEMRI were compared for 1)detection of additional lesions 2) ability to size the index lesion 3) influence onsurgicalplanand4)participantsatisfaction.

ResultsAminimumof19participantswasanalysedforeachstudyobjective.Forthedetectionofadditionallesions(n=21),theadditionofCESMtoconventionalimagingincreasedsensitivity from50% to67%withspecificityunchanged (47%).AdditionofCEMRI tostandard imaging increased sensitivity from 50% to 100% but with considerablereduction in specificity (47% to 7%). The geometric mean of index lesion size atpathologywassimilarforCESMandCEMRI(n=24).For19patients,CESMandCEMRIhad identical influence on the surgery plan. Participants preferred CESM to CEMRI(n=34,p=0.0005).

ConclusionsResultssofarsuggestCESMhassimilardiagnosticcapacitytoCEMRIandispreferredbypatients.

References1 LobbesM,SmidtM,HouwersJ,Tjan-HeijnenV,WildbergerJ.Contrastenhanced

mammography: Techniques, current results, and potential indications. Clinical Radiology.2013.

2 JochelsonMS,DershawDD,SungJS,HeerdtAS,ThorntonC,MoskowitzCS,etal.Bilateralcontrast-enhanceddual-energydigitalmammography:feasibilityandcomparisonwithconventionaldigitalmammographyandMRimaginginwomenwithknownbreastcarcinoma.Radiology.2013Mar;266(3):743-51.PubMedPMID:23220903.

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NOTES PREDICTORS OF RESPONSES AND SExUAL FUNCTION FOR WOMEN IN THE ST GEORGE BREAST BOOST RANDOMIZED TRIAL (STGBBT)Graham P.H*1, Browne L1, Capp A2, Delaney G3, Fox C4, Millar E.K1, Nasser E4, Papadatos G5.1 CancerCareCentre,StGeorgeHospital,Kogarah,Australia2 MaterHospital,Newcastle,Australia3 CancerTherapyCentre,LiverpoolHospital,Liverpool,Australia4 CancerCareCentre,WollongongHospital,Wollongong,Australia5 MacarthurCancerCareCentre,CampbelltownHospital,Campbelltown,Australia

Background and purposeTodescribetheStGBBTsexualfunctiondatasetandassociationsofresponsetosexualfunctionassessment.

Methods688womenparticipatedintheStGBBTaspreviouslyreported.Qualityoflife(QOL)andSexualfunctiondatawascollectedfrombaseline(pre-radiotherapy)toyear10annually.

Results92% completed QOL questionnaires. 81% responded to sexual partner status butresponderstoothersexualfunctionquestionsrangedfrom59to64%.Responseratesweremaintainedto10years,werehighestinmarrieds,lowestinsingles,intermediatefor divorcees/widows. 97% <60 years and 81% aged 60-79 of married had sexualpartners, versus 35% and 5% divorcees, 5% aged 69-79 widows. Of responders, atbaseline60%marriedversus75%non-marriedreportedtheirtreatedbreastdidnotaffecttheirsexualfunction.Sexualdesirewasreportednormalin47%marriedversus35%non-married.Sexualfrequencyneverversusatleastweeklywasreportedin22%and33%ofmarrieds,68%and17%ofnon-marrieds.Sexualenjoymentwasreportedasnormalin60%ofmarriedand47%ofnon-married.

ConclusionsFrom this unique large long-term Australian data set for sexual function in breastcancertreatedwomenlongitudinaldataandpredictorswillbepresented.Responseratesandsexualpartnershipstatusaresimilartolargecommunitypopulationsexualhealthsurveys.ReferencesHau E, Browne LH, Khanna S, Cail S, Chin Y, Clark C, Inder S, Swajcer A, GrahamPH. Radiotherapy breast boost with reduced whole breast dose is associated withimprovedcosmesis:TheresultsofacomprehensiveassessmentfromtheStGeorgeand Wollongong Randomized Breast Boost Trial. Int J Radiat Oncol Biol Phys. 2012;82(2):682-689.MercerCH,TantonC,PrahP,etal.ChangesinsexualattitudesandlifestylesinBritainthroughthe lifecourseandover time:findings fromtheNationalSurveysofSexualattitudesandlifestyles(Natsal).Lancet2013;382:1781-94.

NOTESWHAT IS THE VALUE OF AxILLARY STAGING IN ELDERLY WOMEN WITH BREAST CANCER? REVIEW OF FOUR YEARS PROSPECTIVE SERIES FROM A SINGLE INSTITUTIONMurugappan K*1, Dijkstra B2

1 Departmentofsurgery,ChristchurchHospital,Christchurch,NewZealand2 Departmentofsurgery,ChristchurchHospital,Christchurch,NewZealand

Background and purposeTheoptimummanagementofelderlywomenwithbreastcanceriscomplex.Currentguidelines are based on expert panel recommendations due to paucity of majortrials1.Inparticular,thereislackofevidencetoguideaxillarymanagementinelderlywomen(specifically≥80years).Ouraimistoevaluatetheroleofaxillarysurgeryinthemanagementofwomenaged≥80withbreastcanceranditsimpactontheiroutcomes.

MethodFrom2009–2013,130patients ≥80yearswere identified.Patientdemographics,presentation, diagnosis, surgical and non-surgical management and pathologicalcharacteristicswerederivedfromaprospectivedatabaseseries.Followupperiodwasamedianof2years(range1-4).

ResultsOfthe130patients,83(64%)patientsunderwentBreast+/-axillarysurgery,39(30%)patients primary endocrine therapy alone; 4 (3%) had combination of endocrineandradiotherapy,2 (1.5%)patientshadprimaryradiotherapy,2patientsrefusedalltreatment.52patients(62%)whowereclinicallyorradiologicallynegativeforaxillarymetastaticlymphnode(LN)involvementunderwentSLNBx(36patients)andALNDx(13 patients). Positive axillary LN was found in 5 patients from ALNDx group and 8patientshadpositiveSLNBxwith4ofthesepatientsproceedingtocompletionALNDx.ChemotherapywasnotofferedtoanyonewithpositiveaxillaryLN.Fourpatientswithpositive axillary LN underwent radiotherapy. 38 of 57 patients with clinically nodenegative disease had recommendation for adjuvant endocrine therapy. Patients’functional and medical comorbidities were analyzed to determine their impact onadjuvantmanagementplan.

ConclusionThe vast majority of patients with clinically node negative disease are undergoingaxillarysurgerythatdoesnotaltertheirsubsequentadjuvanttreatmentplan.Elderlypatients’functionalstatusandmedicalcomorbiditiesplaysacrucialroleinadjuvantmanagementplanning.

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NOTES PET SCANS FOR LOCALLY ADVANCED BREAST CANCER AND DIAGNOSTIC MRI TO DETERMINE THE ExTENT OF OPERATION AND RADIOTHERAPY (PET LABRADOR); TROG 12.02Ahern V*CrownPrincessMaryCancerCentre,WestmeadHospital,Wentworthville,Australia.

BackgroundThisstudyinvestigateswhetherwomenwithStageIIInon-inflammatorybreastcancer(LABC)canundergobreastconservingsurgery(BCS)insteadofmastectomywithalowchanceofrecurrence,andwhetherbreastMRIandPETarebetterwaysofassessingtumourresponsetoprimarysystemic(chemo-/hormone)therapy(PST)comparedtomammogram,ultrasoundandphysicalexamination.

MethodsThisisamulti-centrephaseIIpilotstudy.WomenparticipateirrespectiveofhormoneorHER2status.70womenundergoingBCSneedtobeenrolled(220overall),poweredtoexcludeadetrimentof20%,with90%confidenceand80%power.BreastMRIandPET are performed at diagnosis, after 8 weeks of PST and at completion of PST.PST is per institutional preference (at least 2 cycles of trastuzumab prior to localtherapyforHER2positivepatients).WomenmaybeenrolledonELIMINATE.Allwomenreceiveradiotherapydeliveredaccordingtoprotocol,andsubsequenthormonetherapyifrelevant.

ResultsThisstudyhascommencedrecruitmentwithsmall localgrants. Itbringstogetherthe multi-disciplinary team caring for these patients, builds expertise in breastMRIandPET,andcanpotentiallyimprovethequalityoflifeofthesewomen.Whilepathological response will be reported and a bio-specimen bank will be obtainedwithimagingcorrelation,thefocusofthisstudyislocalcontrolandqualityoflifeforwomenwithLABC.

ConclusionsThis standardised clinical protocol allows both the opportunity to choose BCSfor women with LABC and the opportunity to choose the most effective PST byidentifyingthemostaccuratewayofassessingdiseaseextentatdiagnosisandinresponsetoPST.

NOTESSESSION 7: MULTIDISCIPLINARY MEETING CASE REVIEW

Inthissession,anumberofcontemporarybreastcancercaseswillbepresentedtoaMultidisciplinaryTeamofAustralianandInternationalbreastcancerspecialists.Eachcasewillfeatureaspecificareaofinterest.AudienceparticipationwithamobilephoneAPPwilladdtothediscussion.

Chair/Moderator: JamesKollias

PanelSurgeons: HiramCody,AnneTansley,ElisabethElderRadiationoncologist: MarieBurkeMedicaloncologists: CatherineShannonandNatashaWoodwardGeneticist: MichaelGattasPathologist: GelarahFashidRadiologist: BrunoGiuffreBreastCareNurse: TBA

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NOTES SESSION 8: GREAT DEBATES IN BREAST CANCER

“THE AxILLA IS THE RESPONSIBILITY OF THE SURGEON NOT THE RADIATION ONCOLOGIST”Margot Lehman

• Theappropriatechoiceofmanagementfortheaxillaistheresponsibilityofboththesurgeonandtheradiationoncologist.

• Traditionally, the role of surgical dissection of the axilla was two-fold:1)toprovidestaginginformationtoguidethechoiceofadjuvanttherapiesand2)toprovideregionalcontrol.

• Giventhattheuseofadjuvanttherapyislessdependentonnodalstatusnowadays,theneedforcompleteaxillarydissectionislessapparent.

• Furthermore,radiationtherapyprovidesexcellentloco-regionalcontrol.Recentdatafromamulti-institutionaltrialinpatientswithT1-T2cN0diseaserandomisedtocompletionaxillarylymphnodedissectionoraxillaryradiationtherapyfollowingsentinellymphnodebiopsy,foundbothdissectionandradiationtherapyprovidedexcellent loco-regionalcontrolwith axillaryradiationtherapyassociatedwithalowerrateofcomplications.

• Withthechangingclinicalpresentationofbreastcancerpatients,theincreasinguse of information other than nodal therapy to guide adjuvant therapy choiceand the proven benefit of well-designed,modern radiation therapy techniquesinachievingloco-regionalcontrolwithminimalmorbidity,radiationtherapywillbecomethetreatmentofchoiceforthemanagementoftheaxilla.

“THE AxILLA IS THE RESPONSIBILITY OF THE SURGEON NOT THE RADIATION ONCOLOGIST” Teresa Nano

Stagingandtreatmentoftheaxillainbreastcancerisnecessarytoallowprognosis,determinetreatmentanddecreaselocalrecurrence.TheSurgeonis“TheMasteroftheAxilla”aspreviouslywithaxillaryclearancealoneandnowwiththeuseofsentinelnode biopsy as well as axillary clearance, surgery still provides the most accuratestagingtoolavailableandthetreatmentwiththelowestriskoflocalrecurrence.

NOTES

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“ONCOPLASTIC SURGERY SERVES TWO MASTERS POORLY: ONCOLOGY AND PLASTICS”Hiram Cody and Richard Sutton

Hiram S Cody III MDBreastService,DepartmentofSurgery,MemorialSloan-KetteringCancerCenterandWeillCornellMedicalCollege

1) Shouldthedevelopmentofbreastcancerbecometheoccasionforanoperation,oftenbilateral,whichthepatientwouldnototherwisehavechosentodo?

2) Whatproportionofallnewlydiagnosedbreastcancerpatients:a. arefamiliarwithoncoplasticsurgicaloptions?b. areorbecomeinterested?c. areanatomicallysuitable?d. actuallyhavethesurgery?

3) How does oncoplastic breast conservation surgery compare to conventionalmethods,re:a. extentofresection?b. marginstatus?c. re-excisionrated. conversiontomastectomy?e. complications?f. long-termresults?g. patient-reportedoutcomes?

4) Should the oncologic and the oncoplastic surgeon be the same individual, ordifferent?

5) Whichoncoplasticprocedurescanbedoneby theoncologicsurgeonandwhichrequireaplasticsurgeon?Howandwheredowedrawtheline?

6) Intheeventofalawsuitwhoisliable:a. forthebadoncologicresult?b. forthebadcosmeticresult?

Referencesi HauE,BrowneLH,KhannaS,CailS,ChinY,ClarkC,InderS,SwajcerA,Graham

PH. Radiotherapy breast boost with reduced whole breast dose is associatedwith improved cosmesis: The results of a comprehensive assessment from theStGeorgeandWollongongRandomizedBreastBoostTrial.Int J Radiat Oncol Biol Phys.2012;82(2):682-689.

ii MercerCH,TantonC,PrahP,etal.ChangesinsexualattitudesandlifestylesinBritainthroughthelifecourseandovertime:findingsfromtheNationalSurveysofSexualattitudesandlifestyles(Natsal).Lancet2013;382:1781-94

NOTES POSTERS

EVALUATION OF METHODS USED TO GUIDE BREAST CONSERVING SURGERY BY AUSTRALIAN AND NEW ZEALAND BREAST SURGEONSDonna B. Taylor*1,2, Anita G. Bourke2,3, Max Hobbs1,2, Glenys Dixon1, Christobel Saunders1,2

1 DepartmentofRadiology,RoyalPerthHospital.2 SchoolofSurgery,UniversityofWesternAustralia.3 DepartmentofRadiology,SirCharlesGairdnerHospital.4 DepartmentofMedicalTechnologyandPhysics,SirCharlesGairdnerHospital.

BackgroundScreeningmammographyhasseenanincreaseinimpalpablebreastlesionsrequiringimage guided localization for breast conserving surgery (BCS). Techniques includehook-wire localization (HWL), carbon tracks, surgeon performed intraoperativeultrasound (IOUS) and more recently radio-guided methods using Technetium 99mcolloidor iodine125seeds.Minimalobjectivedataconcerningcurrentuseof thesemethods in Australia and what are considered “acceptable” pathological marginsexists.Theaimofthisstudywastoprovidethisinformation.

MethodsAn on-line questionnaire regarding preferred localisation techniques was madeavailabletosurgeonsthroughalinkontheBreastSurgANZwebsitebetweenSeptember2013 and June 2014. Information on practice demographics, case load, acceptablepathologicalmargins,equipmentandtrainingwascollected.

Results79 surveys were returned. Most surgeons performed general and breast surgery,weremetropolitanbased,practicedinbothpublicandprivatesectorsandundertook<10casesofBCSperweek.Forinvasivedisease,56%acceptednotumoratink,34%requiringmargins>2mm.ForhighgradeDCIS,20%acceptednotumourat inkand56%requiredmargins>2mm.AccesstoUSequipmentintheatrewasreportedby70%of surgeons. Whilst 59% of surgeons reported using IOUS (27% regularly), 41% didnot, relying solely on radiological techniques. HWL was the commonest method oflocalisation,usedby90%ofrespondents.Attendanceatcourseswasthecommonestmethod of training in breast ultrasound. Only 4% reported training during theirfellowship.ThecostofUSequipmentusedbymostsurgeonswas<$60,000.Surgeonscited movement of hook-wires and timing of current localisation techniques as thecommonestdisadvantages.

ConclusionDespiteincreaseduptakeofIOUSbyAustralianandNewZealandsurgeons,HWListhemostfrequentlyusedlocalisationtechnique.Whilstoverhalfofthesurgeonsaccepted“notumouratink”asadequateforinvasivedisease,mostrequiredmargins>2mmforDCIS.

NOTES

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A NOVEL METHOD OF ANALYZING AND INITIATING A TARGETED INTERVENTION FOR POPULATIONS AT RISK OF LATE-STAGE BREAST CANCER Goltsman D*1,2, Warrier S1,2, Bruce E2,3, Mak C1,2, and Carmalt H1,2

1 DepartmentofSurgery,RoyalPrinceAlfredHospital,Camperdown,NSW,Australia.2 UniversityofSydney,Camperdown,NSW,Australia.3GeocoastalResearchGroup,SchoolofGeosciences,UniversityofSydney,Australia.

Background and purposeAmyriadofriskfactorshavebeenestablishedforbreastcancer.Preventionamongat-riskwomenremainsanareawheresignificantgainscanbeachieved.Atalocallevel,thesuccessofinterventionsaimedatbreastcancerpreventionhavebeenchallengedby theirability tosuccessfullyadapt to theriskprofileof thearea 1.Socioeconomicfactors,especiallydisadvantage,havebeenshowntoplayanespeciallyimportantroleinthedifferentialdistributionofthedisease2.

Thisstudyaimsistoimproveratesofcancerscreeningandoutcomesbyidentifyingsub-groupsinalocalhealthdistrictthathaveincreasedriskofpresentingwithlate-stagebreastcancer(LSBC).

MethodsAll patients presenting to the Royal Prince Alfred Hospital (RPAH) between July2005-March 2013 were identified. For each patient, data were collected on:sociodemographics (including country-of-birth), geographical area of residence,socioeconomic characteristics of residential area and the clinical features andoutcomesofthecancer.

Thedatawereanalyzedtoidentifysub-groupsatgreatestriskofpresentingwithLSBC.Geospatial analyses were conducted to ascertain if LSBC clustered in geographicalareasorwasassociatedwitharea-levelsocioeconomiccharacteristicscapturedbytheSEIFA(socioeconomic-indexes-for-areas)index.

ResultsA total of 5317 patients presented with breast cancer over the study period. Most(47.54%;n=2536)wereAustralian-born, followedbythoseborn inSouthern/EasternEurope(12.80%;n=683)andNorth-EastAsia(8.61%;n=459).

AmongpatientspresentingwithLSBC,most(50.11%;n=1151)wereAustralian-born,followedbySouthern/EasternEuropeans(11.84%;n=683).

LBSC was associated with area-level socioeconomic disadvantage within somepostcodes; patients residing in the northeastern and western regions of the healthdistricthadagreaterlikelihoodofpresentingwithLSBC(relative-riskof1.51-2.25).Theseareaswerealsocharacterizedbysocioeconomicdisadvantage.

ConclusionsInthishealthdistrict,patientsresidinginsocioeconomically-deprivedareas,whoareofAustralianorEastern/SouthernEuropeandescentweremorelikelytopresentwithLSBC.Focusedinterventionstargetingthiscohortarerequired.

References1 HenleySJ,KingJB,GermanRR,RichardsonLC,PlesciaM.Surveillanceofscreening-

detectedcancers(colonandrectum,breast,andcervix)-UnitedStates,2004-2006.MMWRSurveillSuumm.2010Nov26;59(9):1-25.

2 FreemanHaroldP,ChuKennethC.Determinantsofcancerdisparities:barriersto cancer screening, diagnosis, and treatment. Surg Oncol Clin N Am. 2005Oct;14(4):655–v.

NOTES TRENDS IN AxILLARY MANAGEMENT OF BREAST CANCER IN AUCKLAND, NEW ZEALANDRussell, P* and Gerred, S*DepartmentofGeneralSurgery,WaitemataDistrictHealthBoard,Auckland,NewZealand

Background and PurposeThe American College of Surgeons Oncology Group (ACSOG) Z0011 Trial and otherstudies have strongly challenged traditional surgical management of the axillafollowingapositivesentinelnodebiopsyresult.Thegrowingbodyofevidencesuggestsaxillarynodedissection(AND)inclinicallyT1/2,N0,M0invasivebreastcancerpatientswith1-2positivesentinelnodesisunnecessary.ThisstudyaimstoquantifythetrendspreandpostthelandmarkpaperanditsimpactinAuckland,NewZealand.

MethodsWe performed a retrospective review of all women who underwent lumpectomy ormastectomyandsentinelnodebiopsyforT1-T2breastcancerbetweenJanuary2009andJune2012inAuckland.WeidentifiedpatientswhowouldfulfilltheZ0011inclusioncriteriaandcomparedtherateofANDpreandpostFebruary2011whentheZ0011trialwaspublished.

ResultsOnly7.5%ofclinicalT1/T2,N0,M0 invasivebreastcancerpatientswould fulfill thecriteriaofZ0011.TherateofprogressiontoANDsignificantlydroppedinthetimeperiodpostpublicationofZ0011(89.6%pre,65.5%post,P=0.0005).Thisresultwasagainseeninpatientswithmicrometastaticdiseaseonly(68.2%pre,38.6%post,P=0.0148).Therewere no significant differences in patient or tumor characteristics between the twogroups. Further metastatic nodes were detected pathologically in 40.2% of patientswhohadanAND.

ConclusionsThetrendinthispatientsubgroupislikelytobeexplainedbyincreasingevidenceagainstcompletionAND inmacroandmicrometastaticsentinelnodediseaseThissignifiesasubstantialreductioninmorbidityassociatedwithANDforthesepatients.Howeverthefindingsremainapplicabletoonlyasmallproportionofbreastcancerpatients.

CHANGING ROLE OF THE FINE NEEDLE ASPIRATION BIOPSY IN BREAST SCREENINGHema Mahajan*TissuePathologyICPMR,WestmeadHospital,NSWAustralia

Background and purposeThere has been a gradual decline in the popularity of fine needle aspiration (FNA)biopsy of breast with increased usage of core biopsy of breast (CB). Nevertheless,FNAcontinuestobetheessentialpartoftriplemodalityassessment,inthecontextofbreastscreeningservice.

OuraimwastoseeifthereisachangeinpracticeinuseofFNAofbreastwithregardstoindicationandfrequency.Inaddition,theaccuracyofFNAversuscorebiopsywasascertainedasaprimarydiagnosticmodalityfortheworkupofabnormalitiesdetectedatscreeningmammography.

MethodsWe looked at the breast screen cases performed during the years 2002 & 2012 byconducting a search through breast screen data base at Breast Cancer Institute atWestmeadhospital.

NOTES

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Wecomparedthetypesoflesions,thescreeningcategories,whethercorebiopsywasperformed;accuracyoffinaldiagnosisofFNAversusCBwasdetermined.

ResultsThere was a significant increase in the numbers of FNA & CB performed in 2012withasignificantsmallernumberscalledasindeterminateonFNA.In2012,alargerproportionofpatientshadFNAperformedforabenignassuranceofalesion,whereasinmanycasesonlyCBwasdone if therewasradiologicalsuspicionofamalignantlesion.OverallthecorrelationbetweenFNAandCBwasexcellentoverbothyears.

ConclusionWethinkFNAstillplaysanimportantroleintheinitialtriageofbreastlesions.Therehas been an evolution in how FNA is used in the screening setting. There is moretendencytouseFNAforconfirmationofabenigndiagnosisandlessinclinationtouseFNAtoconfirmamalignantdiagnosis.IncreasingroleofFNAoflocoregionallymphnodes in the management of breast cancer has also been highlighted. The addedadvantagesofperformingFNAarehighlighted.

References1. SmallenburgVB,NederendJ,VoogdACetal.Br J cancer2013;109(1):242-9.2. Youngetal.Arch pathol lab med2002;126:1453-1457.

GEOSPATIAL VARIABILITY OF BREAST CANCER ACCORDING TO AGE: THE ROYAL PRINCE ALFRED ExPERIENCEGoltsman D*1,2, Warrier S1,2, Bruce E2,3, Mak C1,2 and Carmalt H1,2

1 DepartmentofSurgery,RoyalPrinceAlfredHospital,Camperdown,NSW,Australia2 UniversityofSydney,Camperdown,NSW,Australia3GeocoastalResearchGroup,SchoolofGeosciences,UniversityofSydney,Australia

Background and purposeFew studies have assessed the geographic variability of age based cancer risk inhospitalcatchmentareas.Thisstudyattemptstocategorisethefrequencyofbreastcancerbasedonageofdiagnosisandlocationofresidencewithinacatchmentarea.

Theprimaryriskfactorforbreastcancerinmostwomenisolderage.Theincidenceofbreastcancerriseswithincreasingageuntilapproximately50years.Itthenstartstoslowdown,withincidencestartingtoplateauanddeclineat80years1.

Australiandatain2010showedthat,22.9%ofnewbreastcanceroccurredinwomen≤50years;52.5%inwomen50–69years;and24.6%inwomenaged≥70years2.

The resultsof thisstudyareaimedatdesigning targetedpreventioncampaigns fordifferentpopulationdemographics,toimprovescreeninginareasoftheSydneylocalhealthdistrictcatchmentarea(SLHD).

MethodsAll patients presenting to RPAH between July 2005 - March 2013 were identified.Informationregardingpatientdemographics,breastcancerdetailandclinicaloutcomewerecollected.

PatientswerestratifiedaccordingtoagegroupsthatreflectcurrentbreastscreeningpracticeinAustralia:<40years,40-49,50-69,and≥70.

Spatial analysis was used to determine geographic variability in the relative-risk ofbreastcanceroccurrencebypostcodesintheSLHD.Choroplethmapsweregeneratedforeachindex.

NOTES ResultsInthestudyperiod,7.27%(n=388)ofpatientswere<40years;21.33%(n=1138)were40-49;56.64%(n=3021)were50-69;and14.75%(n=787)were≥70.

Forthe<40agegroup,higherrelative-riskoccursintheeasternregionoftheSLHD;40-49higherrelative-riskoccursintheeasternandsoutheasternregions;50-69yearshigherrelative-riskoccursintheeastern,northeasternandcentralregionsandfor≥70higherrelative-riskoccursintheeast-centralregion.

ConclusionThisnovelmethodofgeospatialanalysishasshowndifferingtrendsforbreastcancerriskbyagegroupsintheSLHDcatchmentarea.Indicatingthatearlyandlate-stagebreastcancercanbemoreeffectivelytargetedintheSLHD.

References1 HulkaBS,StarkAT.Breastcancer:causeandprevention.Lancet1995;346:883.2 Australian Cancer Incidence and Mortality (ACIM) Books - Breast cancer for

Australia(ICD10C50).http://www.aihw.gov.au/acim-books/

IMMEDIATE BREAST RECONSTRUCTION WITH INFERIOR DERMAL FLAP TECHNIqUE: AN INITIAL ExPERIENCESyed S*, Majeed UDepartmentofSurgery,CalvaryHealthcare,ACT,Australia

PurposeAcellulardermalmatrix(ADM)isbeenutilisedwithincreasingfrequencytoassistwithimplantor tissueexpanderbasedprimarybreast reconstruction1.Besides thecost,studieshavesuggestedtechnicalproblemsandhigherriskofwoundcomplicationswithADM2.Thede-epithelializedinferiordermalflapfollowingaskinsparingmastectomycanbeutilizedtoprovideimplantcoverageandsupport,asanalternativetoADMinselectedpatients.Candidatessuitableforthisprocedurearewomenwithlargebreasts,orbreastptosiswhowishbreastreductionatthetimeofmastectomywithreconstruction.Wepresentourinitialexperiencewiththeinferiordermalflaptechnique.

MethodologyThe safety and efficacy data were obtained for 14 patients undergoing skin-sparingmastectomiesandimmediatebreastreconstructions(13unilateralforbreastcancer,1 bilateral risk reducing mastectomies for BRCA mutation) between Jan 2012 andJune2014.13patientshaddirecttoimplantreconstructionusingsilimedpolyurethaneimplants,andthepatientwithbilateralmastectomiesunderwentreconstructionwithtissueexpanders.Theinferiordermalflaptechniquewasutilisedinallpatients.

Results1 bilateral procedure and 11 unilateral procedures were uncomplicated withsatisfactorycosmeticoutcomesonfollowup(6to24months).2unilateralprocedureswerecomplicatedbycellulitis,whichresolvedwithantibiotictherapy.

ConclusionsTheinferiordermalflapisasimple,reproducible,andcostefficientprocedurethatcanbeusedasanalternativetoacellulardermalmatrixinselectedpatients,withexcellentcosmeticoutcome.

References1 JoAnna Nguyen T, Carey JN, Wong AK. J Plast ReconstrAesthet Surg. Dec

2011;64(12):1553-15612 LanierST,WangED,ChenJJ,etal.Ann Plast Surg.May2010;64(5):674-678.

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LUNG VOLUME CHANGES AFTER ADJUVANT BREAST CANCER RADIOTHERAPYPramana A*1,2, Browne L1, Or M1, Saba S1, Pham K1, Trakis S1, Crawford K1, Hall M1, Batchelor N1, Graham P1,2

1 Radiation Oncology Department, St George Cancer Care Centre, Sydney, NSW,Australia

2 TheUniversityofNewSouthWales,Sydney,NSW,Australia

PurposeThereisnodataforlungvolumechangesafteradjuvantbreastcancerradiotherapy.Lungvolumeat restandairspacevolume increasewithaging1.Thestudyaim is toprospectively evaluate lung volume changes for patients who received adjuvantradiotherapytothebreastorchestwallarea.

MethodsLungcomputedtomography(CT)wasperformedin170patientsatminimumperiodof 12 months after completion of adjuvant radiotherapy. This CT was replannedand compared with the original radiotherapy treatment plan CT images to recordresting-freebreathinglungvolume(RFB-LV)changeandtoassessCTdensityvalueofvariouslungregionsasthequantitativemeasurementoffibrosis2.Thein-portallungregionsencompassedbythebreastradiotherapytangentsweredefinedascentralaxis(CA),5cmsuperiortoCA,and5cminferiortoCA.Pairedt-testandregression-analysiswereusedtodeterminesignificance.

ResultsThemeanageofstudypatientswas62years(48-83).Themeantimeintervalbetweenradiotherapystartdates tostudyCTwas1.25years (1-3.5).Overall,both ipsilateralandcontralateralmeanRFB-LVpostradiotherapywerehighlycorrelatedbut largerthan the original values. The mean RFB-LV change were 100cc (1349 to 1449) and212cc (1286 to 1498) for the ipsilateral and contralateral side. The degree of meanRFB-LVincreasewasconsistentlylargerforcontralaterallung.IncreasedCTdensitiesinmultipleipsilateralin-portallungregionsweresignificantlyassociatedwithdecreaseinipsilateralRFB-LVvalues.

ConclusionsThisstudyhasindicatedthatRFB-LVincreasespostadjuvantradiotherapy.Thiscouldbe explained partly due to physiological aging process or any lung pathology thatcausehyper-inflationoflungvolume.However,thedegreeofincreaseislessontheipsilaterallungpossiblyduetoincreasefibrosisintheipsilateralin-portalregionsofthelungwhichleadstosubsequentreductionofairspacevolume.

References1 Sharma G, Goodwin J. Effect of aging on respiratory system physiology and

immunology.Clinical Interventions in Aging (2006)1(3):253–260.2 AndoK,SekiyaM,TobinoKetal.RelationshipbetweenquantitativeCTmetricsand

pulmonaryfunctionincombinedpulmonaryfibrosisandemphysema.Lung(2013)191:585–591.

NOTES BILATERAL PROPHYLACTIC MASTECTOMY IN AUSTRALIA: TIME FOR A RETHINK?Hwang S1, Warrier S1,2, Mak C2, Carmalt H2 1 DepartmentofSurgery,PrinceofWalesHospital,RandwickNSW2 DepartmentofBreastSurgery,RoyalPrinceAlfredHospital,CamperdownNSW

PurposeBilateralprophylacticmastectomies(BPM)maybeperformedforpatientswithBRCAmutations. In Australia, patients are offered genetic counselling and advised of themanagementoptionsincludingroutinescreening,hormonaltherapiesand/orbilateralprophylacticmastectomy+/-oophorectomy.

However,thecurrentrateofBPMinAustraliaislow,withanecdotalevidencesuggestingthatitisrarelyperformed.Inconductingthisreview,theauthorsaimtoestablishthecurrentrateofBPMinBRCApositivewomeninAustraliaandcomparethistoUSA.

MethodsPubmed was searched for the term “bilateral prophylactic mastectomy”. Abstractsweresearchedforrelevance.

ResultsTherateofBPMinAustraliawasassessedbyPhillipsetal.andat3yearsfollowupfromgenetictesting,9/134(7%)womenhadundergoneBPM1.

Thiscompares to twomulti-centrestudies fromUSAshowinghigherratesofBPM:Friebel et al reports 89/406 (19.7%) had BPM at 6 months follow up from genetictesting,whileMetcalfeetalfound115/317(36.3%)hadBPMat18months2,3.

ConclusionThe decision-making process to undergo BPM is difficult, and patients may beinfluencedbypersonalandsocialfactors.WedemonstratethattherearesignificantdifferencesinpublishedratesofBPMbetweenAustraliaandUSA.

References1 PhillipsKA,JenkinsMA,LindemanGJ,etal.Risk-reducingsurgery,screeningand

chemopreventionpracticesofBRCA1andBRCA2mutationcarriers:aprospectivecohortstudy.Clinical genetics2006;70:198-206.

2 FriebelTM,DomchekSM,NeuhausenSL,etal.BilateralprophylacticoophorectomyandbilateralprophylacticmastectomyinaprospectivecohortofunaffectedBRCA1andBRCA2mutationcarriers.Clinical breast cancer2007;7:875-82.

3 MetcalfeKA,Birenbaum-CarmeliD,LubinskiJ,etal.InternationalvariationinratesofuptakeofpreventiveoptionsinBRCA1andBRCA2mutationcarriers.Int J Cancer2008;122:2017-22.

NOTES

SECTION 2 I P71

OPERATIVE TIMES AND RE-OPERATION RATES BEFORE AND AFTER INTRODUCTION OF AN INTRA-OPERATIVE SPECIMEN RADIOGRAPHY MACHINE FOR BREAST CONSERVING SURGERYOng J1, Teh J1, Phillips M2, Taylor D*3

1 RadiologyDepartment,RoyalPerthHospital,Perth,WesternAustralia2 HarryPerkinsInstituteforMedicalResearch,UniversityofWesternAustralia,Perth,

WesternAustralia3 SchoolofSurgery,UniversityofWesternAustralia,Perth,WesternAustralia

Background and purpose In 2010, 607 WA women were diagnosed with breast cancer. 63.9% hadbreast-conservingsurgery(BCS),thusplacingafocusonoperativeefficiency.Operativeefficiencyisalsoatargetforremunerationinactivitybasedfundedpublichospitals,butshouldnotoccurattheexpenseofadversepatientoutcomese.g.re-operation.

Intra-operative specimen radiography (IOSR) machines allow instantaneousassessmentofradiographicmargins,minimisingdelaysinintraoperativere-excision.Reductions inoperating timeofup to19minuteshavebeenobservedcompared toconventional specimen radiography (CSR) protocols1. Use of IOSR machines is notassociatedwithhigherre-operationratesforadequatemarginclearance2.

AimThisauditcomparedoperativetimesandre-operationratesinwomenundergoingBCSbeforeandafterintroducingIOSR.

MethodsFollowing ethics approval, women who had undergone BCS before and after theintroduction of a portable IOSR machine were identified. We excluded patients withmammographically occult and/or palpable lesions without hookwire or iodine seedlocalisation.Sixtywomenineachgroupwerereviewed.Differencesinsurgicaldurationandre-excisionrateswerecompared.

Results Therewasaslight(5minutes,p=0.12)reductioninmeanoperatingtimeintheIOSRgroup.Thenon-significantpvaluepossiblyreflectssmallsamplesize.Nodifferenceinthefrequencyofsecondoperations(p=0.862)wasobserved.

Conclusions IOSRcanreducemeanoperatingtimewithoutadverselyaffectingre-operationrates.

Review of a larger sample for greater power and multivariate analysis to evaluate theinfluenceoflesiontype,surgeonandexcisedtissuevolumeispending.

References1 Kaufman CS, Bachman BA, Jacobson L, Kaufman LB, Mahon C, Gambrell L.

Intraoperative digital specimen mammography: prompt image review speedssurgery.Am J Surg2006;192:513-5.

2 KimSH,CornacchiSD,HellerB,FarrokhyarF,BabraM,LovricsPJ.Anevaluationofintraoperativedigitalspecimenmammographyversusconventionalspecimenradiography for the excision of nonpalpable breast lesions. Am J Surg 2012;205:703-10.

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