Many techniques have been proposed to address the problem of increased lateral adiposity in patients undergoing mastectomy, however, there is no standard approach. This cosmetic deformity at the lateral end of the mastectomy scar, also known as a dog ear, is especially common in obese patients. This defect can be unsightly and uncomfortable. We describe a technique for creating a winged incision to eliminate the dog ear deformity. The Angel Wings Incision results in tissue flaps that create a smooth body contour upon closure in patients with increased lateral adiposity. The technique is reproducible, aesthetically pleasing, and improves patient satisfaction.

e19008 Background: Patients with metastatic melanoma have a poor outcome. We hypothesize that combination immunotherapy can synergistically activate host immunity to generate an effective treatment option for high risk, resected stage III, recurrent, refractory or stage IV melanoma patients. Methods: We completed a phase II clinical trial of HyperAcute-Melanoma vaccine (HAM, NLG12036, NewLink Genetics) combined with pegylated interferon (Sylatron, Merck). Trial design was a 12-week regimen with the initial 4 weekly treatments consisting of HAM alone (intradermally) followed by 8 additional treatments of HAM + Sylatron (subcutaneously, 6 µg/kg). Trial endpoints include clinical response, overall safety and correlative findings for observed anti-tumor effect. Results: N=25, median age 60, 68% male with 21 patients completing the trial, 4 stopped due to progressive disease (PD). HAM-related common side effects include erythema and induration at the injection site, without significant grade 3 or 4 toxicities associated with the vaccine. By RECIST criteria, of 16 stage IV patients, there were 2 complete responders (CR), 2 with stable disease (SD) and 3 with no evidence of disease (NED) after resection. For stage III patients, 3/9 remain NED, 1 patient with slowly progressive disease remaining alive for over 30 months. The median overall survival is 29 months, with 50% of the patients surviving for 2 years and 12/25 (48%) still alive. The anti-αGal Ab values increased after vaccination in 24/25 patients by up to 100-fold (median 15, range 3-127). All evaluable patients (21/21) seroconverted, developing autoimmune antibodies. Anti-tyrosinase Ab’s developed in 7/23 correlating with 1 CR and 1 patient NED. Vitiligo developed in 4/25 patients, correlating with 2 CR and 2 NED. Conclusions: Combinatorial immunotherapy with HAM plus Sylatron shows clinical efficacy with tumor regression and concomitant immune activation. Optimization of dosing schedules and addition of other potentially synergistic agents should be explored to further enhance the benefit of this immunotherapeutic approach.

Introduction: Intraoperative radiation therapy (IORT) is a convenient treatment option for appropriate women with early stage breast cancer. Some patients undergoing IORT also need adjuvant whole breast radiation therapy due to adverse final pathologic features. Although there are various reports of the complication rates with patients undergoing IORT, comparisons with patients undergoing other forms of radiation therapy such as whole breast or accelerated partial breast radiation are sparse. Methods: A total of 293 patients underwent breast conserving surgery at the study institution between January 2016 and December 2019 for either ductal carcinoma in situ (DCIS) or invasive breast cancer. Three patients had bilateral breast cancer and one patient had a local recurrence having refused adjuvant treatment following breast conserving surgery, for a total of 297 treated breasts. 124 received whole breast radiation therapy, 70 did not receive radiation therapy, 47 received IORT alone, 15 received IORT and whole breast radiation therapy, 30 received accelerated partial breast radiation using external beam radiation (APBI-EB), and 9 received Ir-192 based high dose rate accelerated partial breast radiation (APBI-HDR). One patient with bilateral breast cancer did not complete whole breast radiation therapy to either breast. Complications included cellulitis, wound drainage, symptomatic seroma, delayed wound healing, and wet desquamation. Interventions included observation, antibiotics, wound packing, debridement, fluid aspiration, hydrogel dressings, and wound vacuums. Results: For the entire group, the incidence of wound complications was 20%. The risk of complications was 27.4% for those undergoing IORT (with or without whole breast radiation) compared to 18.3% for those not receiving IORT, which was not statistically different at the 5% significance level. For those who received both IORT and whole breast radiation, however, the proportion having complication was 53.3% versus 18.4% in the other groups. The difference was significant with a p-value 0.0032. Conclusion: Patients who undergo both IORT and whole breast radiation have an increased risk for wound complications. Citation Format: James Wheeler, Houman Vaghefi, Laura Morris, Fang Liu, Irina Sparks, Fiona Denham, Leonard Henry, Ashley Hardy, Meghan Schrock, Vanessa DePue, Leon Coody. Breast complications in patients who received intraoperative radiation therapy compared to other forms of radiation therapy following breast conserving surgery [abstract]. In: Proceedings of the 2020 San Antonio Breast Cancer Virtual Symposium; 2020 Dec 8-11; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2021;81(4 Suppl):Abstract nr PS15-03.

The Oncotype DX DCIS Score was developed to assist in determining a low risk for recurrence subgroup of patients who can avoid radiation therapy following breast conserving surgery. We sought to evaluate our experience using the Oncotype DX DCIS Score and to see if a greater number of patients who did not receive radiation therapy were experiencing a local recurrence than the score predicted. Between February 23, 2011 and November 29, 2017, 145 women were diagnosed with ductal carcinoma in situ (DCIS) without an invasive component. 126 (87%) underwent breast conserving surgery. Thirty-five underwent Oncotype DX DCIS Score, of whom 26 (74%) were low risk, four were intermediate risk (11%), and five were high risk (14%). The scores ranged from 0 (7 patients) to 100 (1 patient). Of the 26 patients with low risk scores, one chose to undergo mastectomy, three received radiation therapy, 20 chose observation without radiation therapy, and two patients were unknown because they had no further treatment or follow-up at our facility. Two of the four intermediate risk patients underwent radiation therapy and two did not. Four of the five high risk patients underwent radiation therapy, but one did not. Twenty-two of the 35 patients who underwent Oncotype DX Score met the criteria for size (based on grade) and margins (at least 3 mm). Ten patients had margins that were less than 3 mm but met the size criteria. Two patients did not meet the size criteria but had at least 3 mm margins. One patient did not meet either the size or margin criteria. None of our 20 patients with low risk Oncotype DX DCIS Score and who met both the size and margin criteria recurred. With the median follow-up of approximately 2-1/2 years, three of the 21 patients (14%) with low or intermediate risk scores who underwent Oncotype DX DCIS Score and did not receive radiation therapy suffered a local recurrence. The predicted average recurrence risk for these patients based on their Oncotype DX DCIS Score was 12%. Two of these patients who recurred had margins less than 3 mm, and one patient met the size and margin criteria, but had an intermediate risk score. By comparison, five of 61 (8%) of patients who underwent breast conserving surgery and adjuvant radiation therapy had a local recurrence. Twenty of the 23 (87%) low risk Oncotype DX DCIS Score patients did not receive radiation therapy and overall 20/35 (57%) of the patients undergoing Oncotype DX DCIS Score did not receive radiation therapy. Although the follow-up is still relatively short, Oncotype DX DCIS Score allows a considerable number of women to avoid adjuvant radiation therapy. Citation Format: Wheeler JA, Vaghefi H, Liu F, Owens V, Morris L, Denham F, Coody L. Effectiveness of Oncotype DX DCIS scoring in a community setting [abstract]. In: Proceedings of the 2018 San Antonio Breast Cancer Symposium; 2018 Dec 4-8; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2019;79(4 Suppl):Abstract nr P5-18-12.