To clip or not to clip the breast tumor bed? A retrospective look at the geographic miss index and normal tissue index of 110 patients with breast cancer

Oncoplastic breast surgery - a pictorial classification system for surgeons and radiation oncologists (OPSURGE)

INTRODUCTION

Changes to the tumour bed following oncoplastic breast surgery complicate the administration of adjuvant radiotherapy. Consensus guidelines have called for improved interdisciplinary communication to aid adjuvant boost radiotherapy. We propose a framework of tumour bed classification following oncoplastic surgery to enhance understanding and communication between the multidisciplinary breast cancer team and facilitate effective and more precise delivery of adjuvant boost radiotherapy.

METHODS

A classification system was devised by grouping oncoplastic procedures based on skin incision, tissue mobilization, tumour bed distortion, seroma formation and flap reconstruction. The system is supplemented by a colour-coded pictorial guide to tumour bed rearrangement with common oncoplastic procedures.

RESULTS

A 5-tier framework was developed. Representative images were produced to describe tumour bed alterations.

CONCLUSION

The proposed framework (OPSURGE) improves the identification of the primary tumour bed after initial breast-conserving surgery, which is imperative to both the surgeon in planning re-excision and the radiation oncologist in planning boost radiotherapy.

Long-Term Outcomes of an International Cooperative Study of Intraoperative Radiotherapy Upfront Boost With Low Energy X-Rays in Breast Cancer

Purpose

The purpose of this study was to assess the effectivity of upfront kilovoltage intraoperative radiotherapy (IORT) as a boost in high-risk early-stage breast cancer patients from an international pooled cohort.

Materials/Methods

Patients from four centers in three different countries were retrospectively screened. Those with a minimum 1-year follow-up were included. Cumulative local (LR), regional (RR), and distant metastasis rates (DM) were analyzed. Additionally, the estimated overall survival (OS) was assessed. The Cox regression analysis was performed to identify failure predicting factors.

Results

A total of 653 patients from centers in Peru, Spain, and Germany were included. The median follow-up was 55 (12-180) months, and age was 58 (27-86) years. Clinical tumor (T) staging was T1 65.85%, T2 30.17%, and T3 3.98%. Positive margins were found in 7.9% and in-situ component in 20.06%. The median IORT dose was 20 (6-20). The median time from IORT to EBRT was 74.5 (13-364) days. An overall 3.4% (n = 22) of patients developed local recurrence at some point during follow-up. The 12-, 60-, and 120-month cumulative LR were 0.3%, 2.3%, and 7.9%, respectively. After multivariate analysis, only age <50 remained to be a significant prognostic factor for local recurrence (HR 0.19, 95% CI 0.08-0.47; p < 0.05). The 10-year estimated OS was 81.2%.

Conclusion

Upfront boost with IORT yields similar local control outcomes to those EBRT-based reports. Results from prospective trials, regarding toxicity, cosmesis, and effectivity are awaited to confirm these findings.

Effective of Pre-operative 2-Deoxy-2-[fluorine-18] fluoro-d-glucose/Positron Emission Tomography/Computed Tomography in the Determination of Boost Volume in Adjuvant Radiotherapy after Breast-conserving Surgery

Objectives:

Determining boost volume (BV) during breast radiotherapy can be challenging at times. Therefore, surgical clips are now being widely used. At times, when surgical clips are inadequate in determining the BV, other additional imaging methods are required. In the present study, we aimed to demonstrate that pre-operative positron emission tomography/computed tomography (PET-CT) can be used to determine the BV after a breast-conversing surgery.

Methods:

We selected thirty patients who underwent breast-conserving surgery with surgical clips and had preoperative Fluorine-18-Fluorodeoxyglucose PET (18 FDG PET/CT). The BV in planning tomography (CT) and primary tumor volume (TV) in pre-operative F-18 FDG PET/CT was contoured by a radiation oncologist. These two volumes were superposed using rigid image fusion. In every patient, two BVs were measured. The mean shift between the two volumes by the calculation of the center of mass and percentage of the PET-CT TV (PET-CT TV) in planning the BV (planning target volume [PTV]-BV) was calculated.

Results:

The median age was 52 years (range 25–72 years). The pre-operative PET-CT TV median was 8.89 cm³ (range 1.00–64.30 cm³). The median PTV-BV was 62.92 cm³ (12.57–123.07 cm³). The median shifts between the center of volumes were 1.76 cm (range 0.90–3.50) in X(coronal), 1.73 cm (range 0.60–3.60) in the Y(axial), and 1.20 cm (0.40–2.80) in the Z(sagittal) directions, respectively. The shifts in these three planes were determined to be statistically significant (p<0.001). The percent volume of PET-CT TV included PTV TV, ranging from 35% to 100% (mean 54%, standard deviation 29.53) and 100% in two out of 31 patients.

Conclusion:

Our study has shown that pre-operative PET-CT cannot be used to determine the BV in patients who replaced surgical clips and had undergone breast-conserving surgery. To define a more accurate BV, surgical clips should be placed in four planes, and more PTV margins should be given in treatment planning.

Consensus statement on tumour bed localization for radiation after oncoplastic breast surgery

Background

Oncoplastic surgery (ops) is becoming the new standard of care for breast-conserving surgery, leading to some challenges with adjuvant radiation, particularly when accurate tumour bed (tbd) delineation is needed for focused radiation (that is, accelerated partial breast irradiation or boost radiation). Currently, no guidelines have been published concerning tbd localization for adjuvant targeted radiation after ops.

Methods

A modified Delphi method was used to establish consensus by a panel of 20 experts in surgical and radiation oncology at the Canadian Locally Advanced Breast Cancer National Consensus Group and in a subsequent online member survey.

Results

These are the main recommendations:■ Surgical clips are necessary and should, at a minimum, be placed along the 4 side walls of the cavity, plus 1-4 clips at the posterior margin if necessary.■ Operative reports should include pertinent information to help guide the radiation oncologists.■ Breast surgeons and radiation oncologists should have a basic understanding of ops techniques and work on "speaking a common language."■ Careful consideration is needed when determining the value of targeted radiation, such as boost, in higher-level ops procedures with extensive tissue rearrangement.

Conclusions

The panel developed a total of 6 recommendations on tbd delineation for more focused radiation therapy after ops, with more than 80% agreement on each statement. All are summarized, together with the corresponding evidence or expert opinion.

A novel, adaptable, radiographically opaque, multi-plane continuous filament marker for optimizing tissue identification, radiation planning, and radiographic follow-up

Background

In breast cancer treatment, marking the tumor bed is an important aspect of the surgical component of therapy. Clear delineation of the tumor bed allows radiation oncologists a defined target for planning and delivering postoperative radiation therapy (XRT). Tumor bed marking also allows radiographic follow-up of the tumor bed on subsequent breast imaging. The aim of this assessment is to evaluate the ease and feasibility of utilizing a tumor bed filament marker (VeraFormÒ, Videra Surgical inc., USA) as a marker in post-operative benign surgical sites and malignant breast surgical tumor beds in breast cancer surgery.

Methods

The filament marker is a novel radiopaque surgical filament that in lieu of clips and other markers is implanted in the surgical tumor bed during breast surgery. Following development of the filament marker, the researchers used breast phantoms and radiographic images to develop a series of geometric patterns of placement options that optimize comprehensive multi-plane radiographic interpretation of the exact tumor bed or surgical margin. Three breast surgeons at 3 separate institutions then used this filament as a continuous multi-plane marker in 20 patients during breast conservation surgery. In these patients, the filament marker was thus used to mark the tumor bed (breast cancer surgery) or surgical site (benign breast disease) instead of the more traditional devices such as clips or other metallic open framework devices. We then assessed 2 important factors related to this device; (I) the ease, feasibility, and accuracy of in vivo placement with oncoplastic and non-oncoplastic breast conservation surgery techniques; (II) the radiographic footprint this device left on standard imaging protocols of post-operative mammogram (MMG), computed tomography (CT) scan, breast magnetic resonance imaging (MRI) examinations, and ultrasounds (USs) for both routine follow-up imaging and for standard radiation planning.

Results

There were no adverse events reported with the use of this device. The cases were then reviewed by a multidisciplinary team that included the original surgeon, a breast radiologist, and radiation oncologist. Their unanimous evaluation was that the filament marker clearly delineated all sides and planes of the tumor bed (cancer surgery) or surgical site (benign disease). Regardless of surgical technique utilized, this information provided precise 3D guidance for radiation planning and delivery as well as radiographic follow-up. The surgeons involved reported that delineating the bed with the filament marker was a quick and easy procedure and did not interfere with performing the planned surgical technique. Radiologists, surgeons, and radiation oncologists found that the filament marker was not only radiographically opaque on CT and MMG, but also caused no significant artifact on CT, MRI, US, or MMG.

Conclusions

The continuous multi-plane filament marker is a new device that fulfills the heretofore unmet need for safe and improved tumor bed and tissue site marking. It is an easy to place, non-palpable continuous multi-plane radiographic opaque tissue marker that seems to better delineate the tumor bed, regardless of type of breast surgery performed, while providing a more accurate 3D image for radiation planning and radiographic follow-up on MMG MRI, CT and US.

Sentinel Lymph Node Biopsy After Initial Lumpectomy (SNAIL Study)-a Prospective Validation Study

Tertiary oncology center clinicians are commonly faced with the problem of managing patients with a diagnosis of breast cancer made after lumpectomy in the Primary Health Care (PHC) setting. There are no studies or guidelines that address the further surgical management in this group of patients regarding sentinel lymph node biopsy (SLNB) and need for breast post-operative cavity excision. Prospective observational study was planned to evaluate the feasibility of SLNB and defining the need for definitive breast surgery in patients diagnosed with breast cancer after lumpectomy in PHC. The study was carried out from January 2015 to August 2017 in Tata Medical Center, India, approved by institutional review board (EC/TMC/36/14). Seventy patients who underwent lumpectomy with a definitive histological analysis of breast cancer were included in this study. Each patient had definitive breast surgery and SLNB using subareoral blue dye injection followed by validation axillary dissection. The identification rate (IR) for SLNB was 92% (64/70). The median number of SLNs removed was 2 (IQR 1, 3). There were 2 patients with false negative results resulting in false negative rate (FNR) of 11%. Overall, SLNB procedure has the sensitivity of 89%, NPV of 96%, and accuracy was 97%. Peri-areoral incision of initial surgery was associated with low IR (84%) and high FNR (33%). Final histopathology showed residual invasive cancer in 43% and ductal carcinoma in situ in 14% of patients. Among 21 patients where initial lumpectomy histopathology margin was free of cancer, residual malignancy was found in 57% of patients. Prior excision of lumps for breast cancer does not affect the accuracy of SLNB. Peri-areoral scar may be associated with high FNR and low IR, although further studies are needed to validate this statement. Definitive breast surgery is required for all patients, irrespective of initial lumpectomy histopathological margin status.