Application of delayed-enhancement MRI in lumpectomy cavity delineation for patients after breast-conserving surgery in prone radiotherapy using deformable image registration

Objective To assess the feasibility of delayed-enhancement MRI in contouring the lumpectomy cavity (LC) for patients with invisible seroma or a low cavity visualization score (CVS≤2) in the excision cavity after breast-conserving surgery (BCS). Methods Twenty-six patients with stageT1-2N0M0 who underwent prone radiotherapy after BCS were recruited. The LC delineated on CT simulation images was denoted as LCCT. The LCs delineated on T2WI, as well as on different delayed phases (2-, 5-and 10-minute) of delayed-enhancement T1WI were defined as LCT2, LC2T1, LC5T1 and LC10T1, respectively. Subsequently, the volumes and locations of the LCs were compared between CT simulation images and different sequences of MR simulation images using deformable image registration. Results The volumes of LCT2, LC2T1, LC5T1 and LC10T1 were all larger than that of LCCT. A statistical significance was found between the volume of LCCT and those of LC2T1 or LC5T1, respectively (both P<0.05). The conformal index (CI), degree of inclusion (DI), dice similarity coefficient (DSC) and the distance between the center of mass of the targets (COM) of LCCT-LC10T1 were better than those of LCCT-LCT2, LCCT-LC2T1 and LCCT-LC5T1, however, there was no statistical difference among them (all P>0.05). Conclusions It is feasible to delineate the LC based on prone delayed-enhancement MR simulation images in patients with low CVS after BCS. Meanwhile, the LCs derived from prone delayed-enhancement T1WI of 10-minute are the most similar with those derived from prone CT simulation scans using titanium clips, regardless of the volumes and locations of LCs.     

Positive margins prediction in breast cancer conservative surgery: Assessment of a preoperative web-based nomogram

Margin status of the surgical specimen has been shown to be a prognostic and risk factor for local recurrence in breast cancer surgery. It has been studied as a topic of intervention to diminish reoperation rates and reduce the probability of local recurrence in breast conservative surgery (BCS).This study aims to validate the Dutch BreastConservation! nomogram, created by Pleijhus et al., which predicts preoperative probability of positive margins in BCS.Patients with diagnosis of breast cancer stages cT1-2, who underwent BCS at the Breast Center of São João University Hospital (BC-CHSJ) in 2013–2014, were included. Association and correlation were evaluated for clinical, radiological, pathological and surgical variables. Multivariable logistic regression and ROC curves were used to assess nomogram parameters and discrimination.In our series of 253 patients, no associations were found between margin status and other studied variables (such as age or family history of breast cancer), except for weight (p-value = 0.045) and volume (p-value = 0.012) of the surgical specimen.Regarding the nomogram, a statistically significant association was shown between cN1 status and positive margins (p-value = 0.014). No differences were registered between the scores of patients with positive versus negative margins. Discrimination analysis showed an AUC of 0.474 for the basic and 0.508 for the expanded models.We cannot assume its external validation or its applicability to our cohort. Further studies are needed to determine the validity of this nomogram and achieve a broader view of currently available tools.     

Omission of chemotherapy for low-grade,luminal A N1 breast cancer: Patterns of care and clinical outcomes

PurposeMultiple ongoing randomized studies are assessing the impact of omission of chemotherapy (CT) in low-risk node-positive Luminal A breast. The goal of this investigation was to evaluate trends and practice patterns of adjuvant CT use in Luminal A pT1-3N1 breast cancer, along with determining the clinical benefit from adjuvant CT in this patient population.MethodsThe National Cancer Data Base was queried (2004–2014) for women with pT1-3N1 luminal A invasive ductal carcinoma receiving adjuvant hormonal therapy (HT). Multivariable logistic regression ascertained factors associated with adjuvant CT administration. Kaplan-Meier analysis evaluated overall survival (OS) between patients treated with CT/HT vs. HT alone, while sub-stratifying patients by age.ResultsOf 8548 total patients, 5182 (61%) received CT/HT, while 3366 (39%) received HT alone. A steady rise in omission of adjuvant CT was observed, from 14% (2004–2005) to 41% (2012–2014). A decision not to use CT was more likely in more recent time periods, in older patients, at academic centers, following lumpectomy, and with lower T classification (p < 0.05 for all). CT was associated with higher OS in all patients (p < 0.001) and women ≤50 years old (p = 0.030), but not for ages 51–60 (p = 0.116), 61–70 (p = 0.222), or >70 (p = 0.239).ConclusionsUsing CT for Luminal A N1 breast cancer is decreasing over time, primarily in older patients and at academic centers. Although CT is still associated with an OS advantage in all patients, subgroup analysis demonstrated no OS benefit in women >50 years of age. These results have implications on the ongoing randomized trials.     

Novel and programmatic improvements to the workflow associated with the AccuBoost breast brachytherapy procedure

PurposeWhile the noninvasive breast brachytherapy (NIBB) treatment procedure, known as AccuBoost, for breast cancer patients is well established, the treatment quality can be improved by the efficiency of the workflow delivery. A formalized approach evaluated the current workflow through failure modes and effects analysis and generated insight for developing new procedural workflow techniques to improve the clinical treatment process.Methods and MaterialsAccuBoost treatments were observed for several months while gathering details on the multidisciplinary workflow. A list of possible failure modes for each procedure step was generated and organized by timing within the treatment process. A team of medical professionals highlighted procedural steps that unnecessarily increased treatment time, as well as introduced quality deficiencies involving applicator setup, treatment planning, and quality control checks preceding brachytherapy delivery. Procedural improvements and their impact on the clinical workflow are discussed.ResultsThe revised clinical workflow included the following key procedural enhancements. Prepatient arrival: Improvement of prearrival preparation requires advance completion of dose calculation documentation with patient-specific setup data. Patient arrival pretreatment: Physicists carry out dwell time calculations and check the plan, while the therapist concurrently performs several checks of the ensuing hardware configuration. Treatment: An electronic method to export the associated HDR brachytherapy paperwork to the electronic medical record system with electronic signatures and captured approvals was generated. Posttreatment: The therapist confirms the applicators were appropriately positioned, and treatment was delivered as expected.ConclusionsThe procedural improvements reduced the overall treatment time, improved consistency across users, and eased performance of this special procedure for all participants.     

Breast-Conservative Surgery Followed by Radiofrequency Ablation of Margins Decreases the Need for a Second Surgical Procedure for Close or Positive Margins

BackgroundExcision of breast cancer followed by radiofrequency ablation (eRFA) is a technique designed to increase negative margins in breast-conservative surgical procedures. The objective of this study is to analyze the impact of eRFA in avoiding a second surgical procedure for close or positive margins after a breast-conservative surgical procedure.Material and MethodsFrom February 2008 to May 2010, 20 patients were included. After lumpectomy, the eRFA was performed in the lumpectomy cavity, and biopsies from each margin from the radial ablated cavity walls were obtained. Biopsy samples were assessed for tumor viability.ResultseRFA was successful in 19 of 20 patients. In all patients, the devitalized tissue extended beyond a 5- to 10-mm radial depth of the biopsy sample. Overall, 6 patients (31%) had margins < 2 mm, 4 of them with < 1 mm margin. All 6 of these patients had no tumor viability according to analysis of biopsy samples stained with 2,3,5-triphenyltetrazolium chloride. At a median follow-up of 46 months, no local recurrence had been found.ConclusionThis study supports the feasibility of eRFA treatment. In our study, the eRFA method has spared 31% of patients from undergoing a re-excision surgical procedure, and it may, in the long-term, reduce local recurrences.     

A prospective, randomized, controlled, multicenter study of a real-time, intraoperative probe for positive margin detection in breast-conserving surgery

BACKGROUND: This randomized, double-arm trial was designed to study the benefit of a novel device (MarginProbe, Dune Medical Devices, Caesarea, Israel) in intraoperative margin assessment for breast-conserving surgery (BCS) and the associated reduction in reoperations. METHODS: In the device group, the probe was applied to the lumpectomy specimen and additional tissue was excised according to device readings. Study arms were compared by reoperation rates and by correct surgical reaction confirmed by histology. RESULTS: Three hundred patients were enrolled. Device use was associated with improved correct surgical reaction, defined as additional re-excision in all histologically detected positive margins, with tumor within 1 mm of inked margin. The repeat lumpectomy rate was significantly reduced by 56% in the device arm: 5.6% versus 12.7% in the control arm. There were no differences in excised tissue volume or cosmetic outcome. CONCLUSIONS: Intraoperative use of the MarginProbe for positive margin detection is safe and effective in BCS and decreases the rate of repeat operations.     

Optical segmentation of unprocessed breast tissue for margin assessment

Visual and tactual examination of unprocessed breast specimens is the standard for intraoperative surgical margin assessment in the United States. However, this procedure does not provide surgeons or pathologists with microscopic views of the tissue, which makes it difficult to accurately assess margin status or the extent of the disease, especially in non-palpable cases. We use a combination of spectral and polarization macroscopic imaging to optically segment the adipose and collagen tissues thus highlighting regions suspected of containing epithelium in order to facilitate optical microscopy techniques. A small study on five lumpectomy and mastectomy samples showed a sensitivity of 70% ± 20% and specificity of 50% ± 10% for adipose segmentation and a sensitivity of 50% ± 20% and specificity of 50% ± 20% for collagen segmentation. This sensitivity and specificity are sufficient for providing morphological information to the pathologist in order to guide microscopic examination of regions likely to be of clinical significance.     

Factors which affect use of breast conservation and mastectomy in an underinsured Hispanic population

BackgroundDespite no difference in overall survival between breast conservation and mastectomy, significant variation exists between institutions and within populations. Less data exists about racial and ethnic minority populations. The current study was performed to evaluate variables that affect use of breast conservation and mastectomy in an underinsured Hispanic population.MethodsA retrospective review was performed of all patients who self-identified as of Hispanic ethnicity and underwent breast cancer operations from July 2001 to February 2011 at a safety net hospital. Sociodemographic, clinical, and treatment variables were evaluated. All patients with documented contraindications to breast conservation were excluded. Univariate analysis and multivariate analysis were performed to identify variables which were associated with type of operation.ResultsThe average age of the 219 patients included was 50 years. Most of the patients (93%) were insured with Medicaid or uninsured and 59% presented with clinical stage 2A/B cancers. Mastectomy was performed in 33% of patients and 67% had breast conservation. In adjusted multivariate analysis higher pathologic stage (p = 0.01) and English speakers (p = 0.03) were associated with mastectomy. By contrast, higher BMI (p = 0.03) and use of preoperative chemotherapy (p = 0.01) were associated with breast conservation.ConclusionsIn this underinsured Hispanic population, patients with higher pathologic stage and English speaking patients were more likely to undergo mastectomy. Patients who underwent preoperative chemotherapy and who had higher BMI were more likely to undergo breast conservation.     

Optimal management of the axilla in patients with Breast Cancer

BACKGROUND: Although most surgeons perform some form of axillary lymph node dissection (ALND) as part of locoregional management of operable breast cancer, the extent of dissection remains controversial. Patients and methods: Observation of the axilla trial (protocol I) and partial dissection trial (protocol I) began in January 1996. Between January 1996 and May 2000, 45 post-menopausal and 207 women with clinically node-negative breast cancer were enrolled into protocol I and protocol II respectively. RESULTS: The 4-year cumulative incidence rate of axillary recurrence was 7% in patients with untreated the axilla. The 4-year overall survival rate was 98% in patients with untreated the axilla. The 4-year disease-free and overall survival rates were 96% and 98% respectively in patients treated with partial dissection. CONCLUSION: Total axillary dissection seems to be unnecessary in Japanese breast cancer patients with relatively small tumors.