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

Stabilised hyaluronic acid gel marker versus surgical clips for tumour bed delineation in breast cancer radiotherapy using MRI-simulation

BACKGROUND AND PURPOSE

Compare breast cancer tumour bed (TB) delineation using stabilised hyaluronic acid (sHA) gel and MRI-simulation versus surgical clips and CT-simulation within same patient cohort.

MATERIALS AND METHODS

Prospective single arm study of patients undergoing breast conserving surgery. Patients had both clips (≥5) and sHA gel markers inserted to define the TB and underwent MRI and CT simulation scans. Six observers delineated the TB aided by gel on MRI, and clips on CT. The primary measure was the inter-observer variability (inter-OV) of the delineated TB using the overlap difference of using clips and CT versus sHA gel and MRI, measured according to the general definition of the conformity index (CIgen).

RESULTS

Of 35 patients recruited, 30 underwent inter-OV analysis of contours and 5 required further breast surgery for positive margins. There was no significant difference in mean CIgen between TB delineated using gel and MRI versus clips and CT (0.463 vs 0.434, p = 0.235). Observers reported higher usefulness of gel in patients who underwent oncoplastic surgery (median utility score 8.2 vs 6.6, p = 0.024), and higher visibility of gel in patients who had their scans within 6 weeks than beyond post-op (median visibility score 8.1 vs 6.1, p = 0.013). When the cavity visualisation score was higher (4-5), the median utility score of gel was lower (5.54 vs 8.0, p < 0.001), and the mean CIgen of clips and CT delineated TB was higher (0.64 vs 0.37, p < 0.001).

CONCLUSION

sHA gel has similar inter-OV of TB delineation compared to ≥5 clips, hence is a reliable alternative to clips when MRI-simulation is used.

Oncoplastic Surgery: Where Are We Now?

In the 1970s, we learned breast conservation therapy (BCT) was not inferior to mastectomy. Early BCT methods could result in deformities that were unacceptable to patients and to their surgeons. By the 1990s, surgeons began to apply the principles of plastic surgery to improve outcomes. The term oncoplastic surgery was first described in the 1990s by Werner Audretsch. We offer a review of principles, techniques, current controversies, and challenges in broadening the utilization of OPS.

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.

The Oncological and Surgical Outcomes of Immediate Oncoplastic Breast Reconstruction With Contralateral Breast Adjustment

BACKGROUND

Oncoplastic surgery is an expanding approach for managing breast conservation because it offers improved cosmetic outcomes while maintaining oncological safety.

OBJECTIVES

This study aimed to assess the oncological and surgical outcomes of patients who underwent oncoplastic procedures at a single institution.

METHODS

The study population includes all consecutive breast cancer patients who underwent lumpectomy followed by immediate oncoplastic breast reconstruction with contralateral breast adjustment between 2010 and 2021. Following IRB approval, patient demographics, tumor characteristics, surgical details, complications, and follow-up were evaluated for this group. Quality of life (QOL) and patient-reported outcome measures were assessed through questionnaires.

RESULTS

Following multidisciplinary tumor board discussion, 77 patients (82 breasts) underwent oncoplastic surgery. Of these, 92.2% underwent breast MRI prior to surgery with mean mass enhancement of 2.35 cm (range, 0-8.5 cm) and non-mass enhancement of 5.77 cm (range, 0-14 cm), and 44% presented with multifocal disease. The final positive surgical margin rate was 2.4%, and all conserved breasts received adjuvant radiation therapy. The 5-year local recurrence rate for invasive tumors was 4.1%. QOL scores were generally high, with most patients reporting good to excellent cosmetic outcomes and high personal satisfaction with breast appearance and softness. Physicians reported breast symmetry in 89.5%.

CONCLUSIONS

The findings suggest that oncoplastic surgery with contralateral breast adjustment is safe, effective, and an excellent option for breast cancer patients wishing for breast conservation even for large or multifocal masses, with favorable oncologic and cosmetic outcomes. The QOL analysis indicates high patient satisfaction. These results support the use of oncoplastic surgery in the management of breast cancer.

LEVEL OF EVIDENCE: 4

Stabilised Hyaluronic Acid (sHA) gel as a novel marker for breast cancer tumour bed cavity: Surgical feasibility

Introduction

Consistent delineation of the breast conserving surgery (BCS) tumour bed (TB) for breast cancer remains a challenge for radiation oncologists. Accurate delineation allows for better local control and reduces toxicity when planning partial breast or TB boost radiation therapy (RT).

Methods

In the operating theatre (OT) breast surgeons inserted stabilised hyaluronic acid (sHA) gel as small drops approximately one cm into the walls surrounding the resection cavity. Surgical feasibility was determined by the rate of successful sHA gel insertion procedure, the ease of insertion as rated by surgeons, the time required for insertion procedure, the quantity used, and any adverse events (AE) relating to sHA gel insertion.

Results

Thirty-five patients were enrolled. All patients underwent sHA gel insertion successfully. The procedure added a median of 2.8 min to the OT time and was rated as 'easy' in 89 % of patients. There were no immediate AE in OT. Five (14 %) patients experienced a grade 2 or higher AE. Three of the five patients were prescribed oral antibiotics for breast infection. Two of the five patients experienced a grade 3 AE - haematoma which required evacuation in OT day 1 post-BCS, and infected seroma which required drainage and washout in OT 2 months post-BCS. All five patients recovered and underwent the planned adjuvant therapies for their BC. The AE data reflects common risks with standard BCS and are not clearly attributed to sHA gel insertion alone.

Conclusion

We show that sHA gel is surgically feasible as a marker to help define the TB cavity for post-BCS adjuvant MRI-based RT planning.

Oncoplastic reduction mammoplasty: Systematic review and proportional meta-analysis of surgical outcomes

BACKGROUND

Breast-conserving surgery is the standard of care for early-stage breast cancer but can often result in unsatisfactory cosmetic outcomes. Oncoplastic surgery aims to address these issues by combining local excision with plastic surgery techniques to improve oncologic and esthetic outcomes. By incorporating breast reduction techniques into cancer surgery, wider margins of excision can be achieved, leading to enhanced oncological safety and reduced recurrence rates without causing significant asymmetry. This systematic review and meta-analysis aims to provide an updated understanding of the surgical outcomes associated with oncoplastic reduction mammoplasty.

METHODS

A systematic review of the literature was conducted according to PRISMA guidelines. Articles reporting post-operative outcomes following the oncoplastic reduction mammoplasty were included. A proportional meta-analysis of post-operative complications was performed to obtain their proportions and 95% Confidence Intervals (CIs).

RESULTS

Eighteen studies met the inclusion criteria, representing a total of 2711 oncoplastic reduction mammoplasty procedures in 2680 patients. The overall complication rate was 20% (95% CI: 15-25%). The positive margin rate following oncoplastic reduction mammoplasty was 11% (95% CI: 6-17%). The re-excision rate was 6% (95% CI: 3-12%). The completion mastectomy rate was 3% (95% CI: 2-6%).

CONCLUSIONS

Oncoplastic reduction mammoplasty is a safe and effective alternative to mastectomy and traditional breast-conserving surgery in the treatment of early-stage breast cancers.

System describing surgical field extension associated with flap reconstruction after resection of a superficial malignant soft tissue tumor

BACKGROUND

Flap reconstruction after resection of a superficial malignant soft tissue tumor extends the surgical field and is an indicator for potential recurrence sites.

AIM

To describe a grading system for surgical field extension of soft tissue sarcomas.

METHODS

Grading system: CD-grading is a description system consisting of C and D values in the surgical field extension, which are related to the compartmental position of the flap beyond the nearby large joint and deeper extension for the pedicle, respectively. C1/D1 are positive values and C0/D0 are negative. With a known location, 1/0 values can be "p" (proximal), "d" (distal), and "b" (in the tumor bed), and the description method is as follows: flap type, CxDx [x = 0, 1, p, d or b].

RESULTS

Four representative patients with subcutaneous sarcomas who underwent reconstruction using fasciocutaneous flaps are presented. The cases involved a distal upper arm (elbow) synovial sarcoma reconstructed using a pedicled latissimus dorsi (pedicled flap: CpDp); a distal upper arm (elbow) pleomorphic rhabdomyosarcoma reconstructed using a transpositional flap from the forearm (transpositional flap: CdD0); an undifferentiated pleomorphic sarcoma in the buttocks reconstructed using a transpositional flap (transpositional flap: C0D0); and a myxofibrosarcoma in the buttocks reconstructed using a propeller flap from the thigh (pedicled flap: CdDd).

CONCLUSION

The reconstruction method is chosen by the surgeon based on size, location, and other tumor characteristics; however, the final surgical field cannot be determined based on preoperative images alone. CD-grading is a description system consisting of C and D values in the surgical field extension that are related to the compartmental position of the flap beyond the nearby large joint and deeper extension for the pedicle, respectively. The CD-grading system gives a new perspective to the flap reconstruction classification. The CD-grading system also provides important information for follow-up imaging of a possible recurrence.

Implementation of a Breast Intraoperative Oncoplastic Form to Aid Management of Oncoplastic Surgery

INTRODUCTION

Oncoplastic breast conservation surgery (BCS) uses concurrent reduction and/or mastopexy with lumpectomy to improve aesthetic outcomes. However, tissue rearrangement can shift the original tumor location site in relation to external breast landmarks, resulting in difficulties during re-excision for a positive margin and accurate radiation targeting. We developed the Breast Intraoperative Oncoplastic (BIO) form to help depict the location of the tumor and breast reduction specimen. This study seeks to assess physician perspectives of the implementation outcomes.

METHODS

From February 2021 to April 2021, the BIO form was used in 11 oncoplastic BCS cases at a single institution. With institutional review board approval, surgical oncologists (SOs), plastic surgeons (PSs), and radiation oncologists (ROs) were administered a 12-question validated survey on Acceptability of Intervention Measure (AIM), Intervention Appropriateness Measure (IAM), and Feasibility of Intervention Measure (FIM), using a 5-point Likert scale during initial implementation and at 6-month reassessment.

RESULTS

Twelve physicians completed the survey initially (4 SOs, 4 PSs, and 4 ROs). The mean scores for Acceptability of Intervention Measure, Intervention Appropriateness Measure, and Feasibility of Intervention Measure were high (4.44, 4.56, and 4.56, respectively). Twelve completed the second survey (5 SOs, 3 PSs, and 4 ROs). The mean scores were marginally lower (4.06, 4.21, and 4.25). There were no significant differences when stratified by number of years in practice or specialty. Free text comments showed that 75% of physicians found the form helpful in oncoplastic BCS.

CONCLUSIONS

The data indicate high feasibility, acceptability, and appropriateness of the BIO form. Results of this study suggest multidisciplinary benefits of implementing the BIO form in oncoplastic BCS.

Use of tumour bed boost radiotherapy in volume replacement oncoplastic breast surgery: A systematic review

Tumour bed boost radiotherapy (RT) following breast conserving surgery reduces local recurrence in high-risk disease. There is recent debate over challenges to accurately localise tumour bed for RT boost delivery following volume replacement oncoplastic breast surgery (VR-OBS). This review evaluates the reporting of RT boost following VR-OBS in the literature published between January 2010 and December 2021. This review was in line with Preferred Reporting Items for Systematic Reviews and Metaanalysis statement.Nine studies met the inclusion criteria (n=670 patients), and RT boost was used in eight studies. Boost was administered in total to 384 patients (62.5% of irradiated patients). Only two studies reported boost planned target volumes and only one compared these against surgical specimen volumes.RT boost was not reported in most published studies on VR-OBS. Future prospective research are strongly needed to evaluate long-term outcomes of VR-OBS following RT boost, especially on breast cosmesis and patients' satisfaction. DATA AVAILABILITY: Data will be made available upon request.

Sometimes it is better to just make it simple. De-escalation of oncoplastic and reconstructive procedures

Simple breast conservation surgery (sBCS) has technically advanced onto oncoplastic breast procedures (OBP) to avoid mastectomy and improve breast cancer patients' psychosocial well-being and cosmetic outcome. Although OBP are time-consuming and expensive, we are witnessing an increase in their use, even for cases that could be managed with sBCS. The choice between keeping it simple or opting for more complex oncoplastic procedures is difficult. This review proposes a pragmatic approach in assisting this decision. Medical literature suggests that OBP and sBCS might be similar regarding local recurrence and overall survival, and patients seem to have higher satisfaction levels with the aesthetic outcome of OBP when compared to sBCS. However, the lack of comprehensive high-quality research assessing their safety, efficacy, and patient-reported outcomes hinders these supposed conclusions. Postoperative complications after OBP may delay the initiation of adjuvant RT. In addition, precise displacement of the breast volume is not effectively recorded despite surgical clips placement, making accurate dose delivery tricky for radiation oncologists, and WBRT preferable to APBI in complex OBP cases. With a critical eye on financial toxicity, patient satisfaction, and oncological outcomes, OBP must be carefully integrated into clinical practice. The thoughtful provision of informed consent is essential for decision-making between sBCS and OBP. As we look into the future, machine learning and artificial intelligence can potentially help patients and doctors avoid postoperative regrets by setting realistic aesthetic expectations.

Breast Radiotherapy after Oncoplastic Surgery-A Multidisciplinary Approach

Oncoplastic breast surgery encompasses a range of techniques used to provide equitable oncological outcomes compared with standard breast surgery while, simultaneously, prioritizing aesthetic outcomes. While the outcomes of oncoplastic breast surgery are promising, it can add an extra complexity to the treatment paradigm of breast cancer and impact on decision-making surrounding adjuvant therapies, like chemotherapy and radiotherapy. As such, early discussions at the multidisciplinary team meeting with surgeons, medical oncologists, and radiation oncologists present, should be encouraged to facilitate best patient care.

Partial Breast Irradiation and Surgical Clip Usage for Tumor Bed Delineation After Breast-Conserving Surgery in Canada: A Radiation Oncology Perspective

PURPOSE

Our purpose was to evaluate the usage and perceived benefit of surgical clips for breast radiation therapy planning in Canada, focusing on partial breast irradiation (PBI) after breast-conserving surgery.

METHODS AND MATERIALS

A retrospective institutional review identified patients eligible for PBI based on clinicopathologic criteria, and tumor bed visualization was determined from computed tomography-planning scans. An online survey was subsequently distributed to Canadian radiation oncologists addressing the usage and added value of surgical clips for breast radiation therapy planning purposes. The survey also evaluated PBI usage and regimens. Responses were collected over a 4-week period. PBI regimen usage at our institution was also reviewed from May 1 to December 18, 2020.

RESULTS

Based on clinicopathologic criteria, 306 patients were identified between 2013 and 2018 who were eligible for PBI. However, only 24% (72/306) of cases were noted to have surgical clips, of which over 50% did not assist in tumor bed localization due to inconsistent clip positioning. Similarly, nearly two-thirds (28/43) of survey respondents indicated that surgical clips are placed in the tumor bed in less than 50% of cases. Almost all respondents (42/43) indicated that surgical clips facilitate breast radiation therapy planning and favor the development of guidelines to increase the consistent placement of surgical clips in the tumor bed after breast-conserving surgery. Approximately two-thirds of respondents (28/43) offer PBI to eligible patients as routine treatment, with moderate hypofractionated regimens most commonly recommended. However, the 1-week daily regimen of 26 Gy in 5 fractions is now offered to the majority (77%) of patients at our institution.

CONCLUSIONS

There was strong agreement among Canadian radiation oncologists that surgical clip placement facilitates breast radiation therapy planning, and most favor the development of surgical guidelines for the consistent placement of surgical clips in this setting. With the growing use of PBI, accurate localization of the tumor bed is extremely important.

Can we rely on surgical clips placed during oncoplastic breast surgery to accurately delineate the tumor bed for targeted breast radiotherapy?

PURPOSE

Oncoplastic breast surgery (OBS) is gaining popularity among surgeons for breast-conserving surgery treatments. OBS relies on complex relocation and deformation of breast tissue involving the tumor bed (TB). In this study, we investigate the validity of using surgical clips with OBS for accurate TB delineation in adjuvant, targeted breast radiotherapy.

METHODS

Different OBS techniques were simulated on realistic breast phantoms. Surgical clips were used to demarcate the TB. Following tumor resection and closure, the true TB (TB_True) was extracted. Each phantom was CT imaged at several phases of surgery in order to record pre- and post-OBS closure surgical clip displacements. Two senior radiation oncologists (ROs) were asked to delineate TBs on CTs by relying on surgical clips placed as per standard protocol, and by referring to operative notes. Their original contours, as well as those expanded using 5-15 mm margins, were compared with the accurate TB_True using the dice similarity coefficient (DSC), Hausdorff Distance (HD), and over- and under-contoured volumes. Inter- and intra-RO contour agreements were also evaluated.

RESULTS

Post-OBS surgical clips were significantly displaced outside the original breast quadrant. Inter- and Intra-RO TB contours were consistent, yet systematically differed from TB_True (DSC values range = 0.38 to 0.69, and maximum HD range = 17.8 mm to 38.0 mm). Using expansion margins did not improve contour congruence and caused significant over-contoured volumes.

CONCLUSION

Following OBS, surgical clips alone are not reliable radiographic surrogates of TB locations and accurate TB delineation is challenging. For complex OBS cases, indication of any type of partial breast irradiation is very questionable.