A multi-institutional analysis of intraoperative radiotherapy for early breast cancer: Does age matter?

BACKGROUND

Single-session intraoperative radiation therapy (IORT) minimizes treatment demands associated with traditional whole breast radiation therapy (WBRT) but outcomes on local disease control and morbidity among the elderly is limited.

METHODS

A multi-institutional retrospective registry was established from 19 centers utilizing IORT from 2007 to 2013. Patient, tumor, and treatment variables were analyzed for ages <70 and ≥70.

RESULTS

We evaluated 686 patients (<70 = 424; ≥70 = 262) who were margin and lymph node negative. Patients <70 were more likely to have longer operative time, oncoplastic closure, higher rates of IORT used as planned boost, and receive chemotherapy and post-operative WBRT. Wound complication rates were low and not significantly different between age groups. Median follow-up was 1.06 (range 0.51-1.9) years for < 70 and 1.01 (range 0.5-1.68) years for ≥ 70. There were 5 (0.73%) breast recurrences (4 in <70 and 1 ≥ 70, p = 0.65) and no axillary recurrences during follow-up.

CONCLUSIONS

IORT was associated with a low rate of wound complication and local recurrence on short-term follow-up in this cohort.

TARGIT-R (Retrospective): North American Experience with Intraoperative Radiation Using Low-Kilovoltage X-Rays for Breast Cancer

BACKGROUND

Single-dose intraoperative radiotherapy (IORT) is an emerging treatment for women with early stage breast cancer. The objective of this study was to define the frequency of IORT use, patient selection, and outcomes of patients treated in North America.

METHODS

A multi-institutional retrospective registry was created, and 19 institutions using low-kilovoltage IORT for the treatment of breast cancer entered data on patients treated at their institution before July 31, 2013. Patient selection, IORT treatment details, complications, and recurrences were analyzed.

RESULTS

From 2007 to July 31, 2013, a total of 935 women were identified and treated with lumpectomy and IORT. A total of 822 patients had at least 6 months' follow-up documented and were included in the analysis. The number of IORT cases performed increased significantly over time (p < 0.001). The median patient age was 66.8 years. Most patients had disease that was <2 cm in size (90 %) and was estrogen positive (91 %); most patients had invasive ductal cancer (68 %). Of those who had a sentinel lymph node procedure performed, 89 % had negative sentinel lymph nodes. The types of IORT performed were primary IORT in 79 %, secondary IORT in 7 %, or planned boost in 14 %. Complications were low. At a median follow-up of 23.3 months, crude in-breast recurrence was 2.3 % for all patients treated.

CONCLUSIONS

IORT use for the treatment of breast cancer is significantly increasing in North America, and physicians are selecting low-risk patients for this treatment option. Low complication and local recurrence rates support IORT as a treatment option for selected women with early stage breast cancer.

Abstract P3-13-08: A prospective, single-arm, multi-site, clinical evaluation of the SAVI SCOUT® surgical guidance system for the location of non-palpable breast lesions during excision

Background and Objectives: The standard preoperative technique for localizing non-palpable breast lesions is wire localization (WL). Radioactive seed localization (RSL) is an alternative approach that addresses a number of clear disadvantages associated with WL but, the adoption of RSL has been impacted by considerable regulatory requirements for the handling of radioactive materials. To advance the progress made with RSL and eliminate issues associated with radioactive components, the SAVI SCOUT® surgical guidance system was developed. SAVI SCOUT is an FDA-cleared medical device that utilizes non-radioactive electromagnetic wave technology to provide real-time guidance during excisional breast procedures. The purpose of this study is to evaluate the performance of SAVI SCOUT in guiding the removal of non-palpable breast lesions.

Methods: Following a 50 patient pilot study that showed SAVI SCOUT to be safe and effective, IRB approval was granted for this prospective, single-arm, multi-site study for women with a non-palpable breast lesion. Pts underwent localization and excision with the SAVI SCOUT system, which consists of an electromagnetic wave reflective device (reflector), handpiece and console. Using mammographic or ultrasound guidance, the reflector was implanted into the target tissue. Before making an incision, the surgeon used the handpiece, which emits electromagnetic waves and infrared light, to detect the location of the reflector and subsequently plan the surgical incision. During the procedure, the surgeon used the handpiece to guide the localization and removal of the reflector along with the surrounding breast tissue. The console provides audible feedback of reflector proximity to the handpiece. Successful reflector placement, localization and retrieval were the primary endpoints.

Results: A total of 61 pts have participated in the study to date, along with 7 surgeons and 9 radiologists across 6 institutions. The reflectors were successfully placed in all pts, including 27 under mammographic guidance and 34 under ultrasound guidance. In 28 cases, the reflectors were placed on the same day as surgery. Otherwise, the reflectors were placed up to 7 days (average 2.9 days) before surgery. Thirteen pts underwent excisional biopsy and 48 pts had a lumpectomy. The intended lesion and reflector were successfully removed in all pts. Reflector migration did not occur and no adverse events occurred. Final pathology is currently available for 52 pts: 8/10 excisional biopsy pts had no invasive or in situ carcinoma identified. For pts with cancer and complete data, 39/39 had clear margins, but one patient was recommended for re-excision due to a close margin (1 mm) for DCIS.

Conclusions: The preliminary data from this prospective, multi-site study show that real-time surgical guidance with SAVI SCOUT is an accurate technique for directing the removal of non-palpable breast lesions and is reproducible at multiple clinical sites. At present, the study has yielded 100% surgical success with a re-excision rate of 3.0%. Ongoing accrual to this clinical evaluation study will validate these findings with planned enrollment of 150 pts at up to 15 total sites.

Citation Format: Cox CE, Prati R, Blumencranz P, Allen K, Banull C, Cline M, Howard T, Portillo M, Whitworth P, Funk K, Police A, Lin E, Combs F, Anglin B, King J, Shivers SC. A prospective, single-arm, multi-site, clinical evaluation of the SAVI SCOUT® surgical guidance system for the location of non-palpable breast lesions during excision. [abstract]. In: Proceedings of the Thirty-Eighth Annual CTRC-AACR San Antonio Breast Cancer Symposium: 2015 Dec 8-12; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2016;76(4 Suppl):Abstract nr P3-13-08.

Intraoperative margin assessment with the MarginProbe at different mammographic breast densities

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Background: Mammographic breast density (BD) is known to affect breast imaging. MarginProbe is an RF Spectroscopy intraoperative margin assessment tool. We looked at the effect of mammographic breast density (BD) on the performance of the device. Mammographic density was assigned by Breast Imaging-Reporting and Data System (BI-RADS) classification prior to breast conserving surgery with the MarginProbe. Methods: For the current study we analyzed MarginProbe device arm data from the MarginProbe Pivotal Trial for which BD data was available. Clear margins of the main specimen, which is where the MarginProbe was applied, were defined as no tumor on ink. Clinical benefit was defined as clearing positive main specimen margins or cancer in the shaving. Analysis was performed based on logistic and linear regression, with univariate analysis. Results: The dataset for the analysis included 196 patients for which preoperative BD data was available. With higher BD, there was an increase in the rate of main lumpectomy specimen with positive margins (OR 1.65 per change in density category, p=0.025). The rate of shavings with clinical benefit showed an upward trend, with increasing BD. The number of shavings per patient increased with BD, however the overall volume of shavings did not increase. There was an increase in the per patient relative clinical benefit as BD increased (OR 1.6 per change in density category, p=0.024). Conclusions: With higher breast density patients and surgeons face an increase in risk for main specimen positive margins. With the increased BD and main specimen positivity more shavings were removed, but shavings volume did not increase as average shaving volume decreased with higher BD. Higher level of patient clinical benefit was observed with higher BD.

A randomized prospective study of lumpectomy margin assessment with use of MarginProbe in patients with nonpalpable breast malignancies

Background

The presence of tumor cells at the margins of breast lumpectomy specimens is associated with an increased risk of ipsilateral tumor recurrence. Twenty to 30 % of patients undergoing breast-conserving surgery require second procedures to achieve negative margins. This study evaluated the adjunctive use of the MarginProbe device (Dune Medical Devices Ltd, Caesarea, Israel) in providing real-time intraoperative assessment of lumpectomy margins.

Methods

This multicenter randomized trial enrolled patients with nonpalpable breast malignancies. The study evaluated MarginProbe use in addition to standard intraoperative methods for margin assessment. After specimen removal and inspection, patients were randomized to device or control arms. In the device arm, MarginProbe was used to examine the main lumpectomy specimens and direct additional excision of positive margins. Intraoperative imaging was used in both arms; no intraoperative pathology assessment was permitted.

Results

In total, 596 patients were enrolled. False-negative rates were 24.8 and 66.1 % and false-positive rates were 53.6 and 16.6 % in the device and control arms, respectively. All positive margins on positive main specimens were resected in 62 % (101 of 163) of cases in the device arm, versus 22 % (33 of 147) in the control arm (p < 0.001). A total of 19.8 % (59 of 298) of patients in the device arm underwent a reexcision procedure compared with 25.8 % (77 of 298) in the control arm (6 % absolute, 23 % relative reduction). The difference in tissue volume removed was not significant.

Conclusions

Adjunctive use of the MarginProbe device during breast-conserving surgery improved surgeons’ ability to identify and resect positive lumpectomy margins in the absence of intraoperative pathology assessment, reducing the number of patients requiring reexcision. MarginProbe may aid performance of breast-conserving surgery by reducing the burden of reexcision procedures for patients and the health care system.

Laser Doppler velocimetry in critically ill patients

Cutaneous blood flow may be an indirect measure of circulatory function estimated by continuous, noninvasive laser Doppler velocimetry (LDV). It has been postulated that LDV may be a useful monitor of cardiac output changes. To test this hypothesis, LDV was evaluated in 67 critically ill adult patients with simultaneous measurements of cardiac index (CI) and other physiologic variables. Heated and unheated laser probes were utilized. The results indicate that LDV reflects acute directional changes of CI. Further, with the heated laser probe, the magnitude of acute CI change is reflected. However, there are gradual changes over time of LDV which may occur independently of CI or other monitored variables. Hence, absolute LDV values are not predictive of absolute CI values.