53 Background: A three dimensional bioabsorbable coiled tissue marker has been developed to facilitate targeting for radiation therapy post lumpectomy. Proposed advantages are a) clarified targeting of closest margins to the excised tumor, b) providing a three dimensional structure that allows fibrosis to add volume to contribute to cosmesis, c) aiding in re-excision localization. Our experience has demonstrated the array of clinical findings after placement, the imaging findings over time, and pathologic findings for early and late removal. Methods: Consecutive lumpectomy patients who were candidates for targeted radiation therapy were implanted with the 3-D bioabsorbable marker from May 2014 to June 2015. After informed consent, each of 36 patients were followed to gather clinical, imaging and pathologic findings. Standard breast cancer management decisions were made (NCCN). Patients requiring re-excision were examined for pathologic findings related to the device. Routine imaging with mammography and ultrasound were obtained at 6 and 12 months post lumpectomy. Results: The use of the spiral tissue marker with the fixed array of six titanium clips provided a predictable target for radiation treatments. As the tissue marker was sewn to the closest tumor bed, inadvertent dissection planes caused by oncoplastic techniques could be avoided. Clinically the lumpectomy site was firm/dense in 94% of patients at 3 months (n = 36), but in only 60% at one year (n = 21). Two patients who underwent re-excision for positive margins were guided by the 3-dimensional device. Two patients had removal at one month and at 12 months for reasons unrelated to the tissue marker. Histologic examination demonstrated typical foreign body reaction and organization (fig 1b). Mammography at one year demonstrated marker clips coalescing as the bioabsorbable device dissolves with maintenance of the volume of the cavity in 50% of patients(fig 1c). Cosmetic outcome has been good to excellent measured at 6 and 12 months. Conclusions: Clinical, radiologic and pathologic findings during use of a novel bioabsorbable 3-dimensional tissue marker were presented. A national registry to further define these attributes will soon be started.
Introduction: The appearance after breast surgery has become an important aspect of survivorship. The post lumpectomy/post radiation hollow surgical defect negatively impacts cosmesis and patient satisfaction. Oncoplastic procedures will mobilize surrounding tissues into the lumpectomy cavity but adds no volume to the breast. Use of a bioabsorbable 3-dimensional tissue implant (used for targeting radiation) has the additional benefit of adding volume to the breast and enhances the overall cosmetic appearance. Our experience over 3 years provides serial mammograms from which we may objectively categorize cosmetic contour. We report on our 2 and 3 year serial images of our treated patients compared with baseline. Methods: Between May 2014 and June 2018, during lumpectomy for breast cancer we implanted a 3-D tissue implant marker in 170 patients, often combined with oncoplastic reconstruction and followed by radiation treatment. For long term follow-up we had 37 patients with serial mammograms at 2 or 3 years to assess cosmesis. All patients had interviews, physical exams, and serial mammograms to evaluate their cosmetic appearance. Both physician and patient graded their appearance. We also objectively measured and compared the pre-treatment mammogram and the 2-year and 3-year, post-treatment mammogram for symmetry and size using each breast as its own control. Using the post-treatment mammograms, we compared the relative anterior-posterior (depth) measurement of the quadrant bearing the implant as well as the non-cancer quadrant to the similar locations of the pre-treatment mammogram. Both mammogram positioning and radiation effects would balance. We compared the relative change from baseline in the non-cancer portion of the breast to the change from baseline in the cancer portion of the breast as a percent difference from baseline. Results: Patients were treated with lumpectomy, oncoplastic reconstruction, and placement of a 3-D tissue implant. Three implants were removed due to positive margins. No implants were removed for any other reason. There have been no local recurrences. Overall, radiation oncologists felt the 3-D implant was useful for treatment planning in 85% of patients. Of the 37 consecutive patients who have completed an average of 27.8 months of follow-up, cosmesis was rated as excellent/good by clinicians (96%) and patients (94%). Mammograms taken at 2-3 years were compared with initial images. Whole-breast radiation effect varied among patients. Some had significant shrinkage while others had none. These changes were equal in the non-cancer post-radiation quadrants (86.2% vs 87%) demonstrating maintenance of normal breast contour. Our use of the 3-D implant and oncoplastic tissue advancement maintained the pre-operative contour of the breast after lumpectomy with radiation. Conclusions: Breast cancer surgery and radiation is often complicated by poor cosmesis with retraction and volume loss. Using a combination of oncoplastic surgery combined with a 3-D tissue implant, we found the forward projection and contour of the breast at the lumpectomy site was preserved and patient satisfaction was good to excellent. Further investigation of the long-term cosmetic effects of breast cancer surgery should be encouraged. Citation Format: Kaufman CS, Hall W, Behrndt VS, Wolgamot GM, Zacharias K, Rogers A, Smith A, Hill LM, Schnell N. Enhance post-lumpectomy breast contour using oncoplastic surgery (OPS) plus a bioabsorbable 3-D tissue implant [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 P5-16-02.
59 Background: About 75% of newly diagnosed breast cancers are not palpable and require image localization to remove the target lesion. Digital specimen mammography devices were developed to identify lumpectomy targets in the operating room. Despite the availability of two-dimensional digital specimen mammography (2D), the re-excision rate for lumpectomy remains significant. Specimen tomosynthesis (3D) may provide a more detailed image than standard 2D with consecutive image slices of the lumpectomy specimens for immediate review. Methods: A consecutive series of 28 breast cancer patients underwent intraoperative specimen imaging with both 2D and 3D imaging. Data recorded for each specimen on each device included 1) accuracy of identification of target lesion, 2) time required to produce comparable images, 3) ease of forwarding images via PACS to radiology, 4) predicted closest margin according to each specimen imaging device compared with final pathologic measured margin, and 5) ease of use by the surgeon and/or nurse. Results: The central focus of all 28 lesions were accurately identified with both 2D and 3D. After a short learning curve, details on the tomosynthesis images were seen not clearly shown on the 2D unit including some spiculated masses and architectural distortions. The location of closest margin was more specific with the 3D device due to “Z-axis” measurements which obtain the vertical distance of the target within the specimen. The spatial relationship of marginal calcifications or marking clips at the edge of the specimen provided by the 3D “Z-axis” was superior to the 2D orthogonal views. Although the time taken to obtain the 3D image was 74 seconds longer than a single image with the 2D device (106 vs. 32 seconds), this was equal to the time taken to obtain the two orthogonal images using the 2D device. Ease of use was equal for both 2D and 3D. Too few patients with positive margins were found to assess a difference in intraoperative positive margin prediction. Conclusions: Our initial experience with 3D tomosynthesis of lumpectomy specimens demonstrate clear images and increased information available for the breast surgeon. Research is planned to further examine the added value of high resolution tomosynthesis in breast surgery.
Body: BACKGROUND: Specimen mammography aids in the determination 1) if the target lesion has been removed and 2) whether there is a clear margin at excision. In the past, two orthogonal views using 2-D imaging has been considered to be equivalent to a three dimensional perspective. Yet tomosynthesis for screening mammography has demonstrated the value of thin sliced imaging over two view screening mammography. In March, 2015, we began using true 3-D tomosynthesis of breast specimens at lumpectomy and have compared 2-D and 3-D specimen mammography. •METHODS: We have examined 125 consecutive breast cancer patients with both 2-D and 3-D imaging of the same specimens since March 2015. The circulating nurse would take the specimen and obtain two orthogonal views using both 2-D and 3-D devices with images sent to the radiology department. It was not felt ethical to blind the surgeon from having both images available to make an intraoperative clinical decision regarding immediate re-excision. We compared the data noted from each method and which method best aided the decision to perform immediate re-excision, and time required to obtain the images. •RESULTS: We have studied 125 patients over 11 months since March 2015. Confirmation of complete lesion excision was easier with 3-D tomosynthesis than with 2-D as the 3-D slice did not include overlying skin or dense breast tissue surrounding the lesion in the image, making the target lesion stand out more clearly. Although the 2-D images may appear to have higher contrast than the individual 3-D slices, the tomosynthesis 3-D images contained more actionable data than the 2-D. Also decisions to excise more tissue during the procedure were enabled by the additional information included in the 3-D images. In addition, the 3-D images provided the depth of field to enable accurate re-excision using the Z-axis (see figures). Finally, it took about a minute longer to obtain and review the 3D images, although this difference did not delay surgical decisions nor prolong operative time. •CONCLUSIONS: 3-D specimen tomosynthesis facilitates the reduction of postoperative re-excision for lumpectomy patients by providing more information than 2-D orthogonal views, providing easier, more accurate confirmation of the extent of the target excision. Additionally, serial 1mm slices of the specimen allowed the integration of Z-axis targeting, ensuring that any necessary margin excision during surgery was accomplished immediately with maximum tissue conservation. More studies are planned to further validate these findings of these first 125 patients.
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