How to integrate APBI with oncoplasty...or can you?

[thesauce]

Just curious. Our breast surgeons have started doing oncoplasty at the time of lumpectomy and are now wondering if it's at all possible to do APBI with an HDR device like SAVI in these patients? I don't know how the heck it could be done. Any thoughts?

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[Neuronix]

I suppose you could do intrabeam or xoft. Just be ready to back it up with WBRT if the final pathology results aren't favorable. Whether IORT is really as good as brachytherapy has become something of a holy war, and I'm wondering if the long term data from "prepathology" stratum of TARGIT-A will really continue to show non-inferiority.

Intraoperative techniques aren't as lucrative as brachytherapy, but that's ok I hope.

 

[OTN]

IORT is garbage, the physics are garbage, the data is garbage.

I can't stand the phrase "oncoplastic" - oncologic surgery and plastics shouldn't be done by the same person. Different goals, etc. I think the small benefit cosmetically to oncoplastic lumpectomy isn't worth at all eliminating APBI as a tx modality, but this is something I fight with our breast surgeons all the time about. I don't think there's any way to do APBI after oncoplastic lumpectomy, but it seems fellowship-trained breast surgeons insist on doing it more and more.

 

[thesauce]

I have to agree with OTN on this one. TARGIT has 1.5 years of followup and the lead statistician took himself off because he felt the data was unethically presented. When something sounds too good to be true...

 

[Neuronix]

In all fairness, the median follow-up in the TARGIT-A update paper was 29 months. I know, that's not enough follow-up for breast cancer. I agree. I trained at an institution that uses a lot of IORT, so I try to stay neutral on the argument about its suitability.

That said, if you're in the camp that doesn't like IORT, I have to agree with not doing APBI after reconstructions.

 

[Gfunk6]

Agree with above posters that IORT is compatible with Oncoplasty (irradiate the cavity intraop and then fill it in) but not APBI.

 

[medgator]

Any recommendations regarding ebrt with oncoplasty? I'm getting a referral out of area and the patient may end up having this done at a larger center

I imagine the boost can be skipped obviously. Anything else? Hypofractionation?

 

[evilbooyaa]

Don't see why not. Oncoplastics is just local tissue rearrangement.

 

[medgator]

Don't see why not. Oncoplastics is just local tissue rearrangement.

I thought it was an extended lumpectomy/breast reduction at the same time (for a woman with pendulous breasts)?

 

[Burt Radnolds]

I've seen some surgeons place Biozorbs at the time of "oncoplasty" and lumpectomy. They act pretty confident that it accurately represents the site of the tumor. I suppose it somewhat depends where the lumpectomy site is and where they are hoping to move tissue around at.

 

[evilbooyaa]

I thought it was an extended lumpectomy/breast reduction at the same time (for a woman with pendulous breasts)?

Were you asking about EBRT APBI? Or EBRT whole breast? I wouldn't do any sort of APBI with an oncoplastic surgery. For the latter I don't see how even what you described would affect your volumes.

To answer your question, I was under the impression it was local tissue rearrangement to "fill in" the lumpectomy cavity and minimize look of patient having surgery (kind of like a lumpectomy + breast lift? idk cosmetic plastic surgery descriptors), but it's all cosmetic.

 

[medgator]

Were you asking about EBRT APBI? Or EBRT whole breast? I wouldn't do any sort of APBI with an oncoplastic surgery. For the latter I don't see how even what you described would affect your volumes.

Whole breast. I pretty much never do apbi via ebrt as a rule.

To answer your question, I was under the impression it was local tissue rearrangement to "fill in" the lumpectomy cavity and minimize look of patient having surgery (kind of like a lumpectomy + breast lift? idk cosmetic plastic surgery descriptors), but it's all cosmetic.

Yeah I wasn't really sure, it's not really done in my neck of the woods but a outside surgeon had called wondering if we do anything special radiation wise after it

 

[seper]

I just omit.

 

[evilbooyaa]

Yeah I'd omit too

 

[Gfunk6]

how are people doing boosts post mammoplasty?
I've heard one person say they add on a couple of extra fractions whole breast when there's no cavity to boost.
or would you just omit .....?

It depends on the level of risk for recurrence. If they are age < 50 (premenopausal), had close margins, node positive, or ER negative then I would consider adding a few fractions to whole breast if I could not id resection cavity for conformal boost.

 

[Burt Radnolds]

I have boosted in these situations if clinically indicated (young, high grade). I have personally called the surgeon to get an idea of what the heck they did in there. As mentioned above, some put a Biozorb at the tumor bed and they tell me that they didn't muck with the tumor site.

I have definitely seen situations where there was no tumor bed to speak of, but the patient was both young and high grade. In those situations, I spoke with the surgeon and used preoperative imaging to reconstruct the tumor bed site to the best of my ability. This was after having a conversation with the patient on the uncertainty of the tumor bed, the data behind the radiation boost (improved local control, worse cosmesis etc), and giving them an option on whether or not they wanted to opt for a boost based on that information.

I have never added extra whole breast fractions (not saying its wrong...), but I do engage in some hair splitting such as doing 4256/16 instead of my usual 4005/15, or 5000/25 instead of something closer to 4500 for the whole breast portion, although my standard is typically 5000 anyway if I'm going that route.

There are some articles out there that tackle this topic to some degree. Oncoplastic breast surgery in the setting of breast-conserving therapy: A systematic review