Lumpectomy Surgery Research Articles

Survival in patients with locally advanced breast cancer after neoadjuvant docetaxel (T), carboplatin (C), and trastuzumab (H)

e11573 Background: Neoadjuvant chemotherapy (NAC) has been widely used in patients with LABC. Although survival rates after neoadjuvant and adjuvant therapy are similar, NAC was shown to increase lumpectomy surgery and allow in vivo evaluation of treatment response. It is thought that pathologic complete response (pCR) after NAC by itself or together with other factors could predict overall survival (OS) and/or relapse free survival (RFS). Methods: Seventy-one of the 74 enrolled patients (mean tumor size=7.7cm) were analyzed. All patients received 4 cycles of T (75mg/m2) and C (AUC=6) before and after surgery. HER2+ patients were randomized to receive either TCH or TC preoperatively; both received 1 year of H. Tumor size and nodal status were estimated clinically at baseline and pathologically after surgery. Bi & multivariate analyses were performed on pCR, clinical and pathologic characteristics to predict OS and RFS. Hazard ratios (HR) are reported. Results: The median follow up was 2.0 years with 8 deaths and 9 recurrences. Nineteen (26.8%) had pCR. Kaplan-Meier RFS was 82.0% & 54.2% and OS was 88.9% vs 70.6% at 3 years follow up for pCR & non-pCR respectively. In the bivariate analysis, pCR (HR=0.32, p=0.114), lower tumor stage (p=0.097) and negative LN (p=0.0695) trended a favorable RFS. Lower tumor stage (p=0.032), negative LN (p=0.029) and lumpectomy surgery (p=0.023) were associated with better OS. In multivariate analysis, inflammatory breast cancer (p=0.041) and triple negative breast cancer-TNBC (p=0.044) predicted poor OS. Conclusions: With few deaths/recurrences we were unable to conclusively identify predictors for OS or RFS. Inflammatory and TNBC remain poor prognosticators for OS and RFS. pCR was a suggestive predictor (HR<1) but not statistically significant probably due to low sample size and high number of pCR cases that were TNBC. [Table: see text]

Lumpectomy and Partial Breast Irradiation - Risks and Benefits for Early Breast Cancer

Breast-conserving surgery followed by radiation therapy is the standard local treatment of early primary breast cancer. Radiation therapy limited to the part of the breast closest to the site of the excised tumor (accelerated partial breast irradiation, APBI) might be beneficial for these patients, but definitive results of ongoing trials should be awaited. Partial breast intraoperative radiation (IORT) has recently been developed to further improve the results of partial irradiation. Given that tumornegative margins are required for IORT, Schiller et al. considered how to identify and select patients for IORT by predicting those with tumorfree excision margins. The authors analyzed data from 708 patients who underwent 730 lumpectomies and found a 17% rate of positive margins at first resection. They could accurately (98%) predict negative margin status for the subset of patients older than 50 years with a preoperative core needle biopsy (CNB) showing invasive cancer less than 3 cm that can be localized under ultrasound. Are these patients truly ideal for consideration of IORT, as the authors suggest? What about the other subsets of patients including those aged <50 years, with a family history of breast cancer, extensive intraductal component, and multicentricity and multifocality? Local recurrence after lumpectomy or breast-conserving surgery still remains a substantial problem despite modern radiation therapy, with a local relapse rate of 10% or greater at 10 or 20 years after therapy. Young age, family history, BRCA1/2 mutation carriers and positive or close resection margins are considered risk factors for local recurrence after breast-conservation therapy (BCT). Partial breast irradiation either as APBI or IORT is probably an inappropriate treatment for patients at high risk of local recurrence. Treatments that achieved a reduction in local recurrence were also associated with a reduction in mortality after long-term follow up in a recent landmark meta-analysis of randomized trials. Thus, every effort should be made to achieve local control. This principle of local control appears to be important also for other solid cancers, such as, gastric cancer. Overall, prognosis of gastric cancer is poor with exception early-stage gastric tumors. Despite the validation of the efficacy of adjuvant systemic chemotherapy, local control with adequate D2 surgery or D1 surgery plus chemoradiotherapy may improve survival. There is currently a trend toward less extensive surgery and partial breast irradiation with the aim of reducing adverse effects and improving quality of life, but strong evidence is needed that these modern therapies are safe and do not increase local recurrence or reduce overall survival. Research on molecular and genetic biomarkers already provides promising findings towards personalized treatment. 26–28 More work is required for prospective validation before these markers can be used in the clinic for selecting breast cancer patients for minimal surgery and partial breast irradiation. Published online February 1, 2008. Address correspondence and reprint requests to: D. Ziogas, MD; E-mail: deziogas@hotmail.com

SU‐FF‐T‐303: Ion Loss Measurements for a Large‐Volume Free‐Air Ionization Chamber

Purpose: To extend the capabilities of large‐volume ionization chambers to higher‐fluence sources by thoroughly evaluating ion loss in preparation for Electronic Brachytherapy air‐kerma strength measurements. Method and Materials: Electronic Brachytherapy was recently approved by the FDA as a low‐energy photon‐emitting source for the treatment of breast tumor cavities after lumpectomy surgery. The dosimetry for these types of treatments is based on well‐established AAPM TG 43 protocols for low‐energy photon‐emitting brachytherapy sources. This task group recommends that source strength for low‐energy brachytherapy sources be measured with a large‐volume free‐air ionization chamber to determine the air‐kerma rate absolutely. Until now, using such a chamber for Electronic Brachytherapy sources has not been possible because of the higher x‐ray energies of Electronic Brachytherapy sources (up to 50 keV) as well as their significantly greater exposure rates. There is convincing evidence that the air‐kerma strength of Electronic Brachytherapy sources may be measured with the Variable‐Aperture Free‐Air Chamber (VAFAC). To this end, a systematic investigation of the mechanisms of ion loss has been completed by varying exposure rates, plate separations, and high‐voltage biases. Results: Measurements of ion‐loss agreed with empirical predictions to within 0.2% using the VAFAC for low‐energy photon‐emitting brachytherapy sources with strengths up to 5000 U, more than 50 times higher than the upper limit of the current U.S. national standard (100 U), and within the estimated source strength of new Electronic Brachytherapy sources. Measurements of two coefficients for conventional ion‐loss equations are and , which are within the range of values published in the literature. Conclusion: The VAFAC's measurement capabilities have been extended to higher‐fluence sources (up to 5000 U) in preparation for air‐kerma strength measurements of Electronic Brachytherapy sources. Measurements of empirical coefficients are within the range of values listed in the literature.

Real-time Raman system for in vivo disease diagnosis

Raman spectroscopy has been well established as a powerful in vitro method for studying biological tissue and diagnosing disease. The recent development of efficient, high-throughput, low-background optical fiber Raman probes provides, for the first time, the opportunity to obtain real-time performance in the clinic. We present an instrument for in vivo tissue analysis which is capable of collecting and processing Raman spectra in less than 2 s. This is the first demonstration that data acquisition, analysis, and diagnostics can be performed in clinically relevant times. The instrument is designed to work with the new Raman probes and includes custom written LabVIEW and Matlab programs to provide accurate spectral calibration, analysis, and diagnosis along with important safety features related to laser exposure. The real-time capabilities of the system were demonstrated in vivo during femoral bypass and breast lumpectomy surgeries. Such a system will greatly facilitate the adoption of Raman spectroscopy into clinical research and practice.

The effects of radiation therapy on the tissue capsule of soft tissue implants.

A prosthesis has been developed for cosmesis after lumpectomy surgery for breast carcinoma. The device is saline filled and percutaneously adjustable in volume to permit an optimal cosmetic result after surgical wound healing. A series of 24 studies of 18 weeks' duration using the adult rabbit animal model were first used to study tissue capsule formation around textured versus smooth surface control implants and to evaluate the effects of volume adjustments on the tissue capsule. Single or multiple adjustments of implant volume had no effect on tissue capsule thickness or morphology. Because lumpectomy surgery is invariably followed by radiation therapy, a series of six studies was then conducted to determine the effects of a typical course of radiation therapy on tissue capsule formation. One week after device implantation, a 4 x 4 cm field including the implant was irradiated with 5,000 rad (200 rad/day x 5 days/week x 5 weeks). The animals were maintained for a 6 week period after radiation treatment. After sacrifice, the implants were removed, and the tissue capsules studied using conventional histologic techniques, including scanning and transmission electron microscopy. There was no statistically significant difference in tissue capsule thickness compared to nonirradiated controls. Tissue capsule morphology, however, differed markedly. Radiation therapy decreased angiogenesis, cellularity, and the inflammatory cell response to the implants. Qualitatively, radiation treatment seemingly improved rather than compromised the connective tissue response to the implants.