Presence Of Clips Research Articles

Patient Characteristics and Clinical Factors Affecting Seroma Volume

Partial breast irradiation (PBI) has increased in utilization recently, with the postoperative seroma and clips used to guide target volumes. The ideal post-surgical timing to perform computed tomography (CT)-based treatment planning for this technique is unclear. Prior studies have examined change in volume over time from surgery, however, the effect of patient characteristics on seroma volume has not been previously reported. We sought to investigate patient and clinical factors that may contribute to larger post-surgical seromas, and therefore would predict for larger PBI volumes.212 consecutive women with invasive or in situ breast cancer underwent planning CT after breast-conserving surgery at a single institution with four radiation centers during the year 2020. 215 total lumpectomy cavities were contoured per institutional standard. Contoured volume was computed using the treatment planning system. Generalized estimating equation methods were used to analyze the combined data, using treatment center as the cluster effect. Univariate and multivariate analyses (MVA) were performed to evaluate the associations between the seroma volume and patient and clinical factors.Distribution among sites were 61 patients (28.4%), 24 patients (11.2%), 57 patients (26.5%), and 73 patients (34.0%). Patient characteristics included median age 61.0 years (range, 30-85) and median BMI 30.1 kg/m² (17.3-53.9). 94% of patients did not receive neoadjuvant hormone therapy, 47.9% did not have hypertension, 93.5% of patients did not have coronary artery disease, 34.4% were treated in prone position, mean interval from surgery to CT simulation was 58.0 days ± 49.1, and mean seroma volume was 43.3 cm3 ± 46.1. Longer interval from surgery was significantly associated with smaller seroma volume, P = 0.0360. Age, BMI, hypertension, position, coronary artery disease, and use of neoadjuvant hormone therapy remained significant on MVA (P < 0.05 for all), and thus were independently associated with seroma volume. Increased age, BMI, and prone position vs. supine were associated with larger mean seroma volume; absence of hypertension, absence of coronary artery disease, and absence of neoadjuvant hormone therapy were associated with decreased seroma volume. Surgical re-excision, oncoplastic reduction, prior breast surgery, receipt of chemotherapy, race, diabetes, smoking status, and presence of clips were not significantly associated.Increased age, higher BMI, hypertension, coronary artery disease, and prone position were associated with larger seroma volume, and longer interval from surgery to simulation was associated with smaller seroma volume. Especially relevant for patients planned to receive PBI, these data may be used to select patients for which longer time to simulation may result in smaller seroma volumes and therefore smaller PBI target volumes. Larger datasets and prospective evaluation would be ideal to confirm these hypotheses.

Volumetric Changes in Lumpectomy Cavity During Whole Breast Irradiation after Breast Conserving Surgery

Introduction: Irradiation to the conserved breast consists of whole breast radiotherapy (WBRT) followed by tumour bed boost. Seroma in the tumor bed is a commonly observed side effects after breast-preservation, which can alter the shape of breast during WBRT and also lead to tumour bed shrinkage during boost irradiation, causing larger volumes of normal tissue irradiated. The aim was to evaluate the change in the lumpectomy cavity volumes before and after WBRT. Materials and Methods: Thirty-three patients with demonstrable lumpectomy cavity after breast conservation surgery (BCS) were included in the study. CT simulation of the breast was performed twice, initially before the start of WBRT and then 2 days prior to completion of WBRT. WBRT was delivered after contouring breast and lumpectomy volumes guided by the presence of surgical clips, seroma, and other surgical changes. Change in volume of lumpectomy cavity was analysed by Students’ paired T-test. Results: The volume reduction in the lumpectomy cavity was noted in 97% of patients (32/33). The change in lumpectomy cavity volume decreased by a mean value of 34.59% (range 0 - 72%) (p &lt; 0.0001). The mean change in breast volume was 8.44% (range, -2.44 to 10.12%) (p - 0.394). Age, weight, location of tumour, T stage, breast volume, lumpectomy cavity volume, presence of clips and pre-radiation chemotherapy were not significantly associated with volume reduction of the lumpectomy cavity. Conclusion: The results of this study have shown that a significant volume reduction of the lumpectomy cavity after WBRT.

Improvement of consistency in delineating breast lumpectomy cavity using surgical clips

BackgroundDelineation of lumpectomy cavity for whole breast radiation therapy after breast conserving surgery can be challenging because of poor visualization of the cavity. The use of surgical clips on lumpectomy cavity walls has been suggested as an effective and low-cost method to improve the accuracy and consistency of lumpectomy cavity delineation. Materials and methodsTwenty-three eligible female breast cancer patients who were treated with lumpectomy and adjuvant radiation therapy were recruited for this study. During breast conserving surgery, four surgical clips were placed on the superior, inferior, lateral, and medial walls of the lumpectomy cavity. Patients were imaged prior and during radiation treatment. Software was developed to anonymize the image sets and digitally remove the clips from the computed tomography images. Three radiation oncologists contoured the lumpectomy cavity volume, with and without presence of clips. Contoured image sets were analyzed with regard to cavity volume, dimensions, and concordance index. Statistical analysis was performed using a paired t-test. ResultsThe presence of clips significantly increased the average lumpectomy cavity volumes from 23.50 cc to 26.42 cc (P < 0.0001). The presence of clips also significantly increased the mean craniocaudal, anteroposterior, and mediolateral dimensions by 6.8, 2.3, and 2.9 mm, respectively (all P < 0.01). In addition, the presence of surgical clips improved the consistency in delineation in CC dimension by significantly decreasing the standard deviation (P < 0.006). ConclusionsThe presence of surgical clips improves the accuracy of lumpectomy cavity delineation. However, consistency is only improved in CC dimension.

Evaluating a Role for Oncotype Dx Breast Cancer Assay in the Management of Ductal Carcinoma In Situ

lumpectomy and adjuvant radiation at the Nova Scotia Cancer Center from July 2010 to December 2011. During breast conserving surgery, four surgical clips were placed on superior, inferior, lateral and medial walls of the lumpectomy cavity. Patients were imaged twice, first with CT for treatment planning and again between fractions 11 and 13 of the adjuvant radiation. To assess the effect of the clips on delineating using the same image data, in-house software was developed to digitally remove the clips from CT images using texture synthesis algorithm. Four radiation oncologists specializing in breast cancer treatment contoured the lumpectomy cavity volume, first with the clips digitally removed, and then several weeks later with the clips restored. Contours from three of the four participating radiation oncologists were included in the analysis, based on adherence to contouring guidelines. Contoured image sets were analyzed with regard to cavity volume, dimensions and concordance index. Statistical analysis was performed using a paired ttest. Results: The presence of clips significantly increased lumpectomy cavity volumes to 26.42 cc from 23.50 cc without clips (p < 0.0001). The presence of clips significantly increased the mean craniocaudal (CC), anteroposterior (AP) and lateral dimension by 7 mm, 2.3 mm, and 3 mm (all p < 0.01). Surgical clips improved consistency in delineation among observers in the craniocaudal dimension (p Z 0.005). Anteroposterior and lateral standard deviations were not affected significantly. There was also no significant difference in average concordance index with the presence of the surgical clips. Conclusions: The presence of surgical clips improves consistency of lumpectomy cavity delineation among radiation oncologists and also influences average delineated cavity volume and dimensions. Author Disclosure: S. Atrchian: None. P. Sadeghi: None. W. Cwajna: None. L. Helyer: None. D. Rheaume: None. M. Nolan: None. R. Rutledge: None. V. Calverley: None. S. Bennett: None. J. Robar: None.

Multiinstitutional study on target volume delineation variation in breast radiotherapy in the presence of guidelines

Purpose This study aims to determine magnitude, causes and consequences of post-operative breast tumour target volume delineation variation among radiation oncologists in the presence of guidelines. Materials and methods Excision cavities, CTVs and PTVs of eight breast cancer patients were delineated on CT scans by 13 Dutch radiation oncologists (observers) from 12 Dutch institutes participating in the international Young Boost Trial. Delineated volumes and conformity indices were determined. CTV delineation variation (SD) was determined for anatomically relevant regions. Non-parametric statistics were performed to establish effects of observers, patient characteristics and regions on delineation variation. Results Even in the presence of delineation guidelines considerable delineation variation is present (0.24 < SD < 1.22 cm). Presence of clips or seroma reduced interobserver variation (0.24 < SD < 0.62 cm). Region-specific analysis showed distinct regions of higher variability per patient. This could not always be ascribed to anatomical features, suggesting interobserver variation is not solely due to lack of image quality. Conclusions In this study, interobserver delineation variation in breast tumour target volume delineation is larger than, e.g. setup inaccuracies and results from limited reliable visual guidance as well as interpretation differences between observers, despite guidelines. Reduction of delineation variation is essential in view of current developments in planning techniques, particularly for External Partial Breast Irradiation.

New Frontiers in the Evaluation of Cardiac Patients for Noncardiac Surgery

New Frontiers in the Evaluation of Cardiac Patients for Noncardiac Surgery

210 Variations of total dose to tumoral bed in breast irradiation

Purpose To evaluate the variations of the total dose given to tumoral areas in breast irradiation. Materials and Methods 50 patients consecutively submitted to CT for treatment planning were admitted in this study. The planes were elaborated on Varian Cadplan 2.61 both for whole breast irradiation (2 or 3 tangential fields of a cobalt unit, with compensator wedges, 2 Gy per fraction to 50 Gy) and for boost (fixed electrons field of adequate energy, 2 Gy per fraction to 10 Gy) according to ICRU 50 report. The doses were calculated localizing the tumoral areas with presurgical mammography or breast echography, description of the operation, possible presence of clips, and treatment planning CT. Results The dose on tumoral areas varies from a minimum of 46.55 Gy to a maximum of 53.45 (average 50.75, range 6.9 = 13%) with the tangential fields. The RBE varies from 55.25 to 64.9 Gy (average 61.05, range 9.65 = 16%). The total dose to tumoral beds varies from 57.8 to 63.5 Gy and the correspondent RBE from 69.1 to 76.9. Condusions The evaluation of the radiotherapy efficacy in breast irradiation must be also related to the dose to tumoral bed and not only to the prescribed dose. In facts, its high variations (and, consequently, its remarkable differences in RBE) might falsify the data interpretation, especially when the relationship between local relapse and boost usefulness is considered.

Reoperative management of intracranial aneurysms.

Nineteen patients underwent 20 operative procedures for the treatment of recurrent or residual aneurysms. There were 13 small, three large, and four giant lesions; with one exception, all were in the anterior circulation. Five individuals presented with recurrent subarachnoid hemorrhage, six were referred for symptoms of mass effect, and nine were known to have had inadequate treatment at the time of the initial operative procedure. The average time interval from initial treatment to either recurrent subarachnoid hemorrhage or compressive effects was 10.5 and 9.75 years, respectively. No deaths resulted from the reoperative procedures. Two patients suffered moderate disability and one had severe disability. Malpositioned or slipped clips, intraoperative rupture, and inadequate exposure were responsible for 75% of the initial operative failures. The technical difficulty of the reoperative procedure correlated with the length of time between initial and reoperative treatment, the presence of clips and coating agents, and the complexity of the lesion. A classification scheme for preoperative planning and case selection is proposed based on the technical adjuncts required for reoperative aneurysm procedures.