Skip to main content

Advertisement

SpringerLink
Log in

Full-Thickness Closure in Breast-Conserving Surgery: The Impact on Radiotherapy Target Definition for Boost and Partial Breast Irradiation. A Multimodality Image Evaluation

  • Breast Oncology
  • Published:
Annals of Surgical Oncology Aims and scope Submit manuscript

Abstract

Background

During breast-conserving surgery (BCS), surgeons increasingly perform full-thickness closure (FTC) to prevent seroma formation. This could potentially impair precision of target definition for boost and accelerated partial breast irradiation (APBI). The purpose of this study was to investigate the precision of target volume definition following BCS with FTC among radiation oncologists, using various imaging modalities.

Methods

Twenty clinical T1–2N0 patients, scheduled for BCS involving clip placement and FTC, were included in the study. Seven experienced breast radiation oncologists contoured the tumor bed on computed tomography (CT), magnetic resonance imaging (MRI) and fused CT–MRI datasets. A total of 361 observer pairs per image modality were analyzed. A pairwise conformity among the generated contours of the observers and the distance between their centers of mass (dCOM) were calculated.

Results

On CT, median conformity was 44 % [interquartile range (IQR) 28–58 %] and median dCOM was 6 mm (IQR 3–9 mm). None of the outcome measures improved when MRI or fused CT–MRI were used. In two patients, superficial closure was performed instead of FTC. In these 14 image sets and 42 observer pairs, median conformity increased to 70 %.

Conclusions

Localization of the radiotherapy target after FTC is imprecise, on both CT and MRI. This could potentially lead to a geographical miss in patients at increased risk of local recurrence receiving a radiation boost, or for those receiving APBI. These findings highlight the importance for breast surgeons to clearly demarcate the tumor bed when performing FTC.

This is a preview of subscription content, log in via an institution to check access.

Access this article

Log in via an institution

Price excludes VAT (USA)
Tax calculation will be finalised during checkout.

Instant access to the full article PDF.

Institutional subscriptions

Fig. 1
Fig. 2
Fig. 3

Similar content being viewed by others

References

  1. Nystrom L, Andersson I, Bjurstam N, Frisell J, Nordenskjold B, Rutqvist LE. Long-term effects of mammography screening: updated overview of the Swedish randomised trials. Lancet. 2002;359:909–919.

    Article  PubMed  Google Scholar 

  2. Fracheboud J, Otto SJ, van Dijck JA, Broeders MJ, Verbeek AL, de Koning HJ; National Evaluation Team for Breast cancer screening (NETB). Decreased rates of advanced breast cancer due to mammography screening in The Netherlands. Br J Cancer. 2004;91:861–867.

    PubMed  CAS  PubMed Central  Google Scholar 

  3. Darby S, McGale P, Correa C, et al. Effect of radiotherapy after breast-conserving surgery on 10-year recurrence and 15-year breast cancer death: meta-analysis of individual patient data for 10,801 women in 17 randomised trials. Lancet. 2011;378:1707–1716.

    Article  PubMed  CAS  Google Scholar 

  4. Whelan TJ, Pignol JP, Levine MN, et al. Long-term results of hypofractionated radiation therapy for breast cancer. N Engl J Med. 2010;362:513–520.

    Article  PubMed  CAS  Google Scholar 

  5. Bartelink H, Horiot JC, Poortmans PM, et al. Impact of a higher radiation dose on local control and survival in breast-conserving therapy of early breast cancer: 10-year results of the randomized boost versus no boost EORTC 22881-10882 trial. J Clin Oncol. 2007;25:3259–3265.

    Article  PubMed  Google Scholar 

  6. Indelicato D, Grobmyer SR, Newlin H, et al. Association between operative closure type and acute infection, local recurrence, and disease surveillance in patients undergoing breast conserving therapy for early-stage breast cancer. Surgery. 2007;141:645–653.

    Article  PubMed  Google Scholar 

  7. Paterson ML, Nathanson SD, Havstad S. Hematomas following excisional breast biopsies for invasive breast carcinoma: the influence of deep suture approximation of breast parenchyma. Am Surg. 1994;60:845–848.

    PubMed  CAS  Google Scholar 

  8. Mukesh MB, Barnett G, Cumming J, et al. Association of breast tumour bed seroma with post-operative complications and late normal tissue toxicity: results from the Cambridge Breast IMRT trial. Eur J Surg Oncol. 2012;38:918–924.

    Article  PubMed  CAS  Google Scholar 

  9. Jolicoeur M, Racine ML, Trop I, et al. Localization of the surgical bed using supine magnetic resonance and computed tomography scan fusion for planification of breast interstitial brachytherapy. Radiother Oncol. 2011;100:480–484.

    Article  PubMed  Google Scholar 

  10. Smitt MC, Birdwell RL, Goffinet DR. Breast electron boost planning: comparison of CT and US. Radiology. 2001;219:203–206.

    Article  PubMed  CAS  Google Scholar 

  11. Clough KB, Kaufman GJ, Nos C, Buccimazza I, Sarfati IM. Improving breast cancer surgery: a classification and quadrant per quadrant atlas for oncoplastic surgery. Ann Surg Oncol. 2010;17:1375–1391.

    Article  PubMed  Google Scholar 

  12. Shaikh T, Narra V, Goyal S, et al. Lumpectomy closure technique does not affect dosimetry in patients undergoing external-beam-based accelerated partial breast irradiation. Ann Surg Oncol. 2013;20:1323–1328.

    Article  PubMed  Google Scholar 

  13. Poortmans PM, Collette L, Horiot JC, et al. Impact of the boost dose of 10 Gy versus 26 Gy in patients with early stage breast cancer after a microscopically incomplete lumpectomy: 10-year results of the randomised EORTC boost trial. Radiother Oncol. 2009;90:80–85.

    Article  PubMed  Google Scholar 

  14. Collette S, Collette L, Budiharto T, et al. Predictors of the risk of fibrosis at 10 years after breast conserving therapy for early breast cancer: a study based on the EORTC Trial 22881-10882 ‘boost versus no boost’. Eur J Cancer. 2008;44:2587–2599.

    Article  PubMed  Google Scholar 

  15. Vrieling C, Collette L, Fourquet A, et al. The influence of patient, tumor and treatment factors on the cosmetic results after breast-conserving therapy in the EORTC ‘boost vs. no boost’ trial. EORTC Radiotherapy and Breast Cancer Cooperative Groups. Radiother Oncol. 2000;55:219–232.

    Article  PubMed  CAS  Google Scholar 

  16. Borger JH, Kemperman H, Smitt HS, et al. Dose and volume effects on fibrosis after breast conservation therapy. Int J Radiat Oncol Biol Phys. 1994;30:1073–1081.

    Article  PubMed  CAS  Google Scholar 

  17. den Hartogh MD, van Asselen B, Monninkhof EM, et al. Excised and irradiated volumes in relation to the tumor size in breast-conserving therapy. Breast Cancer Res Treat. 2011;129:857–865.

  18. Olivotto IA, Whelan TJ, Parpia S, et al. Interim cosmetic and toxicity results from RAPID: a randomized trial of accelerated partial breast irradiation using three-dimensional conformal external beam radiation therapy. J Clin Oncol. 2013;31:4038–4045.

    Article  PubMed  Google Scholar 

  19. Schaverien MV, Stallard S, Dodwell D, Doughty JC. Use of boost radiotherapy in oncoplastic breast-conserving surgery: a systematic review. Eur J Surg Oncol. 2013;39:1179–1185.

    Article  PubMed  CAS  Google Scholar 

  20. Azu M, Goyal S, Patel U, Haffty B, Kearney T. Has placement of surgical clips in the lumpectomy bed fallen out of favor? Ann Surg Oncol. 2011;18:1529–1532.

    Article  PubMed  Google Scholar 

  21. Pezner RD, Tan MC, Clancy SL, Chen YJ, Joseph T, Vora NL. Radiation therapy for breast cancer patients who undergo oncoplastic surgery: localization of the tumor bed for the local boost. Am J Clin Oncol. 2013;36:535–539.

    Article  PubMed  Google Scholar 

  22. Kirby AN, Jena R, Harris EJ, et al. Tumour bed delineation for partial breast/breast boost radiotherapy: what is the optimal number of implanted markers? Radiother Oncol. 2013;106:231–235.

    Article  PubMed  Google Scholar 

  23. Shaikh T, Chen T, Khan A, et al. Improvement in interobserver accuracy in delineation of the lumpectomy cavity using fiducial markers. Int J Radiat Oncol Biol Phys. 2010;78:1127–1134.

    Article  PubMed  Google Scholar 

  24. Coles CE, Wilson CB, Cumming J, et al. Titanium clip placement to allow accurate tumour bed localisation following breast conserving surgery: audit on behalf of the IMPORT Trial Management Group. Eur J Surg Oncol. 2009;35:578–582.

    Article  PubMed  CAS  Google Scholar 

  25. Nichols EM, Feigenberg SJ, Marter K, et al. Preoperative radiation therapy significantly increases patient eligibility for accelerated partial breast irradiation using 3D-conformal radiotherapy. Am J Clin Oncol. 2012;36:232–238.

    Article  Google Scholar 

  26. Palta M, Yoo S, Adamson JD, Prosnitz LR, Horton JK. Preoperative single fraction partial breast radiotherapy for early-stage breast cancer. Int J Radiat Oncol Biol Phys. 2012;82:37–42.

    Article  PubMed  Google Scholar 

  27. van der Leij F, Elkhuizen PH, Janssen TM, et al. Target volume delineation in external beam partial breast irradiation: less inter-observer variation with preoperative compared to postoperative delineation. Radiother Oncol. 2014;110(3):467–470.

    Article  PubMed  Google Scholar 

  28. Barry M, Ho A, Morrow M. The evolving role of partial breast irradiation in early-stage breast cancer. Ann Surg Oncol. 2013;20:2534–2540.

    Article  PubMed  Google Scholar 

  29. den Hartogh MD, Philippens ME, van Dam IE, et al. MRI and CT imaging for preoperative target volume delineation in breast-conserving therapy. Radiat Oncol. 2014;9:63.

    Article  Google Scholar 

  30. Vaidya JS, Wenz F, Bulsara M, et al. Risk-adapted targeted intraoperative radiotherapy versus whole-breast radiotherapy for breast cancer: 5-year results for local control and overall survival from the TARGIT: a randomised trial. Lancet. 2014;383:603–613.

    Article  PubMed  Google Scholar 

Download references

Acknowledgment

We would like to thank the breast radiation oncologists from the Odette Cancer Center, Sunnybrook Health Science Center, for participating as observers in this study.

Disclosure

This manuscript is not under publication or consideration for publication elsewhere. Furthermore, Mariska D. den Hartogh, H. J. G. Desirée van den Bongard, Melanie T. M. Davidson, Alexis N. T. J Kotte, Helena M. Verkooijen, Marielle E. P. Philippens, Marco van Vulpen, Bram van Asselen, and Jean-Philippe Pignol have no conflicts of interest to disclose.

Author information

Authors and Affiliations

  1. Department of Radiation Oncology, University Medical Center Utrecht, Utrecht, The Netherlands

    Mariska D. den Hartogh MD, H. J. G. Desirée van den Bongard MD, PhD, Alexis N. T. J. Kotte PhD, Helena M. Verkooijen MD, PhD, Marielle E. P. Philippens MD, PhD, Marco van Vulpen MD, PhD & Bram van Asselen PhD

  2. Department of Radiation Oncology, Odette Cancer Center, Sunnybrook Health Sciences Center, Toronto, ON, Canada

    Melanie T. M. Davidson PhD & Jean-Philippe Pignol MD, PhD

Authors
  1. Mariska D. den Hartogh MD
    View author publications

    You can also search for this author in PubMed Google Scholar

  2. H. J. G. Desirée van den Bongard MD, PhD
    View author publications

    You can also search for this author in PubMed Google Scholar

  3. Melanie T. M. Davidson PhD
    View author publications

    You can also search for this author in PubMed Google Scholar

  4. Alexis N. T. J. Kotte PhD
    View author publications

    You can also search for this author in PubMed Google Scholar

  5. Helena M. Verkooijen MD, PhD
    View author publications

    You can also search for this author in PubMed Google Scholar

  6. Marielle E. P. Philippens MD, PhD
    View author publications

    You can also search for this author in PubMed Google Scholar

  7. Marco van Vulpen MD, PhD
    View author publications

    You can also search for this author in PubMed Google Scholar

  8. Bram van Asselen PhD
    View author publications

    You can also search for this author in PubMed Google Scholar

  9. Jean-Philippe Pignol MD, PhD
    View author publications

    You can also search for this author in PubMed Google Scholar

Corresponding author

Correspondence to Mariska D. den Hartogh MD.

Rights and permissions

Reprints and permissions

About this article

Check for updates. Verify currency and authenticity via CrossMark

Cite this article

den Hartogh, M.D., van den Bongard, H.J.G.D., Davidson, M.T.M. et al. Full-Thickness Closure in Breast-Conserving Surgery: The Impact on Radiotherapy Target Definition for Boost and Partial Breast Irradiation. A Multimodality Image Evaluation. Ann Surg Oncol 21, 3774–3779 (2014). https://doi.org/10.1245/s10434-014-3801-8

Download citation

  • Received:

  • Published:

  • Issue Date:

  • DOI: https://doi.org/10.1245/s10434-014-3801-8

Keywords

Search

Navigation