The surgeon's role in breast brachytherapy.

Although two-thirds of invasive breast cancers and half of non-invasive breast cancers are amenable to lumpectomy, only about 70% of such patients choose breast conservation. Of that group, up to one-third do not follow-up with radiation therapy despite it being clinically indicated. The reasons include the patient's and surgeon's attitude toward breast conservation as well as the inconvenience and distance of a suitable radiation facility. The advent of shorter courses of radiation therapy may encourage more patients to seek adjuvant therapy. An increasingly popular and more convenient alternative to traditional whole-breast radiation therapy in patients with early-stage breast cancer is accelerated partial breast irradiation (APBI), for which the American Society of Breast Surgeons and the American Brachytherapy Society have promulgated guidelines for candidate selection. Although several methods are emerging, the most widely used brachytherapy technique utilizes the MammoSite single-catheter balloon brachytherapy device. In a best practices symposium convened in 2006, breast surgeons from academic and community practices with extensive experience in balloon brachytherapy developed general guidelines for integrating APBI into a breast surgical practice. Important considerations include patient age, histology, tumor location and size, and breast size. Thoughtful lumpectomy planning is essential to optimize balloon placement. Real-time sonographic guidance is essential as the surgeon should attend closely to volume excised and cavity shape. A cavity evaluation device can act as a place holder while patient suitability for APBI is considered. Many breast surgeons expert in this procedure insert the balloon catheter in the office either through a de novo skin entrance site removed from the lumpectomy incision or through the original incision. Optimally, insertion occurs within 2-3 weeks after lumpectomy. Close and continual communication with the radiation oncologist is essential to assure optimal outcomes. In this review, several key aspects of a successful APBI program from a surgeon's perspective as well as a consensus panel from a best practices symposium on the topic herein are highlighted.

Prospective randomized study comparing cryo-assisted and needle-wire localization of ultrasound-visible breast tumors.

BACKGROUND: This study compared the surgical results of 2 localization methods-cryo-assisted localization (CAL) and needle-wire localization (NWL)-in patients undergoing breast lumpectomy for breast cancer. METHODS: A total of 310 patients were treated in an institutional review board-approved study with 18 surgeons at 17 sites. Patients were randomized 2:1 to undergo either intraoperative CAL or NWL. A cryoprobe was inserted under ultrasound guidance in the operating room and an ice ball created an 8- to 10-mm margin around the lesion. The palpable ice ball then was dissected. NWL was placed according to institutional practice and resection was performed in a standard fashion. Surgical margins, complications, re-excisions, tissue volume, procedure times, ease of localization, specimen quality, and patient satisfaction were evaluated. Positive margins were defined as any type of disease present 1 mm or less from any specimen edge. RESULTS: Positive margin status did not differ between the 2 groups (28% vs. 31%). The volume of tissue removed was significantly less in the CAL group (49 vs. 66 mL, P = .002). Re-excisions were similar in both groups. CAL was superior in ease of lumpectomy, quality of specimen, acute surgical cosmesis, short-term cosmesis, patient satisfaction, and overall procedure time for the patient. CAL had a lower invasive positive margin rate (11% vs. 20%, P = .039) but a higher observed ductal carcinoma in situ-positive margin rate (30% vs. 18%, approaching statistical significance, P = .052). CONCLUSIONS: CAL is a preferred alternative to standard wire localization because it provides a palpable template, removes less tissue and improves cosmesis, decreases overall procedure time, and is more convenient for the patient and surgeon.

Interim results from the FibroAdenoma Cryoablation Treatment Registry.

OBJECTIVE: The aim of this prospective study was to assess the intermediate- (6 months) and longer-term (12 months) follow-up of patients with breast fibroadenomas treated by cryoablation in community-based practice settings. METHODS: The FibroAdenoma Cryoablation Treatment (FACT) registry was created to systematically collect procedural and follow-up data for patients with fibroadenomas treated by cryoablation without subsequent excision. This report summarizes the experience from 55 different practice settings across the United States. Baseline and follow-up clinical data at 6 months and 12 months were tabulated for all patients. RESULTS: Data from 444 treated fibroadenomas were analyzed. The mean tumor diameter was 1.8 cm. Before cryoablation, 75% of fibroadenomas were palpable by the patient. Follow-up at 6- and 12-month intervals revealed palpability of the treated site in 46% and 35%, respectively. When fibroadenomas were grouped by size, for lesions 2 cm, residual cryoablation induce changes were visible by ultrasound in 39% of the patients at 6 months. The treatment area was palpable in 78% of the cases at the same time. Visibility by ultrasound was 32%, and palpability was 59% at 12 months follow-up. Patient satisfaction with the procedure was rated as high at 91% and 88% at 6 and 12 months follow-up, respectively. CONCLUSIONS: Before implementing this technique, patients should be apprised of the likely persistence of a palpable mass of the treated site for a prolonged period that will reabsorb over time. Palpability of the treated site persists for a substantially longer period of time for lesions greater than 2 cm in diameter. For patients with a fibroadenoma smaller than 2 cm, complete resolution can be expected in two thirds and three quarters of the patients at 6 and 12 months, respectively. We will continue to follow these patients to better define the length of time and factors influencing the resolution of the treatment induced physical and radiographic findings.