Factors influencing local control after MR-guided stereotactic body radiotherapy (MRgSBRT) for adrenal metastases.

Purpose: Stereotactic body radiotherapy (SBRT) is an effective treatment for adrenal gland metastases, but it is technically challenging and there are concerns about toxicity. We performed a multi-institutional pooled retrospective analysis to study clinical outcomes and toxicities after MR-guided SBRT (MRgSBRT) using for adrenal gland metastases. Methods and Materials: Clinical and dosimetric data of patients treated with MRgSBRT on a 0.35 T MR-Linac at 11 institutions between 2016 and 2022 were analyzed. Local control (LC), local progression-free survival (LPFS), distant progression-free survival (DPFS) and overall survival (OS) were estimated using Kaplan-Meier method and log-rank test. Results: A total of 255 patients (269 adrenal metastases) were included. Metastatic pattern was solitary in 25.9 % and oligometastatic in 58.0 % of patients. Median total dose was 45 Gy (range, 16-60 Gy) in a median of 5 fractions, and the median BED10 was 100 Gy (range, 37.5-132.0 Gy). Adaptation was done in 87.4 % of delivered fractions based on the individual clinicians' judgement. The 1- and 2- year LPFS rates were 94.0 % (95 % CI: 90.7-97.3 %) and 88.3 % (95 % CI: 82.4-94.2 %), respectively and only 2 patients (0.8 %) experienced grade 3 + toxicity. No local recurrences were observed after treatment to a total dose of BED10 > 100 Gy, with single fraction or fractional dose of > 10 Gy. Conclusions: This is a large retrospective multi-institutional study to evaluate the treatment outcomes and toxicities with MRgSBRT in over 250 patients, demonstrating the need for frequent adaptation in 87.4 % of delivered fractions to achieve a 1- year LPFS rate of 94 % and less than 1 % rate of grade 3 + toxicity. Outcomes analysis in 269 adrenal lesions revealed improved outcomes with delivery of a BED10 > 100 Gy, use of single fraction SBRT and with fraction doses > 10 Gy, providing benchmarks for future clinical trials.

Identifying the Variables for Oncoplastic Reconstruction: Preoperative Assessment Tool for Breast Conserving Treatment.

BACKGROUND: A wide range of surgical techniques has been described for breast conservation treatment (Oncoplasty) based on breast size and shape, as well as tumor size and location. However, there is a lack of standardization regarding the indications for oncoplastic reconstruction. This study aims to identify the presurgical parameters associated with poor cosmetic outcomes post-breast conserving treatment. We hope this preoperative model can assist in evaluating whether there is a need for oncoplastic intervention. METHODS: The study group involved 136-adult females (age 35-77) who previously undergone breast conserving surgery and radiation, without oncoplastic intervention between 2007 and 2017. Patient demographics, medical and physical parameters were collected, and each patient filled Breast-QTM-questionnaire and six angles' photographs were taken. Patients' photographs were evaluated by 15 board-certified plastic surgeons. Both univariate and multivariate logistic regression analysis was performed to identify potential confounders for poor outcome in each of the experts' and patients' average-grades. RESULTS: Our analysis identified several variables correlated with poor surgical outcome: high BMI, high chest-wall-circumference, high breast-width and larger volume-removed. The general-aesthetic-result as evaluated by our experts was favorably influenced by an upper lateral quadrant tumor while the breast shape was negatively influenced by a lower medial quadrant tumor. Interestingly, no correlation was found between the patients' and panel's evaluations, nor did we find any clinically significant parameter related to the patients' reported well-being. CONCLUSION: Patients with high BMI, high chest-wall-circumference, large breast-width and larger inferomedial tumors could benefit from early plastic surgery evaluation and intervention. Patient's psychosocial well-being as well as sexual well-being are independent from positive surgical outcome evaluated by plastic surgeons. LEVEL OF EVIDENCE III: This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .

Treatment-Induced Bone Marrow Enhancement at MRI in Breast Cancer Patients Receiving Granulocyte-Colony Stimulating Factor Adjunct to Chemotherapy.

RATIONALE AND OBJECTIVES: Granulocyte-colony stimulating factor (G-CSF) induces the reconversion of fatty bone marrow to hematopoietic bone marrow. The bone marrow changes are detectable as signal intensity changes at MRI. The aim of this study was to evaluate sternal bone marrow enhancement following G-CSF and chemotherapy treatment in women with breast cancer. MATERIALS AND METHODS: This retrospective study included breast cancer patients who received neoadjuvant chemotherapy with adjunct G-CSF. The signal intensity of sternal bone marrow at MRI on T1-weighted contrast-enhanced subtracted images was measured before treatment, at the end of treatment, and at 1-year follow-up. The bone marrow signal intensity (BM SI) index was calculated by dividing the signal intensity of sternal marrow by the signal intensity of the chest wall muscle. Data were collected between 2012 and 2017, with follow-up until August 2022. Mean BM SI indices were compared before and after treatment, and at 1-year follow-up. Differences in bone marrow enhancement between time points were analyzed using a one-way repeated measures ANOVA. RESULTS: A total of 109 breast cancer patients (mean age 46.1 ± 10.4 years) were included in our study. None of the women had distal metastases at presentation. A repeated-measures ANOVA determined that mean BM SI index scores differed significantly across the three time points (F[1.62, 100.67] = 44.57, p < .001). At post hoc pairwise comparison using the Bonferroni correction BM SI index significantly increased between initial assessment and following treatment (2.15 vs 3.33, p < .001), and significantly decreased at 1-year follow-up (3.33 vs 1.45, p < .001). In a subgroup analysis, while women younger than 50 years had a significant increase in marrow enhancement after G-CSF treatment, in women aged 50 years and older, the difference was not statistically significant. CONCLUSION: Treatment with G-CSF as an adjunct to chemotherapy can result in increased sternal bone marrow enhancement due to marrow reconversion. Radiologists should be aware of this effect in order to avoid misinterpretation as false marrow metastases.

Comparison of intravenous 5-Fluorouracil with Oral Capecitabine in the Treatment of Anal Squamous Cell Carcinoma Using Modern Radiation Techniques.

BACKGROUND: Anal squamous cell carcinoma (ASqCC) is a rare malignancy, traditionally treated with combined chemoradiation, with a continuous infusion of 5-fluorouracil (5-FU) and mitomycin C (MMC). Replacing intravenous (IV) 5-FU with oral capecitabine (oral fluoropyrimidine) has been reported as a non-inferior treatment option. However, these data are scarce, with variable results. OBJECTIVES: To examine the outcome of patients with ASqCC treated with either IV 5-FU or capecitabine concomitantly with radiation therapy. To compare treatment side effects, local recurrence, and general outcome. METHODS: We reviewed charts of patients who were diagnosed with stage I-III ASqCC. All participating patients received chemoradiation at the Assuta Medical Center between 2011 and 2019. RESULTS: In this study, 43 patients with ASqCC were eligible; 14 received 5-FU and 29 were treated with capecitabine. Basic characteristics were similar between the two groups, with longer follow-up for the 5-FU group. Six months following treatment, 100% (13/13 with adequate follow-up) of the 5-FU group had complete clinical response, compared to 84% in the capecitabine group (21/24), P = 0.143. The local recurrence incidence was higher in the 5-FU group at 23% (7, 10, 26 months following therapy, and none in the capecitabine group (P = 0.088). Although local and hematological toxicities were similar between groups, one patient receiving capecitabine died during chemoradiotherapy. CONCLUSIONS: Oral capecitabine demonstrated non-inferior disease control in ASqCC treated with chemoradiotherapy. We recommend oral capecitabine over continuous IV 5-FU in locally and locally advanced ASqCC. Close monitoring of side effects is required to reduce major toxicity.

Autologous Fat Grafting With CO2 Tissue Preparation (Carbo-pneumodissection): A Safe Method for Expanding and Enhancing Recipient Site Capacity and Aesthetic Outcomes.

BACKGROUND: Autologous fat grafting (AFG) is commonly used as part of aesthetic and reconstruction procedures, but expanding and enhancing the recipient site capacity remains a major challenge. OBJECTIVES: The aim of this study was to describe and assess an innovative intraoperative carbon dioxide (CO2) pneumodissection (CPD) recipient site preconditioning procedure intended to improve recipient site capacity and AFG outcomes. METHODS: From June 2019 to August 2021, 53 patients after mastectomy or lumpectomy (76 breasts) underwent 96 AFG procedures as a separate stage immediately following tissue preconditioning with CPD. RESULTS: There were no systemic or major local complications. The mean number of AFG procedures required to complete the reconstruction was 1.3 per breast. The vast majority of patients achieved a final satisfactory aesthetic outcome with either 1 or 2 procedures (77.6% and 18.4%, respectively). The volume of fat graft delivered into the recipient site per session following CPD was higher than previous literature reports for all study groups. Furthermore, the CPD procedure was associated with a reduced need for subsequent AFG to complete the reconstruction. The positive effect of CPD, in terms of AFG volume delivered, was even more prominent among scarred irradiated breasts. Despite the large fat graft volumes delivered in our study, only 5.3% of breasts experienced fat necrosis following the procedure. CONCLUSIONS: CPD constitutes a safe, innovative, intraoperative method to expand and enhance recipient site capacity and fat grafting outcome. CPD allows cavernous expansion alongside preservation of the microcirculation. CPD works for both healthy and compromised tissues, in either reconstructive or aesthetic procedures.

Risk-Reducing Mastectomy and Reconstruction Following Prophylactic Breast Irradiation: Hope Sustained.

Risk-reducing mastectomy (RRM) is often advocated for BRCA1/2 mutation carriers who face a heightened lifetime risk of breast cancer. However, many carrier patients seek alternative risk-reducing measures. In a phase II nonrandomized trial, we previously reported that prophylactic irradiation to the contralateral breast among BRCA carriers undergoing breast-conserving treatment significantly reduced subsequent contralateral breast cancer. Herein, we report the outcome of salvage mastectomy and reconstruction in 11 patients that suffered reoccurrences of breast cancer in either the ipsilateral or contralateral breast or elected to have the procedure for risk reduction during the eight-year follow-up period. Patients' satisfaction with the procedure and physicians' assessment of the cosmetic outcome were not inferior for previously irradiated compared to non-irradiated breasts. Although the numbers are small, the results are encouraging and sustain hope in a challenging population. Our findings support continuing research as well as a discussion of risk-reduction alternatives besides mastectomy, including prophylactic breast irradiation, in BRCA1/2 mutation carriers.

Continuous positive airway pressure with deep inspiration breath hold in left-sided breast radiation therapy.

A dosimetric study to evaluate the use of continuous positive airway pressure (CPAP), with free-breathing (CPAP-FB) or with deep inspiration breath hold (DIBH-CPAP) an adjunct and alternative to DIBH to reduce heart and lung dose in the radiation therapy (RT) of breast cancer planned for left side RT with regional nodes and internal mammary. A retrospective analysis of 10 left-sided breast cancer patients whose heart or lung dose constraints were not met after RT planning based on FB or DIBH simulations and were referred for CPAP-based planning. All patients were simulated using FB, DIBH, CPAP-FB, and CPAP-DIBH. Treatment plans were calculated to cover the breast/chest wall and regional nodes using tangential field-in-field technique (FiF). Dose-volume parameters for heart, ipsilateral lung, and contralateral breast were compared using the Wilcoxon signed-rank test. For all RT plans, mean heart dose (Gy) was lower for treatment plans with CPAP: CPAP-FB (mean 3.4 vs 7.4, p = 0.001) and CPAP-DIBH (mean 2.5 vs 7.4, p = 0.006) compared to FB alone. CPAP-DIBH also significantly reduced MHD as compared to DIBH alone (mean 2.5 vs 4.3 Gy, p = 0.013). CPAP-DIBH significantly reduced mean lung dose as compared to both FB (mean 14.4 vs 20.1, p = 0.005) and DIBH alone (mean 14.4 vs 17.4, p = 0.007). Eight of 10 patients did not meet ipsilateral lung V20Gy dose constraints (≥35% of lung receiving 20 Gy) in either the free breathing or DIBH plans, whereas 8 out of 10 met lung V20Gy goal constraints (≤30% of lung receiving 20 Gy) in the CPAP-DIBH plans. Based on the outcomes of our study, CPAP could be a strategy for reducing lung and heart dose, both in patients not able to execute DIBH and as an adjunct in those not deriving sufficient dose reduction from DIBH alone.

"We are a transit station here": The role of Israeli oncology social workers in responding to mental health distress and suicidality in patients with cancer.

Social workers have a prominent role in responding to cancer patients' mental health needs. Given the risk of mental health distress in cancer patients, and given that social workers are responsible for responding to these needs, the purpose of this study was to explore how social workers describe their role in responding to mental health distress and suicidality in people with cancer. The Grounded Theory method of data collection and analysis was used. Eighteen social workers were recruited and interviewed. Social workers saw themselves and acted as an interprofessional hub for their patients. This approach was based on the values of holistic care, multiple treatment modalities, interpersonal consultation, and continuity of care. From this standpoint, social workers offered their patients (and at times, their families) comprehensive services providing emotional, behavioral and practical support within the hospital setting, but also outside of it in the patient's communities. Consideration should be paid to promote systemic changes to acknowledge and compensate oncology socials workers' invisible labor that includes both emotional carryover and continuous engagement in their role as liaison and intermediaries for their patients.

Oncologists, oncology nurses and oncology social workers experiences with suicide: impact on patient care.

OBJECTIVE: To explore how oncology healthcare workers' (HCPs) personal experiences with suicide impacts their practice with cancer patients. DESIGN: The study was designed using Grounded Theory strategies in data collection and analysis. PARTICIPANTS: Eighteen social workers, 23 oncologists, and 20 nurses, participated in the research. METHODS: Themes emerged from systematic line-by-line coding of the interview transcripts. FINDINGS: HCPs reported that personal experiences with suicide: impacted the way they communicated with patients about suicide; made them vigilant about signs of suicidality; and made them aware of specific indicators of this distress. CONCLUSIONS: HCPs drew a direct line between their experiences with suicide to the ways in which they care for their patients. IMPLICATIONS: Increasing HCP awareness of these issues alongside training using evidence-based guidelines for identifying and responding to suicide risk in patients will ensure providing the best quality of care for patients.

Radiation-Associated Secondary Malignancies in BRCA Mutation Carriers Treated for Breast Cancer.

PURPOSE: Radiation therapy (RT), a standard breast cancer (BC) treatment modality, is associated with a small increased risk of in-field second primary malignancy (SPM). SPM rates after RT in BRCA mutation carriers have rarely been reported. An elevated risk of SPM would affect the safety of breast conservation for early BC or prophylactic radiation as a method of prevention. We analyzed a population of BRCA carriers irradiated for BC to determine whether there is an elevated rate of SPM. METHODS AND MATERIALS: Patients with BC who were BRCA1 or BRCA2 carriers and were treated with breast and/or chest wall RT with or without regional lymph nodes between 1991 and 2012 at a single institution were retrospectively identified. Only those with ≥5 years of follow-up with adequate demographic, tumor, and radiation data were included. SPMs were recorded, and previously delivered RT doses to the organ and site of malignancy were determined. RESULTS: Two hundred thirty women, of whom 80% carried an Ashkenazi Jewish founder mutation, met entry criteria with 3-dimensional RT delivered to 266 breasts or chest walls, including regional nodes in 110 (41%). With a median follow-up of 10 years (range, 5-27; mean 11.4) comprising 3042 person-years, 6 SPMs developed, of which only 1 (papillary thyroid carcinoma) was within the radiation field (crude rate of 0.38% of irradiated breasts or chest walls), diagnosed 17 years after RT. This corresponds to an incidence of 0.32 per 1000 woman-years. The Kaplan-Meier estimate of 20-year freedom from a radiation-induced SPM is 99.5%. Calculated dose exposure to the out-of-field SPMs ranged from 0.1 to 1 Gy. No patient developed an in-field skin cancer or sarcoma. CONCLUSIONS: In this largest cohort of women treated with radiation therapy for BRCA-associated breast cancer, we identified no signal for an increased risk of radiation-induced SPMs compared with the general BC population, and the risk is extraordinarily small. Although larger cohorts and longer follow-up are needed, these results support the safety of RT in BRCA carriers.

Contrast-enhanced spectral mammography (CESM) in women presenting with palpable breast findings.

OBJECTIVE: Palpable breast abnormalities in women warrant diagnostic evaluation. Contrast-enhanced spectral mammography (CESM) is a novel technique which has demonstrated early promising results in the diagnostic imaging setting. The purpose of this study was to evaluate the role of CESM for imaging of palpable breast abnormalities and compare it to the current routine imaging work-up. MATERIALS AND METHODS: This retrospective study included women with palpable breast masses who underwent diagnostic CESM and ultrasound between 2012 and 2019. Diagnostic parameters for low-energy images, CESM and targeted ultrasound were calculated and compared. Analysis was performed at the lesion level. Additional incidental findings were reported separately. RESULTS: Included in this study were 138 women with 147 palpable breast abnormalities, of which 38 were cancers. Standard 2D mammography revealed 36/38 cancers (sensitivity 94.7%). All 38 cancers (100%) were detected at CESM and at targeted ultrasound. Negative predictive value for 2D mammography was 97.8% (91/93), and 100% for both ultrasound (74/74) and for CESM (80/80). None of the palpable masses that were negative at CESM but positive at ultrasound (n = 13) were malignant. Two additional incidental cancers were detected with CESM at the contralateral breast to the palpable lump. CONCLUSION: CESM could be useful for assessment of palpable breast abnormalities, potentially decreasing the number of unnecessary benign biopsies performed.

Thermal Monitoring of Tumor and Tissue State during Radiation Therapy - A Complex Case of Radiation Recall.

Common radiation dermatitis over radiation fields can be mild as minor erythema but can also be associated with blisters and skin desquamation. This phenomenon has been widely investigated and documented, especially in breast cancer patients. Obesity, smoking, and diabetes are known risk factors; however, we cannot predict the severity of radiation dermatitis prior to treatment. The overwhelming radiation recall dermatitis is an acute inflammatory reaction confined to previously irradiated areas that can be triggered when chemotherapy agents are administered after radiotherapy. This rare, painful skin reaction leads to treatment cessation or alteration. In this study, we investigate the feasibility of using thermography as a tool to predict the response of normal breast tissue and skin to radiation therapy and the risk of developing radiation recall dermatitis. Six women with viable in-breast tumor (breast cancer) and eight women who underwent tumor resection (lumpectomy) were monitored by a thermal camera prior to radiotherapy treatment (breast region) and on weekly basis, in the same environmental conditions, through the radiation course of treatment. One patient developed radiation recall dermatitis when treated with chemotherapy following radiation therapy, and needed intensive local treatments and narcotics with full recovery thereafter. Clinical and treatment data as well as response to radiation were collected prospectively. The ongoing thermal changes observed during the radiation treatment for all patients, with and without viable tumor in the breast, were documented, analyzed, and reported here with detailed comparison to the recognized data for the patient diagnosed with radiation recall dermatitis.

The Role of Culture/Ethnicity in Communicating with Cancer Patients About Mental Health Distress and Suicidality.

To explore the role of culture in communicating with cancer patients about mental health distress and suicidality. The Grounded Theory method of data collection and analysis was used. Healthcare professionals (HCPs) reported that language competency was a facilitator while being unable to speak the language or understand the nuances of their patient's communication could be a barrier. HCPs noted that being culturally matched with their patients helped them communicate effectively. HCPs also spoke about religious taboos on suicide as being a barrier to having conversations, either because patients did not feel comfortable discussing these issues, or because they perceived that this was not a topic they could bring up. Some HCPs reported that the culture/ethnicity of their patients had no effect on their ability to communicate effectively with them about mental health distress or suicidality. Advancing effective cross-cultural communication is a challenge faced by HCPs. Raising awareness about communication styles is an important step in addressing communication gaps about mental health and suicide with cancer patients. Training should facilitate skill development to engage in a culturally humble approach to cross-cultural communication including diversity training which encourages asking and actively listening to patients' needs and preferences.

Prophylactic breast irradiation reduces background parenchymal enhancement (BPE) on MRI: A secondary analysis.

PURPOSE: We recently showed that prophylactic breast irradiation (PBI) reduces the risk of contralateral breast cancer in BRCA mutation carriers undergoing treatment for early breast cancer. It has been suggested that Background Parenchymal Enhancement (BPE) may be a biomarker for increased risk of breast cancer. METHODS: For participants in the trial we reviewed the MRI prior to enrollment and following radiation treatment and scored the contralateral breast for BPE and density. RESULTS: Significant reduction of BPE was more commonly noted following PBI (p = 0.011) compared to the control group. CONCLUSION: Reduction of BPE by PBI may contribute to its prophylactic effect.

Breast cancer surveillance for BRCA1/2 mutation carriers - is "early detection" early enough?

BACKGROUND: Annual MRI screening is associated with a significant reduction in advanced-stage breast cancer diagnosis in BRCA1/2 mutation carriers. The impact that early detection has on subsequent oncological treatment is less frequently reported. In this study we compared disease stage and therapeutic approaches in BRCA1/2 mutation carriers who developed breast cancer while adhering to the recommended surveillance scheme ("known carriers"), with women who became aware of their BRCA mutation status after breast cancer diagnosis ("latent carriers"). METHODS: Data on tumor characteristics, disease stage, and therapeutic decisions were collected on BRCA1/2 mutation carriers treated for breast cancer at the Chaim Sheba Medical Center. RESULTS: Data were available for 298 BRCA1/2 carriers. Median follow-up was 77.4 months (range, 3.5-520). Age at diagnosis was not statistically different between known carriers (n = 96; median age at diagnosis 44.7 years) and latent carriers (n = 202; 43.7 years); p = 0.8284. Of known carriers, 19.8% were diagnosed with carcinoma in situ vs. 5% of latent carriers (p = 0.0012). Stage T1N0 disease was diagnosed in 54/96 (56.3%) of known carriers vs. 59/202 (29.2%) of latent carriers (p < 0.00001). Neoadjuvant or adjuvant chemotherapy was administered to 46/96 (47.9%) of known carriers compared with 162/202 (80.2%) of latent carriers (p < 0.00001). CONCLUSIONS: While early stage breast cancer was diagnosed frequently among known BRCA1/2 carriers under tight surveillance, almost half of these women were treated with chemotherapy. Healthy BRCA1/2 mutation carriers should be informed about these rates while discussing risk-reducing surgical options.

Oncology health care professionals' perspectives on the causes of mental health distress in cancer patients.

OBJECTIVE: To explore oncologists, social workers, and nurses' perceptions about the causes of their cancer patient's mental health distress. METHODS: The grounded theory (GT) method of data collection and analysis was used. Sixty-one oncology health care professionals were interviewed about what they perceived to be the causes of mental health distress in their patients. Analysis involved line-by-line coding and was inductive, with codes and categories emerging from participants' narratives. RESULTS: Oncology health care professionals were sensitive in their perceptions of their patients' distress. The findings were organized into three categories, namely, disease-related factors, social factors, and existential factors. Disease-related themes included side effects of the disease and treatment, loss of bodily functions, and body image concerns as causing patient's mental health distress. Social-related themes included socio-economic stress, loneliness/lack of social support, and family-related distress. Existential themes included dependence/fear of being a burden, death anxiety, and grief and loss. CONCLUSIONS: Oncology health care professionals were able to name a wide range of causes of mental health distress in their patients. These findings highlight the need to have explicit conversations with patients about their mental status and to explore their understanding of their suffering. A patient-centered approach that values the patient's conceptualization of their problem and their narrative to understanding their illness can improve the patient-provider relationship and facilitate discussions about patient-centered treatments.

Local recurrence of breast cancer: Salvage lumpectomy as an option for local treatment.

INTRODUCTION: The best local management for breast cancer recurrence following conservative treatment for breast cancer (BC) continues to be an open question. In this study, we compared patients' outcome after salvage lumpectomy (SL) vs mastectomy for ipsilateral breast tumor recurrence (IBTR). MATERIALS AND METHODS: Between 1987 and 2014 we identified 121 patients with pT0-2, N0-3, M0 BC who had BCT as their primary treatment, and subsequently had IBTR (unifocal). 47 patients underwent SL and 74 salvage mastectomy (SM) as the local treatment for their 1st recurrence. RESULTS: Median follow-up was 14 years (1-30) from first BC diagnosis. For the SL and SM cohorts, 8 and 10 patients (17%, 13.5%, P = 0.22), respectively, developed subsequent local recurrence as a 3rd event. Although in MVA, woman who underwent SL had higher chances of having a 2nd recurrence (3rd event), P = 0.020, at a median follow-up of 14 years, 95.8% of SL patients are alive, NED, 85% are mastectomy free. 87% of patients who opted for SM are alive, NED. Having re-irradiation following SL did not protect against 2nd breast cancer recurrence (3rd event, P = 0.42). CONCLUSION: Salvage lumpectomy following IBTR, while associated with higher second LR rate than SM is not associated with inferior outcome. With survival >95% at 14 years in the SL cohort, salvage lumpectomy with or without re-radiation, in a selected population (unifocal T), represents an acceptable treatment option for patients in order to delay time to mastectomy without reducing BC survival. Both options should be discussed prior to any surgical decision.