Sharing Perspectives on the Reconstructive Lumpectomy: A Discussion for Surgeons and Radiation Oncologists
Originally Broadcast: Thursday, January 21 at 4PM PST (7PM EST)
An interactive, case-based panel discussion designed to:
highlight optimal breast reconstruction and localization techniques
provide insight to technology's impact on the surgeon - radiation oncologist partnership
Participants will have an opportunity to ask questions and hear about the latest breast reconstruction methods from a multi-disciplinary team, including two surgeons and a radiation oncologist, practicing in both Academic and Community based centers.
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Ah, okay. Thank you, everyone, for joining tonight's discussion. Sharing perspectives on the reconstructive ectomy, A discussion for surgeons and radiation oncologists. My name is Macy Nelson, senior manager, medical education for breast surgery. And I'm going to be one of your co hosts for tonight. I'm excited to be here, but more importantly, I'm excited to be joined by four of the of my colleagues for an insightful discussion. My other co host this evening is Dr Anthony Luci from M. D. Anderson, Department of Breast Surgical Oncology, University of Texas, Dr Karen Barbosa, University of Maryland Shore Regional Health and to Radiation Oncologist Dr Assault Brahimi, an associate professor of radiation oncology with U T. Southwestern Medical Center. And finally Joshua Man Shine, Tennessee Oncology PRA Vision, Proton Therapy Center. We're hopeful that tonight's session is going to spark meaningful conversation and discussion on technology's impact on the surgeon and the radiation oncology partnership. But before we get started, I wanna walk you through a couple of housekeeping items. First and foremost. We're going to start tonight session with a brief bios orb overview led by Dr Barbosa, and then we're going to segue into a round table discussion, and this truly will be a round table discussion. So we encourage you all throughout the night. If you have a question, please. You drop it into the question section of your screen, and we will do our absolute best to bring your your rather your question into the conversation. Following tonight's session. There is going to be a survey that we're going to send you, and the surveys are incredibly valuable. And in fact, the survey from our Last Women are back in May was some of the information that we used for the topics tonight. So if you were at that session in May, this event will feel somewhat similar. Um, on the screen. You should be seeing some polling questions if you haven't had a chance. Thio answer those poll questions please do, because that also gives us really important information so our faculty can adjust and Taylor some of their answers based upon our audience members. Tonight, I'm gonna give you just one more quick moment to take the pole. Our Panelists are experienced clinicians, and they're here to discuss complex issues and challenges, along with potential solutions that surgeons and radiation oncologists are encountering as they aim to treat patients with breast cancer. So, Dr Barbosa, please do introduce us to bios Orb. Okay. Thank you for having me. Um, I want to thank a logic for having this webinar. I think it's really helpful, especially in the time of Kobe to be able to see someone and interact and get an education. Um, one of the things that I'd like to do is just briefly touch on some of our disclosures that the Panelists have. So we'll get that out of the way. Um, the disclosure I have is $200 worth of genomic health stock that I bought as a fellow Loomis L I'm a consultant for one of their research projects. I am a consultant for Hologic. As the other Panelists tonight, I am also a consultant for Striker Data Research, and Dr Russell has her disclosure here for her grant for accurate and educational speaker. Yeah, all right, now that we've got the housekeeping out of the way, let's do an aerial view of what bios orb is. So basically, it's a three d marker that we use to place in the tumor bed to mark the tumor cavity it's bio absorbable. It has titanium clips that are embedded in it so they don't move. It's built into this lattice, that is, is framework. Um, the bio absorbable framework will slowly incorporate over time, and the incorporation time really varies depending on the patient's breast tissue. I found when I first started working with bio Absorb, they said it was about two years. I've had patients that say, You know, they can kind of feel it in three years and by four years it's less palpable on by five years. They don't feel it. Eso it's variable. And I had patients that in, you know, the first year they don't feel it at all. So some of it will be, you know, the patient's body habits and their breast tissue. Part of it will also be the type of bios or been the location you use it in. So that's going to be all what we discussed tonight, a little bit later on. But it's very important to understand that the discussions should be had regarding the fact that it does get incorporated into the breast tissue and can be palpable. Um, like I said, this is valuable because it marks the tumor bed cavity, and it helps us a surgeon's recreate the breast form. I use it a scaffolding. So when we look at the different types, you can see here on this slide that we have several different sizes. But the different designs as well. The spiral is more full and gives you more volume on DNA that is, you know, best placed in the lower outer or inner quadrant or the upper outer quadrant, where you have a lot more breast tissue. The low profile is really great for the upper inner quadrant, where we don't have a lot of breast tissue immediately, and we're going to try to bring breast tissue to cover it. Um, and you don't have a lot of wiggle room, the more volume of tissue that you have to place over the bios or the less palpable it's going to be to the patient and the more it's going to be able to recreate the form. So having a variety of different sizes is really helpful as well as the different shapes. What we hope to do is try to incorporate this into today's teaching for how to use each and where on this picture, I think is really great because it shows you that on the first slide, the BIOS orb here is really incorporated into the breast tissue. And I can speak to this myself. This isn't my slide. But what I will tell you is that I actually had a patient to didn't follow up on her treatment and then eventually needed a mastectomy. And when we spiced the slice, the specimen pathology showed the same Inc. Which was pretty incredible to see how well and I think in hers was only two years afterwards that we found such a great Inc. Um, and you can see the pathology in the middle there, and at the end you can see kind of how it looks before it's really gotten incorporated. If you take it out sooner, I'm going to go to the next slide. The next slide here is a great example of why it's so beneficial for the radiologist to see Ah, lot of times will place clips and clips can migrate, but the bios or will stay in the tumor bed nicely while it creates scaffolding for the reconstruction. But you can also see beautifully how it delineates the cavity bed. So the radiologist for years to come can look at this and reevaluate whether there's calcifications, that air nearby, the tumor bed or some tissue that feels abnormal. So it's really nice. And patients like to see this as well because they can see it very distinctly on their image ing. The other thing that's important is here. When we look at it, it's very easy to see on damaging the three D marker, and we can see this once again. This isn't my slide, but you can see the three D marker, um, after chemotherapy here. And if we go to the next slide, this is what we used to have back in the day prior to the BIOS, or we would market with clips that could migrate. And even before that, before clips, there were some surgeons that just literally would move tissue and there be the aroma cavities that would be left in the deficit, where that would be the target planning for the radiation oncologist. So I think that when you see the difference of how well the bios orb from this previous slide to this slide, you know it really kind of limits the amount of radiation that you're going to be exposing a patient, too, Because so Roma's contract under the tissue planes, Um, even if you're not moving flaps and when we look at on capacity, we're removing a lot of tissue. You create a lot more tracking of aromas if you have any, so I'll go to the next slide here. And this is Ah CTL Excell Guide. For those of you who aren't familiar, the pictures are a little bit small, but this is a great delineation between where we were with clips. Onda Cero, Roma to where we are now with bios are clearly marking the tumor bed and really giving us a precise tumor marker and target. So if we continue on and we look at, why are we doing this? Here is, um, breast tissue conservation challenges, right? Patients want to keep their breast, they wanna have sensation. They don't wanna overdo their surgery, and especially in the day and age of covitz, some of them are just afraid to go to the O. R. So being in the hospital for a long period of time or having the risk of a complication or an infection is, you know, a concern. When we look at these, you're looking at deformities that air caused by volume loss on these, our most likely closed with the fact that there's a Ciroma there that eventually will get incorporated or absorbed over time and or get incorporated or absorbed and radiated at the same time, and that only exacerbate the dimpling. So when we look at the last one, this is what's called a bird beak deformity. So if you look on your screen, that inferior poll, if you take out that tissue, it looks great. And surgeons will be very proud of themselves and the post op Fareed, because that's aroma fills it up beautifully. But over time, that fluid will get incorporated. It absorbed, even if you don't do radiation. But if you add radiation to that, it's only going to make the breast tissue more fi bra tickets going to scar it down, and then you're going to get this bird beak deformity. That's really difficult to treat. So Uncle Plastic Surgery gives you techniques that you can use in the lower poll of the breast to re approximate breast tissue bios orb, creating some volume so you can recreate the form the two of these blend perfectly. And then we don't have to pick on our surgical, um, beds as they get radiated. And we don't have toe pick on our radiation oncology colleagues for damaging our work. Actually, the onus is on the breast surgeon to tee it up for the rat on so that they don't have to worry. They could do their job if we do our job a little bit better. And that's where Uncle Plastic really rolls in and does a great job of helping the rat ox get a good outcome cosmetically, if we set them up for success. So in this slide, this is kind of a blending of the technology of surgical uncle plasticky fused with the bio absorb that clearly marks the tumor bed cavity. And like I mentioned, I use it as a scaffolding where I can rotate flaps of tissue over the cavity and obliterate the bios orb so that it's not exposed. You never want that, but that you could get these great forms where to a lot of people, they don't even realize they've had surgery. The scars will fade um, and you can get a really nice cosmetic outcome. So when we start looking at doing uncle plastic surgery, something of the things that we wanna suggest, you know, tips for, you know, on capacity 101 and how to work with that? You know, the most important thing is kind of what we're doing here tonight, which is getting all of your colleagues on board. I had places that were calling my post surgical, um, cavities with bios, orb. A buyer adds three. There's a mass there. They didn't understand that that clip and what they were seeing was a bios or so, making sure you're radiologist to know what it is, you know, making sure your rat ox know that you've placed one. Because when you're placing them, you might be rotating large flaps of tissue, and it might not represent where the surgical scar is. You know, making sure that if you're not adept at doing some of the larger, you know, excisions and reconstructions by yourself that you're comfortable working with your plastic surgeon, you can work together, and that's basically going to be what your comfort level is. What your plastic surgeon's comfort level is, but I think that the camaraderie working with your plastic surgeon and you, especially if you're new to this, could be the most beneficial teamwork available. And like I said, the medical oncologist like to know, because sometimes if they're doing an exam, it's helpful for them to understand that you've done the surgery and how you've reconstructed the patient just so that they understand. Maybe there is something that's a little palpable in the post op, but that'll soften over time. Um, ma'am, a text wanna be aware of it? And you also want to make sure that you dictated in Europe notes so that you can refer back in years to come and say, Wow, this patient looks great. Did I use the bio reserve on this? Or is this you know, before I started using buyers or it's nice to have that comparison that you could go back in your notes and look at who you used what and what size. And it's a learning curve as you progress through using these technologies, whether it's just the surgical skills and or in conjunction with the bios orb marker, um, and then also let the PCP no, let them. You know, the primary care doctors. They're gonna be feeling these patients and looking at him so letting them know what you've done, I think it's pretty helpful. So let's go to the next slide here. You know, setting expectations. I think this is a really important slide to discuss, because when we look at expectations, you know it's not just expectations of you know, you and what you're hoping to provide to the patient with a good cosmetic outcome. But more importantly, the expectations of the patient, you know, letting them know that they are going to be having their cancer removed, that positive margins are still possible. Even though you're taking out this cancer and using surgical oncology techniques that optimize the cosmetics, this is still cancer surgery. What I always explain is you can't see it. You can't feel it. Even with palpable masses. At best, you're getting a estimation of the true side. There might be some microscopic disease that will be, you know, evaluated further on the surgical pathology. So basically what I do is set the patient up to understand what we're looking at and what we're trying to achieve. You know pre op education once again is what you know we're trying to do is basically take out the cancer. Try to take out more tissue with a negative margin to avoid to take back and at the same time be able to recreate the breast form so that they're left with a scar, which we can't help but leave them with a scar but hiding the scar. Perry Ariola Infirmary Fold Axillary We're really trying to move away from making large incisions on the belly of the breast or around the breast that are visible. And when we have these abilities to make these incisions, it helps patients. Psychologically, they're not looking in the mirror all the time and seeing, you know, a scar right in their cleavage when they were having a low cut dress or at the beach in a bikini. Um, and like I said several times the palp ability, and I'll stress it again. Palp ability is best addressed pre operatively upfront when you introduced the option of bringing it into their surgery. I also put it on my consent when we look at the palp ability. Like I said, I've seen patients who have relatively prominent profile spiral, and yet they don't feel it, um, in the upper inner quadrant, because they have so much breast tissue. Or they have an older patient with more glandular tissue where I like to actually get a little bit more coverage. I believe the Hologic perspective is two centimeters above is is fine. But I always say, If you've got glandular older breast tissue, you want to be careful because glandular older breast tissue has, ah, higher propensity towards fat necrosis. So once again, it's the size. It's the type that you're using the shape, whether it's a spiral or a low profile. And where do you put it? Um, and you know, I heard a lot of people say Rub it like you love it on drubbing The site really won't affect the absorption rate, but I think some patients like to feel like they're doing something so that I leave that up to the, uh, surgeons discretion when we look at surgical techniques and abilities basically marking the tumor bed, Um, you know, talking about who's a candidate for radiation and knowing, um, if you're going to radiate something, giving them a little bit more wiggle room. Um, if you're planning to do catheter A a p B I patient education. Like I said, I put it on my consent form Contra indication, If there's an active site of infection, you really don't wanna be putting that in there because just like any other implant, you don't put implants in a bit of infection. Um, I always use I v antibiotics pre operatively. I always try to orient my bios orb and future it in, and we'll talk a little bit more about that later on. But it goes back Thio side selection and location. Um, and it doesn't always need to be the same size as the tumor. That was, I think, initial training. But now what we're really trying to do is re approximate the breast tissue around the BIOS orb. So once the cancers out, even if it's this, we're bringing the edges together and we're really closing down circumferential e around the tumor. And that's why the importance of the BIOS orb is really there. So we can radiate less tissue but really get the margins that were around your initial cancer. So full coverage, single insertion breaking catheter might be difficulty, but I've heard of some people trying to do that. Location and fat composition of the breast is really going to be what your overriding guiding factor is is to what to use and when and where. Um when you have really large breasts, you really want to avoid that thin skin flap for interior coverage. And like I said, the glandular older breast tissue is going to be more at risk. If you have a young, dense breasted woman, then you're going to be able to get away with a little bit less tissue. But like I said, two centimeters, at least off coverage is always a good idea, because if you place it too superficial, you could cost him sucking in. And you don't want that. You really don't want to set up your rat ox for failure. Like I said, it's really in the hands of surgeon. So let's just take a quick look at this. When we talk about ankle plasticky, you can see just looking at this slide. There's a variety of approaches, and where we make our scar doesn't always represent where we're actually taking the cancer out because you can see we can get almost any quadrant, depending on our surgical approach. Yeah, Karen, this is a really interesting slide and really important for radiation Oncologist to see when patients come in and see us in consultation. The next step is for them to have a planning scan or a CT scandal. Let's plan the radiation. And at that time we really outlined all of the breast tissue. But we also outlined the scar, which to us typically represents where the tumor was removed. So in cases of ankle plastic surgery, where your obliterating the cavity so you don't have a Ciroma to target. And oftentimes clips may not be left behind. If you don't have, you know, buys or device, then you're really left kind as a racial colleges guessing where that tumor was located because you really don't have any of the three the scar to help you the or this aroma or clips. So that that that kind of brings up a unique challenge for radiation oncologists. Yeah, so that was a great Karen. I thought that was a really great overview on the on the bios orb. And I think you know, obviously, nowadays we as surgeons are have the ability to move tissue around and to do uncle plastic reconstruction, which I know you're gonna talk about more in detail. But I want to stop for a minute and ask radiation oncology colleagues. You know, when we move the tissue, what can we be doing as surgeons? To make this easier for you to know exactly. You know where you want to target how you do your planning. I'll start with doctor. He me? What do you think? I know. Many of us for years have used clips. We just put clips around each of the the margins. Is that adequate or do you really prefer, You know, Do you prefer something like bias orb? So eso I mean, any kind of marking is really great. The issue is, though, is that now that we're getting into this era of more Uncle Plastics with just clips, the clips could be kind of all over the breast, kind of just depending on what type of manipulation has been done with the uncle plastic surgery. So what we're seeing is that a lot of patients want to come in in their early stage and their candidates for partial breast but they're not eligible anymore for partial breast just because the clips are all over the place or there are no clips. So this has become a really big challenge in the era of partial breast radiation, and especially now with all the new data that has come out that has shown that whole breast radiation is a partial breast is equivalent to whole breast radiation. People want partial breast radiation on day. Can't have it sometimes in situations when we don't have that communication between the radiation oncologist and the surgeon. So having a device in there, that kind of localizes exactly where the clips are before a lot of that manipulation happens is very crucial to being able to dio to being able to do partial breast radiation in the era of uncle plastic surgery on. But I think just having the team kind of working together and discussing these issues and really knowing what what job each one of us has to do and how we can make it better for the patient is really crucial to make that happen to make that successful. Yeah, that's really good. Doctor Munchen, what about you? Do you have some thoughts to help because I think the whole point of this is to facilitate a discussion of what we could be doing a surgeons to make it easier for you guys to do partial bar, you know, planning, treatment, target boost. Whatever. So so what do you think? What? I think all of Dr Rahim ease comments are really excellent. There was a recent editorial in the Journal of Clinical Oncology which basically discussed how you know, really nationwide partial breast radiation is underutilized, and I think there could be a number of reasons why. So I don't think there's just any one reason. But I think for patients who meet the Astro criteria, which we consider to be quote unquote suitable for partial breast radiation and the under the current guidelines that's women 50 or older. Typically t one tumors e r positive, you know, excise with clear margins. You know, the probably the majority these women should be getting, or at least offered as a potential option, partial breast radiation on. And I think part of the reason why it's underutilized, I think, is what I've heard when I've kind of surveyed colleagues is that there's sort of a low confidence when they get a patient and do the planning scan of exactly you know how to outline the cavity on a consistent basis. So I agree with Dr Rahimi. I think any markers are good thing. Issue is that there's a lot of variability. Surgeon, a surgeon on how clips are left. And also, um, you know, the clips aren't really left in a perfect three D pattern around the tumor, So it's hard for us to consistently, you know, outline where it was removed. So I think by default, most radiation oncologist will go go toe whole breast radiation because we know you know you're not going to miss your target. So I think I think that's kind of the heart of the issue. I think that's actually really helpful information, because I know all of us have been guilty of the in the past of using clips, putting them around the margins and then either remove tissue of the plastic surgery team, move tissue to a point where it may make it very difficult for you guys to really know what what's going on. So, Karen, I think you're gonna talk. Speak to that because I think the thing is, I'm at an institution where we use clips, and I think there's also a financial concern. Andi clips, you know, are what most people would be using. But what I'll say is that there are certain cases like what, like Dr Luigi was saying is where you're really going to need something like bios orb to help you if you're going to keep the breast. And so I think, trying to integrate it, Um, And if you're at an institution that's using clips, maybe just trialing on a few of the larger cavities that you're doing Thio bring it in for that and then you'll see the utility s. So I just wanted because I was looking at the poll and it looks like the majority of patients, uh, patients are. Everyone's a patient to me. Um, the majority of attendees tonight are actually using clips, So I just wanted to address that my current institution, we are using clips primarily. And then I'm trying to get them to let me use it on cases that I really needed E. I wanted to make one more comment, too. So, you know, this discussion doesn't just apply to partial breast is also applies for the boost, which has been shown in several trials. Toe have, ah, local recurrence reduction when we do the boost. And so when some of these uncle plastics are done and even when clips air done and like we had mentioned before, they are all over the place or we can't see them because reduction surgeries have been done and the clips have been removed. We're removing a component of the oncological care, and that's not good. So we really need to make sure that, you know Kozmus is is very important. And I'm all about Kaz missus. But it's also about curing the patients and giving them the best outcomes. So these some type of localization is gonna be very important just for the actual oncological care of the patient. I think that's a great comment, and I think really is helpful to us. And I have to admit, you know, one of the reasons I started using Bowser was because I really liked the ability to reconstruct large defects. But to know that it has that really big benefit of for the radiation oncologist, I think adds a lot. Um Karen, I think you're gonna talk a little bit more in detail about how much tissue were moving and for for all of us, both surgeons. Radiation Oncologist, can you just talk a little bit more about the types of uncle plastic? So we know. Kind of what? When we see a not know what we're looking at? Yeah, sure. Um, e just wanted to say if I could get control back of the screen, I'll move through it. I could move it for you. All right. Okay. So, I mean, I think this slide basically exemplifies, you know, the different patterns. But when we look at this slide, we have to understand the different levels. Um, so let's move away from the minutia of the pictures to the bigger concept, which is which are the levels. So we go to the next slide, we'll see. Um, the level one is less than 20% of the breast. So basically, what we're doing is we're just simply reshaping closing the cavity on bears. No skin excision. You might be doing a little bit of a crescent lift. Andi, that really is the most you want to move. It is about three centimeters, the plastic surgeons will gas. But the fact that you're doing a crescent because the nipple areola complex known as the NAC has very soft tissue. And if you actually move it and you don't go circumferential e around the nipple, what's gonna happen is you'll get a little football elongation of the next. So you really don't want to use that? Um, too much. But if they're going to get radiated, the radiation is actually your friend in this. And it'll actually tethered down that breast tissue so that you don't get a lot of that stretch that we would see if you didn't do that on Ben. You know, like I mentioned just now is that you know, if you go circumferential all the way around, people will call it a Benelli or around Plock or a donut, and basically that's going around the nipple completely and then creating a perimeter around that and that is basically going to keep it. If they're two concentric circles, one and then another one around it, then you're the nipple will stay right where it is. If it's e centric, it'll lifted up or drop it down on you can move it medial or lateral if the tumor is on the medial and lateral side to compensate for any radiation boost that you might be getting. But there are limitations to that procedure as well, because when you do too much of a circumferential change basically your flattening the breast form by narrowing the nipple areola complex. Uh, with a vertical limb, you can get it to actually look better. But for the most part, simple, Easy way to understand this is 20% of the breast or less is level one. Level two is more complex, 20% or greater. And I would say also depending on the size of the breast, right? So if you've gotta be size breast, if it's a B cup and you're taking out 20% that could. Actually, even though it's only 20% it could be depending on what quadrant you're in. Like I said, the upper inner is the most difficult to reconstruct. It could be a lot more challenging. Basically, when we're looking at 50% you know, we're looking at a large volume loss and hear. A lot of times we're gonna look to dio skin removal so you know those air times that you definitely want to incorporate. Ah, vertical master Peck. See where you're going to take out tissue from the below the nipple to tighten up that skin envelope. The way I described this to patients on other doctors who are doing this when they're learning it for the first time is if I have a pillow and I take out half that pillow. But I keep the same pillow case. It's gonna look terrible. Well, think of the pillow as the breast prank Imma. Think of the pillowcase as the skin. So if you're taking out the pillow, then you better take out some of the pillowcase so that, like, begets like and that the volumes match. So you really want a nice, tight skin envelope over a nice tight breast. And that's where the volume replacement becomes really critical issue. And that's why I like to use the BIOS or on Ben. There's different techniques that you can use Master Pepsi, which is raising the nipple, ma'am, a plastic techniques like reduction. And, you know, once again it's going to speak to your level of comfort. When I was in New York, my best friend was a plastic surgeon. We were mutton Jeff in the O. R. And we would do these cases together. When I got to Alaska, the plastic surgeons didn't wanna have anything to do with me. And I have patients who had, you know, either Tricare or Medicare and the plastic surgeons have the pick of the litter. And I couldn't get anyone really to work with me on DSO. They would say you do it and you know, on for cases for re cons like implants will be there s so it was a really different spectrum and paradigm for me. And that's where I started doing more and more of this and and it's really about one of the things is understanding what your comfort zone is. You know? What is your facility with the procedures? What is your hospital like? What are they gonna let you do what? Your plastic surgeon availability. So working within your spectrum just because other people are doing it? Don't jump off the cliff. Make sure that you're ready to go before you jump. So partnering with the plastic surgeon is a great way to get started and really a way to avoid having a complication. I always say, if you're starting to do this for the first time, if you have a mistake, you're a butcher. If the plastic surgeon has a mistake or a complication, well, these things happen. So just be aware that were a little bit more under the microscope. And I start Doctor Luci grinning under his beard. We can go to the next life. And I think this is Josh. Uh, Josh, you enlighten us a little bit more about what s so what are the kind of difficulties you have and show us kind of some of the issues regarding your planning when you're using, let's say, a Ciroma versus using, ah, device that can actually outlined the cavity. What do you got? Sure, you know, it's a It's a good question. So in terms of what the radiation College has thio use, if there is not, you know, a surgical cavity marker in place. You know, really, we're left with either using this aroma, you know, or potentially if there some surgical clips that are left behind. And, you know, we know that these air very imprecise. Um, you know, they've been multiple papers written about this, but with aromas. The issue is that they can overestimate the size of the surgical cavity because they can seep into surrounding tissues. So when the radiation oncologist outlines the cavity, we actually wind up essentially irradiating mawr normal breast tissue than we'd like. Thio Onda problem with clips is against it can migrate, so they're just not a reliable target. Um, when you're trying to outline cavity So those air kind of the two central issues that we see way the next slide and this is a slide Looking at what? What modern three D based treatment planning looks like for the radiation oncologist with a BIOS or marker in place. So this is the first phase of radiation. Um, this is a lady getting whole breast radiation what we call tangent fields where we're targeting the whole breast. For the first phase of treatment, the majority of women will qualify for hypo fractionated radiation therapy, which is traditionally given over the course of about three weeks. And then, like Dr Rahimi mentioned, we go to the next slide. The majority of women will qualify for a boost. A boost is essentially giving targeted radiation to the cavity itself to reduce the risk of local recurrence on. But this is a slide that demonstrates how that boost can be done rather nicely with the BIOS or been place. Because you know exactly what you're treating. You could put a consistent margin on it that can vary from institution institution or what protocol of patients being treated on typically around the room of one cm. Um, but it depends on the protocol. But at least with this, you have a consistent marker in place for that boost phase. Yeah, so I'm just jump in and say, I saw that there's a registry data that was published by Kaufman. I think it was annals of surgical oncology late last year, and I noticed they asked Radiation Oncologist, you know, do you prefer having buys services? Not. I was actually shocked. I think it was like 87% said that it helped him with planning boost targets. S o. Obviously that must be something very useful. Tohave versus a bunch of clips. Kind of e actually worked at a place where I have a very old radiation oncologist who's very old school and set in his ways and this was actually the one thing that he actually had asked the university to bring to the system years ago. So just saying that I didn't believe it would be really but yes, eso the registry was actually interesting. It also brought up another point, which you address. Karen is always try to use one size, smaller and covered with tissue because that really there was there was a mention of probability. But when that was done, it reduced it. And I think that's what I've noticed. Talking to other surgeons is one of the main reasons people has tended to say. I've heard it could be palpable, but I've always tried to go a size smaller or even used the flat two by three by one and just mark the bed with it and pull some tissue over. You still get great tissue replacement. But sorry. I mean, to jump in the radiation oncology a flow. But I think those were important points out of the out of the registry data eyes to, you know, go with smaller size and cover it if you leave it right up near the skin. Obviously that's gonna be a problem. Can also ask Doctor, he me what are your thoughts on the cavity size and yeah, no, I mean, I think that that's a perfect segue way into what I wanted to discuss. So I mean treatment volume for radiation oncologists really matters, especially when we're doing like sophisticated techniques like partial breast radiation. Eso There are many different types of partial breast radiation. One of the newer techniques that we have is called Steri attacked IQ partial breast radiation. And for those that are not familiar with that, it's basically doing less than five treatments, five treatments or less of partial breast radiation and just kind of using some some different immobilization technique. So we don't have to have these really large margins that we typically have toe have with the external beam partial breast. But coming back to the point of the cavity size and having you know a smaller device, Um, it's very important because we know that treatment volume for radiation, higher treatment volumes, larger treatment volumes basically correlates to higher toxicity on. There's a direct correlation, and specifically for the pressed it has been shown to correlate with higher rates of fat necrosis. So one of the trials that we had done, which was a stereotype Tick partial breast radiation trial found that this fat necrosis typically will develop in, um in about 15% of patients and it would happen in about one year on bond. It was directly correlated to the P TV volume, which is basically the volume that were prescribing are dose, too. Um, and the bigger the volume, the higher the incidents and the higher the percentage of fat necrosis development. And there was a cut off of about 100 ccs for really kind of predicting for a higher probability of fat necrosis. So, you know, selecting a device that is as small as possible so you can actually kind of, in other words, shrink the cavity rather than in comparison to just kind of leaving it open would really help us radiation on colleges. Because then we can have a smaller volume that we have to treat, which will then correlate to some of these other things that we were just mentioning. Eso treatment volume matters for basically any type of partial breast radiation, whether it's external beam, whether it's catheter based or steri attacked. IQ partial breast. Um so just kind of really quickly just on the the topic of the stereotype tick partial breast. Some of the other factors that we found that were associated with fat necrosis if you move to the next slide are women that had larger breasts were also associated with higher fat necrosis. And then people that got their fractions of radiation when they're doing the stereotype tick techniques, um, like, on consecutive days and just hire treatment, higher treatment prescription doses. So if you go to the next slide, Um, yeah, and this just kind of just shows the incidents of fat necrosis over time with the median being around one year. But it can happen even out toe like three years. So and and and when we're doing these partial breast techniques, that's really important toe, you know, know what that is so that we can. So we can first of all, calm down the patients and basically just document that with like, an ultrasound and continue to follow along. But treatment size really does matter. And selection of a device that would actually reduce the cavity size so that the radiation oncologist can treat a smaller volume is key uh, those were actually think really great comments. You know, one of the big things now for us, the surgeons, is we're really we always want to offer breast conservation whenever possible and some of the limitations before we're well, it may not look good. Like Karen said, you take half the pillow away, the pillowcase doesn't fit. I actually used the same analogy. That's a great analogy about you're taking out the pillow. You need the case. So So you know, I think it's been It's interesting because now we're always looking for is Thio deescalate therapy, deescalate radical surgery, you know, be able to extend breast conservation. So I just wanted to point out, you know, one of the other things is that we haven't talked yet, but his localization. So, you know, when we're talking about localization, we've talked about, you know, see, or whatever. There's like many different ways wires. People have used wires. One of the things we've done and I've really liked using is the localizer, and I have to say that the really I think big benefit that I've seen is that you when your each of your R f I D markers especially your bracketing a lesion. When you place the probe over the market, you get a unique R f I D signal. So this kind of, I think illustrates that this was a lesion that was bracketed. And so when you place your probe over each marker, you get a code that tells you which is the entire marker, which is the post your marker or let's say you have three. Sometimes we have three, even four. You may tell you, which is the media or lateral, so you actually know which way you're going. Which marker you're going after. Sometimes when you don't have a unique identifying, especially if the markers air close. Now these markers were fairly close, and that's why I want to point out we actually, when we did the case, you could really tell where which one was which, which was your anterior, which was your post here because you're getting a unique r f I D signal. So I I found, you know, I look at the poll and see what the different people, what different modalities people are using. But I have found that to be really useful, um, and Karen, I know you're going to talk about a case of breast conservation. I think we can segue right into that. And then we'll talk more about this is we go on about different localization techniques? Yeah, Yeah, I think that this is a great example. And I think this is also very poignant because this is one of my first cases that I did. I had brought the bios, are about to Alaska and, you know, championed it for my patients. And she had a probably b slash C cup, not a very large breast Tissue concedes she's got some toast is going on. And she had two biopsies done which were both returned as cancer. Basically, at the 12 o'clock and the one o'clock, so they weren't really weren't that close or far from each other. But they felt that, you know, you know that these were two separate lesions when I look at them and they had the sizing about 2.6 centimeters on the other, one being 1.7. I felt they were so close clock faces that they were actually one large unit e r p r. Positive Her two negative. She was bracket negative. Um and, you know, clinically no negative that she was very concerned about fertility and really was a young woman and wanted thio make sure that she could keep her breasts. So if we go to the next slide, what I recommended was neo a given to shrink the tumors due to the size and the upper inner quadrant was the location, so we really didn't have much to work with. When is a positive margin A good thing when you're first starting off with BIOS Urban, You place a spiral thinking that you're marking the two tumors that you thought were all one tumor in the upper in the quadrant. Well, luckily, we got a positive margin and I got to take her back and redo what I had done. I went back, I took a re excised margin. It was nice because it actually turned out to be negative. But I dropped too low profiles in the upper inner quadrant and I rotated a flap of tissue over that area. So when we did it, it gave me the opportunity to re evaluate what was going on on dachlan ycl e. She couldn't feel it anymore. And we marked the tumor bed appropriately because they were on pathology. Two distinct tumors and the re excision margin was indeed negative. As is usually the case, let's go to the next slide. And this was her post op picture where she was really now loving her cancer breast but not loving her native breast. And she complained that she didn't like her native breast. So she was also military and wanted to stay in the area and didn't want to get PS out to another location. So she used her need to stay with her uncle plastic surgeon in Alaska for symmetry. So she waited a year for the radiation changes, um, to settle, and then we went back and we did a vertical master Pepsi on the contra lateral side. So if we go to the next slide, I'll show you that, um, here it is. I basically did a vertical master peck. See, the middle picture is kind of what we call what I call the double bubble. Taking that empathy analyzed ring above the nipple and taking that the empathy legalized flap of tissue below the nipple basically is closing that pillowcase. The inferior poll is now being tightened up and pushing tissue into the upper quadrant, which, if you look at her first picture on this slide, you can see she's really flat here and on the other side, it looks like she's got an implant. In fact, when I asked my plastics friends what to do with her, they said, Just use the same size implant Anyway, Um, when we did her symmetry ization, we did the vertical master pixie pushing the tissue up, tightening up the skin envelope in the lower pole. And if we go to the next slide, we'll see that she had a pretty good symmetry with her nipples being at the same level. And this is pretty much, I think, about three weeks post op. So she's got a little bit of post op swelling, and you can still see her scar lines. Um, pretty prominently. And those will fade over time. She was incredibly happy with her scar and her cosmetic outcome, and it really marked the tumor, Bedwell. So we can go to the next slide, I think, and pass this off to our pal, Dr Yeah. Thank you. So Yeah. Well, thank you. That was a very nice example, eso really? I mean, you know, kind of just to make sure all the viewers are really understanding kind of. How much? Um, this device could be so good for us is that I mean, it really serves as a marker for the surgeon and the radiation on colleges so we can communicate with each other and really kind of nowhere. What were we need to target andan on top of that? Also kind of helping collapse the cavity so that we can have smaller volumes to treat. So here is an example on the left side, where we're using a two by two centimeter device on then the radiation oncologist treatment volume after doing all of our, um, margin, Um, enlargements is about 57 ccs versus a similar case that just has the clips placed the P TV volume, the treatment volume. It's much more difficult to discern. You can kind of see the one clip there, but you can kind of it's hard to know where the edges are. Onda volume is twice as large as 121 cc. S. I mean, obviously, this is not the same patient, but but you know that kind of just gives a sense of from a radiation oncology perspective. How this all ties in? Yeah, very nice. I think that really illustrates that fact. Um, so let's talk a little bit about Onda again. I think this is obviously a timely issue, but can you just come in a little bit on what's been, um, you know, about partial breast. And especially now, with all of us facing issues about can we access the O. R. Can we get patients in? Um, you know, how do we maximize resource use during radiation? Could you come in a little bit about that? Yeah. So I think that back in March, when the covert pandemic really hit and, you know, everything was just kind of shut down. Um, there were a lot of trends that we had seen, and I think as a field everybody had seen on dso you know, one was, you know, the conservation of PPE and to, you know, the resource is including the operating room and just the personnel and kind of reducing exposures. And so there were several manuscript that came out about breast radiation oncology at this time and kind of giving some guidelines as far as um, you know what we should be doing in this in this type of era? And also, I think they commented on surgical surgical issues as well. And so some of the things that were commented on were really kind of discouraging the use of breaky therapy at the time. If your particular hospital had a surge and didn't have enough PP and didn't have the personnel and, you know, you're trying to reduce exposure risks to really kind of take a second thought about doing breaking therapy and if you're going to do partial breast toe actually do kind of more of like the external being because it would help with those particular resource is and also there could be potential reduced infection rates s oh, that was the first thing. And then the second thing was really for this early stage. Um, breast cancer kind of like suitable criteria is really trying. Thio do partial breast for those patients. Um and also, you know, doing a lot of more new adjuvant endocrine therapy to postpone the actual surgical, the actual surgery, so that we could utilize those Oh, ours for other situations. But but trying to offer those patients partial breast radiation rather than doing whole breast radiation in the situation of co vid one to reduce exposure for patients coming into the radiation oncology. Sweet and waiting and waiting rooms. And so they would have less trips. And we would have less people coming in and out of the radiation oncology sweet on Ben to just kind of more of a convenience and then three. Reducing PPE if you're not doing breaking therapy and doing like external being partial breast radiation techniques and then kind of like we mentioned the new adjuvant endocrine therapy to try to help postpone, um, postpone the surgery if necessary. If your particular hospital require that, um, there's several different ways that partial breast radiation could be done with an external being technique. There's a 38.5 grade and 10 fraction B i. D technique that was, um, that was published up to 10 years in the rapid trial and then is a B P. 39. However, there was some issues with Kaz missus, um, in in those studies, so that is, if you are going to use that regiment and use FBI diffraction nation. It is definitely urged that you discuss cosmetic outcomes with the patients. Um, there have been several other regiments that have showed kind of better cosmetic outcomes. Um, including a 40 grand, 10 fraction or a 30 grand five Fraction Technique, a t University of Florence, And that was published in the phase three clinical trial using I M r T as their technique which actually showed very good cause, Mrs. So there are different options, and different practitioners are going to feel have a different comfort level with each of these different fraction nations. But the's air, These are things that we should really kind of think about in the cove it pandemic and kind of being able to offer these to our patients. So So can I ask, You guys have has bundling of payments that had any effect on your treatment, planning and Dr Moonshine or doctor He me, I think you know the alternative payment model or R o. A. P M is new. I mean, basically, this is rolled out recently, um, in certain areas being delayed. But, uh, I think most audience members will be familiar, but the general concept is that no providers, you know, our hospital systems will be paid set professional fee and a set technical fee regardless of what modality you know they choose to use. So essentially, you know, you know what this is likely born out of is that for years there have been some centers that have essentially, you know, potentially put up patients on treatment plans, which required, you know, essentially mawr fractions, arm or treatments in the ideas the point of this payment models to really incentivize healthcare systems and providers to choose the most appropriate, you know, regiment for their patients. Um, so I think, to answer the question it hasn't it's It's been out for such a short period of time that, you know it's It will take time to be able to survey providers to see how this has changed practice. But I think it will certainly push people in the right direction of thinking of you know how to stay within guidelines. Um, in treating patients with the most appropriate regiment you know, based on their ideology and tumor type e, I would just add that, you know, I think that the trend is going to be that we're seeing is to do these shorter fraction nation courses. Um, for many different sub sites in the body as faras radiation oncology. I mean, even in Europe, they recently published doing whole breast radiation and five treatments. Eso these air things that we're gonna, you know, that we're going to be seeing as kind of more trend. A lot of people are now doing Canadian Fraction Nation, so they're doing 15 or 16 treatment fractions on Ben even with the partial breast. I mean, we have a clinical trial where we're doing one fraction on that's been done quite commonly in in Europe and some of the other institutions that have intra operative radiation. But we can. We can now do that with Steri attacked IQ partial breast. So I think the trend is doing less is more. And if it's just it's effective, then why not offer that to our patients? It's more convenient for, you know, patients, and it has less strain on hospital systems and and now, with the covert pandemic that all of that is just ballooned, you know, it's just kind of it's just that's more convenient for everybody at this point, yes, so we have five minutes to the hour. I just wanna make sure if there's any attendees that had any questions or Macy. Do we have any questions that have been proposed? I would hope we could answer those before that way, Dio. So first of all, let me just say thank you to the four of you for leading us through a really fantastic conversation. I think you addressed a lot of the questions that were coming in from our audience. But there are a few that I saved to the end on the first actually would be opposed to the two surgeons. So when you're moving a lot of tissue on doing tissue transfers, how do you handle a positive margin? You wanna go first? Yeah, sure. I think the thing is, the sooner you could go back the better. Because what will happen is you could basically unravel the roles that you've placed. And what I try to do is just popped the suitors, like with a knife gently. Just open it up and then go down. Since it's fresh, you know, the suitors haven't really embedded. They haven't dissolved yet. You can find your way back on Ben since you placed it yourself. You know where to go. So I don't think it's a contra indication when you're moving tissue and it's helpful. Like I said, if you document things in Europe, note. Like I said, What size bios or you use What? How did you rotate this flap just so that you have a way to find your way back. But the sooner you go back is is a really big helpful tip. Yeah, I would say that. Yeah. And I I would say the best way to deal with it is to try to not have one. Um, but todo do that involves in a time, investment up front. And so what we do is we actually do specimen radiographs. We do whole specimen. Then we do slice specimen radiographs. The radiologist looks at each slice specimen and tells us that there's any density, any abnormality, anything there, any of the margins. We would take that during the case on. The pathologist, then is also looking grossly to make sure there's nothing. Now this all takes time, but I think that investment in time has resulted in us having an extremely low margin positivity rate so that I can. I don't want to jinx anything, but I don't remember. So it's been really fortunate. That doesn't happen often, so it's kind of an investment upfront to avoid it down on the back side. You know, some people would rather not do that. I understand that. But I actually think the best way is to try not to have one. And when you do, I agree with what, what Karen said. Go back. And if the Bible service completely covered in away from the area, oftentimes you can leave it in place. Um, if it's if that's the whole point of putting the tissue over it and putting it deeper, not right under the skin. Yeah, I think it's important to understand that every facility or hospital has different abilities. I use inter operative imaging as well on Did you know having the surgical oncology techniques such as angioplasty really does limit because it makes you able to take more tissues, So a positive margin just by having on the plastic in your back pocket really allows you to take more tissue and recreate the cavity so that you do get less margins. But you know for those of you, if you do have a positive margin, don't be afraid. It's not a contra indication. And you know the tip is really go back sooner rather than later. But like Dr Luci, when you do intra operative imaging, your re excision rates really dropped dramatically. It's hugely helpful. Yeah, and actually bring up a good point. The whole reason I started using riser because I needed something to fill in the space because I wanted to be able to do larger lumpectomies. And even if you're going to do in adjacent tissue transfer some, you know, really simple technique, adding that in made it so much easier to replace the volume. So I'm glad is providing benefits to the Radiation oncologist as well. But are selfish reason was because we could make the breast look better. That's the honest thing, because this was my eye opening that you guys actually liked it. Like I said, when my rat on who was really old school and actually paper charting, um, said I wanted this years ago, it was an eye opener, and then when we had the discussion about putting this panel together, I was like, You guys actually really like it. Isn't that important to you? Um, I was doing it because I was being selfish. I wanted great outcomes for my patients. I wanted to look like a study is a surgeon. What surgeon doesn't want that? And I think patients really do benefit by having a lesser surgery going to mastectomy. Just because you can't make the breast look like a breast is really more of a disservice to patients. Complications with contracture could be an issue. Loss of sensation, you know, doesn't always last. You know, implants sometimes need to get replaced after years. So I think the more we pro game with, you know, trying to keep a woman's breast is the best plan. Wonderful. Well, listen, we're coming up to the very top of the hour. For those of you that did put a question into our question box. Thank you so much if we didn't get an opportunity to answer it. Trust me. We will answer it via email after the completion of the program. Um, I just want to say thank you to everyone for participating. A huge thank you for our four Panelists. It has been a pleasure listening to all of you talk. I will say for our audience members, if you would like additional medical education offerings, please do visit Hologic at dot com. And it is again just been our pleasure. Thank you so much. Enjoy the rest of your evening. Thank you, everyone. Thank you. Hi. Yeah.