Introduction: The appearance after breast surgery has become an important aspect of survivorship. The post lumpectomy/post radiation hollow surgical defect negatively impacts cosmesis and patient satisfaction. Oncoplastic procedures will mobilize surrounding tissues into the lumpectomy cavity but adds no volume to the breast. Use of a bioabsorbable 3-dimensional tissue implant (used for targeting radiation) has the additional benefit of adding volume to the breast and enhances the overall cosmetic appearance. Our experience over 3 years provides serial mammograms from which we may objectively categorize cosmetic contour. We report on our 2 and 3 year serial images of our treated patients compared with baseline. Methods: Between May 2014 and June 2018, during lumpectomy for breast cancer we implanted a 3-D tissue implant marker in 170 patients, often combined with oncoplastic reconstruction and followed by radiation treatment. For long term follow-up we had 37 patients with serial mammograms at 2 or 3 years to assess cosmesis. All patients had interviews, physical exams, and serial mammograms to evaluate their cosmetic appearance. Both physician and patient graded their appearance. We also objectively measured and compared the pre-treatment mammogram and the 2-year and 3-year, post-treatment mammogram for symmetry and size using each breast as its own control. Using the post-treatment mammograms, we compared the relative anterior-posterior (depth) measurement of the quadrant bearing the implant as well as the non-cancer quadrant to the similar locations of the pre-treatment mammogram. Both mammogram positioning and radiation effects would balance. We compared the relative change from baseline in the non-cancer portion of the breast to the change from baseline in the cancer portion of the breast as a percent difference from baseline. Results: Patients were treated with lumpectomy, oncoplastic reconstruction, and placement of a 3-D tissue implant. Three implants were removed due to positive margins. No implants were removed for any other reason. There have been no local recurrences. Overall, radiation oncologists felt the 3-D implant was useful for treatment planning in 85% of patients. Of the 37 consecutive patients who have completed an average of 27.8 months of follow-up, cosmesis was rated as excellent/good by clinicians (96%) and patients (94%). Mammograms taken at 2-3 years were compared with initial images. Whole-breast radiation effect varied among patients. Some had significant shrinkage while others had none. These changes were equal in the non-cancer post-radiation quadrants (86.2% vs 87%) demonstrating maintenance of normal breast contour. Our use of the 3-D implant and oncoplastic tissue advancement maintained the pre-operative contour of the breast after lumpectomy with radiation. Conclusions: Breast cancer surgery and radiation is often complicated by poor cosmesis with retraction and volume loss. Using a combination of oncoplastic surgery combined with a 3-D tissue implant, we found the forward projection and contour of the breast at the lumpectomy site was preserved and patient satisfaction was good to excellent. Further investigation of the long-term cosmetic effects of breast cancer surgery should be encouraged. Citation Format: Kaufman CS, Hall W, Behrndt VS, Wolgamot GM, Zacharias K, Rogers A, Smith A, Hill LM, Schnell N. Enhance post-lumpectomy breast contour using oncoplastic surgery (OPS) plus a bioabsorbable 3-D tissue implant [abstract]. In: Proceedings of the 2018 San Antonio Breast Cancer Symposium; 2018 Dec 4-8; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2019;79(4 Suppl):Abstract nr P5-16-02.

Introduction: Breast MRI in the workup of a new breast cancer diagnosis is both a valuable and costly imaging study. The decision to obtain a breast MRI is often made by the surgeon who is referred the newly diagnosed breast cancer patient. That is followed by a delay in their management due to scheduling the MRI. Our breast center program leadership developed a protocol to move the time of MRI prior to the surgeon's evaluation while avoiding unnecessary breast MRIs ordered by some well-intentioned primary care providers. Coordinating a breast MRI protocol can optimize timely performance of breast MRI, guiding primary care to become the ordering clinician while avoiding unnecessary breast MRIs. Methods: Recognizing a delay in the journey of newly diagnosed breast cancer patients that have their breast MRI ordered only after the multidisciplinary conference or surgical consultation, we developed a protocol to improve timeliness of care. Guidelines were identified by our breast program leadership when a newly diagnosed breast cancer patient would warrant a breast MRI. Agreed upon indicators included dense breast tissue, invasive lobular breast cancer, patients typically under 50 years old, and vague imaging of primary lesions. When these findings were identified, the radiologist included a statement with the core needle biopsy report. It stated that our breast program leadership identified this patient as benefiting from a breast MRI ordered soon after the positive biopsy. This avoided the issue of self-referral since our breast leadership created the guidelines. The message went to the primary care provider who now ordered the breast MRI prior to conference or surgical consultation. We examined sixty consecutive patients from two time periods, half before and half after institution of the MRI protocol. Results: Prior to this policy, patients who needed breast MRI would obtain the study on average 12 days after our multidisciplinary breast conference (MDC), while after institution of the policy breast MRI was obtained 3 days PRIOR to conference. Before only 43% of necessary breast MRIs were ordered prior to surgical consultation while after the protocol 100% of breast MRIs were ordered PRIOR to surgical consultation. Before the protocol rarely did primary care order breast MRIs. After the protocol primary care providers ordered 80% of all breast MRIs. While ordering more breast MRIs, primary care ordered less unnecessary studies. After the protocol was instituted, inappropriate studies as determined by the MDC decreased from 21% deemed unnecessary to only 10%. Conclusions: Institution of a breast MRI ordering guideline by the breast program leadership with participation of primary care had the benefits of obtaining the breast MRI before the multidisciplinary conference and/or surgical consultation while avoiding unnecessary breast MRI orders. Institution of a breast MRI protocol enhances patient care, eliminates delays in treatment, avoids unnecessary tests, shifts appropriate care to primary care providers and allows initial surgical consultation to have all the data necessary to make definitive decisions. This quality improvement effort via program leadership improved comprehensive care. Citation Format: Kaufman CS, Behrndt VS, Hall W, Moses K, Wolgamot GM, Crabo L, Backer L, Carpenter K, Smits S. Improving efficiency of breast MRI utilization by coordinating primary care, breast imaging and surgeons [abstract]. In: Proceedings of the 2018 San Antonio Breast Cancer Symposium; 2018 Dec 4-8; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2019;79(4 Suppl):Abstract nr P5-02-02.

Background: Breast conservation surgery (BCS) may preserve the breast but many women have less than optimal cosmetic outcomes. Increasingly, this has been addressed by the use of oncoplastic reconstruction.Now, targeting radiation treatment for boost or partial breast irradiation (PBI) using the seroma has become more difficult due to the adjacent tissue rearrangement and resultant “benign” seromas. Since the radiation dose generated increases by the third power of the radius (r3), there is a need to accurately focus radiation therapy to avoid chronic radiation side effects.We have used a 3-dimensional bioabsorbable tissue marker to accurately target the tumor bed while excluding inadvertent seromas caused by oncoplastic procedures. We report on tissue marker implantation on 61 consecutive breast conservation patients in regards to targeting, impact on cosmesis, imaging followup, ease of re-excision, as well as side effects and patient satisfaction. METHODS: Consecutive lumpectomy patients who were candidates for targeted radiation therapy were considered for implantation with the 3-D bioabsorbable marker from May 2014 to June 2016. The tissue marker has a fixed array of 6 titanium clips and was sutured to the site of the excised breast cancer during lumpectomy.The framework of the implant resorbs slowly over time, while the clips remain permanently. All patients had oncoplastic reconstruction with total implant coverage. The marker was utilized for boost or partial breast irradiation (PBI) planning or treatment targeting. Data includes patient demographics, breast size, tumor characteristics, surgical and radiotherapy techniques, follow-up imaging, cosmesis and patient satisfaction. Results:Data on 61 patients with median follow-up 12.7 months was analyzed (range 1.5–25.5). Median age was 62.4 years (range 33-74), 5 of women were postmenopausal and 15% had comorbidities. Cancer histology was in-situ (13%), invasive ductal (84%), invasive lobular (3%) of sizes T0 (13%), T1 (59%), T2 (25%), T3-4 (3%). Laterality and tumor location within the breast were typical. Re-excisions occurred in 11% of patients. No infections occurred in the postoperative period. One infection occurred with chemotherapy and another with repeated aspirations of oncoplastic area.No device was removed for infection, misplacement or patient-generated concerns. No cancer recurrences have been reported. Size of device used reflected size of the tumor; 2X2cm (44%), 2X3cm (34%) and 3X3cm (20%). The device was utilized by radiation oncologists for boost or PBI planning and treatment. Data on ease of setup and boost planning is being collected. Mammography at one year demonstrated marker clips coalescing as the bioabsorbable device dissolves. Evaluation of cosmetic appearance has shown good to excellent cosmesis as judged separately by both physicians and patients (92% and 94%). Conclusions: Initial experience with 61 patients implanted with a novel 3-D absorbable device prospectively followed for an average of 12 months can be used in an array of breast cancer patients without device specific morbidity. Good to excellent cosmesis may be related to the addition of volume to the lumpectomy bed not seen with rearrangement of existing tissues. Citation Format: Kaufman CS, Hall W, Behrndt V, Wolgamot G, Hill L, Zacharias K, Rogers A, Nix S, Schnell N. Use of a 3-D bioabsorbable tissue marker in 61 patients over two years [abstract]. In: Proceedings of the 2016 San Antonio Breast Cancer Symposium; 2016 Dec 6-10; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2017;77(4 Suppl):Abstract nr P3-13-20.

Objective: Increased use of oncoplastic procedures makes it difficult to distinguish the lumpectomy margins from seroma fluid. Many side effects of radiation therapy are due to overestimated treatment volumes due to seroma based planning. A novel 3-dimensional (3D) absorbable device sutured to the lumpectomy tumor bed allows greater precision in targeting of the margins while avoiding normal tissues. A multi-center clinical registry was established to assess use of this device over time. This initial report of the first 300 patients provides insight into patient selection, tumor characteristics, method of implantation and initial outcomes.Methods: A bioabsorbable 3D implantable marker with a fixed array of 6 titanium clips was sutured to the site of the excised breast cancer during lumpectomy with or without oncoplastic closure techniques. The framework of the implant resorbs slowly over time, while the clips remain permanently. The marker was utilized for boost or partial breast irradiation (PBI) planning or treatment targeting. To date the registry has accrued 300 patients from 12 centers. Data includes patient demographics, breast size, tumor characteristics, surgical and radiotherapy techniques, cosmesis and follow-up.Results: Data on 300 patients with median followup 10.4 months was analyzed. Median age was 64.4 years, 83% of women were postmenopausal and 10% had comorbidities. Breast size was evenly distributed between cup size B, C and >D. Cancer histology was in-situ (20%), invasive ductal (62%), invasive lobular (9%) and others (10%) measuring T1 (80%) and T2 (20%). Laterality and tumor location within the breast were typical. Most patients had oncoplastic rearrangement (74%) at the time of lumpectomy. Re-excision (including mastectomy for extensive disease) occurred in 14% of patients. Infections occurred in 2% of patients and in one patient the device was removed during surgical debridement of the postoperative infection. No devices have been removed during follow-up due to misplacement or patient-generated concerns. No cancer recurrences have been reported. In most cases, size of the device reflected size of the tumor with the 2X2cm (47%) and 2X3cm (32%) devices used most often. The device was utilized by radiation oncologists for boost or PBI planning and treatment. Data on ease of setup and boost planning is being collected. Early reports regarding cosmetic appearance show a trend for excellent or good cosmesis as judged separately by both physicians and patients (93% and 92%). Conclusions:A novel 3-dimensional absorbable device sutured into the tumor bed provides clarity in radiation targeting of tissues at greatest risk while sparing adjacent normal tissues mobilized during surgery. This initial report of a multi-center clinical registry on over 300 patients characterizes patient selection, treatment methods and followup. Ongoing collection of additional data, regarding radiation regimen, cosmesis and patient satisfaction, have been accumulated and provide insight regarding clinical attributes of ...

INTRODUCTION: Breast conservation rates have been utilized as a quality metric, yet mastectomy rates have been noted to be increasing nationwide. The purpose of this study was to evaluate the factors associated with breast conservation in 437 US breast centers surveyed by the National Accreditation Program of Breast Centers (NAPBC).