Oncoplastics & Partial Breast Radiation: Enabled by Marking

Valerie J. Gorman, M.D., F.A.C.S.

Breast Surgeon Oncologist

Chief of Surgery & Medical Director of Surgical Services

Baylor Scott & White Medical Center, Waxahachie TX

Clinical Assistant Professor of Medical Education, Texas A&M College of Medicine

Complex breast cancer surgery has evolved and so have the challenges for radiation oncologists.   As surgical techniques, such as tissue rearrangement (oncoplastics), have refined, a higher burden has been placed on radiation oncologists to accurately define and develop an effective treatment plan. Further, the significant clinical adoption of partial breast radiation has increased this complexity. Here, higher radiation doses with less fractions demands greater precision. It is therefore essential to accurately delineate the tumor bed cavity, especially in situations involving oncoplastic techniques with a combination of Partial Breast/APBI radiation that follows.

As a breast surgeon, once I have removed the tumor with the lumpectomy, it is important for me to accurately identify and mark the lumpectomy cavity for the radiation oncologist. Appropriate identification of the cavity is critical for optimal outcomes. Since lumpectomy cavities are not symmetric and are frequently rearranged, clearly defining the volumetric dimensions of the cavity allows for precise targeting of the tumor bed while minimizing radiation to surrounding healthy tissues.  Dependence on titanium clips or postoperative seroma location is often inaccurate due to clip migration or inconsistency with tissue rearrangement at the time of surgery. I have found the VeraForm marker to be an innovative and practical solution for this challenge.

VeraForm is a radiopaque filament marker designed to provide volumetric/3D delineation of the lumpectomy cavity after breast surgery. Unlike surgical clips, which really do not define the true volume of the tumor bed, VeraForm is placed around the perimeter on the cavity at the margins. It is flexible and easily sutured into the cavity walls once the tumor is removed with appropriate margins. It easily contours to the surrounding tissue and does not interfere with cosmesis or closure. VeraForm easily moves with the tumor bed planes as the cavity is rearranged, therefore always marking each plane surface.

Oncoplastic techniques in my practice allow for excellent oncologic treatment of the tumor with improved cosmetic outcomes for my patients. Oncoplastic breast surgery often leads to cavity displacement and tissue rearrangements. These tissue flaps can often add complexity to identifying the exact location of the initial tumor. As flaps are mobilized for volume replacement, clips often fail to represent the true tumor bed. Integrating VeraForm for marking the lumpectomy cavity immediately after tumor removal occurs allows for preserving the critical information needed for precise radiation targeting despite extensive tissue rearrangement.

On postoperative planning CT, radiation oncologists are able to easily identify the cavity for targeting of APBI and even allows for improved targeting if whole breast radiation is indicated. By enabling the option of APBI or allowing for more defined radiation volumes, increased post-radiation complications can be minimized, which may lead to reduced fibrosis and improved cosmetic outcomes. It’s also important to mention that in situations where I need to go back for a re-excision, VeraForm provides a visual roadmap I follow to aid in the location of each plane.

The VeraForm marker allows for consistent and reliable delineation of the lumpectomy cavity for radiation planning that can include accelerated partial breast irradiation or more accurate whole breast radiation. For these reasons, I have adopted VeraForm as a simple solution that helps my breast cancer patients remain eligible for these state-of-the-art treatments.