The role of surgical clips in Breast Conserving Therapy: Systematic review of the Literature

Introduction Conservative breast therapy consists of wide local excision followed by local control of the breast cancer by boost radiotherapy. For radiologists, identification of breast tumor bed (TB) is an essential first step for them to start their radiotherapy. There is number of ways to identify the tumor bed, one of them is inserting the metallic clips in the tumor bed cavity intraoperative. They mark the tumor cavity against the whole breast normal tissue as they appear radioopaque during radiotherapy. Purpose The primary aim of this study is to investigate the need & validity of surgical clips insertion in breast tumor bed and its effect on further breast radiotherapy through a systematic review that includes all published studies which used clips for marking the breast tumor bed. The secondary aim is to define the needed number of surgical clips to define the breast tumor bed clearly and obviously and what are the best types of surgical clips to be used for this purpose. Methods The literature review was done by searching on different databases using the keywords for only English studies reporting using surgical clips for localization in breast surgeries. There was no restriction to specific period or study design. Assessment of included studies was done by 2 independent researchers. Results 54 articles (n = 3427 patients) were the total number of studies that met our inclusion criteria. These studies were of different study designs. Cohort studies were the most representing type about 40 articles. The most common used clips type (21 study, n = 1444 patient) was metallic hemostatic clips according to the sum of operated patients and count of studies. Although all studies confirmed the importance and effectiveness of using clips for tumor bed localization, there was no standard optimum number of clips that can be used for localization. However, most studies used definite number of clips as 4 or 5 clips or used number ranging from 1-5 clips. The same for inserted clips margins at tumor bed, only few studies mentioned definite cavity margins. The 4 main margins (anterior, posterior, superior, inferior) were the commonest reported sites. Conclusion Using surgical clips whatever their type is very helpful for radiologists to define breast tumor bed especially with the obvious increase in using oncoplastic techniques. It’s recommended to use more than 5 clips at tumor bed cavity with special concern to insert them at least 4 margins of tumor bed.

Hypofractionated Simultaneous Integrated Boost Radiotherapy Versus Conventional Fractionation Radiotherapy of Early Breast Cancer After Breast-Conserving Surgery: Clinical Observation and Analysis

Purpose: The objective of this retrospective study is to evaluate the efficacy and safety of hypofractionated simultaneous integrated boost radiotherapy for early breast cancer patients undergoing breast-conserving surgery. Methods: A total of 185 women with early breast cancer undergoing breast-conserving surgery were retrospectively divided into hypofractionated simultaneous integrated boost group and conventional fractionation group. Hypofractionated simultaneous integrated boost included 104 patients and the dose of whole-breast radiation reached 42.56 Gy in 16 fractions and simultaneously tumor bed boost to 48 Gy in 16 fractions, which course of radiotherapy was 22 days. The 81 patients of the conventional fractionation group received whole breast radiation to 50 Gy in 25 fractions and followed by tumor bed boost to 10 Gy in 5 fractions, which course of radiotherapy was 40 days. Clinical information including patients’ characteristics, skin toxicity, myelosuppression, radiation pneumonia, and cosmetic effects was recorded to analyze the influence of age, chemotherapy, position, and breast volume on the results of radiotherapy. Results: Hypofractionated simultaneous integrated boost group had no case of recurrence after a median follow-up of 25.6 months (9-47 months)) as compared with 2 after a median follow-up of 33.4 months (25-45 months) in the conventional fractionation group. The 2 groups had similar results in skin toxicity, cosmetic outcomes, and radiation pneumonia. In terms of myelosuppression, grade 1, grade 2, and grade 3 of myelosuppression in the hypofractionated simultaneous integrated boost group accounted for 16.7%, 12.3%, and 3.5% as compared with 30.0%, 21.1%, and 12.3% of the conventional fractionation group, respectively ( P = .000). Conclusions: HF-SIB RT is a considerable option in patients after breast-conserving surgery with a lower degree of myelosuppression and shorter treatment time.