IORT with Oncoplastic Surgery: A Beautiful Combination?

Julie Reiland SOS 2016 (1)

Julie Reiland, MD, FACS

Breast cancer care continues to see remarkable growth in knowledge of the disease and advances in treatment. That was certainly evident at the recent School of Oncoplastic Surgery (SOS), in Dallas last month.

The school, which was founded by breast surgeon Gail Lebovic, M.D. with a grant from the Mary Kay Ash Foundation, recently had its eighth annual session in Dallas. This year’s session was sponsored by the National Consortium of Breast Centers and the American Society of Breast Disease Clinical Track.

Among the highlights of that three-day training workshop was a talk by Julie Reiland, MD, FACS. An SOS faculty member, Dr. Reiland is a breast surgeon at Avera Medical Group Comprehensive Breast Care, in Sioux Falls, SD. Speaking to a packed room at SOS, Dr. Reiland talked about the convergence of oncoplastic surgery and intraoperative radiation therapy (IORT).

In particular she talked about combining oncoplasty with the IntraOp® Mobetron®. This innovative technology is the first mobile, self-shielded electron linear accelerator (LINAC) that delivers IORT to cancer patients during surgery. It’s designed to provide safe and portable radiation to an OR without the need for costly shielding renovations or retrofits.

IORT has been used to treat various cancers for some decades, including colorectal, esophageal, head and neck, gynecological, bladder, pancreatic, renal, and pediatric cancers. Its application in breast cancer was of particular interest to the approximately 60 surgeons attending the school.

Dr. Reiland said she was especially interested in how intraoperative therapy with electrons can be combined with oncoplastic surgery to treat breast cancer.

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Click to watch Dr. Reiland summarize her talk

In the cases of patients who have a small tumor and require just a single surgery, she said IORT facilitates a “one and done” approach.  These lower-risk patients can have a lumpectomy with oncoplastic surgery to improve cosmetic outcomes and, during the surgery, have a single dose of radiation delivered to the tumor bed and the immediately surrounding tissue. In these cases, their treatment for local control of cancer is essentially complete.

With higher-risk or younger patients, she said, IORT can be done during surgery as a boost, followed by several weeks of whole breast irradiation.

Oncoplastic surgery, which Dr. Reiland has been doing for nearly a decade, can address one of the potential shortcomings of standard lumpectomy surgery. A lumpectomy removes the tumor and immediately surrounding tissue while preserving the breast (as opposed to breast removal with mastectomy). Traditional breast-conserving lumpectomies provide excellent cancer control when combined with radiation. But they may also result in less-than-perfect cosmetic outcomes.

To remedy this shortcoming, oncoplastic surgery combines reconstructive and plastic surgery to achieve a more desirable cosmetic outcome, without compromising disease control. Oncoplastic surgeons emphasize techniques to minimize scarring and achieve better breast symmetry after surgery.

“With oncoplasty, we can give them a reduction or a lift to make that breast beautiful right from the start,” Dr. Reiland said. “Then when we do IORT, we have fewer problems with any deformity because we’ve fixed the spaces that have been left from a lumpectomy.”

Research findings validate this approach, including study findings presented last year showing the value of combining Mobetron IORT with oncoplastic techniques (details here). A variety of additional research also supports IORT.

In recent years the heavily publicized decisions by Angelina Jolie and other celebrities to have mastectomies have increased patients’ interest in mastectomy. Rates for the surgery have increased 34% in the US between 1998 and 2011. However, the pendulum may be swinging back, due in part to new research presented last year at the San Antonio Breast Cancer Symposium.

Those two studies at SABCS concluded that lumpectomy-plus-radiation on average has better overall outcomes for early-stage breast-cancer, when compared to mastectomy plus reconstruction. The findings also indicated that lumpectomy-plus radiation has fewer complications and is less expensive.

With new research like that finding its way into the mainstream, we expect that more patients may choose to have a lumpectomy when indicated.  For patients who choose lumpectomy and the physicians who treat them, the combination of IORT and oncoplastic surgery is an approach worth consideration.

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