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Accelerated partial breast irradiation (APBI) and hypofractionated partial breast irradiation (PBI) have emerged as alternative treatments to whole breast irradiation (WBI) for many patients with early breast cancer (BC) based on randomized clinical trials involving > 10,000 patients. As trial data matured, many societies, including the American Society for Radiation Oncology, issued consensus statements regarding suitability of patients for APBI or PBI (A/PBI). However, there are few data regarding utilization of A/PBI in patients with early BC. We examine the National Cancer Database (NCDB) to evaluate the hypothesis that A/PBI use has increased over time but is still used in a minority of patients. Within the NCDB, we identified patients who underwent margin-negative breast conserving surgery and adjuvant radiation therapy in the years 2010-2021 with the following favorable criteria: hormone-receptor positive/human epidermal growth factor receptor 2 negative (HR+/HER2-); age ≥50 yr; pathologic T1N0; grade 1-2; non-lobular histology; no neoadjuvant systemic therapy use. Patients with missing dosimetry data, those coded as receiving total dose > 66Gy and/or > 36 fractions (Fx), and/or dose groups in which fewer than 250 patients were treated were excluded from analysis. We further classified by type of APBI/PBI technique: external beam (EB-APBI), brachytherapy (Brachy), intraoperative radiation therapy (IORT), or hypofractionated external beam PBI (EB-PBI). We used the following definitions:18Gy/1Fx or 34Gy/10Fx (Brachy); 20Gy in 1Fx or 21Gy/1Fx (IORT); 30Gy/5Fx or 38.5Gy/10Fx (EB-APBI) From 2018-2021, patients that received 40-40.5Gy/15Fx and coded as having received PBI were classified as EB-PBI. All others WBI. Chi-Square test is used to evaluate trends in A/PBI use. Of an initial 3,956,621 patients in the NCDB, 317,437 patients met the eligibility criteria and 242,817 had complete radiation dosimetry data. In this cohort, 25,973(10.7%) received A/PBI, while 216,844(89.3%) underwent WBI. Among patients that underwent A/PBI, 36.7% received EB-APBI, 32% brachy, 20.5% IORT, and 10.7% EB-PBI. The use for A/PBI increased from 8.0% (2010-2017) to 13.7% (2018-2021) (p<0.001). The use of 30Gy/5Fx EB-APBI also increased significantly from 512(1.7%) in 2019 to 2,672(8.8%) in 2021 (p<0.001). In the final year, among the 30,346 patients analyzed, 5444(17.9%) received any form of A/PBI and 3,213(10.6%) were treated with either 30Gy/5Fx EB-APBI or brachy. Over the past decade there has been a significant rise in A/PBI use in patients with low-risk HR+/HER2- BC. Despite the increasing trend, even in the most recent year, less than one in five potentially eligible patients receive A/PBI. Further, among patients treated in 2021, only one in ten patients receive 30Gy/5Fx EB-APBI or brachytherapy, two forms of APBI which possess the combination of similar cancer control outcomes, greater convenience and less toxicity compared to WBI. [ABSTRACT FROM AUTHOR]

Background: In previous studies, breast cancer patients with positive sentinel lymph node(s) (SLN) after neoadjuvant chemotherapy (NAC) frequently had additional nonSLN involvement. Per guidelines, residual SLN disease warrants completion axillary lymph node dissection (cALND), which has increased morbidity. Given recent improvements in NAC, we hypothesized that nonSLN positivity may be lower than previously reported for certain subgroups. Methods: We retrospectively reviewed breast cancer patients who received NAC and had positive lymph nodes on SLN biopsy or targeted axillary dissection and underwent cALND at one institution in 1/2018-8/2023. Associations between nonSLN positivity and clinicopathologic factors were assessed with Fisher's exact test and multivariable logistic regression. Results: There were 122 female patients. Median age was 48 years. Initially, 15 patients (12.3%) were cN0 and 107 patients (87.7%) were cN1. Largest SLN deposit was macrometastasis in 96 patients (78.7%), micrometastasis in 23 patients (18.9%), and isolated tumor cells in 3 patients (2.5%). Overall, 53 patients (43.4%) had nonSLN involvement. NonSLN positivity was higher in patients with cN1, ER+ HER2-, ypT2-3, SLN macrometastasis, and multiple positive SLN. On multivariable analysis, cN1 and ER+ HER2- remained associated with nonSLN positivity. Discussion: Among patients with positive SLN after NAC, clinically node positive and ER+ HER2- patients were more likely to have nonSLN involvement. Our findings support guidelines to consider omitting cALND in clinically node negative patients. With improving NAC, optimal axillary sampling, and radiation, omitting cALND may be safe in some clinically node positive triple negative or HER2+ patients with low volume residual disease, but further research is needed., Competing Interests: Declaration of Conflicting InterestsThe author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Gross intraoperative assessment can be used to ensure negative margins at the time of surgery. Previous studies of this technique were conducted before the introduction of consensus guidelines defining a "positive" margin. We performed a retrospective study examining the accuracy of this technique since these guidelines were published. We identified all specimens that were grossly examined at the time of breast conserving surgery from January 2014 to July 2020. Gross and final microscopic diagnoses were compared and the performance of intraoperative examination was assessed in terms of false positive and false negative rates. Logistic regression models were used to examine the effect of clinicopathologic covariates on discordance. 327 cases were reviewed. Gross exam prompted re-excision in 166 cases (61%). The rate of false negative discordance was 8.6%. In multivariate analysis, multifocality on final pathology was associated with discordance. We consider the false negative rate acceptable for routine clinical use; however, there is an ongoing need for more accurate methods for the intraoperative assessment of margins.

Introduction: The California Prehospital Antifibrinolytic Therapy (Cal-PAT) study seeks to assess the safety and impact on patient mortality of tranexamic acid (TXA) administration in cases of trauma-induced hemorrhagic shock. The current study further aimed to assess the feasibility of prehospital TXA administration by paramedics within the framework of North American emergency medicine standards and protocols., Methods: This is an ongoing multi-centered, prospective, observational cohort study with a retrospective chart-review comparison. Trauma patients identified in the prehospital setting with signs of hemorrhagic shock by first responders were administered one gram of TXA followed by an optional second one-gram dose upon arrival to the hospital, if the patient still met inclusion criteria. Patients administered TXA make up the prehospital intervention group. Control group patients met the same inclusion criteria as TXA candidates and were matched with the prehospital intervention patients based on mechanism of injury, injury severity score, and age. The primary outcomes were mortality, measured at 24 hours, 48 hours, and 28 days. Secondary outcomes measured included the total blood products transfused and any known adverse events associated with TXA administration., Results: We included 128 patients in the prehospital intervention group and 125 in the control group. Although not statistically significant, the prehospital intervention group trended toward a lower 24-hour mortality rate (3.9% vs 7.2% for intervention and control, respectively, p=0.25), 48-hour mortality rate (6.3% vs 7.2% for intervention and control, respectively, p=0.76), and 28-day mortality rate (6.3% vs 10.4% for intervention and control, respectively, p=0.23). There was no significant difference observed in known adverse events associated with TXA administration in the prehospital intervention group and control group. A reduction in total blood product usage was observed following the administration of TXA (control: 6.95 units; intervention: 4.09 units; p=0.01)., Conclusion: Preliminary evidence from the Cal-PAT study suggests that TXA administration may be safe in the prehospital setting with no significant change in adverse events observed and an associated decreased use of blood products in cases of trauma-induced hemorrhagic shock. Given the current sample size, a statistically significant decrease in mortality was not observed. Additionally, this study demonstrates that it may be feasible for paramedics to identify and safely administer TXA in the prehospital setting., Competing Interests: Conflicts of Interest: By the WestJEM article submission agreement, all authors are required to disclose all affiliations, funding sources and financial or management relationships that could be perceived as potential sources of bias. No author has professional or financial relationships with any companies that are relevant to this study. There are no conflicts of interest or sources of funding to declare.