First analysis of patient demographics, technical reproducibility, cosmesis, and early toxicity

Partial breast irradiation: a review of techniques and indications

The addition of whole-breast external beam radiotherapy (EBRT) to breast-conserving surgery results in a significant reduction in the risk of death due to breast cancer, but this may be offset by an increase in deaths from other causes and toxicity to surrounding organs. Because of this, and with a view to patterns of local recurrence, irradiation of the tumour bed has been explored in selected patients with early breast cancer using a variety of radiotherapeutic modalities. This review article explores the treatment options for partial breast irradiation and examines their role within the field of breast cancer treatment.

Dosimetric Improvements in Balloon Based Brachytherapy Using the Contura® Multi-Lumen Balloon (MLB) Catheter to Deliver Accelerated Partial Breast Irradiation

Purpose

Preliminary dosimetric findings in patients managed with the Contura^® Multi-Lumen Balloon (MLB) breast brachytherapy catheter to deliver accelerated partial breast irradiation (APBI) on a multi-institutional phase IV registry trial were reviewed.

Material and methods

CT-based 3D planning with dose optimization was performed for all patients. For the study, new ideal dosimetric goals were developed: 1) ≥ 95% of the prescribed dose (PD) covering ≥ 90% of the target volume (TV), 2) a maximum skin dose ≤ 125% of the PD, 3) maximum rib dose ≤ 145% of the PD, and 4) the V150 ≤ 50 cc and V200 ≤ 10 cc. The frequency of concurrently achieving these dosimetric goals using the Contura^® MLB was investigated.

Results

194 cases were evaluable. Employing the MLB, all ideal dosimetric criteria were achieved in 76% of cases. Evaluating dosimetric criteria separately, 90% and 89% of cases met the new ideal skin and rib dose criteria, respectively. In 96%, ideal TV coverage goals were achieved and in 96%, dose homogeneity criteria (V150 and V200) were met. For skin spacing ≥ 5-7 mm, the median skin dose was 121% of the PD and when < 5 mm, the median skin dose was 124.4%. For rib distancees < 5 mm, the median rib dose was reduced to 136.4% of the PD. For skin spacing < 7 mm and distance to rib < 5 mm, the median skin and rib doses were concurrently limited to 121% and 142.8% of the PD, respectively.

Conclusions

The Contura^® MLB catheter provides potential improvements in dosimetric capabilities (i.e., reduced skin and rib doses and improved TV coverage) in many clinical scenarios.

Initial surgical experience evaluating early tolerance and toxicities in patients undergoing accelerated partial breast irradiation using the Contura Multi Lumen Balloon breast brachytherapy catheter

We reviewed our surgical experience with the Contura Multi Lumen Balloon breast brachytherapy catheter used to deliver accelerated partial breast irradiation and determined short-term treatment efficacy, cosmesis, and toxicity. Forty-six patients undergoing breast conserving therapy, including the use of Contura catheter, were analyzed. Thirty-four Gray were delivered in 10 fractions. Fourteen patients had stage 0, 24 had stage I, and 8 had stage II breast cancer. Catheters were placed with a closed cavity technique. Median minimum skin spacing was 10 mm (range, 2-18 mm). Median maximum skin doses were 99.7 per cent of the prescription dose. Nine patients were treated with a skin spacing < or = 5 mm (2 patients with 2 mm skin spacing). The percentage of patients with excellent/good cosmesis at 6 (n = 26) and 12 (n = 13) months was 100 per cent, respectively. Patient tolerance was assessed on a scale of 0-10 (0 = no pain, 10 = requiring narcotic analgesics). Pain was graded < or = 3 in 98 per cent of patients at catheter insertion and 84 per cent at catheter removal. Four breast infections (8.8%) and one symptomatic seroma developed. Adjuvant accelerated partial breast irradiation using the Contura Multi Lumen Balloon exhibited similar toxicities to standard single lumen, single dwell balloon brachytherapy with improvements in dosimetric capabilities allowing the treatment of patients with skin spacing < or = 5 mm.

Long-term cosmesis after lumpectomy and brachytherapy in the management of carcinoma of the previously irradiated breast

OBJECTIVE

To evaluate the cosmetic outcome of brachytherapy after lumpectomy in the management of carcinoma of the previously irradiated breast.

MATERIALS AND METHODS

Between January 1998 and April 2008, 26 patients with TIS or T1 breast carcinoma were offered interstitial or intracavitary brachytherapy after lumpectomy in a previously irradiated breast as an alternative to salvage mastectomy. Twenty-five of 26 patients had prior lumpectomy followed by standard postoperative external beam radiotherapy for early stage carcinoma of the breast [dose range 5000-6040 cGy]. One patient developed breast cancer after full mantle irradiation [4500 cGy to the mediastinum and axillae] for Hodgkin Lymphoma 27 years earlier. All tumors were excised with final margins of resection free of disease per National Surgical Adjuvant Breast and Bowel Project definition. After lumpectomy, tumor bed implantation was carried out utilizing a low dose rate interstitial technique in 22 patients, whereas 3 patients were treated with high dose rate brachytherapy using the MammoSite brachytherapy catheter and 1 patient was treated with high dose rate brachytherapy using the Contura catheter. The low dose rate treatment consisted of 4500 to 5000 cGy at 35 to 50 cGy per hour to the tumor bed plus a 1.0 cm margin, whereas the high dose rate treatment consisted of 3400 cGy in twice daily fractions of 340 cGy currently used in National Surgical Adjuvant Breast and Bowel Project B-39. Cosmesis was graded according to the B-39 cosmesis scale for de novo treatments: grade I as excellent, grade II as good, Grade III as fair, and Grade IV as poor.

RESULTS

Eighteen patients were scored as grade I, 6 as grade II, and 2 as grade III. No patient received a Grade IV score. All 4 balloon brachytherapy patients were scored as Grade I. Twenty-five of 26 patients remained free of local failure with a median follow-up of 38 months (range 6-75 months). The only patient to develop a second local recurrence was graded as grade I before salvage mastectomy. Two patients developed wound dehiscence after immediate postlumpectomy implantation. Two have succumbed to metastatic breast carcinoma at 17 and 24 months after salvage implant therapy. An additional patient has succumbed to chronic obstructive pulmonary disease. All patients, regardless of cosmesis grade were satisfied with their decision for repeat conservation therapy. Factors affecting cosmesis were distance from the implant to the skin, the type of device used, and the amount of residual breast tissue after repeat lumpectomy.

CONCLUSIONS

The cosmetic effect of brachytherapy after lumpectomy in the management of recurrent carcinoma of the previously irradiated breast is acceptable in highly selected patients. Intracavitary technique may provide superior cosmetic results for patients retreated with brachytherapy for salvage.

Local recurrence of invasive micropapillary breast cancer after MammoSite brachytherapy: a case report and literature review

Controversy exists over the optimal patient selection criteria for accelerated partial-breast irradiation (APBI), which has been introduced as an alternative to whole-breast irradiation. The goal is to select patients with the lowest risk for tumor spread outside of the original lumpectomy bed targeted by the local internal radiation dose. Therefore, patients with more aggressive types of breast cancer might not be ideal candidates for partial breast irradiation. We discuss the case of a 67-year-old woman who presented with local recurrence of invasive micropapillary breast cancer, a rare aggressive tumor type, 5 years after MammoSite brachytherapy. The patient's primary tumor possessed all favorable indicators except for the histology of invasive micropapillary carcinoma. This is the first report of invasive micropapillary carcinoma recurring after APBI. Although this is a single case, it supports the hypothesis that more aggressive types of breast cancer have a higher risk of local recurrence after APBI. We propose that invasive micropapillary carcinoma be considered a potential exclusion criterion until it can be validated in prospective clinical trials. More aggressive treatment approaches including whole-breast irradiation and/or chemotherapy might be needed to reduce the risk of local recurrence for invasive micropapillary breast cancer.

Phase I/II study evaluating early tolerance in breast cancer patients undergoing accelerated partial breast irradiation treated with the mammosite balloon breast brachytherapy catheter using a 2-day dose schedule

PURPOSE

Initial Phase I/II results using balloon brachytherapy to deliver accelerated partial breast irradiation (APBI) in 2 days in patients with early-stage breast cancer are presented.

MATERIALS AND METHODS

Between March 2004 and August 2007, 45 patients received adjuvant radiation therapy after lumpectomy with balloon brachytherapy in a Phase I/II trial delivering 2800 cGy in four fractions of 700 cGy. Toxicities were evaluated using the National Cancer Institute Common Toxicity Criteria for Adverse Events v3.0 scale and cosmesis was documented at >or=6 months.

RESULTS

The median age was 66 years (range, 48-83) and median skin spacing was 12 mm (range, 8-24). The median follow-up was 11.4 months (5.4-48 months) with 21 patients (47%) followed >or=1 year, 11 (24%) >or=2 years, and 7 (16%) >or=3 years. At <6 months (n = 45), Grade II toxicity rates were 9% radiation dermatitis, 13% breast pain, 2% edema, and 2% hyperpigmentation. Grade III breast pain was reported in 13% (n = 6). At >or=6 months (n = 43), Grade II toxicity rates were: 2% radiation dermatitis, 2% induration, and 2% hypopigmentation. Grade III breast pain was reported in 2%. Infection was 13% (n = 6) at <6 months and 5% (n = 2) at >or=6 months. Persistent seroma >or=6 months was 30% (n = 13). Fat necrosis developed in 4 cases (2 symptomatic). Rib fractures were seen in 4% (n = 2). Cosmesis was good/excellent in 96% of cases.

CONCLUSIONS

Treatment with balloon brachytherapy using a 2-day dose schedule resulted acceptable rates of Grade II/III chronic toxicity rates and similar cosmetic results observed with a standard 5-day accelerated partial breast irradiation schedule.

Accelerated partial breast irradiation consensus statement from the American Society for Radiation Oncology (ASTRO)

PURPOSE

To present guidance for patients and physicians regarding the use of accelerated partial-breast irradiation (APBI), based on current published evidence complemented by expert opinion.

METHODS AND MATERIALS

A systematic search of the National Library of Medicine's PubMed database yielded 645 candidate original research articles potentially applicable to APBI. Of these, 4 randomized trials and 38 prospective single-arm studies were identified. A Task Force composed of all authors synthesized the published evidence and, through a series of meetings, reached consensus regarding the recommendations contained herein.

RESULTS

The Task Force proposed three patient groups: (1) a "suitable" group, for whom APBI outside of a clinical trial is acceptable, (2) a "cautionary" group, for whom caution and concern should be applied when considering APBI outside of a clinical trial, and (3) an "unsuitable" group, for whom APBI outside of a clinical trial is not generally considered warranted. Patients who choose treatment with APBI should be informed that whole-breast irradiation (WBI) is an established treatment with a much longer track record that has documented long-term effectiveness and safety.

CONCLUSION

Accelerated partial-breast irradiation is a new technology that may ultimately demonstrate long-term effectiveness and safety comparable to that of WBI for selected patients with early breast cancer. This consensus statement is intended to provide guidance regarding the use of APBI outside of a clinical trial and to serve as a framework to promote additional clinical investigations into the optimal role of APBI in the treatment of breast cancer.

Review of MammoSite brachytherapy: advantages, disadvantages and clinical outcomes

BACKGROUND

The MammoSite radiotherapy system is an alternative treatment option for patients with early-stage breast cancer to overcome the longer schedules associated with external beam radiation therapy. The device is placed inside the breast surgical cavity and inflated with a combination of saline and radiographic contrast to completely fill the cavity. The treatment schedule for the MammoSite monotherapy is 34 Gy delivered in 10 fractions at 1.0 cm from the balloon surface with a minimum of 6 hours between fractions on the same day.

MATERIAL AND METHODS

This review article presents the advantages, disadvantages, uncertainties and clinical outcomes associated with the MammoSite brachytherapy (MSB).

RESULTS

Potential advantages of MSB are: high localised dose with rapid falloff for normal tissue sparing, minimum delay between surgery and RT, catheter moves with breast, improved local control, no exposure to staff, likely side-effects reduction and potential cost/time saving (e.g. for country patients). The optimal cosmetic results depend on the balloon-to-skin distance. Good-to-excellent cosmetic results are achieved for patients with balloon-skin spacing of > or =7 mm. There have been very few published data regarding the long term tumour control and cosmesis associated with the MSB. The available data on the local control achieved with the MSB were comparable with other accelerated partial breast irradiation techniques. The contrast medium inside the balloon causes dose reduction at the prescription point. Current brachytherapy treatment planning systems (BTPS) do not take into account the increased photon attenuation due to high Z of contrast. Some BTPS predicted up to 10% higher dose near the balloon surface compared with Monte Carlo calculations using various contrast concentrations (5-25%).

CONCLUSION

Initial clinical results have shown that the MammoSite device could be used as a sole radiation treatment for selected patients with early stage breast cancer providing good local control, minimal complication rate and excellent cosmesis.

Placement of MammoSite brachytherapy catheter under computed-tomography scan guidance

Placement of the MammoSite breast brachytherapy catheter is most commonly performed either intraoperatively or under ultrasound-guided technique. Below, we present a case report of an alternate approach utilizing CT-scan guidance. This is the first reported case of a balloon brachytherapy catheter placement with this technique.

Radiation recall reaction with docetaxel administration after accelerated partial breast irradiation with electronic brachytherapy

PURPOSE

Accelerated partial breast irradiation (APBI) offers several advantages over whole breast irradiation. Electronic brachytherapy may further reduce barriers to breast conserving therapy by making APBI more available. However, its toxicity profile is not well characterized.

METHODS AND MATERIALS

A 60-year-old woman was treated with APBI using Axxent (Xoft, Sunnyvale, CA) electronic brachytherapy. One month after APBI, a cycle of docetaxel and cyclophosphamide was given. Within 3 weeks, the patient developed an ulcerative radiation recall reaction in the skin overlying the lumpectomy cavity. To investigate this toxicity, the skin dose from electronic brachytherapy was compared with the dose that would have been delivered by an iridium-192 ((192)Ir) source. Additionally, a dose equivalent was estimated by adjusting for the increased relative biologic effectiveness (RBE) of low energy photons generated by the electronic source.

RESULTS

Using electronic brachytherapy, the skin dose was 537cGy per fraction compared with 470cGy for an (192)Ir source. Given an RBE for a 40kV source of 1.28 compared with (192)Ir, the equivalent dose at the skin for an electronic source was 687cGy-equivalents, a 46% increase.

CONCLUSIONS

We present a case of an ulcerative radiation recall reaction in a patient receiving APBI with electronic brachytherapy followed by chemotherapy. Our analysis shows that the use of electronic brachytherapy resulted in the deposition of significantly higher equivalent dose at the skin compared with (192)Ir. These findings suggest that standard guidelines (e.g., surface-to-skin distance) that apply to (192)Ir-based balloon brachytherapy may not be applicable to electronic brachytherapy.

Toxicity of three-dimensional conformal radiotherapy for accelerated partial breast irradiation

PURPOSE

To assess the incidence and severity of late normal tissue toxicity using three-dimensional conformal radiotherapy to deliver accelerated partial breast irradiation.

METHODS AND MATERIALS

A total of 60 patients were treated with three-dimensional conformal radiotherapy for accelerated partial breast irradiation. Treatment planning and delivery were in strict accordance with the technique and specified dose-volume constraints of the National Surgical Adjuvant Breast and Bowel Project B-39/Radiation Therapy Oncology Group 0413 protocol. Late toxicity was evaluated according to the Radiation Therapy Oncology Group grading schema. The cosmetic outcome was scored using the Harvard criteria. Univariate logistic regression analysis was performed to evaluate the correlation of dosimetric variables with outcome.

RESULTS

At a median follow-up of 15 months, moderate-to-severe late toxicity developed in 10% of patients. The most pronounced late toxicity was subcutaneous fibrosis: 25% Grade 2-4 and 8.3% Grade 3-4. The modified planning tumor volume/whole breast volume ratio, ratio of the volume of breast tissue receiving 5%, 20%, 50%, and 80% of the prescription dose to the whole breast volume, and maximal dose within the breast correlated with the development of fibrosis (p = .10, p = .03, p = .04, p = .06, p = .09, and p = .046, respectively). The overall cosmetic outcome was good to excellent in 81.7%, fair in 11.7%, and poor in 6.7%. The presence of subcutaneous fibrosis, modified planning tumor volume/whole breast volume ratio, ratio of the volume of breast tissue receiving 5% and 20% of the prescription dose to the whole breast volume, and pathologic specimen volume correlated with the risk of a fair/poor cosmetic outcome (p < .001, p = .02, p = .05, p = .04, p = .01, respectively).

CONCLUSION

The three-dimensional conformal radiotherapy technique for accelerated partial breast irradiation as specified in the National Surgical Adjuvant Breast and Bowel Project B-39/Radiation Therapy Oncology Group 0413 protocol resulted in a remarkably high rate of moderate-to-severe late normal tissue effects, despite the relatively brief follow-up period. The toxic events correlated clearly with several dose-volume parameters.

Initial radiation experience evaluating early tolerance and toxicities in patients undergoing accelerated partial breast irradiation using the Contura Multi-Lumen Balloon breast brachytherapy catheter

PURPOSE

We reviewed our institution's experience treating patients with the Contura Multi-Lumen Balloon (SenoRx, Inc., Irvine, CA) breast brachytherapy catheter to deliver accelerated partial breast irradiation.

METHODS AND MATERIALS

Forty-one patients treated with breast-conserving therapy received adjuvant radiation using the Contura catheter (34Gy in 3.4Gy fractions). Thirteen patients had Stage 0, 21 had Stage I, and 7 had Stage II breast cancer. Median followup was 8 months (range, 1-17).

RESULTS

Median, minimum skin spacing was 10mm (range, 2-17). Median, maximum skin doses (% of prescribed dose [PD]) were 99.7 (range, 57.1-124.1). Eight patients were treated with a skin spacing <or=5mm and 2 had a spacing of 2mm. Median, maximum rib doses were 102.6% of PD (10.0-187.7), and the median percentage of the planning target volume for evaluation (PTV_EVAL) receiving 95% of the PD was 98.8 (range, 79.4-107.4). The median volume receiving 200% of the PD was 5.7cc (range, 1.3-9.9). The percentage of patients with excellent/good cosmetic results at 6 months (n=15) and 12 months (n=12) was 100%. Patient tolerance was assessed on a scale 0-10 (0=no pain, 10=requiring narcotic analgesics). In 37 out of 38 patients, pain was graded <or=3 at the time of catheter insertion. Four breast infections (11%) and one transient symptomatic seroma (3%) developed.

CONCLUSION

Adjuvant accelerated partial breast irradiation using the Contura Multi-Lumen Balloon catheter exhibited similar toxicities to standard single lumen balloon brachytherapy with improvements in dosimetric capabilities (i.e., reduced skin and rib doses and improved PTV_EVAL coverage).

Dose volume histogram analysis of normal structures associated with accelerated partial breast irradiation delivered by high dose rate brachytherapy and comparison with whole breast external beam radiotherapy fields

PURPOSE

To assess the radiation dose delivered to the heart and ipsilateral lung during accelerated partial breast brachytherapy using a MammoSite applicator and compare to those produced by whole breast external beam radiotherapy (WBRT).

MATERIALS AND METHODS

Dosimetric analysis was conducted on patients receiving MammoSite breast brachytherapy following conservative surgery for invasive ductal carcinoma. Cardiac dose was evaluated for patients with left breast tumors with a CT scan encompassing the entire heart. Lung dose was evaluated for patients in whom the entire lung was scanned. The prescription dose of 3400 cGy was 1 cm from the balloon surface. MammoSite dosimetry was compared to simulated WBRT fields with and without radiobiological correction for the effects of dose and fractionation. Dose parameters such as the volume of the structure receiving 10 Gy or more (V10) and the dose received by 20 cc of the structure (D20), were calculated as well as the maximum and mean doses received.

RESULTS

Fifteen patients were studied, five had complete lung data and six had left-sided tumors with complete cardiac data. Ipsilateral lung volumes ranged from 925-1380 cc. Cardiac volumes ranged from 337-551 cc. MammoSite resulted in a significantly lower percentage lung V30 and lung and cardiac V20 than the WBRT fields, with and without radiobiological correction.

CONCLUSION

This study gives low values for incidental radiation received by the heart and ipsilateral lung using the MammoSite applicator. The volume of heart and lung irradiated to clinically significant levels was significantly lower with the MammoSite applicator than using simulated WBRT fields of the same CT data sets.

Patient satisfaction and quality of life after MammoSite breast brachytherapy

PURPOSE

To perform a satisfaction/quality-of-life (QOL) survey of patients undergoing MammoSite brachytherapy (MBT; Hologic, Inc, Marlborough, MA).

METHODS

We asked patients 15 questions regarding treatment decision-making, and experience on-therapy/post-treatment.

RESULTS

A total of 52 patients responded (median follow-up 30 months). Regarding decision-making, 5.8% viewed the avoidance of mastectomy as "not important." If MBT were not available, 55.8% would opt for whole-breast radiotherapy (WBRT) without difficulty, 28.8% would have significant travel/financial difficulty, and 15.4% would refuse radiotherapy/opt for mastectomy. Regarding choice factors, patients selected "focused therapy" (44.2%), "convenience" (36.5%), and "cutting edge" (17.3%). A total of 61.5% patients were not concerned about a second surgical procedure; 90.4% were not/somewhat concerned about infection. During treatment, 73.1% reported no pain/discomfort with catheter, 73.1% no wound difficulty, 51.0% no pain during removal, and 71.2% no pain post-treatment. A total of 98.1% of patients rated the experience good/excellent, 90.4% reported no/minor side effects, 92.3% rated cosmesis good/excellent, 98.1% were very/extremely likely to choose MBT again, and 100% would recommend MBT.

CONCLUSIONS

QOL is high during/after MBT. More data are needed from ongoing trials to compare with WBRT.

Accelerated partial breast irradiation as part of breast conserving therapy of early breast carcinoma: a systematic review

New strategies for adjuvant radiotherapy of early breast cancer are being investigated in several phase III randomised trials at the present time. Accelerated partial breast irradiation (APBI) is a way to offer an early breast cancer patient, who has had breast conservative surgery, an adjuvant radiotherapy of short duration aimed at the tumour bed with a certain margin. The rationale of this strategy is that most local recurrences appear close to the tumorectomy cavity and a wish to spare the patient late radiation morbidity. This review discusses the background for APBI, the different techniques, and we highlight possible pitfalls using these techniques. A systematic overview of all phase I and II studies is provided. Patient selection for this therapy is pivotal and based on evidence from previous studies on patient/tumour characteristics and pattern of local recurrences we propose inclusion criteria for patients in APBI protocols.

Partial breast irradiation as sole therapy for low risk breast carcinoma: early toxicity, cosmesis and quality of life results of a MammoSite brachytherapy phase II study

PURPOSE

The MammoSite is a device that was developed with the goal of making breast-conserving surgery (BCT) more widely available. Our objective was to evaluate the MammoSite device performances after an open cavity placement procedure and quality of life in highly selected patients with early-stage breast cancer.

METHODS AND MATERIALS

From March 2003 to March 2005, 43 patients with T1 breast cancer were enrolled in a phase II study. The median age was 72 years. Twenty-five (58%) patients were treated with high-dose rate brachytherapy using the MammoSite applicator to deliver 34Gy in 10 fractions. The main disqualifying factor was pathologic sentinel node involvement (10/43; 23%). There were no device malfunctions, migration or rupture of the balloon.

RESULTS

After a median follow-up of 13 months, there were no local recurrences and one contralateral lobular carcinoma. Seventeen (68%), 13 (52%), 8 (32%), 5 (20%) and 2 (8%) patients had erythema, seroma, inflammation, hematoma and sever infection, respectively. Only 2 patients developed telangiectasia. At 1 year the rate of "good to excellent" cosmetic results was 84%. Significant changes in QoL were observed for emotional and social well-being between 3 and 12 months. At 24 months, only emotional well-being subscore changes were statistically significant (p=0.015).

CONCLUSIONS

Our data in patients older than 60 years support the previously published data. Histologic features were the main disqualifying criteria. With higher skin spacing levels we observed very low incidence of telangiectasia. QoL evaluation indicates that baseline scores were satisfactory. Changes concerned emotional and social well-being.

The feasibility of a second lumpectomy and breast brachytherapy for localized cancer in a breast previously treated with lumpectomy and radiation therapy for breast cancer

PURPOSE

With accumulating evidence supporting partial-breast irradiation, we conducted a Phase I/II study to evaluate the role of a second conservative surgery and brachytherapy for patients presenting with a local recurrence/new primary in a breast who has previously undergone a lumpectomy and external radiation therapy for breast cancer.

METHODS AND MATERIALS

Fifteen patients with a localized lesion in the breast have undergone a second lumpectomy and received low-dose-rate brachytherapy on protocol. The first 6 patients received a dose of 30Gy. With no unacceptable acute toxicity observed, the brachytherapy dose was increased to 45Gy. Three patients received adjuvant chemotherapy and 8 patients are on antiestrogen therapy.

RESULTS

The median time interval between the primary breast cancer diagnosis and the second cancer event in the ipsilateral breast is 94 months (range, 28-211). With a median followup of 36 months after brachytherapy, the 3-year Kaplan-Meier overall survival, local disease-free survival and mastectomy-free survival are 100% and 89%, respectively. There was no Grade 3/4 fibrosis or necrosis observed. All patients had baseline asymmetry due to the breast volume deficit from the second lumpectomy. With breast asymmetry as a given, the cosmetic result observed in all patients has been good to excellent.

CONCLUSIONS

Early results suggest low-complication rates, high rate of local control and freedom from mastectomy. Additional studies are needed to establish whether a second lumpectomy and breast brachytherapy are an acceptable alternative to mastectomy for patients presenting with a localized cancer in a previously irradiated breast.

Concepts and techniques of intraoperative radiotherapy (IORT) for breast cancer

The standard treatment for early breast cancer comprises wide local excision, sentinel lymph node biopsy or axillary lymph node dissection, adjuvant medical treatment and radiotherapy to the whole breast. Many studies suggest that local control plays a crucial role in overall survival. The local recurrence rate is estimated to be 1% per year and varies between 4 and 7% after 5 years and up to 10 to 20% in the long-term follow up. On the basis of low local recurrence rates the concept of whole breast irradiation comes up for discussion, and partial breast irradiation (PBI) is increasingly under consideration. Intraoperative radiotherapy (IORT) is referred to as the delivery of a single high dose of irradiation directly to the tumor bed (confined target) during surgery. PBI (limited field radiation therapy, accelerated partial breast irradiation APBI) is the irradiation exclusively confined to a breast volume, the tumor surrounding tissue (tumor bed) either during surgery or after surgery without whole breast irradiation. Various methods and techniques for IORT or PBI are under investigation. The advantage of a very short radiation time or the integration of the complete radiation treatment into the surgical procedure convinces at a first glance. The promising short-term results of those studies must not fail to mention that local recurrence rates could probably increase and furthermore give rise to distant metastases and a reduction in overall survival. The combination of IORT in boost modality and whole breast irradiation has the ability to reduce local recurrence rates. The EBCTCG overview approves that differences in local treatment that substantially affect local recurrence rates would avoid about one breast cancer death over the next 15 years for every four local recurrences avoided, and should reduce 15-year overall mortality.

Three-year analysis of treatment efficacy, cosmesis, and toxicity by the American Society of Breast Surgeons MammoSite Breast Brachytherapy Registry Trial in patients treated with accelerated partial breast irradiation (APBI)

BACKGROUND

This report presents 3 years of data on treatment efficacy, cosmetic results, and toxicities for patients enrolled on the American Society of Breast Surgeons MammoSite (Cytyc, Bedford, Mass) Breast Brachytherapy Registry Trial.

METHODS

A total of 1440 patients (1449 cases) with early stage breast cancer who were undergoing breast-conserving therapy were treated with the MammoSite device to deliver accelerated partial breast irradiation (APBI) (34 Gy in 3.4 Gy fractions). Of these, 1255 (87%) cases had invasive breast cancer (IBC; median size = 10 mm), and 194 (13%) cases had ductal carcinoma in situ (DCIS; median size = 8 mm). Median follow-up was 30.1 months.

RESULTS

Twenty-three (1.6%) cases developed an ipsilateral breast tumor recurrence (IBTR) for a 2-year actuarial rate of 1.04% (1.11% for IBC and 0.59% for DCIS). No variables were associated with IBTR. Six (0.4%) patients developed an axillary failure. The percentages of breasts with good to excellent cosmetic results at 12 (n = 980), 24 (n = 752), 36 (n = 403), and 48 months (n = 67 cases) were 95%, 94%, 93%, and 93%, respectively. Breast seromas were reported in 23.9% of cases (30% in open-cavity implants and 19% in closed-cavity implants). Symptomatic seromas occurred in 10.6% of cases, and 1.5% of cases developed fat necrosis. A subset analysis of the first 400 consecutive cases enrolled was performed (352 with IBC, 48 DCIS). With a median follow-up of 37.5 months, the 3-year actuarial rate of IBTR was 1.79%.

CONCLUSIONS

Treatment efficacy, cosmesis, and toxicity 3 years after treatment with APBI using the MammoSite device are good and similar to those reported with other forms of APBI with similar follow-up.

Full-dose intra-operative radiotherapy with electrons (ELIOT) during breast-conserving surgery: experience with 1246 cases

Background:

Previous studies showed that after breast-conserving surgery for breast cancer, radiotherapy may be applied to the portion of the breast where the primary tumour was removed (partial breast irradiation (PBI), avoiding the irradiation of the whole breast. We developed a procedure of PBI consisting of a single high dose of radiotherapy of 21 Gy with electrons equivalent to 58–60 Gy in fractionated doses, delivered during the surgical session by a mobile linear accelerator, positioned close to the operating table.

Patients and methods:

From July 1999 to December 2006, 1246 patients with primary carcinoma of less than 2.5-cm maximum diameter, mostly over 48 years, were treated with electron intra-operative radiotherapy (ELIOT) at a single dose of 21 Gy.

Results:

After a follow-up from 0.3 to 94.7 months (median 26), 24 (1.9%) patients showed a local recurrence and 22 developed distant metastases. Sixteen patients died, seven from breast carcinoma and nine from others causes. The five-year crude survival was 96.5%. Six (0.5%) developed severe breast fibrosis, which resolved in 2–3 years. An additional 40 patients suffered for mild fibrosis. Cosmetic results were good.

Conclusions:

Electron intra-operative radiotherapy is a safe method for treating conservatively operated breasts and avoids the long period of post-operative radiotherapy, greatly improving the quality of life and reduces the cost of radiotherapy. ELIOT markedly reduces the radiation to normal surrounding tissues and deep organs. Results on short- and medium-term toxicity are good. Data on local control are encouraging.

New trends in radiotherapy for breast cancer

PURPOSE OF REVIEW

New radiotherapy techniques are under development to improve tumor control and to decrease the long-term side effects of breast cancer. These include accelerated partial breast irradiation, intensity modulated and image guided radiotherapy.

RECENT FINDINGS

Follow-up data of multicatheter brachytherapy accelerated partial breast irradiation and intraoperative electron beam radiotherapy confirm excellent 5-year local control rates in well selected patients. Early side effects seem to be improved, but recent data show increasing skin toxicity in multicatheter and intracavitary balloon brachytherapy. Intraoperative radiotherapy, proton beam partial breast irradiation, intensity modulated and image guided radiotherapy improve dose homogeneity and decrease normal tissue complication probability. For breast-only treatment, two tangential fields with different segments provide an attractive and feasible alternative to the conventional technique. The proposed intensity modulated radiotherapy techniques for comprehensive locoregional radiotherapy, however, result in increased doses to the contralateral lung and breast.

SUMMARY

Input from long-term clinical data on new radiotherapy techniques is needed. Consensus on target volume contouring and dose volume constraints for nontarget tissue has not yet been reached. Further research on skin toxicity with multicatheter or intracavitary brachytherapy is needed to improve the results.

Impact of increasing margin around the lumpectomy cavity to define the planning target volume for 3D conformal external beam accelerated partial breast irradiation

The purpose of this study was to evaluate the dose to normal tissues as a function of increasing margins around the lumpectomy cavity in accelerated partial breast irradiation (APBI) using 3D-conformal radiotherapy (3DCRT). Eight patients with Stage 0-I breast cancer underwent treatment planning for 3DCRT APBI. The clinical target volume (CTV) was defined as a 15-mm expansion around the cavity limited by the chest wall and skin. Three planning target volumes (PTV1, PTV2, PTV3) were generated for each patient using a 0, 5-, and 10-mm expansion around the CTV, for a total margin of 15, 20, and 25 mm. Three treatment plans were generated for every patient using the 3 PTVs, and dose-volume analysis was performed for each plan. For each 5-mm increase in margin, the mean PTV:total breast volume ratio increased 10% and the relative increase in the mean ipsilateral breast dose was 15%. The mean volume of ipsilateral breast tissue receiving 75%, 50%, and 25% of the prescribed dose increased 6% to 7% for every 5 mm increase in PTV margin. Compared to lesions located in the upper outer quadrant, plans for medially located tumors revealed higher mean ipsilateral breast doses and 20% to 22% more ipsilateral breast tissue encompassed by the 25% IDL. The use of 3DCRT for APBI delivers higher doses to normal breast tissue as the PTV increases around the lumpectomy cavity. Efforts should be made to minimize the overall PTV when this technique is used. Ongoing studies will be necessary to determine the clinical relevance of these findings.

Dose-volume characteristics of a 50-kV electronic brachytherapy source for intracavitary accelerated partial breast irradiation

PURPOSE

To describe dose-volume data from a 50-kV electronic brachytherapy source in intracavitary accelerated partial breast irradiation.

METHODS AND MATERIALS

Three spherical balloon applicators were imaged on a CT scanner in a water phantom and inflated throughout their suggested fill volume range. The planning target volume (PTV) was defined as a 1-cm margin around the balloon surface. Plans were created achieving 80%, 85%, and 90% coverage of the PTV, with a prescription dose of 34Gy in 10 fractions. The PTV, V(90), V(100), V(150), V(200), and V(300) were recorded for each plan.

RESULTS

For 80% target coverage, the V(200) varies from 11 to 14 cm(3) and the V(150) from 26 to 49 cm(3) over all the balloon applicators and fill volumes. For 85% coverage, the V(200) varies from 14 to 18 cm(3) and the V(150) from 27 to 53 cm(3). For 90% coverage, the V(200) varies from 16 to 22 cm(3) and the V(150)cm(3) from 30 to 61 cm(3).

CONCLUSIONS

Fifty-kilovolt electronic brachytherapy can provide PTV coverage similar to (192)Ir in the setting of intracavitary accelerated partial breast irradiation.

[Accelerated partial breast irradiation: a concept to individualize treatment in breast cancer]

Whole breast irradiation delivering an equivalent dose of 50 Gy in 5 weeks, followed by a 10 to 16 Gy-boost to the tumor bed is the standard of care after breast-conserving surgery for early-breast cancer. Accelerated partial breast irradiation (APBI) is currently under investigations in large multi-institutional, prospective, randomized trials to objectively address the critical endpoints of treatment efficacy, toxicity and cosmesis. Patient's selection for this new approach is crucial to individualise treatments and define the subgroups of patients who will really benefit from APBI in terms of quality of life without decreasing long-term results of the disease control and cosmesis. In this review, we will discuss the patients' profiles selection for APBI regarding their general and tumor criteria. The differences between APBI techniques either performed intra or post operatively will be also discussed.

Patterns of Failure After MammoSite Brachytherapy Partial Breast Irradiation: A Detailed Analysis

PURPOSE

To report the results of a detailed analysis of treatment failures after MammoSite breast brachytherapy for partial breast irradiation from our single-institution experience.

METHODS AND MATERIALS

Between October 14, 2002 and October 23, 2006, 78 patients with early-stage breast cancer were treated with breast-conserving surgery and accelerated partial breast irradiation using the MammoSite brachytherapy applicator. We identified five treatment failures in the 70 patients with >6 months' follow-up. Pathologic data, breast imaging, and radiation treatment plans were reviewed. For in-breast failures more than 2 cm away from the original surgical bed, the doses delivered to the areas of recurrence by partial breast irradiation were calculated.

RESULTS

At a median follow-up time of 26.1 months, five treatment failures were identified. There were three in-breast failures more than 2 cm away from the original surgical bed, one failure directly adjacent to the original surgical bed, and one failure in the axilla with synchronous distant metastases. The crude failure rate was 7.1% (5 of 70), and the crude local failure rate was 5.7% (4 of 70). Estimated progression-free survival at 48 months was 89.8% (standard error = 4.5%).

CONCLUSIONS

Our case series of 70 patients with >6 months' follow-up and a median follow-up of 26 months is the largest single-institution report to date with detailed failure analysis associated with MammoSite brachytherapy. Our failure data emphasize the importance of patient selection when offering partial breast irradiation.

Analysis of Treatment Efficacy, Cosmesis, and Toxicity Using the MammoSite Breast Brachytherapy Catheter to Deliver Accelerated Partial-Breast Irradiation: The William Beaumont Hospital Experience

PURPOSE

To review our institution's experience of treating patients with the MammoSite (Cytyc Corp., Marlborough, MA) breast brachytherapy catheter to deliver accelerated partial-breast irradiation (APBI), for determining short-term treatment efficacy, cosmesis, and toxicity.

METHODS AND MATERIALS

From January 2000 to April 2006, 80 patients treated with breast-conserving therapy (BCT) received adjuvant radiation using the MammoSite (34 Gy in 3.4-Gy fractions prescribed to 1.0 cm from the balloon surface). Twenty-three patients (29%) had Stage 0 breast cancer, 46 (57%) had Stage I breast cancer, and 11 (14%) had Stage II breast cancer. The median follow-up was 22.1 months.

RESULTS

Two ipsilateral breast-tumor recurrences (IBTRs) (2.5%) developed for a 3-year actuarial rate of 2.9% (no regional failures were observed). On molecular-based clonality assay evaluation, both recurrences were clonally related. Younger age at diagnosis was the only variable associated with IBTR (continuous variable, p = 0.044; categorical variable [<55 years vs. >/=55 years], p = 0.012). The percentages of patients with good/excellent cosmetic results at 12 and 36 months were 96.9% and 88.2%, respectively (p = NS). Patients with applicator-to-skin spacing <7 mm and those who received adjuvant systemic chemotherapy exhibited lower rates of good/excellent cosmetic results, though the association was not statistically significant. The overall incidence of symptomatic seromas and any seromas was 10% and 45%, respectively. The overall incidence of fat necrosis and infections was 8.8% and 11.3%, respectively.

CONCLUSIONS

Early-stage breast-cancer patients treated with adjuvant APBI using the MammoSite catheter exhibited a 3-year treatment efficacy, cosmesis, and toxicity similar to those observed with other forms of interstitial APBI at this length of follow-up.

Association between operative closure type and acute infection, local recurrence, and disease surveillance in patients undergoing breast conserving therapy for early-stage breast cancer

BACKGROUND

This study investigates the effect of full-thickness versus superficial closure of the breast parenchyma on the likelihood of subsequent infection and local recurrence after lumpectomy for early-stage breast cancer. In patients undergoing breast-conserving therapy (BCT), operative closure technique has been largely influenced by expected cosmetic outcome. However, the common practice of promoting postoperative fluid collection raises concerns about potential bacterial colonization, tumor cell migration, and impaired post-BCT surveillance.

METHODS

From 1985 through 2004, operative closure technique was determined in 516 breasts in 580 women with stage T0-2N0-1 breast cancers undergoing BCT. Medical records were reviewed to determine closure technique, incidence of postoperative infection, and local recurrence characteristics.

RESULTS

Median follow-up was 6.4 years from the completion of radiotherapy. The rate of acute infection was higher with the superficial closure technique: 11.7% (27/230) versus 5.2% (15/286) (P = .009). In T1-2 patients, there was no difference in the rate of local recurrence based on closure type: 5.6% (11/195) versus 3.5% (8/231) (P = .348). On multivariate analysis, acute infections and margin status were associated with increased local recurrence. Superficial closure was associated with larger recurrences less likely to be detected on mammogram. In stage T0-T2 patients, 80% of recurrent tumors after superficial closures were greater than 1 cm compared with no recurrent tumors greater than 1 cm after full-thickness closures (P = .005). In patients with superficial closure, 29% of recurrences in the tumor bed were initially detected on mammogram versus 100% in patients with deep closure (P = .003).

CONCLUSIONS

Closure method was not predictive of local recurrence. Our findings regarding infection and post-treatment surveillance suggest, however, that full-thickness closure may be the preferred technique in BCT patients.

The use of molecular assays to establish definitively the clonality of ipsilateral breast tumor recurrences and patterns of in-breast failure in patients with early-stage breast cancer treated with breast-conserving therapy

BACKGROUND

Results from numerous trials have indicated that breast-conserving therapy (BCT) produces outcomes equivalent to those produced by mastectomy in terms of both locoregional control and survival. However, conservative treatment has resulted in the dilemma of how best to address recurrences when they appear in a breast treated previously with radiation therapy. Attempts have been made to characterize ipsilateral breast tumor recurrences (IBTRs) as either true recurrences of the treated malignancy or new primary carcinomas, because cancers that represent new primary tumors may be associated with a more favorable prognosis compared with cancers that represent true recurrences.

METHODS

The authors studied the clonality of IBTRs relative to the initial invasive carcinomas by using a polymerase chain reaction loss-of-heterozygosity molecular comparison assay in 29 patients who received breast-conserving therapy (BCT).

RESULTS

Twenty-two IBTRs (76%) were related clonally to the initial carcinoma, and 7 IBTRs (24%) were clonally different. Clonally related IBTRs were more frequently higher grade (72.2% vs 14.3%; P = .009) and developed sooner after initial treatment (mean time to IBTR, 4.04 years in clonally related IBTRs vs 9.25 years in clonally different IBTRs; P = .002). Six patients subsequently developed distant metastases, and 5 of those patients (83.3%) had clonally related IBTRs. Clinical IBTR classification and molecular clonality assay results differed in 30% of all patients. The proportion of IBTRs that were related clonally at 5 years, 10 years, and 15 years after BCT were 93%, 67%, and 33%, respectively.

CONCLUSIONS

Clinical classifications of IBTRs were unreliable methods for determining clonality in many patients. Molecular clonality assays provided a reliable means of identifying patients who may benefit from aggressive systemic therapy at the time of IBTR and also provided a more accurate assessment of the efficacy of various forms of local therapy.

Predictors of cosmetic outcome following MammoSite breast brachytherapy: a single-institution experience of 100 patients with two years of follow-up

PURPOSE

To identify the factors that predict for excellent cosmesis in patients who receive MammoSite breast brachytherapy (MBT).

METHODS AND MATERIALS

One hundred patients with Stage 0, I, or II adenocarcinoma of the breast underwent adjuvant therapy using MBT. A dose of 34 Gy, delivered in 10 fractions twice daily, was prescribed to 1-cm depth using (192)Ir high-dose-rate brachytherapy. Patients were assessed for acute toxicity on the day of therapy completion, 4 weeks after therapy, and at least every 3 months by radiation, surgical, and/or medical oncologists. All available data were reviewed for documentation of cosmesis and rated using the Harvard Scale. All patients had a minimum follow-up of 6 months (median = 24 months).

RESULTS

Of 100 patients treated, 90 had adequate data and follow-up. Cosmesis was excellent in 62 (68.9%), good in 19 (21.1%), fair in 8 (8.9%), and poor in 1 (1.1%) patient. Using stepwise logistic regression, the factors that predicted for excellent cosmesis were as follows: the absence vs. presence of infection (p = 0.017), and the absence vs. presence of acute skin toxicity (p = 0.026). There was a statistically significant association between acute skin toxicity (present vs. absent) and balloon-to-skin distance (<8 vs. >8 mm, p = 0.001). Factors that did not predict for cosmesis were age, balloon placement technique, balloon volume, catheter days in situ, subcutaneous toxicity, and chemotherapy or hormonal therapy.

CONCLUSIONS

The acute and late-term toxicity profiles of MBT have been acceptable. Cosmetic outcome is improved by proper patient selection and infection prevention.

Technology Insight: MammoSite®—a new device for delivering brachytherapy following breast-conserving therapy

The MammoSite (Cytyc Corporation, Marlborough, MA) breast brachytherapy applicator was designed to overcome the logistic problems created by external-beam radiation therapy (EBRT) and the technical difficulties associated with multicatheter-based interstitial brachytherapy. The MammoSite catheter has been shown to treat a volume of tissue equivalent to that treated by multicatheter-based brachytherapy. Using ultrasound guidance, the MammoSite applicator can be placed using an open technique at the time of lumpectomy or post-lumpectomy. Initial results have shown favorable cosmesis and few significant side effects. NSABP B-39/RTOG 0413 randomizes patients between EBRT and partial-breast irradiation (PBI). The PBI arm consists of interstitial brachytherapy, MammoSite brachytherapy, or 3D conformal EBRT. This trial has the potential to provide a definitive answer regarding the benefits of PBI for certain subgroups of patients, and hence lead to more women undergoing breast conservation therapy.

Radiation Therapy in the Treatment of Breast Cancer

OBJECTIVES

To explore the advancements in radiation therapy for patients with breast cancer. To review the side effects associated with radiation therapy to the breast.

DATA SOURCES

Medical and nursing journals and texts.

CONCLUSION

Advances in technology and a shift in the paradigm used to treat breast cancer are leading to newer and accelerated methods of treatment. APBI has gained increased attention and is the subject of numerous clinical trials.

IMPLICATIONS FOR NURSING PRACTICE

Nurses must be aware of the technical aspects associated with new technology and the rationale and implications associated with its use. The focus for nurses working in radiation therapy continues to be patient education and side effect management. Nurses must understand the ramifications such treatment entails so as to provide optimal care.

Accelerated partial breast irradiation

BACKGROUND

Breast-conserving surgery followed by whole-breast radiotherapy (WBRT) has become the standard treatment for the majority of patients with early breast cancer. Whereas the indications for systemic adjuvant treatment have continuously expanded, there is a tendency to restrict postoperative radiotherapy to accelerated partial breast irradiation (APBI) instead of WBRT.

METHODS

The different techniques of APBI are described and their respective advantages or potential drawbacks outlined. Moreover, the results described in the literature are briefly reviewed as a basis for the consensus statements and recommendations of the German Society of Radiation Oncology, the German Society of Senology, and the Working Group for Gynecological Oncology of the German Cancer Society.

RESULTS

The methods mainly used for APBI are: interstitial radiotherapy with multicatheter technique, intraoperative radiotherapy (IORT) using either electrons produced by linear accelerators or 50 kV x-rays (Intrabeam), the balloon-catheter technique (MammoSite), or 3D conformal external beam radiotherapy. These techniques have marked differences in dose distribution and homogeneity. The published range of local recurrence rates varies between 0% to 37%, the median follow-up from 8 to 72 months.

CONCLUSIONS

To date, follow-up times mostly do not yet permit a definite judgment concerning the long-term effectiveness and side effects of APBI. The relevant societies in Germany support randomized clinical studies comparing APBI with WBRT in a well-defined subset of low-risk patients. However, the authors expressly discourage the routine use of APBI outside clinical trials. Until definite results show that APBI neither impairs therapeutic outcome nor cosmetic results, WBRT remains the gold standard in the treatment of early breast cancer.