Descriptions and outcomes of insertion techniques of a breast brachytherapy balloon catheter in 1403 patients enrolled in the American Society of Breast Surgeons MammoSite breast brachytherapy registry trial

Feasibility and full-course dosimetry of an intraoperatively placed multichannel brachytherapy catheter for accelerated partial breast irradiation

PURPOSE

Determine feasibility and resultant dosimetry of an intraoperatively placed multichannel intracavitary brachytherapy catheter for accelerated partial breast irradiation (APBI).

METHODS

Patients with breast cancer underwent intraoperative brachytherapy catheter placement based on frozen section analysis with immediate postoperative APBI. The planning target volume evaluation (PTVEval) and organs at risk were contoured on daily pretreatment CT scans for each patient, and the original treatment plan was applied to assess full-course dosimetry.

RESULTS

Of the first 21 patients consented for intraoperative catheter placement, 20 (95%) were able to proceed with treatment as planned. The mean volume of PTVEval receiving 90% of prescription dose (V_90%) and mean percentage of prescription dose to 90% of the PTVEval (D_90%) on initial planning were 96.7 (±1.1%) and 100.2 (±2.1%), respectively. Full-course dose coverage remained excellent with a mean PTVEval V_90% and D_90% of 95.0 (±4.4%) and 100.2 (±9.6%), respectively. Mean full-course maximum dose constraints for chest wall and skin were met by 70% and 95% of patients, respectively. Air accumulation >1 cc during treatment increased the risk of a daily fraction with PTVEval coverage below goal (odds ratio, 9.8; p = 0.05), whereas those with applicators <0.5 cm from the chest wall at planning were at risk of exceeding that organ's maximum dose constraint on a daily fraction (odds ratio, 45; p = 0.02).

CONCLUSIONS

Intraoperative catheter placement and early initiation of APBI based on frozen section pathology is feasible, yields acceptable dosimetry, and is an option for completing breast conserving therapy in less than 10 days.

Accelerated partial breast irradiation with brachytherapy: patient selection and technique considerations

Accelerated partial breast irradiation (APBI) through breast brachytherapy is a relatively recent development in breast radiotherapy that has gained international favor because of its reduction in treatment duration and normal tissue irradiation while maintaining favorable cancer-specific and cosmetic outcomes. Despite the fact that several large national trials have not reported final results yet, many providers are currently offering APBI to select patients and APBI is listed as a treatment option for selecting patients in the National Comprehensive Cancer Network guidelines. Multiple consensus guidelines exist in selecting patients for APBI, some with conflicting recommendations. In this review, the existing patient selection guidelines are reported, compared, and critiqued, grouping them in helpful subcategories. Unique patient and technical selection factors for APBI with brachytherapy are explored.

Timing of infectious complications following breast-conserving therapy with catheter-based accelerated partial breast irradiation

BACKGROUND

Accelerated partial breast irradiation (APBI) has been used as an alternative to whole-breast irradiation as part of breast-conserving therapy. Indications and outcomes are topics of ongoing investigation. Previous publications have focused on early postoperative infections and reported low rates of delayed infection. We investigated the pattern of infection after catheter-based APBI at our institution.

METHODS

Patients who underwent single-entry catheter-based APBI were identified from an institutional prospective registry including data regarding comorbidities and outcomes. Time of infection was calculated from the date of definitive catheter insertion and classified as early (≤30 days) or delayed.

RESULTS

A total of 91 breast cancer patients were treated with APBI and enrolled in the registry from 2009 to 2011. The median follow-up was 484 days. Breast infection occurred in 13 (14.3 %), with 3 (3.3 %) occurring within 30 days of catheter placement and 10 (11.0 %) in a delayed fashion. Four patients required hospital admission, five underwent percutaneous aspiration, and one underwent incision and drainage. Eight were treated as outpatients with oral antibiotics alone.

CONCLUSIONS

Consistent with other reports, we found an overall infection rate of 14.3 % with single-entry catheter-based APBI. There were substantially fewer infections in the early postoperative period than reported elsewhere, but there were more delayed infections. The intensive follow-up in our study likely identified late infections that may not have otherwise been recognized. Vigilance for infectious complications must continue beyond the immediate treatment period in patients undergoing catheter-based APBI. These infections can range in severity but typically can be managed in an outpatient setting.

Brachytherapy in accelerated partial breast irradiation (APBI) - review of treatment methods

Breast conserving surgery (BCS) with following radiotherapy (EBRT) of the conserved breast became widely accepted in the last decades as the treatment of early invasive breast cancer. In an early stage of breast cancer, research has shown that the area requiring radiation treatment to prevent cancer from local recurrence is the breast tissue that surrounds the area where the initial cancer was removed. Accelerated partial breast irradiation (APBI) is an approach that treats only the lumpectomy bed with 1-2 cm margin, rather than the whole breast and as a result allows accelerated delivery of the radiation dose in four to five days. Published results of APBI are very promising. It is evident that APBI will play a role in the management of a selected group of early breast cancer. We discuss current status, indications, technical aspects and recently published results of APBI using different brachytherapy techniques.

Breast cancer recurrence after inadvertent malpositioning of a partial breast radiation catheter

Accelerated partial breast irradiation (APBI) is an alternative to receiving whole breast radiation in carefully selected patients. Because breast cancer local recurrence rates are low and follow-up has been short-term, the exact cause of recurrences after APBI has been difficult to evaluate. We report the first case of documented radiation balloon catheter malpositioning that resulted in local recurrence. Patients undergo CT imaging of the breast after radiation balloon catheter placement for radiotherapy treatment planning, which evaluates adequate conformance of the balloon to the surrounding breast parenchyma and confirms a >7 mm distance between the balloon surface and the skin surface. Although true local recurrences are rare in appropriately selected partial breast irradiation candidates, inadvertent malpositioning of the radiation treatment catheter can increase the risk. This case is presented to illustrate the importance of comparing CT radiation planning images, with treatment catheter in place, to the original diagnostic breast imaging studies to confirm proper catheter positioning (in addition to measuring balloon to skin distance and conformance) prior to initiating radiotherapy.

Accelerated partial breast irradiation in early breast cancer: focus on intraoperative treatment with electrons (ELIOT)

Wide tumor resection plus postoperative whole breast irradiation is standard treatment for early breast cancer. Irradiation decreases recurrence rates, but may cause poor cosmesis, breast pain, and cardiac and lung toxicity. Accelerated partial breast irradiation is increasingly used in the hope of increasing convenience, decreasing sequelae and maintaining cure rates. Intraoperative radiotherapy with electrons is an attractive accelerated partial breast irradiation technique because collimator placement is under the direct control of the surgeon who removes the tumor, the skin is spared, shielding protects the chest wall and complete irradiation can be given in a single intraoperative session (avoiding 5-7 weeks of whole breast irradiation). Intraoperative radiotherapy with electrons seems as safe as whole breast irradiation; however, long-term results on local control and survival are not available yet.

Six-year analysis of treatment-related toxicities in patients treated with accelerated partial breast irradiation on the American Society of Breast Surgeons MammoSite Breast Brachytherapy registry trial

BACKGROUND

The American Society of Breast Surgeons (ASBrS) enrolled women in a registry trial to prospectively study patients treated with the MammoSite RTS device. This report presents 6-year data on treatment-related toxicities from the trial.

METHODS

A total of 1449 primary early-stage breast cancers were treated with accelerated partial breast irradiation (APBI) using the MammoSite device (34 Gy in 10 fractions) in 1440 women. Of these, 1255 case (87%) had invasive breast cancer (IBC) (median size = 10 mm) and 194 cases (13%) had ductal carcinoma in situ (DCIS) (median size = 8 mm). Median follow-up was 59 months. Fisher exact test was performed to correlate categorical covariates with toxicity.

RESULTS

Breast seromas were reported in 28% of cases (35.5% with open cavity and 21.7% with closed cavity placement). Also, 13% of all treated breasts developed symptomatic seromas, and 77% of these seromas developed during the 1st year after treatment. There were 172 cases (11.9%) that required drainage to correct. Use of chemotherapy and balloon fill >50 cc were associated with the development of symptomatic seromas. Also, 2.3% of patients developed fat necrosis (FN). The incidence of FN during years 1 and 2 were 0.9% and 0.8%, respectively. Seroma formation, use of hormonal therapy, breast infection, and A/B cup size were associated with fat necrosis. There were 138 infections (9.5%) recorded; 98% occurred during the 1st year after treatment. Chemotherapy and seroma formation were associated with the development of infections.

CONCLUSIONS

Treatment-related toxicities 6 years after treatment with APBI using the MammoSite device are similar to those reported with other forms of APBI with similar follow-up.

Factors associated with optimal long-term cosmetic results in patients treated with accelerated partial breast irradiation using balloon-based brachytherapy

PURPOSE

To evaluate factors associated with optimal cosmetic results at 72 months for early-stage breast cancer patients treated with Mammosite balloon-based accelerated partial breast irradiation (APBI).

METHODS AND MATERIALS

A total of 1,440 patients (1,449 cases) with early-stage breast cancer undergoing breast-conserving therapy were treated with balloon-based brachytherapy to deliver APBI (34 Gy in 3.4-Gy fractions). Cosmetic outcome was evaluated at each follow-up visit and dichotomized as excellent/good (E/G) or fair/poor (F/P). Follow-up was evaluated at 36 and 72 months to establish long-term cosmesis, stability of cosmesis, and factors associated with optimal results.

RESULTS

The percentage of evaluable patients with excellent/good (E/G) cosmetic results at 36 months and more than 72 months were 93.3% (n = 708/759) and 90.4% (n = 235/260). Factors associated with optimal cosmetic results at 72 months included: larger skin spacing (p = 0.04) and T1 tumors (p = 0.02). Using multiple regression analysis, the only factors predictive of worse cosmetic outcome at 72 months were smaller skin spacing (odds ratio [OR], 0.89; confidence interval [CI], 0.80-0.99) and tumors greater than 2 cm (OR, 4.96, CI, 1.53-16.07). In all, 227 patients had both a 36-month and a 72-month cosmetic evaluation. The number of patients with E/G cosmetic results decreased only slightly from 93.4% at 3 years to 90.8% (p = 0.13) at 6 years, respectively.

CONCLUSIONS

APBI delivered with balloon-based brachytherapy produced E/G cosmetic results in 90.4% of cases at 6 years. Larger tumors (T2) and smaller skin spacing were found to be the two most important independent predictors of cosmesis.

Electronic brachytherapy as adjuvant therapy for early stage breast cancer: a retrospective analysis

PURPOSE

This multicenter, retrospective study evaluated treatment and clinical outcomes of patients with early stage breast cancer who received adjuvant high-dose rate (HDR) electronic brachytherapy (EBT) treatment post-lumpectomy using the Axxent(®) EBT system. Dosimetric data from the EBT treatment plans were compared with those based on iridium-192 HDR brachytherapy.

MATERIAL AND METHODS

Medical records of 63 patients with early stage breast cancer (Tis, T1a, T1b, T1c, and T2) who were treated post-lumpectomy with EBT alone or in combination with external beam radiation therapy were reviewed. The prescribed EBT dose was 34 Gy (10 fractions over 5 days, 3.4 Gy each) to 1 cm from the balloon surface. Dosimetry data from 12 patients were compared with these of treatment plans using an iridium-192 source prepared for the same 12 patients.

RESULTS

The majority of patients (90.5%) were older than 50 years and had one or more risk factors for breast cancer (80.6%). Tumor sizes were 0.1 cm to 3.5 cm (mean 1.3 cm). Median follow-up was 7 months (1 to 18 months) post-EBT. Balloon applicators were implanted 0 to 85 days (mean 13.4 days) post-lumpectomy/re-excision. The most common adverse events were erythema, rash dermatitis, and pain or breast tenderness. No recurrences were reported. Dosimetric analyses demonstrated comparable target coverage, increased high-dose regions, and a significantly reduced dose to the ipsilateral breast and lungs as well as the heart with EBT as compared with the iridium-192 treatment plans.

CONCLUSION

This retrospective, multicenter study showed that postsurgical adjuvant radiation therapy for early stage breast cancer can be administered using the EBT system with similar toxicity outcomes to those reported with iridium-192 brachytherapy. EBT offers a convenient, portable, nonisotope alternative to HDR brachytherapy using iridium-192.

Dosimetric effects of an air cavity for the SAVI partial breast irradiation applicator

PURPOSE

To investigate the dosimetric effect of the air inside the SAVI partial breast irradiation device.

METHODS

The authors have investigated how the air inside the SAVI partial breast irradiation device changes the delivered dose from the homogeneously calculated dose. Measurements were made with the device filled with air and water to allow comparison to a homogenous dose calculation done by the treatment planning system. Measurements were made with an ion chamber, TLDs, and film. Monte Carlo (MC) simulations of the experiment were done using the EGSnrc suite. The MC model was validated by comparing the water-filled calculations to those from a commercial treatment planning system.

RESULTS

The magnitude of the dosimetric effect depends on the size of the cavity, the arrangement of sources, and the relative dwell times. For a simple case using only the central catheter of the largest device, MC results indicate that the dose at the prescription point 1 cm away from the air-water boundary is about 9% higher than the homogeneous calculation. Independent measurements in a water phantom with a similar air cavity gave comparable results. MC simulation of a realistic multidwell position plan showed discrepancies of about 5% on average at the prescription point for the largest device.

CONCLUSIONS

The dosimetric effect of the air cavity is in the range of 3%-9%. Unless a heterogeneous dose calculation algorithm is used, users should be aware of the possibility of small treatment planning dose errors for this device and make modifications to the treatment delivery, if necessary.

Five-year analysis of treatment efficacy and cosmesis by the American Society of Breast Surgeons MammoSite Breast Brachytherapy Registry Trial in patients treated with accelerated partial breast irradiation

PURPOSE

To present 5-year data on treatment efficacy, cosmetic results, and toxicities for patients enrolled on the American Society of Breast Surgeons MammoSite breast brachytherapy registry trial.

METHODS AND MATERIALS

A total of 1440 patients (1449 cases) with early-stage breast cancer receiving breast-conserving therapy were treated with the MammoSite device to deliver accelerated partial-breast irradiation (APBI) (34 Gy in 3.4-Gy fractions). Of 1449 cases, 1255 (87%) had invasive breast cancer (IBC) (median size, 10 mm) and 194 (13%) had ductal carcinoma in situ (DCIS) (median size, 8 mm). Median follow-up was 54 months.

RESULTS

Thirty-seven cases (2.6%) developed an ipsilateral breast tumor recurrence (IBTR), for a 5-year actuarial rate of 3.80% (3.86% for IBC and 3.39% for DCIS). Negative estrogen receptor status (p=0.0011) was the only clinical, pathologic, or treatment-related variable associated with IBTR for patients with IBC and young age (<50 years; p=0.0096) and positive margin status (p=0.0126) in those with DCIS. The percentage of breasts with good/excellent cosmetic results at 60 months (n=371) was 90.6%. Symptomatic breast seromas were reported in 13.0% of cases, and 2.3% 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 60.5 months, the 5-year actuarial rate of IBTR was 3.04%.

CONCLUSION

Treatment efficacy, cosmesis, and toxicity 5 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.

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.

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.

Incidence and prognostic factors for seroma development after MammoSite breast brachytherapy

PURPOSE

Describe the incidence and identify risk factors for seroma development after MammoSite breast brachytherapy (MBT).

METHODS AND MATERIALS

MBT patient data were prospectively recorded into a quality assurance database. Departmental and electronic records were reviewed to extract patient-, treatment-, and outcome-specific data. Stepwise logistic regression analysis was performed to identify factors associated with development of any seroma including the subset of clinically significant seroma (CSS). CSS was defined as a symptomatic seroma requiring multiple aspirations, biopsy, and/or excision. Variables analyzed included age, weight, number of excisions, time from resection to catheter placement, placement technique, balloon volume, dosimetric factors, and postbrachytherapy infection.

RESULTS

MBT was performed in 109 patients, of whom 97 had minimum 6 months (median, 36) post-MBT follow-up or earlier development of seroma. All patients received 34 Gy to 1cm depth from balloon surface, delivered twice daily in 10 fractions. Seroma developed in 41% of patients at a median of 3 months (range, 0.1-25) post-MBT. One-third of seromas (13% of all patients) were CSS. The only factor identified as statistically significant for development of any seroma was catheter placement on day of resection vs. > or =1 day later (59% vs. 33%; p = 0.0066). Post-MBT infection was highly statistically significant for development of CSS (64% vs. 7%; p<0.0001). Prophylactic antibiotics reduced the risk of post-MBT infection from 37.5% to 6% (p = 0.011).

CONCLUSIONS

The incidence of CSS after MBT is low. Post-MBT infection is statistically significantly associated with CSS development, the incidence of which is reduced with prophylactic antibiotics.

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.

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.

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.

[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.

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.

Placement Technique and the Early Complications of Balloon Breast Brachytherapy

BACKGROUNDS AND OBJECTIVES

Open (OT) and percutaneous closed (PCT) techniques have been described for placement of the MammoSite catheter to deliver accelerated partial breast brachytherapy. We report early complications of both techniques.

METHODS

A total of 125 patients underwent catheter placement for MammoSite high-dose rate brachytherapy, with 108 patients successfully completing treatment. The OT was used in 85 patients and PCT in 40 patients. The mean distance between the balloon surface and breast skin was 1.44 cm and 1.31 cm, respectively. Average skin dose was 278 cGy in the OT group and 295 cGy in the PCT group (P > 0.05). Average gross specimen size was 43.16 cm3 in the OT group and 62.19 cm3 in the PCT group. Median follow-up was 11 months for the OT group and 5 months for the PCT group.

RESULTS

In 17 cases, the catheter was subsequently removed without the patient completing treatment. Two of the patients in the OT group (3%) developed a delayed abscess. The overall incidence of persistent seroma (>6 months) was 20% with all occurring in the OT group, 30% of those patients. There were no acute skin toxicities higher than grade 2. The overall cosmesis is excellent or good in 95% of patients.

CONCLUSION

Despite short follow-up and a small sample size in this study, it seems that the MammoSite brachytherapy was well tolerated by patients with early stage breast cancer when using either the OT or PCT.

Use of Ultrasound in Breast Surgery

The use of ultrasound has grown tremendously since it was introduced in 1951. This article describes use of this modality in patients who have breast disease.

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.

The emergence of advanced brachytherapy techniques for common malignancies

The recent advent and integration of sophisticated radiation planning and imaging modalities has improved the quality of brachytherapy treatments, allowing for more conformal radiation delivery. Further investigation and follow-up are necessary to demonstrate improvements in outcome and morbidity with these refined approaches.

Radiation Options for Early Stage Breast Cancer

OBJECTIVE

To explore the current radiation therapy options for early stage breast cancer.

DATA SOURCES

Research literature and review articles.

CONCLUSION

With 20 years of clinical data supporting the efficacy of whole breast radiotherapy after lumpectomy for early stage breast cancer, the attention has shifted to an even more conservative approach, namely partial breast irradiation following lumpectomy. A number of large clinical trials in North America and Europe are currently enrolling patients for the evaluation of several different techniques, including interstitial brachytherapy, the Mammosite device, 3-dimensional conformal external radiation therapy, and intraoperative radiotherapy.

IMPLICATIONS FOR NURSING PRACTICE

Radiation oncology nurses can significantly impact the coordination of services and the education of patients who enroll in these important clinical trials.

Accelerated Partial Breast Irradiation Using the MammoSite Device: Early Technical Experience and Short-Term Clinical Follow-Up

The MammoSite brachytherapy system is a novel form of intracavitary accelerated partial breast irradiation (APBI) that allows treatment over a 5- to 7-day course after breast conserving surgery (BCS). Fifty-one patients with invasive breast carcinoma underwent BCS and APBI using the MammoSite device, with 30 (59%) patients having drain placement in the lumpectomy cavity. Main outcome measures included time to initiating APBI, cosmesis using the Harvard Scale, and local and distant tumor recurrence with short-term follow-up. Five (9.8%) devices were explanted because of unfavorable final pathological findings or infection. Mean time to the start of APBI in patients without drain placement was 7.2 days (range, 5–12 days) compared with 5.1 days (range, 3–8 days) in patients with drains (P = 0.003). Cosmetic results were excellent in 25 (54.3%) patients, good in 19 (41.3%) patients, and fair in 2 (4.4%) patients. With a mean follow-up of 16 months (range, 6–38 months), no ipsilateral breast recurrences developed in any of the 51 patients. Thirteen patients had at least a 2-year follow-up. Two patients developed brain metastases and died at 19 and 23 months, respectively. The favorable short-term outcomes support further studies comparing APBI with standard whole-breast irradiation in patients undergoing BCS.

Local Recurrence of Breast Cancer after MammoSite® Brachytherapy

Women undergoing breast conservation therapy (BCT) for stage 1 breast cancer have adjuvant external beam radiotherapy (EBR). In addition, the use of brachytherapy radiation is being used. We present two local tumor recurrences for review. Our first patient underwent BCT, sentinel lymph node biopsy (SLNBx) and MammoSite® brachytherapy for a T1N0M0 infiltrating ductal carcinoma (IDC) of the right breast. Pathology: 0.6 cm poorly differentiated ER, PR, and Her-2/ Neu negative IDC. At 18 months, she had palpable axillary lymph nodes. Fine needle aspiration and ultrasound-guided core biopsy of a nodule showed IDC. She underwent modified radical mastectomy (MRM) and EBR. Our second patient underwent BCT, SLNBx, and MammoSite® brachytherapy for a T1N0M0 IDC of the left breast. Pathology: 0.8 cm poorly differentiated, ER+, PR-, and Her-2/Neu negative tumor. At 18 months, a retroareolar mass was detected. Ultrasound guided core needle biopsy showed recurrent IDC. She chose a re-excision and EBR and not MRM. Pathology: 1.3 cm poorly differentiated, ER+, PR-, and Her-2/Neu negative tumor. Our 2 recurrences were >2 cm away from the lumpectomy site and therefor outside the 1 cm treatment plan of the MammoSite® catheter. Both recurrences were biologically identical to the initial tumors and are felt to be local failures rather than new primaries.

Persistent seroma after intraoperative placement of MammoSite for accelerated partial breast irradiation: Incidence, pathologic anatomy, and contributing factors

PURPOSE

To investigate the incidence of, and possible factors associated with, seroma formation after intraoperative placement of the MammoSite catheter for accelerated partial breast irradiation.

METHODS AND MATERIALS

This study evaluated 38 patients who had undergone intraoperative MammoSite catheter placement at lumpectomy or reexcision followed by accelerated partial breast irradiation with 34 Gy in 10 fractions. Data were collected regarding dosimetric parameters, including the volume of tissue enclosed by the 100%, 150%, and 200% isodose shells, dose homogeneity index, and maximal dose at the surface of the applicator. Clinical and treatment-related factors were analyzed, including patient age, patient weight, history of diabetes and smoking, use of reexcision, interval between surgery and radiotherapy, total duration of catheter placement, total excised specimen volume, and presence or absence of postprocedural infection. Seroma was verified by clinical examination, mammography, and/or ultrasonography. Persistent seroma was defined as seroma that was clinically detectable >6 months after radiotherapy completion.

RESULTS

After a median follow-up of 17 months, the overall rate of any detectable seroma was 76.3%. Persistent seroma (>6 months) occurred in 26 (68.4%) of 38 patients, of whom 46% experienced at least modest discomfort at some point during follow-up. Of these symptomatic patients, 3 required biopsy or complete cavity excision, revealing squamous metaplasia, foreign body giant cell reaction, fibroblasts, and active collagen deposition. Of the analyzed dosimetric, clinical, and treatment-related variables, only body weight correlated positively with the risk of seroma formation (p = 0.04). Postprocedural infection correlated significantly (p = 0.05) with a reduced risk of seroma formation. Seroma was associated with a suboptimal cosmetic outcome, because excellent scores were achieved in 61.5% of women with seroma compared with 83% without seroma.

CONCLUSION

Intraoperative placement of the MammoSite catheter for accelerated partial breast irradiation is associated with a high rate of clinically detectable seroma that adversely affects the cosmetic outcome. The seroma risk was positively associated with body weight and negatively associated with postprocedural infection.

Image-guided breast brachytherapy: an alternative to whole-breast radiotherapy

Lumpectomy and whole-breast radiotherapy (ie, breast-conservation treatment) are accepted as viable alternatives to mastectomy in locoregional management of breast cancer. These techniques are used to keep morbidity to a minimum, optimise cosmesis, and maintain treatment outcomes. Pathological and clinical data suggest that most recurrences of cancer in the ipsilateral breast are in the vicinity of the index lesion, and that remote recurrences are uncommon, whether or not whole-breast radiotherapy is delivered. These data lend support to the idea of partial-breast radiotherapy. Such a restricted treatment volume allows safe delivery of an accelerated hypofractionated regimen over a shortened course of 1 week. This technique differs from that of standard whole-breast tangential external-beam radiotherapy and necessitates investigation of accelerated partial-breast irradiation (APBI). Several techniques of APBI are being investigated; however, most experience, and the most favourable early outcomes, has been obtained with image-guided breast brachytherapy. This review highlights the rationale and outcomes of brachytherapy techniques.

Photodynamic therapy of the intact breast

As breast cancer is diagnosed in over a million patients a year it is a significant oncological issue. Treatment paradigms have shifted to emphasize breast preservation protocols. However, due to a lack of equipment and facilities this option is only rarely offered to poverty stricken patients and those in the developing world. Photodynamic therapy may play a role in allowing for greater breast conservation based in part on the emerging success of partial breast radiation. This paper will review the rationale behind and technical aspects for intact breast photodynamic therapy.