The Surgeon’s Role in Breast Brachytherapy

Abstract

Although two-thirds of invasive breast cancers and half of non-invasive breast cancers are amenable to lumpectomy, only about 70% of such patients choose breast conservation. Of that group, up to one-third do not follow-up with radiation therapy despite it being clinically indicated. The reasons include the patient's and surgeon's attitude toward breast conservation as well as the inconvenience and distance of a suitable radiation facility. The advent of shorter courses of radiation therapy may encourage more patients to seek adjuvant therapy. An increasingly popular and more convenient alternative to traditional whole-breast radiation therapy in patients with early-stage breast cancer is accelerated partial breast irradiation (APBI), for which the American Society of Breast Surgeons and the American Brachytherapy Society have promulgated guidelines for candidate selection. Although several methods are emerging, the most widely used brachytherapy technique utilizes the MammoSite single-catheter balloon brachytherapy device. In a best practices symposium convened in 2006, breast surgeons from academic and community practices with extensive experience in balloon brachytherapy developed general guidelines for integrating APBI into a breast surgical practice. Important considerations include patient age, histology, tumor location and size, and breast size. Thoughtful lumpectomy planning is essential to optimize balloon placement. Real-time sonographic guidance is essential as the surgeon should attend closely to volume excised and cavity shape. A cavity evaluation device can act as a place holder while patient suitability for APBI is considered. Many breast surgeons expert in this procedure insert the balloon catheter in the office either through a de novo skin entrance site removed from the lumpectomy incision or through the original incision. Optimally, insertion occurs within 2-3 weeks after lumpectomy. Close and continual communication with the radiation oncologist is essential to assure optimal outcomes. In this review, several key aspects of a successful APBI program from a surgeon's perspective as well as a consensus panel from a best practices symposium on the topic herein are highlighted.

Experience With an Electronic Brachytherapy Technique for Intracavitary Accelerated Partial Breast Irradiation

“…A review of past treatment experiences with BCT reveals that 67% to 85% of tumor recurrences in breast tissue were in the immediate vicinity of the lumpectomy cavity. [11][12][13][14][15] In addition, tumor recurrences outside the lumpectomy region occurred with equal frequency following lumpectomy alone and lumpectomy with WBI. This finding suggests that equivalent local control rates can be achieved with partial breast irradiation limited to the area at highest risk.…”

Surgical perspectives from a prospective, nonrandomized, multicenter study of breast conserving surgery and adjuvant electronic brachytherapy for the treatment of breast cancer

“…Complications associated with the implantation of the balloon applicator are similar to complications reported during the insertion of a post surgical drain [27]. This type of complication has also been reported with 192 Ir-based balloon brachytherapy [11,15,16]. During this EBT study one patient had incisional redness/drainage at 3 months post-treatment, 2 patients had infection at 3 and 6 months, respectively, and 2 patients had seromas at or within 4 weeks of treatment.…”

“…In this study, patients were enrolled and screened post-lumpectomy. For patients undergoing lumpectomy with the intention of pursuing APBI, a surgeon should be able to determine at the time of lumpectomy whether a patient is likely to meet the eligibility requirements for successful post-operative balloon implantation [11]. The surgical technique used at the time of lumpectomy can help promote successful balloon spacing and help the patient meet the eligibility criteria.…”

“…In some patients, implantation of the balloon may be possible at the time of lumpectomy. Alternatively some surgeons have used a removable placeholder device, a cavity evaluation device (CED), to preserve the cavity while fashioning an easily accessible tract between the cavity and the skin surface [11]. This can facilitate balloon implantation in the post-operative period.…”

Ongoing Consideration of Cavity Evaluation Devices in the Treatment of Breast Cancer

“…To facilitate delayed, postoperative, percutaneous insertion of single-entry brachytherapy catheters, many surgeons elect to place temporary, expandable cavity evaluation devices (CED) at the time of lumpectomy to preserve the surgical cavity and maintain a tract between the skin and surgical cavity. 1 At the time of brachytherapy catheter placement, the CED may be deflated, withdrawn from the cavity, and easily replaced by a single-entry brachytherapy catheter inserted through the very same tract.…”