About Breast Cancer

Brachytherapy Treatment

Typical Breast Brachytherapy schedule

Illustration: A photo of inflammatory breast cancer that grew back in the scar area after mastectomy.
Take a moment and watch this excellent video of Dr. Coral Quiet reviewing the breast brachytherapy radiation options. She covers many of the choices, treatments and what you can expect. Just click on the arrow in the video and it will begin.
Illustration: A photo of inflammatory breast cancer that grew back in the scar area after mastectomy.

Breast brachytherapy is a 5-day radiation therapy alternative for women with early stage breast cancer. Some of the highlights are:

 

The preferred treatment for early stage breast cancer is surgical removal of the cancerous lump (lumpectomy) followed by radiation therapy to the breast; radiation therapy following this eliminates the invisibly small deposits of cancer that can remain in the breast after lumpectomy.
External beam radiation therapy is safe and very effective, but can take over six weeks of daily treatment.
Breast Irradiation reduces the local reoccourance rate from approximately 30% (lumpectomy alone) to 5% (lumpectomy + radiation therapy). Two major international trials have compared 6 weeks whole breast irradiation to APBI. The European trial demonstrated equivalent tumor control. The North American clinical trial showed a 0.7% difference favoring the 6 week program.
Breast brachytherapy is an accelerated 5-day treatment for selected patients with early stage breast cancer. This technique treats a much smaller volume of breast tissue and minimizes radiation exposure to the lung, heart, and skin.
Dr Kuske was the first physician in the world to perform breast brachy therapy on a patient with breast implants. Inserting catheters close to a woman’s implant requires great skill and experience, not typically available anywhere else. To read more, please click here.
Dr. Robert Kuske, Dr. Coral Quiet, Dr. Lucy Chen, Dr. Steve Sckolnik and Dr. Scott Tannehill have treated over 3000 patients, by far the largest breast brachytherapy experience in the world!
More than 60% of our patients desiring breast brachytherapy come from out of Arizona or the USA.

What is Breast Brachytherapy (brăk – ē – therapy)?

This year, more than 200,000 new cases of breast cancer will be diagnosed in the United States. Surgical removal of the cancer lump (lumpectomy) is usually the first step. After this surgery, women with early breast cancer are offered mastectomy(surgical removal of the entire breast) or radiation therapy to the breast. Most women choose radiation because the survival rate for such treatment is the same as with mastectomy, and it allows the patient to preserve her breast.

Radiation treatments are given to kill off any possible remaining cancer cells in the breast. Radiation is done to help prevent a recurrence, or return, of breast cancer and can be given with external or internal radiation. External beam radiation, also called whole-breast irradiation (WBI), treats the whole breast from the outside, by aiming highly penetrating x-rays at your tumor cavity.

External beam radiation begins four to six weeks after surgery. Patients receive one treatment a day for six to seven weeks. It is very successful in preventing recurrence of cancer in the breast, but many women find the long duration of treatment to be burdensome.
There is another option – Brachytherapy. Breast Brachytherapy means placing radiation sources (usually tiny pellets the size of pencil lead) inside and adjacent to a cancer, or inside an area that may contain residual cancer after surgical removal of the visible tumor mass.

Take a moment and watch this excellent video of Dr. Robert Kuske discussing breast brachytherapy, how it works and the different methods in providing this 5-day treatment for breast cancer. Just click on the arrow in the video and it will begin.
This is pronounced ‘brak- e – therapy’ with the first ‘a’ pronounced as the ‘a’ in bat. If you are from Harvard, you may prefer to pronounce it ‘bray – key – therapy’ and this is acceptable, but perhaps a tad snobbish. “Brachy” comes from the Greek root meaning from a short distance. For example, the brachysaurus was a dinosaur with short front limbs. In the case of breast cancer, brachytherapy is a form of partial breast irradiation in which tissue adjacent to the original cancerous breast lump is treated after the lumpectomy with radiation sources placed within this area, for a very brief period, over several (in this case usually ten) treatment sessions. This is accomplished by many different catheter (plastic tube) systems commercially available, such as the MammoSite® balloon catheter, the SAVI® (egg-whisk like) device, the Contura® multi-channel balloon catheter, or multiple thin catheters placed individually around the tumor site.
Brachytherapy has been an accepted treatment method for many cancers for no less than 100 years. Brachytherapy was used decades before the first ‘beam’ emitting radiation treatment machine was built. Cancers that are commonly treated with brachytherapy include cancers of the cervix and uterus, mouth and throat, prostate, and cancers of muscles called sarcomas. For cancer of the cervix in women, the use of brachytherapy is considered critical for cure. And today brachytherapy is performed thousands of times each year for men with prostate cancer and is as effective as surgical removal of the prostate for many men with this disease.

How does Brachytherapy work?

Brachytherapy involves placing a radiation source within or close to the cancer. Using brachytherapy, doctors can reduce the radiation exposure to nearby normal tissues that do not need – and can be harmed by – the radiation. Brachytherapy is used to treat many cancers, including prostate cancer and gynecologic cancers.

The beauty of breast brachytherapy lies in the laws of physics: very close to the radioactive seeds, the radiation intensity is very high, but just a short distance away (millimeters) this radiation intensity falls off rapidly. This law of physics gives us a therapeutic advantage: if the seeds are precisely positioned in the tissues containing cancer cells, the normal tissues such as lung, heart, ribs, and skin that are not at risk for having cancer cells can be avoided!

It is regarded as a safe and effective alternative to standard external beam treatment for many patients with breast cancer; overall patient survival with either approach is going to be similar. The primary reason a woman would select breast brachytherapy over standard external beam radiation is time: external beam radiation requires over six weeks of daily treatment, but breast brachytherapy can be completed in one week.

The History of Brachytherapy

Brachytherapy was the second treatment for breast cancer in history. Dr. Robert Kuske is the pioneer of this method of treating breast cancer. 

Breast Brachytherapy Options

To make breast brachytherapy practical for radiation oncologists everywhere, Dr. Kuske developed a technique for doing this procedure with greater ease, quality control, and image-guidance. Now templates with pre-drilled holes and moderate breast compression have simplified the insertion of catheters into the correct locations around the lumpectomy cavity with CT scanner guidance every millimeter of the way.

After the success of this “Multiple Catheter” Technique, developed by Dr. Kuske, the commercial vendors have used this concept and developed so-called ‘single-entry’ devices. These breast brachytherapy devices can be placed by surgeons or radiation oncologists after lumpectomy through a small incision in the skin. Thousands of women with select breast cancers have now been successfully treated with these catheter systems. Examples include the MammoSite®, SAVI®, and the Contura Balloon®

This excellent video below features Dr. Robert Kuske discussing the different breast brachytherapy options for women with breast cancer. The first part of the video features a healthy squash soup recipe. Dr. Kuske’s video begins at the 6:00 minute mark.

Multiple Catheter Technique

For some women, the prospect of having multiple thin plastic catheters in their breast can be intimidating.

Illustration: The template is applied and a “targeting” CT san is done. The cavity is shaded above.

Actually, the catheter insertion is performed under generous local anesthesia, combined with some oral medications to relax the patient and to provide additional pain relief. Our goal is to make this procedure painless and bloodless. We keep a list of treated patients who have agreed to be ‘references.’ Call them and ask about their experience! Breast brachytherapy catheter placements and the radiation treatments are described in detail on our site under Brachytherapy Treatment.

All patients will first have a consultation with one of our physicians. During this consult, we review all of information, perform a careful physical exam, and then counsel the patient carefully about all of her options, including external beam radiation therapy and brachytherapy.

If she chooses breast brachytherapy, we schedule our clinic operating room for the 1 to 2-hour procedure and make sure we have the patient’s favorite music loaded into our stereo system! Remember, you are awake and joking with the physician throughout the procedure. Before the procedure, we offer patients a mild pain killer and a mild relaxing medication, both in pill form.

During the procedure, the patient lays on her back with a pillow under her knees for comfort. The template is positioned carefully around the breast and moderate compression applied with the 2 thin Plexiglas templates.

Illustration: Using the CT information, the template holes to be used are indentified and marked.

As you can see in this actual case, the cavity is seen as deep purple, the skin is colored blue, and the target tissue is pink 2 cm around the cavity.

The holes that cover the target volume are clearly seen and marked with a red X on the form at the top. Meticulous coverage to the millimeter of the target tissue is achieved every time!

Local anesthetic is injected with a very thin needle through the selected holes in the template, which encompass the location of the lumpectomy cavity plus 2 cm (about 3/4 inch) all around.

This local anesthetic is mixed with sodium bicarbonate, so there is none of the usual initial burning pain before it goes numb. This local anesthetic also contains small amounts of epinephrine, which stops bleeding from small blood vessels; there is very little bleeding from this procedure.

Illustration: Local anesthetic is injected into the breast where catheters are to be placed.

Most patients have NO pain and NO bleeding with catheter insertion that follows the anesthetic injection. Patients are awake, talking with us during the procedure and listening to Mozart, Billy Joel, New Age, rock, or their favorite music the whole time (please – no hip-hop or rap!). Most are surprised when it is all over. The local anesthetic wears off in 6 hours and for any soreness or pain that persists, we provide pain medications and mild sleep aids. After one day, however, many patients do not require anything more than Tylenol for the pain.

The following day (sometimes this is done the same day) the patient returns to our clinic for a radiation planning and dose-calculation CT scan. This visit will last about 60 – 90 minutes and the patient does not need to take any contrast ‘dye’ by mouth or in her veins, as many regular diagnostic CT scans require. After this planning CT scan, she can return home. 

Using the information from this planning CT scan, our physicists carefully program the radiation treatment machine to deliver a customized treatment. The treatments start the next day (two days after the catheter placement procedure). We treat patients Mondays-Fridays, but treatment can start on any day of the week. Patients receive ten treatments over five consecutive clinic days (treatments are given twice daily with six hour intervals between treatments). Each visit takes less than an hour. After the last treatment, the catheters are removed easily and painlessly.

The beauty of this technique is that it delivers radiation to the 2 cm (approximately 3/4 inch) of breast tissue surrounding the surgical cavity edge, with elegant precision. It’s worth noting that this 2 cm coverage breadth is more than the treatment distance of the commercially available ‘single-entry’ devices mentioned above.

Furthermore, unlike these devices, this interstitial technique can treat unusual cavity shapes and volumes. The physicians in our practice have more experience with this valuable interstitial multiple-catheter technique than any center in the world!

Illustration: Multiple Catheter Technique. Step 1 – The target for the catheter implant is the tissue around the lumpectomy cavity. Step 2 – An x-ray dye (contrast) is injected into the cavity under local anesthesia.

What to Expect

A typical evaluation and treatment sequence would be:

  • Review of pathology, mammography, ultrasound, and MRI results by the radiation oncologist to determine suitability and feasibility of breast brachytherapy.
  • Consultation with physical exam by the radiation oncologist.
  • Ultrasound and/or CT in our office to evaluate the surgical cavity size and shape. This step confirms that the size and shape of the surgical cavity is appropriate for this procedure.
  • Review of pathology, mammography, ultrasound, and MRI results by the radiation oncologist to determine suitability and feasibility of breast brachytherapy.
  • Discussion with the radiation oncologist regarding possible techniques: interstitial multiple-catheter technique vs SAVI® vs Contura® vs MammoSite®
  • The catheter(s) placement procedure is performed. The interstitial technique is done by one of our physicians, but the SAVI®, Contura®, or MammoSite® can be placed by either your breast cancer surgeon or by one of our physicians.
  • The radiation planning CT is done the day of, or the day after, the catheter insertion. This is a special type of CT scan done in our clinic.
  • Our Physicists require one full day to plan and create the perfect treatment. Treatment begins usually 2 working business days after catheter insertion, often on a Monday.
  • After the last treatment, we remove the catheter(s) and you go home. We see you one week later to check the healing of your breast, and again one month later.
  • Overall duration with catheters in place: usually 8-9 days.
  • Treatments usually last between 6 and 15 minutes each, and the patient is in the clinic for about 40 minutes each time, including nursing time to clean and dress the catheter entry sites. Treatments are generally 6 hours apart. Treatments typically, but not always, take 5 business days (Monday through Friday).
  • The first follow-up mammogram is 6 months after treatment: sign out your films and bring them in to the radiation oncologist for a “second over-reading” of your films with the physician explaining what we look for on the breast images. We integrate your future follow-up visits with the surgeon and medical oncologist; we believe your radiation oncologist is a vital part of your follow-up evaluation and strive to participate in your follow-up long term.

MammoSite®, SAVI®, Contura®, and other present and future devices.

These balloon or egg-whisk shaped devices are single-entry devices and can be inserted by the surgeon or one of our physicians. The beauty of these devices is in their simplicity. The size and shape of the surgical cavity is critically important to whether these devices can be used. The separation of the cavity from the skin is also a key factor. For example, if the MammoSite balloon is less than 7 mm from the skin surface, we will usually pull it and go to another technique. These devices treat 1 cm of tissue beyond the cavity edge (a little more than 1/3 of an inch), rather than the 2 cm of the multicatheter technique, so we select women with favorable breast cancers for the single entry devices. We have reviewed each device in the next section on our website.

Contura® Balloon

Another option for women needing partial breast irradiation after their lumpectomy is the Contura® balloon. The innovative design of the Contura balloon allows the doctor to fill the empty space left by the lumpectomy procedure.

Contura’s radiation balloon creates a vacuum to conform and adhere closely to the lumpectomy site. A targeted radiation dose will then be administered only where it is needed in the breast, sparing exposure to otherwise normal breast tissue. Treatment time is reduced to just five days instead of over six weeks.

This illustration shows 4 offset catheters inside the balloon to sculpt the dose away from the skin or chest wall and provides suction to remove fluid or air in the breast tissue around the balloon.

Compared to traditional radiation therapy, Contura’s benefits are greater accuracy and refinement.

  • Highly focused radiation often cuts treatment time dramatically (5 days vs. 6-7 weeks of treatment)
  • Refined placement of radiation sources and targeted radiation doses will minimize damage to healthy breast and surrounding tissues

Allows for dose shaping by using 5 catheters located inside the balloon.

  • FDA approved May 2007
  • Contura places the radiation source inside the lumpectomy cavity (the space left when a tumor is removed). This delivers radiation to the area where cancer is most likely to recur. Multiple catheters help sculpt the dose away from skin or ribs.
  • The therapy is given on an outpatient basis. No hospital stay is required.
  • Treatment is twice a day (usually 6 hours between treatments).
  • Treatments are painless and usually take about 10 minutes.

What to Expect

A typical evaluation and treatment sequence would be:

  • Consultation with physical exam by the radiation oncologist Review of pathology, mammography, ultrasound, and MRI results by the radiation oncologist to determine suitability and feasibility of breast brachytherapy.
  • An ultrasound and/or CT will be done in our office to evaluate the surgical cavity size and shape. This step confirms that the size and shape of the surgical cavity is appropriate for this procedure.
  • Discussion with the radiation oncologist regarding possible techniques: interstitial multiple-catheter technique vs SAVI® vs Contura® vs. MammoSite®.
  • If you are a candidate for the Contura device, we will make arrangements for placement of the catheter on a separate day.
The device placement procedure is performed either by your surgeon or one of our physicians. Sometimes a temporary balloon device is placed at the time of surgery. If you are a good candidate for this technique, your surgeon will switch out the temporary catheter to the treatment device. Placement of the catheter is done with ultrasound. A small area is numbed up and a nick is made in the skin. A tunnel is created from the skin to the cavity and the device is placed into the cavity. Placement is done in the office and does not require pain medication, only local anesthesia.
Illustration: The pink area on these photos show the approximate area that was irradiated using the Contura Balloon (left) and with traditional whole-breast irradiation (right.)

The radiation planning CT is done the day of, or the day after, the catheter insertion. This is a special type of CT scan done in our clinic. Sometimes the device may need extra tweaking to get it in the perfect place to allow radiation to be given safely and most effectively.

Our Physics Team requires one full day to plan and create the perfect treatment. Treatment begins usually 2 working business days after the catheter insertion.

Treatments usually last between 6-15 minutes each, and the patient is in the clinic for about 40 minutes each time, including nursing time to clean and dress the catheter entry sites. Treatments are generally 6 hours apart. Treatments typically, but not always, are completed in 5 business days (Monday through Friday). Before each treatment, an ultrasound or CT scan will be done to ensure the Contura device is in the exact position.
The overall duration with the catheter in place is usually 8 to 9 days. After the last treatment, we remove the catheter and you go home. You will come back for a follow-up one week later to check the healing of your breast, and again one month later. The first follow-up mammogram is 6 months after treatment: sign out your films and bring them in to the radiation oncologist for a “second over-reading” of your films with the physician explaining what we look for on the breast images. We integrate your future follow-up visits with the surgeon and medical oncologist; we believe your radiation oncologist is a vital part of your follow-up evaluation and strive to participate in your follow-up long term.

MammoSite®

MammoSite®

MammoSite® targets radiation to the tissue adjacent to the lumpectomy site. MammoSite® places the radiation source inside the lumpectomy cavity (the space left when a tumor is removed). This delivers radiation to the area where cancer is most likely to recur.

Drs. Robert Kuske and Coral Quiet were among the first physicians to use this balloon. In fact, Dr. Kuske developed the balloon and did the original experiements with MammoSite® in goats! He still has a scar from where a goat expressed her dissatisfaction with the placement of her balloon.

Linda Rose discusses the Mammosite device and her experience with Dr. Kuske and brachytherapy.

The therapy is given on an outpatient basis. No hospital stay is required. Treatment is twice a day (usually 6 hours between treatments). Treatments are painless and usually take about 10 minutes.

5-year clinical trial data shows:

  • no local recurrences.
  • 82% of the patients had good/excellent cosmetic results.
  • 100% of patients in the initial clinical trial would recommend MammoSite® to a friend or family member.
  • 100% of patients in the initial clinical trial would use MammoSite® again if they had to do it over.

What to Expect

A typical evaluation and treatment sequence would be:

  • Consultation with physical exam by the radiation oncologist.
  • Review of pathology, mammography, ultrasound, and MRI results by the radiation oncologist to determine suitability and feasibility of breast brachytherapy.
  • An ultrasound and/or CT scan will be done in our office to evaluate the surgical cavity size and shape. This step confirms that the size and shape of the surgical cavity is appropriate for this procedure.
  • Discussion with the radiation oncologist regarding possible techniques: interstitial multiple-catheter technique vs. SAVI® vs. Contura® vs MammoSite®.
  • If you are a candidate for the MammoSite catheter, we will make arrangements for placement of the device on a separate day.
Illustration: Mammosite catheter treatment.
The catheter placement procedure is performed either by your surgeon or one of our physicians. Sometimes a temporary balloon device is placed at the time of surgery. If you are a good candidate for this technique, your surgeon will switch out the temporary catheter to the treatment device. Placement of the catheter is done with ultrasound. A small area is numbed up and a nick is made in the skin. A tunnel is created from the skin to the cavity and the device is placed into the cavity. Placement is done in the office and does not require pain medication, only local anesthesia.

The radiation planning CT is done the day of, or the day after, the catheter insertion. This is a special type of CT scan done in our clinic. Sometimes the catheter may need extra tweaking to get it in the perfect place to allow radiation to be given safely and most effectively.

Our Physics Team requires one full day to plan and create the perfect treatment. Treatment begins usually 2 working business days after catheter insertion.
Treatments usually last between 6 and 15 minutes each, and the patient is in the clinic for about 40 minutes each time, including nursing time to clean and dress the catheter entry sites. Treatments are generally 6 hours apart. Treatments typically, but not always, are completed in 5 business days (Monday through Friday). Before each treatment, an ultrasound or CT scan will be done to ensure the MammoSite catheter is in the exact position.
The overall duration with the catheter in place is usually between 8 and 9 days. After the last treatment, we remove the catheter and you go home. You will come in for a follow-up appointment one week later to check the healing of your breast, and again one month later. The first follow-up mammogram is 6 months after treatment: sign out your films and bring them in to the radiation oncologist for a “second over-reading” of your films with the physician explaining what we look for on the breast images. We integrate your future follow-up visits with the surgeon and medical oncologist; we believe your radiation oncologist is a vital part of your follow-up evaluation and strive to participate in your follow-up long term.

SAVI® Accelerated Partial Breast Irradiation

The SAVI is a breast radiation device that targets radiation to the tissue adjacent to the lumpectomy site. It is a single entry device that allows sculping of the dose to avoid the skin, rib or other normal tissue that does not need radiation. It can be custom-fitted to your lumpectomy cavity, regardless of what shape or size it may be. This device is a bundle of soft, tiny catheters.

Pamela Crosset discusses her views about Dr. Kuske, his office staff and the SAVI device.
The SAVI is inserted through a small incision, and the catheter bundle expands uniformly, but its unique design allows it to be opened in a way that truly conforms to the size and shape of your tumor cavity. The radiation dose can be individually controlled through each catheter, allowing precise targeting by our radiation oncologist.

The SAVI applicator is an evolution in radiation therapy for early-stage breast cancer.

Delivering treatment from inside the breast, SAVI uses multiple catheters to direct radiation where it is needed most.

This unique design allows for unparalleled dose sculpting ability that minimizes exposure to healthy tissue and reduces complications, making the benefits of breast brachytherapy available to more women.

The SAVI radiation applicator can be placed at the time of the patient’s lumpectomy, or it may be inserted during a separate surgery. Only a small incision is needed, to allow the compact catheter bundle to be placed within the breast. The incision area and the section of the cather bundle that extends outside the breast will be secured with a dressing until treatment is complete. The catheters are very flexible and soft, so they should be comfortable during the five days of radiation. Please click on the photo to the left to enlarge the diagram.
Treatments are given twice a day for five days and take approximately 30 minutes for each visit. Between 5 to 10 minutes of the appointment will be used for the radiation treatment time. During each treatment, the radiation source is sent down each catheter one at a time. A different amount of radiation dose will be given at different points along the length of each catheter. This provides the best dose for the affected tissue, and the most protection for surrounding healthy tissue. The illustration shows that only a small incision is needed to place the SAVI applicator in the breast. Please click on the photo to the left to enlarge the diagram.
After the final radiation treatment, the SAVI device is removed, which takes about two minutes. It is simple and quick. The incision site is then cleaned and closed with adhesive strips. A bandage or dressing is then placed on top to keep the area clean. Please click on the photo to the left to enlarge the diagram.

Drs. Robert Kuske and Coral Quiet were the first to use the SAVI® catheter and have treated over 100 women with the device with excellent results.

Take a moment and watch this excellent video of Dr. Robert Kuske discussing radiation therapy options, including the SAVI applicator, for early stage breast cancers. Just click on the arrow in the video and it will begin.

Learn More about a Typical Treatment Sequence

A typical evaluation and treatment sequence would be:

  • Consultation with physical exam by the radiation oncologist.
  • Review of pathology, mammography, ultrasound, and MRI results by the radiation oncologist to determine suitability and feasibility of breast brachytherapy.
  • An ultrasound and/or CT in our office will be done to evaluate the surgical cavity size and shape. This step confirms that the size and shape of the surgical cavity is appropriate for this procedure.
  • Discussion with the radiation oncologist regarding possible techniques: interstitial multiple-catheter technique vs. SAVI® vs. Contura® vs. MammoSite® .
  • If you are a candidate for the SAVI catheter, we will make arrangements for placement of the catheter on a separate day.
The catheter placement procedure is performed either by your surgeon or one of our physicians. Sometimes a temporary balloon device is placed at the time of surgery. If you are a good candidate for this technique, your surgeon will switch out the temporary catheter to the treatment device. Placement of the catheter device is done with ultrasound guidance. A small area is numbed up and a nick is made in the skin. A tunnel is created from the skin to the cavity and the device placed into the cavity. Placement is done in the office and does not require pain medication, only local anesthesia.

The radiation planning CT is done the day of, or the day after, the catheter insertion.

This is a special type of CT scan done in our clinic. Sometimes the catheter may need extra tweaking to get it in the perfect place to allow radiation to be given safely and most effectively.

Our Physics Team requires one full day to plan and create the perfect treatment. Treatment begins usually 2 working business days after catheter insertion.

Treatments usually last between 6 and 15 minutes each, and the patient is in the clinic for about 40 minutes each time, including nursing time to clean and dress the catheter entry sites. Treatments are generally 6 hours apart. Treatments typically, but not always, are 5 business days (Monday through Friday). Before each treatment, a CT scan will be done to ensure the SAVI catheter is in the exact position.

Overall duration with the catheter in place: usually 8 to 9 days. After the last treatment, we remove the catheter and you go home. You are scheduled for a one-week follow-up to check the healing of your breast, and again one month later. The first follow-up mammogram is 6 months after treatment: sign out your films and bring them in to the radiation oncologist for a “second over-reading” of your films with the physician explaining what we look for on the breast images. We integrate your future follow-up visits with the surgeon and medical oncologist; we believe your radiation oncologist is a vital part of your follow-up evaluation and strive to participate in your follow-up long term.

Who is Eligible for Breast Brachytherapy?

ABCs has put together the following selection criteria for Accelerated Partial Breast Irradiation (APBI).

To be a candidate for breast brachytherapy, a patient must have:

  • Invasive breast cancer or ductal carcinoma in situ (DCIS) 3 cm or less in size.
  • Node negative of no more than three positive lymph nodes of the axilla (armpit area). For patients with 3 or fewer positive nodes, we insist that the tumor has not penetrated the capsule of a lymph node (medical term: extranodal extension). We believe that patients with more than three nodes involved, or with extranodal extension, should consider comprehensive external beam radiation therapy to the breast and lymph node areas instead of brachytherapy.
  • Clear surgical margins of at least 1 mm.
  • Unicentric breast cancer (no other areas of the breast with cancer).
  • A negative pregnancy test or no possibility of pregnancy.
  • A time interval of no more than 6 weeks from lumpectomy or re-excision surgery, or breast ultrasound or CT evidence for a clear lumpectomy cavity edge for target volume definition.

New Guidelines from the American Society of Radiation Oncology, Biology, and Physics
Please Note – we do not use or condone these extremely strict criteria written primarily by physicians who do not offer accelerated partial breast irradiation, but present them for your information.

Suitable for APBI:

  • Age > 60 years
  • No BRCA 1/2 mutation
  • Tumor size < 2 cm, unicentric
  • Clinically unifocal with total size < 2 cm
  • Invasive ductal, mucinous, tubular, and colloid carcinomas
  • Margins negative by at least 2 mm
  • Node-negative or immunohistochemistry (+) cells only
  • No extensive intraductal component
  • No Lymphvascular Invasion
  • Estrogen receptor positive
  • No pure DCIS
  • No neoadjuvant therapy

Any of these criteria should invoke caution and concern when considering APBI:

  • Age 50 – 59 years
  • Tumor size 2.1 – 3.0 cm (invasive component)
  • Clinically unifocal with total size 2.1 – 3.0 cm
  • Invasive lobular carcinomas
  • Margins close < 2 mm
  • Extensive intraductal component < 3 cm
  • Limited or focal Lymphvascular Invasion
  • Estrogen receptor negative
  • Pure DCIS < 3 cm

Patients unsuitable for breast brachytherapy unless they are on a clinical trial:

  • Age < 50 years BRCA 1/2 mutation present
  • Tumor size > 3.0 cm or stage T3 or T4
  • Multicentricity
  • Multifocal disease > 3 cm in total size or clinically multifocal
  • Positive surgical margins
  • Pathologic involvement of any lymph nodes or if nodal surgery not performed for invasive cancers
  • Extensive intraductal component > 3 cm
  • Extensive Lymphvascular Invasion
  • Pure DCIS > 3 cm
  • Neoadjuvant therapy

ABCs Practice Guidelines for Accelerated Partial Breast Irradiation (APBI)

General Selection Criteria: APBI is an acceptable treatment option for women with unicentric breast cancers that are less than 3 cm in maximum extent, negative axillary lymph nodes or metastatic involvement of up to 3 nodes without extracapsular extension, with clear surgical margins by 1 mm or greater. We do accept synchronous bilateral breast cancers with bilateral APBI if each breast cancer meets the above criteria. Women with breast augmentation are also eligible for APBI if their cancers meet the above requirements. Recurrences or new primary breast cancers after prior radiotherapy may also be re-treated with APBI.

Certain patient subsets should be treated on clinical trial, if the patient is willing:

  • Metastases to 1 – 3 axillary nodes;
  • Young women under the age of 50 years;
  • Estrogen receptor negative;
  • Patients undergoing neoadjuvant chemotherapy whose post-chemo pathology stage and features fit the general criteria noted above.

If patients are eligible for clinical trial and refuse participation or decline randomization, they may receive APBI only by initialing on the consent form that they are choosing a treatment outside current guidelines.

Documenting unicentricity: In older women with fatty-replaced breast tissue, mammography and ultrasound may suffice to document that there is only one lesion in the breast. In younger women or patients with dense breasts or where mammography/ultrasound is not definitive, breast MRI can be helpful in ruling out multicentric breast cancer.

APBI techniques available at ABCs:

  • MammoSite or MammoSite-ml;
  • SAVI mini-6, SAVI 6-1, SAVI 8-1, SAVI 10-1;
  • Contura balloon;
  • CT-guided interstitial brachytherapy with the Kuske Template;
  • Ultrasound-guided interstitial brachytherapy.
    External Beam 3-d Conformal APBI (only for patients resolutely afraid of any device/catheter in her breast)

Choosing the optimal technique:

  1. Communicate with the surgeon as they may have preferences, and ask if they prefer inserting or do they prefer us providing the service;
  2. Perform breast ultrasound and/or CT at ABCs to evaluate the size and shape of the cavity;
  3. Tumor and patient characteristics may influence your decision, such as grade, size, margins, ER status, nodal involvement, or young age, since the PTV margin of expansion varies with different methods;
  4. If the skin separation to the anterior wall of the cavity is < 3 mm without any single entry device in place, then SAVI or interstitial brachytherapy would be the best choice;

If the cavity and seroma are no longer present (for example, the surgeon has sutured the cavity shut, or performed oncoplastic breast surgery, or so much time has elapsed that the seroma has been absorbed or become solid), then interstitial brachytherapy would provide the best option for APBI.

Most breast cancer patients with breast augmentation will require pinch-view interstitial brachytherapy with the template, with the exception being those women with surprisingly ample breast tissue or tumors in the axillary tail of breast above the implant.

Common dose schedules: 340 x 10 fractions over 5 treatment days is our gold standard. When holidays or patient’s vacation/work schedules come into play, other fraction schemes can be prescribed: 400 cGy x 8 over 4 days or 370 cGy x 9 over 4.5 days. For patients with prior RT exposure, we have used 300 cGy x 12 over 6 days.

Logistics: All planned brachytherapy procedures should be cleared through the Brachytherapy Scheduler at each office. The scheduler will coordinate the schedules of the surgeon, radiation oncologist, the medical physicist, the therapists running the HDR unit, and nursing.

Antibiotics: We do not routinely prescribe prophylactic antibiotics, but we have a low threshold for initiating them (usually Keflex or Cipro or Levaquin or Clindamycin or a Z-pack) if symptoms such as fever, chills, tender swelling, red-streaks, or pus arise. Excellent daily nursing care and patient/husband catheter care over weekends usually eliminates the need for antibiotics.

Follow-up: At one-week out from the end of brachytherapy, you will be scheduled for an appointment with your physician to check for a delayed infection or response to antibiotics during therapy. Then at one month out, you will come back so your physician can evaluate your healing after treatment. At 6 months after brachytherapy, you will have a mammogram and visit your physician with the mammogram films in hand for our review. Then, we will see you every 6 months for the first 5 years and yearly thereafter.

Photography: Digital frontal pictures of both breasts for symmetry and an oblique close-up of the treated breast at each and every follow-up visit are taken.

Breast Cancer and Breast Augmentation:
Silicone or Saline Implants

Did you know that breast implants have increased by an astounding 900% over the past decade and a half? Many of these women are now entering the age at which breast cancer risk is real. The number of augmented women who are diagnosed with breast cancer in the last few years has sky-rocketed!

How are these women treated for their breast cancer? More and more surgeons are recommending mastectomies, despite the obvious priority these women place on appearance and cosmetics! The reason for this is the high rate of hardening of the implant (55%) after conventional whole breast irradiation over 6 weeks. Whole breast irradiation wraps radiation dose around the entire implant, causing scar tissue to encompass the implant. Scar tissue tends to contract over time, like a rubber-band, resulting in shrinkage of the breast and sometimes-painful hardening called “capsular contracture.”
Suzanne Martin discusses her experience with Dr. Kuske and brachytherapy treatment with implants.

Is there a way to keep my breast and avoid this hardening of my implant? Yes. ABCs has revolutionized radiotherapy for augmented women by offering breast brachytherapy, or radioactive seed implantation into temporary catheters. Brachytherapy treats just the affected portion of the breast, from the inside-out, over 5-days instead of the traditional 6 weeks. Since very little of the implant receives radiation exposure, the scar tissue does not wrap around the silicone or saline implant, thus avoiding the shrinkage and hardening.

In considering your options, please note that breast reconstruction following a mastectomy produces long scars and a newly-created breast mound that lacks sensitivity and sensuality. So you do have the option of maintaining your breast and implant with partial breast irradiation. We have done pioneering work in this field and have the largest published series in the world on brachytherapy for augmented breast.
Click here to see a 7 Months Post Brachytherapy Treatment Photo

Click here to see 9 Months Post Brachytherapy Treatment Photos

Click here to see a 3.5 Years Post Brachytherapy Treatment Photo

Take a moment and watch this excellent video of Dr. Robert Kuske reviewing breast brachytherapy radiation for women with implants. Just click on the arrow in the video and it will begin.

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