Get 20M+ Full-Text Papers For Less Than $1.50/day. Start a 7-Day Trial for You or Your Team.

Learn More →

Breast conservation therapy without capsular contracture in young augmented women using interstitial brachytherapy

Breast conservation therapy without capsular contracture in young augmented women using... Purpose: To describe a breast-conserving technique using interstitial brachytherapy after lumpectomy and axillary nodal sampling in selected women who are diagnosed with breast cancer in the presence of augmentation mammo- plasty. Material and methods: Over the past 20 years, we have developed and improved a technique of “pinch view” image- guided catheter insertion that avoids implant puncture. Selection criteria include: 1) women of any age with either sub- pectoral or retroglandular, augmentation implants (silicone or saline) who were diagnosed with stages Tis, T1, T2, N0, or N1 breast cancer; 2) any pathologic subtype of malignant breast cancer was accepted; 3) microscopic tumor extent < 3 cm; 4) axillary node negative or metastasis to 1 to 3 nodes without extracapsular extension; and 5) surgical margins clear by the NSABP “no ink on tumor” definition. More than 250 women have been successfully treated. Patients were treated with high dose rate Iridium-192 brachytherapy to 34 Gy in 10 or 32 Gy in 8 twice daily fractions. The target volume was the surgical cavity edge with 1.5 to 2 cm margin using 3-D treatment planning systems. Results: The implant technique as currently employed is described. There have been no implant ruptures, and the Planning Treatment Volume (PTV-eval) exhibited at least 90% coverage by the 90% isodose line in the vast majority of cases. Dose Homogeneity Index exceeded 70% in most cases. The maximum skin dose was below the prescription dose in every case. Other than some patients with pre-existing capsular contracture, less than 5% experience new capsular contracture after interstitial brachytherapy. Conclusions: A technique of reliable and reproducible accelerated partial breast irradiation is described that mini- mizes the risk of capsular contracture by avoiding circumferential dose to the foreign body in the breast. J Contemp Brachytherapy 2014; 6, 2: 231–235 DOI: 10.5114/jcb.2014.43779 Key words: accelerated partial breast irradiation, brachytherapy, breast augmentation, breast cancer treatment. Purpose interstitial brachytherapy to complete breast conservation The number of women who are diagnosed with breast therapy. This technique is known as accelerated partial cancer in the presence of breast augmentation is dramat- breast irradiation (APBI), a 4 or 5-day alternative to 6 or ically increasing each year (Fig. 1). For the past 20 years, 7-week whole breast irradiation (WBI). The advantage is breast augmentation has been one of the most common reducing radiation exposure to only the affected part of surgical procedures in the United State, Brazil, and other the breast in the vicinity of the original tumor site, thereby countries [1]. Women who had their implants a decade or minimizing dose to the lung, heart, chest wall, ribs, and more ago at young ages are now at the age when their normal breast or nodal tissue. In women with augmen- risk of breast cancer is significant. Oncologists are seeing tation, the radiation dose cloud does not encompass the more and more of these patients, and there is little in the entire implant, eliminating circumferential fibrosis that literature about how to treat them. Indeed, the surgical causes capsular contracture. This technique is described literature suggests mastectomy and reconstruction as in this manuscript for the first time. the preferred treatment, because of the reported 55% or higher rate of significant capsular contracture after whole Material and methods breast external beam radiotherapy [2,3]. Over the past 20 years, the author has treated 250 women after lumpec- More than 250 women with breast augmentation and se- tomy and axillary dissection or sentinel node biopsy with lect breast cancers have been treated over the past 20 years Address for correspondence: Robert R. Kuske, MD, FAACE, Virginia G. Piper Cancer Center, Received: 3.06.2014 Scottsdale Healthcare Shea, Scottsdale, Arizona 85258, USA, phone: +1 480 922-4600, fax: +1 480 922-5231, Accepted: 10.06.2014  e-mail: [email protected] Published: 26.06.2014 Journal of Contemporary Brachytherapy (2014/volume 6/number 2) 232 Robert Kuske 400 000 The patient is positioned supine or partly decubitus on the CT table in radiation oncology, usually with the 350 000 ipsilateral arm comfortably at her side. A wide Betadine 300 000 skin prep covers the entire breast. Sterile towels and drapes surround the breast. The breast is massaged to 250 000 loosen it off the augmentation implant, and palpation of 200 000 the lumpectomy site with the ultrasound or CT images in 150 000 mind help plan template orientation. The breast tissue at the lumpectomy site must be bunched up while the im- 100 000 plant is pushed in the reverse direction, similar to Eklund 50 000 or “pinch view” or “push back” mammography that is standard imaging for women with implants. Note that 1991 1997 1999 2001 2003 2005 the thickness of the breast tissue may be only 1.5 cm in the Year relaxed state before pinching, but the thickness increases Fig. 1. Rate of breast augmentation over time to 3 to 4 cm after bunching. With one hand, the breast is strongly lifted up and away from the augmentation im- plant, and the implant pushed backward, while the breast with interstitial brachytherapy. Selection criteria have brachytherapy template is positioned (Fig. 2). The front been consistent and uniform, with tumors less than or and back plates are closed with moderate compression, equal to 3 cm that have been excised with clear margins so that the deep plane is as close to the implant as feasi- (no ink on tumor), and zero to three axillary nodes posi- ble. Side clamps are attached to the template to make the tive without extracapsular extension accepted. The tech- plates parallel. The surgical assistant holds the template nique of image-guided interstitial brachytherapy catheter against the augmentation to prevent slippage. The radia- insertion is described herein. An optional breast ultra- tion oncologist chooses 3 holes for anchoring needles that sound is performed on the day of consultation in the radi- are shallow and safely away from the implant to avoid ation oncology office. When a seroma is clearly seen, the puncture. These holes are chosen to be likely in the target radiation oncologist can visualize the lumpectomy cavity volume. A skin wheal is raised on both the proximal and in 3 dimensions, allowing pre-planning. With oncoplastic distal sides with half-strength buffered local anesthetic, technique, which is a fusion of breast cancer surgery with and dilute tumescent buffered local anesthetic is injected plastic surgical principles, the cavity is usually closed along the chosen pathway (Table 1). Thin 27 G needles when the tissue is re-shaped and approximated. With on- are used for the skin wheal, and a 25 G for the tumescent. coplasty, pre-procedure ultrasound is rarely helpful, so The three anchoring needles are inserted, with care to en- a CT in radiation oncology on the day of the procedure sure that they remain perpendicular to the plane of the defines the cavity. No general anesthesia or conscious template as they traverse the breast, exiting the hole on sedation is necessary. One hour before the procedure, the back template. the patient takes a narcotic (eg. Nucynta, Percocet, or Vi- After the 3 anchoring needles, the template will not codin) and an anxiolytic/muscle relaxer (eg. Valium or slip and will maintain its position relative to the aug- Lorazepam) (Table 1). mentation implant. A breast CT without contrast is ob- tained while the template is attached. These images are Table 1. Local anesthetic formulae and pre-operative sent by Ethernet to the computer with 3-d brachytherapy medications software. Image-guidance is a key to the success of this Local anesthetic formulae and pre-operative medications procedure. On each slice, the medical physicist or dosim- Skin wheal 35 cc 1% lidocaine with epinephrine etrist, under the supervision of the radiation oncologist, 2 cc 8.4% sodium bicarbonate contours the implant, skin, and lumpectomy edges. The software then expands the cavity volume by 1.5 to 2 cm 35 cc lactated Ringer’s solution in all directions, except for 5 mm from the implant and Tumescent 25 cc 2% lidocaine with epinephrine 5 mm from the skin surface, creating a modified planning 3 cc 8.4% sodium bicarbonate treatment volume (PTV-eval). A 3-dimensional rendition 215 cc lactated Ringer’s solution of the breast is rendered by the software, and these im- ages are rotated until the front and back template holes mEq sodium bicarbonate are aligned. The physicist then outlines the maximum Average amount injected per case cross-sectional area of the PTV-eval. The physicist also 30 cc skin wheal mixture through a 27 G needle, 1.25 inches outlines the surface of the implant and the skin, so that long with a 10 cc syringe, on each side of the template they are displayed on the “needles eye view” when the 150 cc tumescent mixture through a 25 G needle, 1.5 inches templates are aligned. The CT slices are then scrolled un- long with a 10 cc syringe, on each side of the template til the large holes on the back template are in view. With the PTV-eval, skin and implant displayed (Fig. 3), Pre-op meds it is simple to choose coordinates of template holes that Nucynta, 50 mg taken p.o. 1 hour before are within or just beyond the PTV-eval, but do not inter- Valium, 5 mg taken p.o. 1 hour before topical EMLA cream, sect with the implant + 5 mm or the go outside the skin 30 gm applied under plastic wrap 1 hour before the procedure surface (Fig. 4). Skin wheal and tumescent local anesthet- Journal of Contemporary Brachytherapy (2014/volume 6/number 2) Number of augmentation Brachytherapy in augmented breasts 233 A A B B C C Fig. 2. The breast brachytherapy template Fig. 3. Image-guided needle insertion with the implant, skin, PTV-eval, and holes of the template displayed ic as described above are then injected. 19 G brachyther- For your first few procedures, you may wish to obtain apy needles are then inserted perfectly perpendicular to a CT at this point to prove to yourself that the needles the plane of the template. have not intersected with the implant. The template is Journal of Contemporary Brachytherapy (2014/volume 6/number 2) 234 Robert Kuske thereafter. Prophylactic antibiotics are not routinely pre- scribed, and less than 20% receive antibiotics later be- cause of fever, chills, unusual erythema, or other signs of infection. Certain dosimetric guidelines are routine. The prescrip- tion isodose line can touch the skin surface, but not extend beyond it. We strive for 95% coverage of the PTV-eval by the 95% isodose. The dose homogeneity index is usually 10% less than what we see with non-augmented breasts – 75-80%, but rarely below 70%. The 150% isodose lines may kiss, but not coalesce. If the brachytherapy does not meet these guidelines, additional needles are inserted under lo- cal anesthetic to improve coverage and homogeneity. Results The average number of catheters in augmented breasts is 19, in contrast to 22 catheters in non-augment- ed breasts, for a 2 cm growth of the cavity volume. No Fig. 4. Diagram of the template with the chosen holes implants have been punctured, and catheter insertion marked was successfully accomplished in all augmented women. The mean coverage of the PTV-eval by the 90% isodose then disassembled and only the needles remain in place line was 96%. The mean dose homogeneity index is 80%. with the breast relaxed from compression. Additional The brachytherapy entry and exit pockmarks become freehand needles can be inserted to cover any gaps in invisible in 90% of patients by one year after treatment. coverage, if necessary, being careful to manually push the Cosmetic outcomes are good/excellent in more than 90% implant away from the needle’s pathway, and keep the of patients treated. 10% of patients are noted to have Bak- needles parallel. Polyethylene catheters are then inserted er 2 to 4 capsular contracture at the time of consultation into each needle, and pulled until the needle is out and before treatment of her breast cancer. Less than 5% expe- the distal button is flush with the skin. A button is placed rience new or additional capsular contracture after inter- on the proximal end and positioned against the skin. stitial brachytherapy. The catheter is then trimmed. The patient then goes to Tumor control, survival rates, cosmetic outcomes, and lunch with her significant other, and returns 2 hours lat- toxicities other than capsular contracture will be reported er, after any swelling has dissipated, for the treatment in another publication. planning CT from which the dwell times and dose cloud shaping is performed. Physics is given 24 hours to perfect Discussion the dose plan, so treatment commences on day 2 after the insertion. This procedure is typically painless and blood- In addition to very low lung and heart doses, and the less. The local anesthetic lasts approximately 6 hours af- advantages to busy women of a shorter treatment time, ter the insertion, and the included epinephrine prevents reduction in the high rate of capsular contracture noted by blood loss. Patients usually require pain medication for other investigators is paramount to this study. Capsular the first 12-24 hours after the procedure, however none contracture is spherical fibrosis caused by circumferential A B Fig. 5. Spherical fibrosis, capsular contracture Journal of Contemporary Brachytherapy (2014/volume 6/number 2) Brachytherapy in augmented breasts 235 exposure of the foreign body implant by whole breast ir- who now practices in British Columbia, Canada. Kristina radiation (Fig. 5). Patients know this as “painful harden- Allen and Carrie Farkas are noted for their administrative ing of the implant”. It can be seen without radiotherapy as assistance for these patients. Margaret Snyder, RN, col- well, and is a known risk of breast augmentation. lected and analyzed the data. The breast surgeons contrib- Neil Handel and Melvin Silverstein reported a capsu- uted their patients and support of the program. lar contracture rate of 55% after whole breast irradiation in the presence of breast augmentation [2,3]. This high Disclosure rate of capsular contracture has led many surgeons to rec- Author reports no conflicts of interest. ommend mastectomy followed by reconstruction as the preferred treatment for early stage breast cancer in wom- References en with implants. This recommendation is disappointing 1. International Society of Aesthetic Plastic Surgery. ISAPS to most of these women, as they have already declared international survey on aesthetic/cosmetic procedures per- their priority on cosmesis by the fact that they have had formed in 2011. Available at: http://www.isaps.org/files/ augmentation in the first place. html-contents/Downloads/ISAPS%20Results%20-%20Pro- Without implants, breast conservation therapy is con- cedures%20in%202011.pdf sidered the preferred method of early-stage breast cancer 2. Handel N. The Effect of Silicone implants on the diagnosis, treatment, because survival rates are the same as mastec- prognosis, and treatment of breast cancer. Plast Reconstr Surg tomy and it allows women to remain whole [4]. Stage for 2007; 120 (7 Suppl 1): 81S-93S. stage, breast conservation should be offered to augmented 3. Handel N, Silverstein MJ. Breast cancer diagnosis and prog- nosis in augmented women. Plast Reconstr Surg 2006; 118: women as well. The scars are not as long, the surgery takes 587-596. less time and is less expensive, and the breast remains sen- 4. NIH Consensus Conference: Treatment of early-stage breast sate. Preventing capsular contracture is key to expanding cancer. JAMA 1991; 265: 391. breast conservation in this growing population of women. 5. Dawson LA, Sharpe MB. Image-guided radiotherapy: ratio- This goal was the focus of this 20-year investigation into nale, benefits, and limitations. Lancet Oncol 2006; 7: 848-858. a technique that minimizes the risk of symptomatic cap- 6. Kuske R, Chowdhury R, Snyder M et al. Accelerated Partial sular contracture. Breast Irradiation for Select Breast Cancers in the Presence of In many cancer types treated in radiation oncology, Augmentation. Int J Radiat Oncol Biol Phys 2012; 84: S87. image-guidance and tighter conformal radiation fields have improved tumor control rates and decreased toxici- ty [5]. Breast brachytherapy is an example of an advance in dose-delivery that conforms precisely to the target vol- ume, minimizing exposure of normal tissues. The rapid dose fall-off, inherent in the physics of brachytherapy, is especially attractive in the treatment of women with aug- mented breasts. The prescription dose is at the periphery, and tissue inside that dose envelope is ~15% higher dose, so the dosimetry follows the biology of breast cancer cell density gradient. Since only a small surface area of the implant is exposed to ionizing radiation, scar tissue does not envelope the silicone or saline implant. The risk of capsular contracture is significantly reduced. Conclusions The concept of inserting sharp local anesthetic and brachytherapy needles close to the implant, without puncturing it, is intimidating to many radiation oncolo- gists. For this reason, a “pinch view” image-guided tech- nique utilizing a template and 3-d treatment-planning software has been developed and is described in this manuscript. As described, the method is simple, safe, and reproducible from one institution to the next. Long-term data [6] supports the conclusion that interstitial breast brachytherapy may be the treatment of choice for select women with early stage breast cancer in the presence of breast augmentation. Acknowledgements The author would like to acknowledge the efforts of Rezwan Chowdhury, MD, a former brachytherapy fellow, Journal of Contemporary Brachytherapy (2014/volume 6/number 2) http://www.deepdyve.com/assets/images/DeepDyve-Logo-lg.png Journal of Contemporary Brachytherapy Pubmed Central

Breast conservation therapy without capsular contracture in young augmented women using interstitial brachytherapy

Kuske, Robert
Journal of Contemporary Brachytherapy , Volume 6 (2) – Jun 28, 2014
Download PDF
5 pages

Loading next page...
 
/lp/pubmed-central/breast-conservation-therapy-without-capsular-contracture-in-young-5u2ahphqkU

References (10)

Publisher
Pubmed Central
Copyright
Copyright © 2014 Termedia
ISSN
1689-832X
eISSN
2081-2841
DOI
10.5114/jcb.2014.43779
Publisher site
See Article on Publisher Site

Abstract

Purpose: To describe a breast-conserving technique using interstitial brachytherapy after lumpectomy and axillary nodal sampling in selected women who are diagnosed with breast cancer in the presence of augmentation mammo- plasty. Material and methods: Over the past 20 years, we have developed and improved a technique of “pinch view” image- guided catheter insertion that avoids implant puncture. Selection criteria include: 1) women of any age with either sub- pectoral or retroglandular, augmentation implants (silicone or saline) who were diagnosed with stages Tis, T1, T2, N0, or N1 breast cancer; 2) any pathologic subtype of malignant breast cancer was accepted; 3) microscopic tumor extent < 3 cm; 4) axillary node negative or metastasis to 1 to 3 nodes without extracapsular extension; and 5) surgical margins clear by the NSABP “no ink on tumor” definition. More than 250 women have been successfully treated. Patients were treated with high dose rate Iridium-192 brachytherapy to 34 Gy in 10 or 32 Gy in 8 twice daily fractions. The target volume was the surgical cavity edge with 1.5 to 2 cm margin using 3-D treatment planning systems. Results: The implant technique as currently employed is described. There have been no implant ruptures, and the Planning Treatment Volume (PTV-eval) exhibited at least 90% coverage by the 90% isodose line in the vast majority of cases. Dose Homogeneity Index exceeded 70% in most cases. The maximum skin dose was below the prescription dose in every case. Other than some patients with pre-existing capsular contracture, less than 5% experience new capsular contracture after interstitial brachytherapy. Conclusions: A technique of reliable and reproducible accelerated partial breast irradiation is described that mini- mizes the risk of capsular contracture by avoiding circumferential dose to the foreign body in the breast. J Contemp Brachytherapy 2014; 6, 2: 231–235 DOI: 10.5114/jcb.2014.43779 Key words: accelerated partial breast irradiation, brachytherapy, breast augmentation, breast cancer treatment. Purpose interstitial brachytherapy to complete breast conservation The number of women who are diagnosed with breast therapy. This technique is known as accelerated partial cancer in the presence of breast augmentation is dramat- breast irradiation (APBI), a 4 or 5-day alternative to 6 or ically increasing each year (Fig. 1). For the past 20 years, 7-week whole breast irradiation (WBI). The advantage is breast augmentation has been one of the most common reducing radiation exposure to only the affected part of surgical procedures in the United State, Brazil, and other the breast in the vicinity of the original tumor site, thereby countries [1]. Women who had their implants a decade or minimizing dose to the lung, heart, chest wall, ribs, and more ago at young ages are now at the age when their normal breast or nodal tissue. In women with augmen- risk of breast cancer is significant. Oncologists are seeing tation, the radiation dose cloud does not encompass the more and more of these patients, and there is little in the entire implant, eliminating circumferential fibrosis that literature about how to treat them. Indeed, the surgical causes capsular contracture. This technique is described literature suggests mastectomy and reconstruction as in this manuscript for the first time. the preferred treatment, because of the reported 55% or higher rate of significant capsular contracture after whole Material and methods breast external beam radiotherapy [2,3]. Over the past 20 years, the author has treated 250 women after lumpec- More than 250 women with breast augmentation and se- tomy and axillary dissection or sentinel node biopsy with lect breast cancers have been treated over the past 20 years Address for correspondence: Robert R. Kuske, MD, FAACE, Virginia G. Piper Cancer Center, Received: 3.06.2014 Scottsdale Healthcare Shea, Scottsdale, Arizona 85258, USA, phone: +1 480 922-4600, fax: +1 480 922-5231, Accepted: 10.06.2014  e-mail: [email protected] Published: 26.06.2014 Journal of Contemporary Brachytherapy (2014/volume 6/number 2) 232 Robert Kuske 400 000 The patient is positioned supine or partly decubitus on the CT table in radiation oncology, usually with the 350 000 ipsilateral arm comfortably at her side. A wide Betadine 300 000 skin prep covers the entire breast. Sterile towels and drapes surround the breast. The breast is massaged to 250 000 loosen it off the augmentation implant, and palpation of 200 000 the lumpectomy site with the ultrasound or CT images in 150 000 mind help plan template orientation. The breast tissue at the lumpectomy site must be bunched up while the im- 100 000 plant is pushed in the reverse direction, similar to Eklund 50 000 or “pinch view” or “push back” mammography that is standard imaging for women with implants. Note that 1991 1997 1999 2001 2003 2005 the thickness of the breast tissue may be only 1.5 cm in the Year relaxed state before pinching, but the thickness increases Fig. 1. Rate of breast augmentation over time to 3 to 4 cm after bunching. With one hand, the breast is strongly lifted up and away from the augmentation im- plant, and the implant pushed backward, while the breast with interstitial brachytherapy. Selection criteria have brachytherapy template is positioned (Fig. 2). The front been consistent and uniform, with tumors less than or and back plates are closed with moderate compression, equal to 3 cm that have been excised with clear margins so that the deep plane is as close to the implant as feasi- (no ink on tumor), and zero to three axillary nodes posi- ble. Side clamps are attached to the template to make the tive without extracapsular extension accepted. The tech- plates parallel. The surgical assistant holds the template nique of image-guided interstitial brachytherapy catheter against the augmentation to prevent slippage. The radia- insertion is described herein. An optional breast ultra- tion oncologist chooses 3 holes for anchoring needles that sound is performed on the day of consultation in the radi- are shallow and safely away from the implant to avoid ation oncology office. When a seroma is clearly seen, the puncture. These holes are chosen to be likely in the target radiation oncologist can visualize the lumpectomy cavity volume. A skin wheal is raised on both the proximal and in 3 dimensions, allowing pre-planning. With oncoplastic distal sides with half-strength buffered local anesthetic, technique, which is a fusion of breast cancer surgery with and dilute tumescent buffered local anesthetic is injected plastic surgical principles, the cavity is usually closed along the chosen pathway (Table 1). Thin 27 G needles when the tissue is re-shaped and approximated. With on- are used for the skin wheal, and a 25 G for the tumescent. coplasty, pre-procedure ultrasound is rarely helpful, so The three anchoring needles are inserted, with care to en- a CT in radiation oncology on the day of the procedure sure that they remain perpendicular to the plane of the defines the cavity. No general anesthesia or conscious template as they traverse the breast, exiting the hole on sedation is necessary. One hour before the procedure, the back template. the patient takes a narcotic (eg. Nucynta, Percocet, or Vi- After the 3 anchoring needles, the template will not codin) and an anxiolytic/muscle relaxer (eg. Valium or slip and will maintain its position relative to the aug- Lorazepam) (Table 1). mentation implant. A breast CT without contrast is ob- tained while the template is attached. These images are Table 1. Local anesthetic formulae and pre-operative sent by Ethernet to the computer with 3-d brachytherapy medications software. Image-guidance is a key to the success of this Local anesthetic formulae and pre-operative medications procedure. On each slice, the medical physicist or dosim- Skin wheal 35 cc 1% lidocaine with epinephrine etrist, under the supervision of the radiation oncologist, 2 cc 8.4% sodium bicarbonate contours the implant, skin, and lumpectomy edges. The software then expands the cavity volume by 1.5 to 2 cm 35 cc lactated Ringer’s solution in all directions, except for 5 mm from the implant and Tumescent 25 cc 2% lidocaine with epinephrine 5 mm from the skin surface, creating a modified planning 3 cc 8.4% sodium bicarbonate treatment volume (PTV-eval). A 3-dimensional rendition 215 cc lactated Ringer’s solution of the breast is rendered by the software, and these im- ages are rotated until the front and back template holes mEq sodium bicarbonate are aligned. The physicist then outlines the maximum Average amount injected per case cross-sectional area of the PTV-eval. The physicist also 30 cc skin wheal mixture through a 27 G needle, 1.25 inches outlines the surface of the implant and the skin, so that long with a 10 cc syringe, on each side of the template they are displayed on the “needles eye view” when the 150 cc tumescent mixture through a 25 G needle, 1.5 inches templates are aligned. The CT slices are then scrolled un- long with a 10 cc syringe, on each side of the template til the large holes on the back template are in view. With the PTV-eval, skin and implant displayed (Fig. 3), Pre-op meds it is simple to choose coordinates of template holes that Nucynta, 50 mg taken p.o. 1 hour before are within or just beyond the PTV-eval, but do not inter- Valium, 5 mg taken p.o. 1 hour before topical EMLA cream, sect with the implant + 5 mm or the go outside the skin 30 gm applied under plastic wrap 1 hour before the procedure surface (Fig. 4). Skin wheal and tumescent local anesthet- Journal of Contemporary Brachytherapy (2014/volume 6/number 2) Number of augmentation Brachytherapy in augmented breasts 233 A A B B C C Fig. 2. The breast brachytherapy template Fig. 3. Image-guided needle insertion with the implant, skin, PTV-eval, and holes of the template displayed ic as described above are then injected. 19 G brachyther- For your first few procedures, you may wish to obtain apy needles are then inserted perfectly perpendicular to a CT at this point to prove to yourself that the needles the plane of the template. have not intersected with the implant. The template is Journal of Contemporary Brachytherapy (2014/volume 6/number 2) 234 Robert Kuske thereafter. Prophylactic antibiotics are not routinely pre- scribed, and less than 20% receive antibiotics later be- cause of fever, chills, unusual erythema, or other signs of infection. Certain dosimetric guidelines are routine. The prescrip- tion isodose line can touch the skin surface, but not extend beyond it. We strive for 95% coverage of the PTV-eval by the 95% isodose. The dose homogeneity index is usually 10% less than what we see with non-augmented breasts – 75-80%, but rarely below 70%. The 150% isodose lines may kiss, but not coalesce. If the brachytherapy does not meet these guidelines, additional needles are inserted under lo- cal anesthetic to improve coverage and homogeneity. Results The average number of catheters in augmented breasts is 19, in contrast to 22 catheters in non-augment- ed breasts, for a 2 cm growth of the cavity volume. No Fig. 4. Diagram of the template with the chosen holes implants have been punctured, and catheter insertion marked was successfully accomplished in all augmented women. The mean coverage of the PTV-eval by the 90% isodose then disassembled and only the needles remain in place line was 96%. The mean dose homogeneity index is 80%. with the breast relaxed from compression. Additional The brachytherapy entry and exit pockmarks become freehand needles can be inserted to cover any gaps in invisible in 90% of patients by one year after treatment. coverage, if necessary, being careful to manually push the Cosmetic outcomes are good/excellent in more than 90% implant away from the needle’s pathway, and keep the of patients treated. 10% of patients are noted to have Bak- needles parallel. Polyethylene catheters are then inserted er 2 to 4 capsular contracture at the time of consultation into each needle, and pulled until the needle is out and before treatment of her breast cancer. Less than 5% expe- the distal button is flush with the skin. A button is placed rience new or additional capsular contracture after inter- on the proximal end and positioned against the skin. stitial brachytherapy. The catheter is then trimmed. The patient then goes to Tumor control, survival rates, cosmetic outcomes, and lunch with her significant other, and returns 2 hours lat- toxicities other than capsular contracture will be reported er, after any swelling has dissipated, for the treatment in another publication. planning CT from which the dwell times and dose cloud shaping is performed. Physics is given 24 hours to perfect Discussion the dose plan, so treatment commences on day 2 after the insertion. This procedure is typically painless and blood- In addition to very low lung and heart doses, and the less. The local anesthetic lasts approximately 6 hours af- advantages to busy women of a shorter treatment time, ter the insertion, and the included epinephrine prevents reduction in the high rate of capsular contracture noted by blood loss. Patients usually require pain medication for other investigators is paramount to this study. Capsular the first 12-24 hours after the procedure, however none contracture is spherical fibrosis caused by circumferential A B Fig. 5. Spherical fibrosis, capsular contracture Journal of Contemporary Brachytherapy (2014/volume 6/number 2) Brachytherapy in augmented breasts 235 exposure of the foreign body implant by whole breast ir- who now practices in British Columbia, Canada. Kristina radiation (Fig. 5). Patients know this as “painful harden- Allen and Carrie Farkas are noted for their administrative ing of the implant”. It can be seen without radiotherapy as assistance for these patients. Margaret Snyder, RN, col- well, and is a known risk of breast augmentation. lected and analyzed the data. The breast surgeons contrib- Neil Handel and Melvin Silverstein reported a capsu- uted their patients and support of the program. lar contracture rate of 55% after whole breast irradiation in the presence of breast augmentation [2,3]. This high Disclosure rate of capsular contracture has led many surgeons to rec- Author reports no conflicts of interest. ommend mastectomy followed by reconstruction as the preferred treatment for early stage breast cancer in wom- References en with implants. This recommendation is disappointing 1. International Society of Aesthetic Plastic Surgery. ISAPS to most of these women, as they have already declared international survey on aesthetic/cosmetic procedures per- their priority on cosmesis by the fact that they have had formed in 2011. Available at: http://www.isaps.org/files/ augmentation in the first place. html-contents/Downloads/ISAPS%20Results%20-%20Pro- Without implants, breast conservation therapy is con- cedures%20in%202011.pdf sidered the preferred method of early-stage breast cancer 2. Handel N. The Effect of Silicone implants on the diagnosis, treatment, because survival rates are the same as mastec- prognosis, and treatment of breast cancer. Plast Reconstr Surg tomy and it allows women to remain whole [4]. Stage for 2007; 120 (7 Suppl 1): 81S-93S. stage, breast conservation should be offered to augmented 3. Handel N, Silverstein MJ. Breast cancer diagnosis and prog- nosis in augmented women. Plast Reconstr Surg 2006; 118: women as well. The scars are not as long, the surgery takes 587-596. less time and is less expensive, and the breast remains sen- 4. NIH Consensus Conference: Treatment of early-stage breast sate. Preventing capsular contracture is key to expanding cancer. JAMA 1991; 265: 391. breast conservation in this growing population of women. 5. Dawson LA, Sharpe MB. Image-guided radiotherapy: ratio- This goal was the focus of this 20-year investigation into nale, benefits, and limitations. Lancet Oncol 2006; 7: 848-858. a technique that minimizes the risk of symptomatic cap- 6. Kuske R, Chowdhury R, Snyder M et al. Accelerated Partial sular contracture. Breast Irradiation for Select Breast Cancers in the Presence of In many cancer types treated in radiation oncology, Augmentation. Int J Radiat Oncol Biol Phys 2012; 84: S87. image-guidance and tighter conformal radiation fields have improved tumor control rates and decreased toxici- ty [5]. Breast brachytherapy is an example of an advance in dose-delivery that conforms precisely to the target vol- ume, minimizing exposure of normal tissues. The rapid dose fall-off, inherent in the physics of brachytherapy, is especially attractive in the treatment of women with aug- mented breasts. The prescription dose is at the periphery, and tissue inside that dose envelope is ~15% higher dose, so the dosimetry follows the biology of breast cancer cell density gradient. Since only a small surface area of the implant is exposed to ionizing radiation, scar tissue does not envelope the silicone or saline implant. The risk of capsular contracture is significantly reduced. Conclusions The concept of inserting sharp local anesthetic and brachytherapy needles close to the implant, without puncturing it, is intimidating to many radiation oncolo- gists. For this reason, a “pinch view” image-guided tech- nique utilizing a template and 3-d treatment-planning software has been developed and is described in this manuscript. As described, the method is simple, safe, and reproducible from one institution to the next. Long-term data [6] supports the conclusion that interstitial breast brachytherapy may be the treatment of choice for select women with early stage breast cancer in the presence of breast augmentation. Acknowledgements The author would like to acknowledge the efforts of Rezwan Chowdhury, MD, a former brachytherapy fellow, Journal of Contemporary Brachytherapy (2014/volume 6/number 2)

Journal

Journal of Contemporary Brachytherapy – Pubmed Central

Published: Jun 28, 2014

There are no references for this article.