Massachusetts General Hospital Experience

The initial clinical data acquired from the first 22 patients who underwent treatment reported by Taghian et al. at a follow-up of 1-6 months supports the feasibility and minimal acute toxicity of 3D conformal APBI demonstrated in other studies. The eligibility criteria included histology of invasive ductal carcinoma < 2 cm, negative lymph nodes, negative margins by at least 2 mm, and no lymphovascular space invasion or extensive intraductal component. The prescribed dose was 32 Gy in eight...

Conformal External Beam APBI

The data available to assess normal tissue effects after 3D conformal external beam APBI are very limited and conclusions are, at best, preliminary. One of the largest experiences reported to date is that from the William Beaumont Hospital (Baglan et al. 2003 Vicini et al. 2003) where 31 patients were treated with 34 or 38.5 Gy in ten twice-daily fractions. After a median follow-up of 10 months, no significant immediate toxicity was seen beyond grade 1 skin erythema. At 4-8 weeks of follow-up,...

Convenience Benefits of APBI

It is clear that APBI offers a convenience advantage over whole-breast irradiation. Five-day APBI treatment approaches are potentially 85 shorter than conventional whole-breast plus tumor-bed boost therapy. However, for patients treated with surgery and chemotherapy, the shortened course of radiation would lead to only a 10-15 decrease in the overall length of the breast cancer treatment. In addition, it should be recognized that there is an alternative to APBI for patients for whom treatment...

Anatomic Patterns of InBreast Failure after Breast Conserving Treatment

The strongest support for partial breast treatment as an appropriate option for early-stage breast cancer is the anatomic location of in-breast failures following lumpectomy. Three prospective randomized studies of lumpectomy only versus lumpectomy plus whole-breast radiotherapy have documented the specific location in the breast of local recurrences (Clark et al. 1992 Fisher and Anderson 1994 Holli et al. 2001 Uppsala-Orebro Breast Cancer Study Group 1990 Veronesi et al. 2001a). The location...

German Austrian Multicentric Trial

In the year 2000 four institutions decided to start the first European multi-institutional phase II trial to investigate the effectiveness and safety of APBI (Ott et al. 2004, 2005a, 2005b Polgar et al. 2005 Strnad et al. 2004). Radiation oncology departments of the University Hospitals of Erlangen and Leipzig from Germany and University Hospital of Vienna and the Barmherzige Schwestern Hospital of Linz from Austria recruited 274 patients between November 2000 and April 2005. Patients were...

Open Cavity Technique

After the axillary procedure and the partial mastectomy are completed, the reference radiation oncologist enters the operating room. The radiation oncology service ascertains that surgical clips are placed to delineate all borders of the excisional cavity. These are placed to delineate the cephalad, caudad, medial, lateral, as well as anterior and posterior margins. With a surgical marking pen, the margins of the excised cavity are projected onto the skin and outlined. Based on the location and...

CTGuided Supine Catheter Insertion with a Special Breast Template

Not every radiation oncologist or surgeon has easy access to a stereotactic core biopsy table in order to perform prone brachytherapy catheter insertion. The procedure can Fig. 9.20 The appearance of the breast 6 months after template interstitial breast brachytherapy be performed on the radiation oncologist's own treatment-planning CT scanner in the supine position. Contrast is injected directly into the lumpectomy cavity as described above under ultrasound guidance. The CT table and the...

European Mammo Site Brachytherapy Trials

APBI with interstitial BT using multicatheter systems requires high experience in all members of the staff. For that reason a new and simple BT system was developed in the US (Edmundson et al. 2002). The MammoSite radiation treatment system (RTS) is a dual lumen spherical balloon catheter. One lumen allows inflation of the balloon to diameter of 4-5 cm the other provides a pathway for the 192Ir source. The advantage of this system is that only one applicator is implanted to perform fractionated...

Image Guided Prone Catheter Insertion with a Special Breast Template

Hanging Breast Pics

In 1996, the lead breast imager at the Ochsner Clinic, Dr. Gunnar Cederbom, asked me if I had ever considered brachytherapy in the prone position on a stereotactic core needle breast biopsy table. He pointed out the major advantages of such an approach 1. In the prone position the breast hangs by gravity, pulling the breast tissue away from the pectoralis major muscle, ribs, and pleura. 2. The built-in mammography equipment under the table could be used to image the breast, facilitating...

Intracavitary Balloon Based Brachytherapy

Mammosite Balloon Brachytherapy

The MammoSite balloon intracavitary radiation delivery device Proxima Therapeutics, Alpharetta, GA allows for insertion of a high dose-rate radiation source at the center of an inflatable balloon. The device can be placed into the lumpectomy cavity at the time of surgery or after surgery when the definitive margin status is known. The MammoSite device is available in three versions one designed to be inflated to a diameter of 4 to 5 cm with a maximum inflation volume of 70 cm3, one designed to...

Mastectomy Studies

The classic pathologic evaluation of mastectomy specimens performed by Holland et al. suggested that microscopic disease was present in a multicentric pattern with relatively high frequency. Breast cancer multifocality was studied in mastectomy specimens by correlated specimen radiography and histologic techniques. It was found that up to 40 of patients undergoing breast conservation therapy BCT might have residual tumor within the breast. This analysis justified the concept that whole-breast...

References

American Society of Breast Surgeons 2005 Consensus statement for accelerated partial breast irradiation. American Society of Breast Surgeons, Columbia, MD. http www.breastsurgeons. org apbi.shtml 2. Arthur D 2003 Accelerated partial breast irradiation a change in treatment paradigm for early stage breast cancer. J Surg Oncol 84 185-191 3. Arthur DW, Vicini FA, Kuske RR, et al 2002 Accelerated partial breast irradiation an updated report from the American Brachytherapy Society. Brachytherapy...

Dose Prescription and Delivery

Dose prescription is 385 cGy per fraction, ten fractions, twice daily. The minimum time between fractions is 6 hours, and duration of treatment is 5-10 days. The dose in this case is prescribed to a reference point, usually the isocenter. Ipsilateral breast constraints are defined at the 50 and 100 dose levels V50 and V100 . In addition to the V50 constraint defined for brachytherapy, no more than 35 of the breast reference volume is allowed to receive the prescription dose 385 cGy per fraction...

The Novac7 System

Hitesys Applicator

The Milan group is also testing the same approach Intra et al. 2002 Veronesi et al. 2001 using a mobile linear accelerator Novac7 see Fig. 12.3 in a randomized trial ELIOT . Novac7 Hitesys, Italy is a mobile dedicated linear accelerator. Its radiating head can be moved by an articulated arm which can work in an existing operating room. It delivers electron beams at four different nominal energies 3, 5, 7, 9 MeV radiation. The beams are collimated by means of a hard-docking system, consisting of...

Mammo Site Brachytherapy

Breast Brachytherapy

The first and perhaps most critical factor to consider in assessing risk of normal tissue effects with MammoSite brachytherapy is that, from the perspective of both dosimetry and radiobiology, it is a distinctly different implant from interstitial brachytherapy. As such, one must be cautious in transferring the lessons learned from interstitial brachy-therapy APBI as they likely have limited relevance to this applicator system. As an example of these inherent differences, Shah et al. 2004...

Beaumont Hospital APBI Fat Necrosis

Breast Brachytherapy

Fig. 17.2 The incidence of fat necrosis as a function of time after interstitial brachytherapy APBI at the William Beaumont Hospital data plotted from Benitez et al. 2004 Fig. 17.2 The incidence of fat necrosis as a function of time after interstitial brachytherapy APBI at the William Beaumont Hospital data plotted from Benitez et al. 2004 can be for both the better and the worse. Some end-point measures significantly improved with time. For example, the cosmetic rating was scored as excellent...

Phase III Trial of Prone 3D Conformal APBI New York University

On the basis of the results of the pilot study, Formenti et al. conducted a study of 47 postmenopausal women with stage I T1N0 breast cancer, who refused to undergo 6 weeks of WBI, treated to 30 Gy in five 6-Gy fractions over 10 days Monday, Wednesday, Friday, Monday, and Wednesday Formenti et al. 2004 . Other eligibility criteria included Fig. 11.2 A PTV and isodose distributions left-right . B PTV and isodose distributions cranial-caudal . New York University Formenti et al. 2002 Fig. 11.2 A...

The William Beaumont Hospital Experience 3D Conformal APBI in Supine Position

Initial clinical experience at William Beaumont Hospital in utilizing 3D conformal radiation therapy to deliver PBI in patients with early-stage breast cancer treated with breast-conserving therapy supported the technical feasibility of such treatment delivery Baglan et al. 2003 Vicini et al. 2003a, 2003b . In this phase I II study, 23 patients were prospectively enrolled between August 2000 and December 2002. An additional 5 patients were treated according to the guidelines of the protocol for...

Judgment Selecting the Optimal Technique for a Particular Patient

When to offer external beam PBI techniques or breast brachytherapy. 2. If you have decided that breast brachytherapy is preferable, do you select balloon intracavitary or interstitial breast brachytherapy techniques For issues and concerns highlighted in the summary section of this chapter, most of the author's patients will receive brachytherapy over external beam PBI. Note that these are theoretical concerns, and more data will be required before one can apply these selection criteria...

European Gecestro Multicentric Randomized APBI Trial

Based on the success of the Hungarian and German-Austrian studies of APBI, a phase III multicentric APBI protocol has been developed by the Breast Cancer Working Group of the GEC-ESTRO Polgar et al. 2005 . As long-term results beyond 5 years are available only with interstitial implants, proving that multicatheter BT can be used with adequate reproducibility, low toxicity, and appropriate local control, it has been decided that only interstitial HDR PDR BT will be allowed for the APBI arm of...

Results of Clinical Trials with the Intrabeam System

Based on the hypothesis that index quadrant irradiation is sufficient, in July 1998 we introduced the technique of TARGIT Vaidya 2002 Vaidya et al. 2001, 2002b, 2004b radiotherapy delivered as a single dose using low-energy x-rays targeted to the peritu-moral tissues from within the breast using the Intrabeam device. In patients with small well-differentiated breast cancers, which are now the majority, this could be the sole radiotherapy treatment. In those with a high risk of local recurrence...

The Intrabeam Machine and Surgical Technique

The Intrabeam machine contains a miniature electron gun and electron accelerator contained in an x-ray tube which are powered by a 12V power supply. Soft x-rays 50 kVp are emitted from the point source. Tissue is kept at a distance from the source by spheri- Fig. 12.1 Top The Intrabeam system - with the x-ray source in the breast wound - and the electron generator and accelerator held by the articulated arm. Bottom The target breast tissue wraps around the applicator giving true conformal...

Intraoperative Radiation Therapy

Intraoperative Breast Radiation

Treatment with a single dose of radiation at the time of surgery is an extremely attractive alternative for patients undergoing lumpectomy for breast cancer. In fact, this one-stop-shopping approach to local control of breast cancer would be the preferred form of APBI for most clinicians and patients if intraoperative radiation therapy IORT proves to be efficacious with minimal short- and long-term complications. However, many questions remain among clinicians in the United States concerning...

Open Freehand Interstitial Catheter Insertion

Apbi Cross Catheter

Open freehand technique depends upon the skill of the brachytherapist to insert catheters or needles in an array that both covers the target volume, and provides a spacing that will insure a homogeneous dose distribution. It was the original method of breast brachytherapy, used by Geoffrey Keynes in England in the 1920s as the original breast conservation therapy Keynes 1937 , Samuel Hellman from the Joint Center for Radiotherapy in the late 1970s and early 1980s as a boost, and myself in the...

Radiobiology of Intraoperative Radiotherapy

The main basis of IORT is that a single dose of IORT could have a biological effect on tissue that is equivalent to a full course of fractionated external beam radiotherapy EBRT . This is therefore being tested in randomized trials. There is already some evidence suggesting the safety and effectiveness of a single dose of radiotherapy in achieving tumor cell kill Vaidya et al. 2004b, 2005b . The theoretical basis for calculation of the biological effects of a given dose of radiation is the...

Target Delineation

Target Volume Delineation Breast

As the post-lumpectomy radiation target decreases from the whole breast to partial breast, the precision of target delineation becomes increasingly important. A universally accepted target definition has not been established and the present definitions used vary depending on physician preferences and biases, specific pathologic findings and the treatment technique used. The partial breast target has most often been defined as a 12 cm margin of normal breast tissue beyond the lumpectomy cavity,...

Patient Selection Study Eligibility

Proper conservative patient selection appears to be crucial to the success of APBI, yet clear boundaries of inclusion and exclusion criteria have yet to be fully tested. The goal of patient selection is to identify those patients without a significant risk of harboring microscopic disease outside the immediate vicinity of the lumpectomy cavity. To provide guidance for those practitioners offering APBI, selection criteria have been endorsed and published by the American Brachytherapy Society ABS...

History of APBI

Over the past 5 years, APBI has generated a great degree of enthusiasm among both cancer care providers and breast cancer patients. However, the first investigations of APBI as an alternative to conventional whole-breast irradiation began some time ago and were abandoned because of lack of efficacy. The first two trials investigating APBI were conducted in the United Kingdom in the early 1990s. Investigators at Guy's Hospital, London, conducted a relatively small phase I II trial in which a...