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Local control, cosmetic outcome and radiation sequelae in women treated with accelerated partial breast irradiation using multicatheter brachytherapy
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Abstracts / Brachytherapy 7 (2008) 91e194
Conclusions: According to our knowledge, we presented the first study using a classical fractionation of APBI applied to a second conservative treatment for IBCR. Compare to APBI used for P, G1e2 acute skin toxicity could be increased for LR pts. HDRB dose distribution optimization leads to a significant increase of both CTV coverage and hyperdosage volume. Longer followup is needed to confirm these results.
PO4 Seroma development following intraoperative MammoSite breast brachytherapy: Incidence and contributing factors Akkamma Ravi, M.D.1,3 Adrian Osian, M.S.1 Karen Karsif, M.D.2 Susan Lee, M.D.2 Kenneth Rifkind, M.D.2 Dattatreyudu Nori, M.D.1,3 1Radiation Oncology, New York Hospital Queens, Flushing, NY; 2Surgery, New York Hospital Queens, Flushing, NY; 3Radiation Oncology, New York Presbyterian Hospital, Weill Cornell Medical College, New York, NY. Purpose: To identify possible risk factors for seroma development following intraoperative Mammosite breast brachytherapy. Methods and Materials: This study evaluated 57 patients who underwent lumpectomy followed by partial breast radiation therapy to a dose of 3400 cGy in 10 fractions using the high dose rate system. MammoSite catheter was placed at the time of lumpectomy. Prophylactic antibiotics were prescribed. Daily wound care was given. 31.6% (18/57) of patients underwent either aspiration, core biopsy or reexcision of the lumpectomy cavity due to persistent seroma. Multiple variables were analyzed between the two groups to identify seroma predictive factors. Chi square test or Fisher’s exact test and student t test was used. Variables analyzed included tumor size, stage, quadrant location, catheter dwell time, skin distance, V100%, V150, V200%, dose homogeneity index, chemotherapy, hormone therapy and postprocedure infection. Results: Median followup of 57 patients was 28 months (range 4e53). 18/57 patients (31.6%) patients underwent either aspiration, core biopsy or reexcision of the lumpectomy cavity due to the persistence of seroma. Development of seroma needing any of these procedures ranged from 3e36 months. 83% (15/18) of patients underwent any of these procedures at least 6 months(range 6- 36months) upon completion of treatment. 50% (9/18) of the patients had reexcision of the lumpectomy cavity. Pathology in these patients showed evidence of fat necrosis, chronic inflammatory cells and fibrosis. There was no evidence of tumor by pathology in any of these 18 patients. None of the analyzed variables between the 2 groups showed statistically significant p value for the development of seroma leading to any of these procedures. None of the patients had acute post procedural infection. 2 patients developed late onset infection. One of them was due to neutropenia from chemotherapy and the other at 5 months following brachytherapy treatment. Conclusions: Development of seroma leading to aspiration, core biopsy or reexcision of the lumpectomy cavity following Intraoperative placement of Mammosite catheter for breast brachytherapy did not reveal any statistically significant predictive factor. Prophylactic antibiotics prevented acute infection. The reexcision pathology specimen showed evidence of chronic inflammation and fat necrosis. Only factor possibly contributing is intraoperative catheter placement as performed in these patients.
PO5 Local control, cosmetic outcome and radiation sequelae in women treated with accelerated partial breast irradiation using multicatheter brachytherapy Ashwini N. Budrukkar, M.D.1 Rajiv Sarin, FRCR1 Rakesh Jalali, M.D.1 Anusheel Munshi, M.D.1 Rajendra Badwe, M.S.2 Tanuja Shet, M.D.3 Vani Parmar, M.S.2 Mandar Nadkarni, M.S.2 Deepak Deshpande, Ph.D.4 Ketayun Dinshaw, FRCR.1 1Radiation Oncology, Tata Memorial Hospital, Mumbai, India; 2Surgery, Tata Memorial Hospital, Mumbai, India; 3 Pathology, Tata Memorial Hospital, Mumbai, India; 4Medical Physics, Tata Memorial Hospital, Mumbai, India. Purpose: The aim of the study is to evaluate the early local control, cosmetic outcome and radiation sequelae in women treated with
accelerated partial breast irradiation (APBI) using multi-catheter brachytherapy. Methods and Materials: During May 2000 to May 2007, 162 women participated in the ongoing prospective study of APBI using interstitial brachytherapy. Women with age O40 years, single tumor up to 3 cm without diffuse microcalcification and clinically negative axilla were considered suitable. Brachytherapy was done either intraoperatively during the breast conserving surgery or postoperatively using 2e4 planes. Tumor bed demarcation was done with radiopaque clips placed during surgery, CT scans, ultrasonography and/or fluoroscopy. Cavity with 1e2 cm margin was treated based on orthogonal pair of rays in initial 118 patients and three dimensional computerized tomography based brachytherapy planning with a margin of 1 cm to the cavity in the remaining patients. The dose of 34Gy in 10 fractions over 1 week was delivered with twice daily fractionation using high-dose-rate iridium source. Results: Implant was done intraoperatively in 101 patients while in remaining patients it was done postoperatively. The median T size was 2 cm. Tumor was infiltrating duct carcinoma in 94% patients with 70% of the tumors being grade III. In 11 patients only 3 or 4 fractions of HDR brachytherapy were delivered and this was followed by 45Gy / 25 # whole breast radiation therapy due to adverse histopathology. Minor wound infection was seen in 4 patients. Three patients developed wound gape of which 1 required surgical intervention. Radiation sequelae included fat necrosis in 11 and ulcer in 2 patients. At a median followup of 30 months, 7 patients have developed recurrence-local recurrence (1), distant metastases (4), regional and distant metastases (2). The actuarial 3 year local control rate was 97.6%, disease free survival was 96.5% while the overall survival was 97.5%. Cosmesis was good to excellent in 65% of the patients. Conclusions: The results of APBI with multicatheter interstitial brachytherapy appear to be encouraging. Fat necrosis is a common radiation sequelae associated with APBI. Local control with APBI appears to be comparable to the standard treatment. Further followup is needed to comment on the long term outcome of the procedure.
PO6 HDR breast boost after conservative surgery: A comparison of cosmetic outcome between intraoperative and postoperative applicator placement Aparna Gangopadhyay, M.D., Subrata Saha, M.D., Kousik Ghosh, M.Sc., Avijit Basu, M.D. Radiotherapy, Medical College Hospital, Calcutta, India. Purpose: Interstitial implant is an accepted technique for boost after conservative surgery and whole breast radiotherapy (WBRT) in selected high-risk patients with early breast cancer. Breast brachytherapy is conventionally carried out after surgery, either before or more commonly after WBRT. But some centers prefer to place applicators intra operatively with direct visualization of tumor bed. Our study aims to compare intra operative against postoperative applicator placement in terms of irradiated breast volume, skin dose and cosmesis. Methods and Materials: This is an on-going, prospective randomized trial since June 2004. So far 148 patients with T1/2, N0/1 M0 patients with tumor situated beyond 2.5 cm from skin and with a median age of 53 years were randomized, after informed consent, to either intra operative i.e. during lumpectomy (Group A) or postoperative (Group B) placement of flexible applicators. Boost dose was 16 Gy/5F, 2F daily (6 hours apart) for both arms. All patients receive WBRT 50 Gy, 6 cycles of FAC chemotherapy with/without hormone therapy. For Group B patients, implant geometry is planned by pre implant CT, on the basis of surgical clip position and seroma cavity. Target volume, number of implant planes and needle entry & exit points are determined from pre-implant CT. In patients of both groups, post insertion CT e based planning is done using geometrical optimization. DVH is analyzed for reference volume, V100, D90, V150, V200, DHI, Coverage Index, DNR, and COIN. Skin dose is recorded in each. Cosmetic outcome is evaluated using four- point (excellent, good, fair, poor) scale by a panel of 5 members. Skin telangiectasia is recorded by modified Turesson score. Results: Initial 76 patients’ data (Group A 5 36 and Group B 5 40) with medium followup of 30 months is being presented. 1 patient of Group A
Abstracts / Brachytherapy 7 (2008) 91e194
Conclusions: According to our knowledge, we presented the first study using a classical fractionation of APBI applied to a second conservative treatment for IBCR. Compare to APBI used for P, G1e2 acute skin toxicity could be increased for LR pts. HDRB dose distribution optimization leads to a significant increase of both CTV coverage and hyperdosage volume. Longer followup is needed to confirm these results.
PO4 Seroma development following intraoperative MammoSite breast brachytherapy: Incidence and contributing factors Akkamma Ravi, M.D.1,3 Adrian Osian, M.S.1 Karen Karsif, M.D.2 Susan Lee, M.D.2 Kenneth Rifkind, M.D.2 Dattatreyudu Nori, M.D.1,3 1Radiation Oncology, New York Hospital Queens, Flushing, NY; 2Surgery, New York Hospital Queens, Flushing, NY; 3Radiation Oncology, New York Presbyterian Hospital, Weill Cornell Medical College, New York, NY. Purpose: To identify possible risk factors for seroma development following intraoperative Mammosite breast brachytherapy. Methods and Materials: This study evaluated 57 patients who underwent lumpectomy followed by partial breast radiation therapy to a dose of 3400 cGy in 10 fractions using the high dose rate system. MammoSite catheter was placed at the time of lumpectomy. Prophylactic antibiotics were prescribed. Daily wound care was given. 31.6% (18/57) of patients underwent either aspiration, core biopsy or reexcision of the lumpectomy cavity due to persistent seroma. Multiple variables were analyzed between the two groups to identify seroma predictive factors. Chi square test or Fisher’s exact test and student t test was used. Variables analyzed included tumor size, stage, quadrant location, catheter dwell time, skin distance, V100%, V150, V200%, dose homogeneity index, chemotherapy, hormone therapy and postprocedure infection. Results: Median followup of 57 patients was 28 months (range 4e53). 18/57 patients (31.6%) patients underwent either aspiration, core biopsy or reexcision of the lumpectomy cavity due to the persistence of seroma. Development of seroma needing any of these procedures ranged from 3e36 months. 83% (15/18) of patients underwent any of these procedures at least 6 months(range 6- 36months) upon completion of treatment. 50% (9/18) of the patients had reexcision of the lumpectomy cavity. Pathology in these patients showed evidence of fat necrosis, chronic inflammatory cells and fibrosis. There was no evidence of tumor by pathology in any of these 18 patients. None of the analyzed variables between the 2 groups showed statistically significant p value for the development of seroma leading to any of these procedures. None of the patients had acute post procedural infection. 2 patients developed late onset infection. One of them was due to neutropenia from chemotherapy and the other at 5 months following brachytherapy treatment. Conclusions: Development of seroma leading to aspiration, core biopsy or reexcision of the lumpectomy cavity following Intraoperative placement of Mammosite catheter for breast brachytherapy did not reveal any statistically significant predictive factor. Prophylactic antibiotics prevented acute infection. The reexcision pathology specimen showed evidence of chronic inflammation and fat necrosis. Only factor possibly contributing is intraoperative catheter placement as performed in these patients.
PO5 Local control, cosmetic outcome and radiation sequelae in women treated with accelerated partial breast irradiation using multicatheter brachytherapy Ashwini N. Budrukkar, M.D.1 Rajiv Sarin, FRCR1 Rakesh Jalali, M.D.1 Anusheel Munshi, M.D.1 Rajendra Badwe, M.S.2 Tanuja Shet, M.D.3 Vani Parmar, M.S.2 Mandar Nadkarni, M.S.2 Deepak Deshpande, Ph.D.4 Ketayun Dinshaw, FRCR.1 1Radiation Oncology, Tata Memorial Hospital, Mumbai, India; 2Surgery, Tata Memorial Hospital, Mumbai, India; 3 Pathology, Tata Memorial Hospital, Mumbai, India; 4Medical Physics, Tata Memorial Hospital, Mumbai, India. Purpose: The aim of the study is to evaluate the early local control, cosmetic outcome and radiation sequelae in women treated with
accelerated partial breast irradiation (APBI) using multi-catheter brachytherapy. Methods and Materials: During May 2000 to May 2007, 162 women participated in the ongoing prospective study of APBI using interstitial brachytherapy. Women with age O40 years, single tumor up to 3 cm without diffuse microcalcification and clinically negative axilla were considered suitable. Brachytherapy was done either intraoperatively during the breast conserving surgery or postoperatively using 2e4 planes. Tumor bed demarcation was done with radiopaque clips placed during surgery, CT scans, ultrasonography and/or fluoroscopy. Cavity with 1e2 cm margin was treated based on orthogonal pair of rays in initial 118 patients and three dimensional computerized tomography based brachytherapy planning with a margin of 1 cm to the cavity in the remaining patients. The dose of 34Gy in 10 fractions over 1 week was delivered with twice daily fractionation using high-dose-rate iridium source. Results: Implant was done intraoperatively in 101 patients while in remaining patients it was done postoperatively. The median T size was 2 cm. Tumor was infiltrating duct carcinoma in 94% patients with 70% of the tumors being grade III. In 11 patients only 3 or 4 fractions of HDR brachytherapy were delivered and this was followed by 45Gy / 25 # whole breast radiation therapy due to adverse histopathology. Minor wound infection was seen in 4 patients. Three patients developed wound gape of which 1 required surgical intervention. Radiation sequelae included fat necrosis in 11 and ulcer in 2 patients. At a median followup of 30 months, 7 patients have developed recurrence-local recurrence (1), distant metastases (4), regional and distant metastases (2). The actuarial 3 year local control rate was 97.6%, disease free survival was 96.5% while the overall survival was 97.5%. Cosmesis was good to excellent in 65% of the patients. Conclusions: The results of APBI with multicatheter interstitial brachytherapy appear to be encouraging. Fat necrosis is a common radiation sequelae associated with APBI. Local control with APBI appears to be comparable to the standard treatment. Further followup is needed to comment on the long term outcome of the procedure.
PO6 HDR breast boost after conservative surgery: A comparison of cosmetic outcome between intraoperative and postoperative applicator placement Aparna Gangopadhyay, M.D., Subrata Saha, M.D., Kousik Ghosh, M.Sc., Avijit Basu, M.D. Radiotherapy, Medical College Hospital, Calcutta, India. Purpose: Interstitial implant is an accepted technique for boost after conservative surgery and whole breast radiotherapy (WBRT) in selected high-risk patients with early breast cancer. Breast brachytherapy is conventionally carried out after surgery, either before or more commonly after WBRT. But some centers prefer to place applicators intra operatively with direct visualization of tumor bed. Our study aims to compare intra operative against postoperative applicator placement in terms of irradiated breast volume, skin dose and cosmesis. Methods and Materials: This is an on-going, prospective randomized trial since June 2004. So far 148 patients with T1/2, N0/1 M0 patients with tumor situated beyond 2.5 cm from skin and with a median age of 53 years were randomized, after informed consent, to either intra operative i.e. during lumpectomy (Group A) or postoperative (Group B) placement of flexible applicators. Boost dose was 16 Gy/5F, 2F daily (6 hours apart) for both arms. All patients receive WBRT 50 Gy, 6 cycles of FAC chemotherapy with/without hormone therapy. For Group B patients, implant geometry is planned by pre implant CT, on the basis of surgical clip position and seroma cavity. Target volume, number of implant planes and needle entry & exit points are determined from pre-implant CT. In patients of both groups, post insertion CT e based planning is done using geometrical optimization. DVH is analyzed for reference volume, V100, D90, V150, V200, DHI, Coverage Index, DNR, and COIN. Skin dose is recorded in each. Cosmetic outcome is evaluated using four- point (excellent, good, fair, poor) scale by a panel of 5 members. Skin telangiectasia is recorded by modified Turesson score. Results: Initial 76 patients’ data (Group A 5 36 and Group B 5 40) with medium followup of 30 months is being presented. 1 patient of Group A