Elsevier

Brachytherapy

Volume 11, Issue 3, May–June 2012, Pages 163-175
Brachytherapy

Review
A comparison of brachytherapy techniques for partial breast irradiation

https://doi.org/10.1016/j.brachy.2011.06.001Get rights and content

Abstract

Accelerated partial breast irradiation has emerged as an important treatment option for select patients with early-stage breast cancer. Numerous techniques for the delivery of accelerated partial breast irradiation have been developed involving both external beam and brachytherapy techniques. Brachytherapy techniques in general have the advantage of directly targeting the tumor bed and are not hampered by the requirement for large planning target volume margins needed with external beam techniques to account for uncertainties in targeting a very mobile organ, easily affected by patient and respiratory motion. We review established brachytherapy techniques and new emerging approaches. Technical considerations, available clinical data, advantages and shortcomings of each technique are reviewed.

Introduction

Approximately 250,000 women in the United States are diagnosed with breast cancer each year, and with the widespread use of mammography, the majority of these women are diagnosed with early-stage disease [1], [2]. The treatment of early-stage breast cancer has dramatically evolved from disfiguring radical surgery (Halstead mastectomy) to breast-conserving surgery with adjuvant whole breast radiation therapy (WBRT) resulting in not only improved outcomes but also preservation of the breast with generally good cosmesis. Partial breast irradiation has emerged as a further evolution in treatment of these patients, not only just minimizing the extent and impact of surgery but also the extent and impact of adjuvant radiation therapy.

The concept of partial breast irradiation arose out the realization that most tumor recurrences occur at or near the region of the lumpectomy site and is supported by pathologic correlation [3], [4], [5], [6]. Thus, for well-selected patients, only the breast tissue surrounding the tumor bed needs radiation treatment. Limiting radiation therapy to a smaller portion of the breast results in two major advantages. First, there is reduction in volume of irradiated tissue, thereby preserving these tissues for potential deleterious radiation effects. Second, by reducing the volume of treatment, the overall treatment time can be safely accelerated to deliver the entire course of radiation within a week or less. This approach is referred to as accelerated partial breast irradiation (APBI), and is generally defined as radiotherapy delivered to less than the whole breast using fractions higher than 1.8–2.0 Gy per day over a period of less than 5–6 weeks. The National Surgical Adjuvant Breast and Bowel Project/Radiation Therapy Oncology Group and the Groupe Européen de Curiethérapie and the European Society for Therapeutic Radiology (GEC-ESTRO) collaborative groups are conducting Phase III randomized trials evaluating the efficacy and safety of APBI in comparison to standard fractionated whole breast irradiation. Until these trials mature, the American Brachytherapy Society, American Society of Breast Surgeons (ASBS), and American Society of Therapeutic Radiation Oncology have published guidelines for appropriate patient selection for APBI (Table 1) [7], [8], [9].

Numerous techniques for the delivery of APBI have been proposed involving both external beam and brachytherapy techniques. Brachytherapy techniques in general have the advantage of directly targeting the tumor bed and are not hampered by the requirement for large planning target volume (PTV) margins needed with external beam techniques to account for uncertainties in targeting a very mobile organ easily affected by patient and respiratory motion. This review is limited to brachytherapy techniques and includes interstitial multicatheter brachytherapy, single-lumen intracavitary balloon catheter brachytherapy (MammoSite), multilumen intracavitary balloon catheter brachytherapy (Contura; MammoSite Multilumen), multilumen gage-like catheter intracavitary brachytherapy (SAVI), electronic balloon catheter intracavitary brachytherapy (Xoft), permanent breast seed implantation, and noninvasive image-guided breast brachytherapy (AccuBoost).

Section snippets

Interstitial multicatheter brachytherapy

The first APBI technique that was developed and has the most mature clinical data is interstitial multicatheter brachytherapy (IMB). This technique dates back several decades and in its inception was used at the time of lumpectomy to deliver the tumor bed boost. As the technique matured, it began being used as a sole modality. Several variations to the implant techniques have been described and published [10], [11]. In general, this approach is characterized by placement of multiple

Single-lumen catheter (MammoSite)

MammoSite (Hologic Inc, Bedford, MA) is an intracavitary balloon brachytherapy (IBB) applicator with a single central lumen compatible with HDR 192Ir remote afterloaders. MammoSite was developed as a simplification of IMB technique. With IBB, the implant placement process is much easier for the clinician as well as the patient, and thus this technique has gained widespread popularity.

IBB involves the percutaneous placement of a single-catheter applicator into the lumpectomy cavity. This is

Electronic balloon brachytherapy (Xoft Axxent)

Xoft Axxent (Ferment, CA) is an electronic balloon brachytherapy (EBB) system, which is similar to IBB using the Mammosite catheter except for the radiation source. Instead of using HDR 192Ir, the source is an electronic microminiature X-ray tube (Fig. 6). The electronic source generated a 50-kV photon spectrum in a roughly spherical distribution. The depth dose characteristics of this source were designed to roughly mimic HDR 192Ir; however, there are important differences (51). The lower

Permanent breast seed implant

Permanent breast seed implant (PBSI) technique is an exciting novel approach to APBI (57). Similar to a permanent seed implant used to treat prostate cancer, PBSI involves the percutaneous insertion of radioactive seeds (palladium-103 [103Pd]) under US guidance, distributed to deliver the prescribed dose to the tumor bed. PBSI has several advantages over other brachytherapy techniques. It is an outpatient procedure realized in a single one-hour session under local anesthesia and light sedation.

Noninvasive image-guided breast brachytherapy (AccuBoost)

Noninvasive image-guided breast brachytherapy (NIBB) using the AccuBoost Brachytherapy System (Advanced Radiation Therapy, Inc., Billerica, MA) is a novel approach to partial breast irradiation (Fig. 8). This technique has been used clinically to deliver the tumor bed after whole breast irradiation. NIBB is noninvasive and uses breast immobilization with image guidance to deliver each fraction of radiation, which makes this technique very attractive for APBI.

NIBB consists of a three-step

Comparison of techniques

Table 4 summarizes the relative advantages and disadvantages of the various brachytherapy APBI techniques. The most mature clinical experience exists for IMB affording us with the most knowledge regarding local control and factor affecting normal tissue toxicities. This technique has the greatest flexibility to conform to complex tumor cavity and normal tissue geometry. It is, however, more technically demanding to perform and requires specialized expertise. Furthermore, this technique requires

Conclusion

Multiple brachytherapy techniques have been developed, each with distinct advantages and limitations. No one technique is superior in all clinical situations. Ideally, the treating physician should have several techniques at his/her disposal to best tailor treatment to the individual patient's clinical situation and personal preferences.

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  • Cited by (0)

    Disclosures: Medical Advisory Board, Advanced Radiation Therapy, Inc.

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