What can we conclude from the results of an out-of-date breast brachytherapy study? In regard to Póti Z, Nemeskéri C, Fekeshazy A, et al. ( Int J Radiat Oncol Biol Phys 2004;58:1022–1033)

Abstract

Póti et al. (1Póti Z. Nemeskéri C. Fekésházy A. et al.Partial breast irradiation with interstitial 60Co brachytherapy results in frequent grade 3 or 4 toxicity Evidence based on a 12-year follow-up of 70 patients.Int J Radiat Oncol Biol Phys. 2004; 58: 1022-1033Abstract Full Text Full Text PDF PubMed Scopus (49) Google Scholar) recently reported on the 12-year-results of 70 women treated with partial breast brachytherapy (BT) using 60Co needles. High rates of Grade 3–4 late side effects (59%) and local recurrence (24%) were observed with their implant technique. In view of the results, the authors concluded that partial breast BT resulted in higher rates of radiation-induced fibrosis, fat necrosis, and telangiectasis than from conventional external beam irradiation (EBI). Furthermore, they expect that contemporary results with fractionated high-dose-rate (HDR) BT would be even more unfavorable.We respect their clinical study for its long-term follow-up. However, their treatment technique description and presentation of the results are full of major dosimetric, clinical, and methodological pitfalls and suffer from personal bias.Eligibility criteria were aimed at enrolling only patients with unifocal pT1–2 tumors. On the contrary, tumor size was undeterminable in 11% (8 patients). Their method of verification for defining “unifocality” remains unclear. In a previous publication of the authors reporting the preliminary results of a similar patient group, they stated that at the end of the 1980s, modern imaging methods (mammography, ultrasound (CT) and pathoanatomical possibilities were apparently not available in their region (2Mayer A. Nemeskéri C. Forms of radiotherapy complementing operations of reduced radicality for early cancer of the breast (Prospective clinical study). [Hungarian].Magyar Sebészet. 1993; 46: 65-68Google Scholar). In that era, the vast majority of pathology reports did not contain relevant information on multifocality. Based on these facts, it is likely that even the very limited predefined patient selection criteria (pT1–2 tumor size, unifocality) were not assured in the study of Póti et al. Furthermore, 19% of patients had tumors containing lobular carcinoma (10%) or pure ductal carcinoma in situ (9%); both have been considered by others as a possible contraindication for partial breast irradiation (3Arthur D.W. Vicini F.A. Kuske R.R. et al.Accelerated partial breast irradiation An updated report from the American Brachytherapy Society.Brachytherapy. 2002; 1: 184-190Abstract Full Text Full Text PDF PubMed Scopus (69) Google Scholar, 4Polgár C. Fodor J. Major T. et al.Radiotherapy confined to the tumor bed following breast conserving surgery Current status, controversies, and future prospects.Strahlenther Onkol. 2002; 178: 597-606Crossref PubMed Scopus (53) Google Scholar, 5Polgár C. Sulyok Z. Fodor J. et al.Sole brachytherapy of the tumor bed after conservative surgery for T1 breast cancer Five-year results of a phase I–II study and initial findings of a randomized phase III trial.J Surg Oncol. 2002; 80: 121-128Crossref PubMed Scopus (220) Google Scholar, 6Vicini F. Arthur D. Polgar C. et al.Defining the efficacy of accelerated partial breast irradiation The importance of proper patient selection, optimal quality assurance, and common sense.Int J Radiat Oncol Biol Phys. 2003; 57: 1210-1213Abstract Full Text Full Text PDF PubMed Scopus (66) Google Scholar). The lack of information on other important pathologic parameters (i.e., margin status, extensive intraductal component, vascular invasion, grade, receptor status) does not allow a definition of the exact proportion of patients being acceptable candidates for either partial breast BT or breast-conserving therapy. Nevertheless, it can be estimated that, using modern standards, the majority of patients nowadays would not at all be eligible for breast conservation. Interestingly, in a previously published series of the Uzsoki Hospital, an unusually high crude local recurrence rate (10%, 3 out of 30 patients) at a short-term follow-up (mean: 16 months) was reported for patients treated with whole-breast EBI supplemented by HDR BT boost (2Mayer A. Nemeskéri C. Forms of radiotherapy complementing operations of reduced radicality for early cancer of the breast (Prospective clinical study). [Hungarian].Magyar Sebészet. 1993; 46: 65-68Google Scholar). These results reinforce that any form of radiotherapy cannot overcome the limitations caused by suboptimal diagnostic workup and surgery.It is also to be noted that in the study of Póti et al. (1Póti Z. Nemeskéri C. Fekésházy A. et al.Partial breast irradiation with interstitial 60Co brachytherapy results in frequent grade 3 or 4 toxicity Evidence based on a 12-year follow-up of 70 patients.Int J Radiat Oncol Biol Phys. 2004; 58: 1022-1033Abstract Full Text Full Text PDF PubMed Scopus (49) Google Scholar) median age of the patients was only 52 years (range: 20–87). Young patient age (below 40–45 years) has also been suggested by others as a possible contraindication for partial breast irradiation (3Arthur D.W. Vicini F.A. Kuske R.R. et al.Accelerated partial breast irradiation An updated report from the American Brachytherapy Society.Brachytherapy. 2002; 1: 184-190Abstract Full Text Full Text PDF PubMed Scopus (69) Google Scholar, 4Polgár C. Fodor J. Major T. et al.Radiotherapy confined to the tumor bed following breast conserving surgery Current status, controversies, and future prospects.Strahlenther Onkol. 2002; 178: 597-606Crossref PubMed Scopus (53) Google Scholar, 6Vicini F. Arthur D. Polgar C. et al.Defining the efficacy of accelerated partial breast irradiation The importance of proper patient selection, optimal quality assurance, and common sense.Int J Radiat Oncol Biol Phys. 2003; 57: 1210-1213Abstract Full Text Full Text PDF PubMed Scopus (66) Google Scholar).The study population underwent breast-conserving surgery with an unknown surgical margin in 27 different surgical departments. Surgical axillary staging was omitted in 21 patients (30%). The number of retrieved nodes was unknown in a further 24 patients (34%). Three women had N1 status. The median number of resected nodes for the remaining 22 patients (31%) was only five. Taking into account the definition of the AJCC/UICC TNM classification, at least 56 out of 70 patients (80%) would have been classified as having unknown pathologic axillary status (pNX). We wonder whether there is any surgeon throughout the world who would accept these surgical techniques for the treatment of invasive breast carcinoma.Thick (2.6-mm diameter) 60Co catheters with 4-cm active length were implanted into the clinically estimated tumor bed in a single plane for all cases without template guidance. The limitations of such an implant technique are obvious. The clinical target volume (CTV) for partial breast BT is usually defined as the excision cavity plus 1–2-cm margin in each direction (3Arthur D.W. Vicini F.A. Kuske R.R. et al.Accelerated partial breast irradiation An updated report from the American Brachytherapy Society.Brachytherapy. 2002; 1: 184-190Abstract Full Text Full Text PDF PubMed Scopus (69) Google Scholar, 4Polgár C. Fodor J. Major T. et al.Radiotherapy confined to the tumor bed following breast conserving surgery Current status, controversies, and future prospects.Strahlenther Onkol. 2002; 178: 597-606Crossref PubMed Scopus (53) Google Scholar, 5Polgár C. Sulyok Z. Fodor J. et al.Sole brachytherapy of the tumor bed after conservative surgery for T1 breast cancer Five-year results of a phase I–II study and initial findings of a randomized phase III trial.J Surg Oncol. 2002; 80: 121-128Crossref PubMed Scopus (220) Google Scholar, 6Vicini F. Arthur D. Polgar C. et al.Defining the efficacy of accelerated partial breast irradiation The importance of proper patient selection, optimal quality assurance, and common sense.Int J Radiat Oncol Biol Phys. 2003; 57: 1210-1213Abstract Full Text Full Text PDF PubMed Scopus (66) Google Scholar). In the Uzsoki Hospital series it was practically impossible to cover such a target volume with single-plane implants. Furthermore, surgical clips or CT images were not used to delineate the tumor bed. This suggests that these suboptimal implants resulted in geographic miss for the vast majority (if not all) of the patients. The results obtained (a 17% rate of true recurrence/marginal miss) clearly demonstrate this.Regarding the dose prescription, the authors repeatedly contradict themselves; we confess that even after several readings we could not understand it. On the one hand, they state that the dose was calculated according to the Paris dosimetry system; on the other hand, it is written in the text that the 50 Gy dose was delivered at 5 mm from the sources. Finally, they state that for “radiobiologic considerations,” the CTV was calculated retrospectively with a 10-mm safety margin, resulting in a 28 Gy dose, 72 cm3 median CTV, and 1.3–2.8 Gy/h dose rate. Unfortunately, both of the latter dose prescriptions are very far from the Paris system's rules (7Pierquin B. Dutreix A. Paine C.H. et al.The Paris System in interstitial radiation therapy.Acta Radiol Oncol. 1978; 17: 33-48Crossref Scopus (45) Google Scholar). According to the Paris system, the thickness of the treated volume is around 0.6 times the separation between the needles for planar implants. For 10-mm spacing between the needles used in the study, the thickness of the treated volume is only 6 mm, which is much less than the 20-mm thickness of the retrospectively created CTV.Moreover, it is clearly not appropriate to redefine the CTV and recalculate the dose rate based on (otherwise not detailed) “radiobiologic considerations.” Definition of CTV and calculation of dose rate should always be based on clinical considerations. According to the original dose prescription, a total dose of 50 Gy was prescribed at 5 mm from the surface of the sources. This 50 Gy was administered during 10–22 h to the virtual lumpectomy plane. It means that in reality, the actual dose rate was in the range of 2.3 to 5.0 Gy/h, and the median volume covered by the reference isodose was significantly smaller (i.e., 36 cm3) than reported. Consequently, a high total dose of continuous medium-dose-rate (not low-dose-rate) treatment was delivered within a short overall treatment time. It has been proved by others that the implant dose rate (for continuous low-dose-rate BT) should be maintained between 0.3 and 0.7 Gy/h to maximize local tumor control and reduce late normal-tissue injury (8Deore S.M. Sarin R. Dinshaw K.A. et al.Influence of dose-rate and dose per fraction on clinical outcome of breast cancer treated by external beam irradiation plus iridium-192 implants Analysis of 289 cases.Int J Radiat Oncol Biol Phys. 1993; 26: 601-606Abstract Full Text PDF PubMed Scopus (31) Google Scholar). Based on radiobiologic calculations, the 50 Gy continuous medium-dose-rate irradiation within 10–22 h is equivalent to the late effects of 86 to 134 Gy of conventional low-dose-rate irradiation (using an alpha/beta ratio of 4 Gy for late effects and 0.5 Gy/h dose rate). Such a high radiobiologically equivalent dose inevitably causes serious late side effects, as demonstrated by the results of Póti et al. (1Póti Z. Nemeskéri C. Fekésházy A. et al.Partial breast irradiation with interstitial 60Co brachytherapy results in frequent grade 3 or 4 toxicity Evidence based on a 12-year follow-up of 70 patients.Int J Radiat Oncol Biol Phys. 2004; 58: 1022-1033Abstract Full Text Full Text PDF PubMed Scopus (49) Google Scholar).Unusual follow-up examinations including dynamic MRI, methoxy-isobutyl-isonitvile (MIBI) single-photon emission computed tomography (SPECT), [11C]methionine positron emission tomography, and [18F]fluorodeoxyglucose positron emission tomography were used by the authors to detect late radiation sequelae. Patients with palpable mass underwent these expensive, inconvenient, and time-consuming methods to decide between fibrosis and local tumor recurrence. We are convinced that these practically continuous diagnostic procedures (and not the palpable mass itself) might impose stress and significant inconvenience to the patients. On the other hand, these imaging methods can serve as tools for detection of otherwise clinically irrelevant “serious side effects” (i.e., small asymptomatic fat necroses and/or oil cysts). In a recent analysis (in revision to the Journal) of contemporary Hungarian studies of partial breast BT, we reevaluated all available follow-up mammography films for patients treated with either HDR BT or EBI, searching for visible signs of asymptomatic fat necroses. Noteworthy: we identified similar high incidence of asymptomatic fat necrosis in both HDR BT (20.0%) and EBI (20.6%) groups. It has also been stated by others that calcified suture materials and coarse calcifications owing to fat necrosis may develop in up to one-third of irradiated breasts (9Dershaw D.D. Evaluation of the breast undergoing lumpectomy and radiation therapy.Radiol Clin N Am. 1995; 33: 1147-1160PubMed Google Scholar). Dershaw (9Dershaw D.D. Evaluation of the breast undergoing lumpectomy and radiation therapy.Radiol Clin N Am. 1995; 33: 1147-1160PubMed Google Scholar) suggested avoiding open biopsy of these findings when possible, because percutaneous biopsy may be useful to differentiate benign lesions from malignant ones.As a summary, what can we conclude from the results of an out-of-date breast BT study? 1.Suboptimal surgical techniques applied after suboptimal diagnostic and pathologic workup should not be used for breast-conserving therapy.2.Poor patient selection, poor implant quality, and lack of quality assurance procedures, in addition to inadequately applied dose rate, inevitably lead to poor treatment outcome, and such BT should not be used in any setting.3.Whatever practice of dose prescription is used, the recommendations of the ICRU Report 58 should be applied for reporting dose and volume specification of interstitial implants to compare results and better relate outcome to treatment.4.The use of standard scoring systems is suggested for the objective documentation of side effects of any radiotherapy methods used in breast-conserving therapy.5.Unfortunately, the study of Póti et al. offers little useful information to assess the efficacy of contemporary studies using continuous LDR or fractionated HDR BT for partial breast irradiation. Póti et al. (1Póti Z. Nemeskéri C. Fekésházy A. et al.Partial breast irradiation with interstitial 60Co brachytherapy results in frequent grade 3 or 4 toxicity Evidence based on a 12-year follow-up of 70 patients.Int J Radiat Oncol Biol Phys. 2004; 58: 1022-1033Abstract Full Text Full Text PDF PubMed Scopus (49) Google Scholar) recently reported on the 12-year-results of 70 women treated with partial breast brachytherapy (BT) using 60Co needles. High rates of Grade 3–4 late side effects (59%) and local recurrence (24%) were observed with their implant technique. In view of the results, the authors concluded that partial breast BT resulted in higher rates of radiation-induced fibrosis, fat necrosis, and telangiectasis than from conventional external beam irradiation (EBI). Furthermore, they expect that contemporary results with fractionated high-dose-rate (HDR) BT would be even more unfavorable. We respect their clinical study for its long-term follow-up. However, their treatment technique description and presentation of the results are full of major dosimetric, clinical, and methodological pitfalls and suffer from personal bias. Eligibility criteria were aimed at enrolling only patients with unifocal pT1–2 tumors. On the contrary, tumor size was undeterminable in 11% (8 patients). Their method of verification for defining “unifocality” remains unclear. In a previous publication of the authors reporting the preliminary results of a similar patient group, they stated that at the end of the 1980s, modern imaging methods (mammography, ultrasound (CT) and pathoanatomical possibilities were apparently not available in their region (2Mayer A. Nemeskéri C. Forms of radiotherapy complementing operations of reduced radicality for early cancer of the breast (Prospective clinical study). [Hungarian].Magyar Sebészet. 1993; 46: 65-68Google Scholar). In that era, the vast majority of pathology reports did not contain relevant information on multifocality. Based on these facts, it is likely that even the very limited predefined patient selection criteria (pT1–2 tumor size, unifocality) were not assured in the study of Póti et al. Furthermore, 19% of patients had tumors containing lobular carcinoma (10%) or pure ductal carcinoma in situ (9%); both have been considered by others as a possible contraindication for partial breast irradiation (3Arthur D.W. Vicini F.A. Kuske R.R. et al.Accelerated partial breast irradiation An updated report from the American Brachytherapy Society.Brachytherapy. 2002; 1: 184-190Abstract Full Text Full Text PDF PubMed Scopus (69) Google Scholar, 4Polgár C. Fodor J. Major T. et al.Radiotherapy confined to the tumor bed following breast conserving surgery Current status, controversies, and future prospects.Strahlenther Onkol. 2002; 178: 597-606Crossref PubMed Scopus (53) Google Scholar, 5Polgár C. Sulyok Z. Fodor J. et al.Sole brachytherapy of the tumor bed after conservative surgery for T1 breast cancer Five-year results of a phase I–II study and initial findings of a randomized phase III trial.J Surg Oncol. 2002; 80: 121-128Crossref PubMed Scopus (220) Google Scholar, 6Vicini F. Arthur D. Polgar C. et al.Defining the efficacy of accelerated partial breast irradiation The importance of proper patient selection, optimal quality assurance, and common sense.Int J Radiat Oncol Biol Phys. 2003; 57: 1210-1213Abstract Full Text Full Text PDF PubMed Scopus (66) Google Scholar). The lack of information on other important pathologic parameters (i.e., margin status, extensive intraductal component, vascular invasion, grade, receptor status) does not allow a definition of the exact proportion of patients being acceptable candidates for either partial breast BT or breast-conserving therapy. Nevertheless, it can be estimated that, using modern standards, the majority of patients nowadays would not at all be eligible for breast conservation. Interestingly, in a previously published series of the Uzsoki Hospital, an unusually high crude local recurrence rate (10%, 3 out of 30 patients) at a short-term follow-up (mean: 16 months) was reported for patients treated with whole-breast EBI supplemented by HDR BT boost (2Mayer A. Nemeskéri C. Forms of radiotherapy complementing operations of reduced radicality for early cancer of the breast (Prospective clinical study). [Hungarian].Magyar Sebészet. 1993; 46: 65-68Google Scholar). These results reinforce that any form of radiotherapy cannot overcome the limitations caused by suboptimal diagnostic workup and surgery. It is also to be noted that in the study of Póti et al. (1Póti Z. Nemeskéri C. Fekésházy A. et al.Partial breast irradiation with interstitial 60Co brachytherapy results in frequent grade 3 or 4 toxicity Evidence based on a 12-year follow-up of 70 patients.Int J Radiat Oncol Biol Phys. 2004; 58: 1022-1033Abstract Full Text Full Text PDF PubMed Scopus (49) Google Scholar) median age of the patients was only 52 years (range: 20–87). Young patient age (below 40–45 years) has also been suggested by others as a possible contraindication for partial breast irradiation (3Arthur D.W. Vicini F.A. Kuske R.R. et al.Accelerated partial breast irradiation An updated report from the American Brachytherapy Society.Brachytherapy. 2002; 1: 184-190Abstract Full Text Full Text PDF PubMed Scopus (69) Google Scholar, 4Polgár C. Fodor J. Major T. et al.Radiotherapy confined to the tumor bed following breast conserving surgery Current status, controversies, and future prospects.Strahlenther Onkol. 2002; 178: 597-606Crossref PubMed Scopus (53) Google Scholar, 6Vicini F. Arthur D. Polgar C. et al.Defining the efficacy of accelerated partial breast irradiation The importance of proper patient selection, optimal quality assurance, and common sense.Int J Radiat Oncol Biol Phys. 2003; 57: 1210-1213Abstract Full Text Full Text PDF PubMed Scopus (66) Google Scholar). The study population underwent breast-conserving surgery with an unknown surgical margin in 27 different surgical departments. Surgical axillary staging was omitted in 21 patients (30%). The number of retrieved nodes was unknown in a further 24 patients (34%). Three women had N1 status. The median number of resected nodes for the remaining 22 patients (31%) was only five. Taking into account the definition of the AJCC/UICC TNM classification, at least 56 out of 70 patients (80%) would have been classified as having unknown pathologic axillary status (pNX). We wonder whether there is any surgeon throughout the world who would accept these surgical techniques for the treatment of invasive breast carcinoma. Thick (2.6-mm diameter) 60Co catheters with 4-cm active length were implanted into the clinically estimated tumor bed in a single plane for all cases without template guidance. The limitations of such an implant technique are obvious. The clinical target volume (CTV) for partial breast BT is usually defined as the excision cavity plus 1–2-cm margin in each direction (3Arthur D.W. Vicini F.A. Kuske R.R. et al.Accelerated partial breast irradiation An updated report from the American Brachytherapy Society.Brachytherapy. 2002; 1: 184-190Abstract Full Text Full Text PDF PubMed Scopus (69) Google Scholar, 4Polgár C. Fodor J. Major T. et al.Radiotherapy confined to the tumor bed following breast conserving surgery Current status, controversies, and future prospects.Strahlenther Onkol. 2002; 178: 597-606Crossref PubMed Scopus (53) Google Scholar, 5Polgár C. Sulyok Z. Fodor J. et al.Sole brachytherapy of the tumor bed after conservative surgery for T1 breast cancer Five-year results of a phase I–II study and initial findings of a randomized phase III trial.J Surg Oncol. 2002; 80: 121-128Crossref PubMed Scopus (220) Google Scholar, 6Vicini F. Arthur D. Polgar C. et al.Defining the efficacy of accelerated partial breast irradiation The importance of proper patient selection, optimal quality assurance, and common sense.Int J Radiat Oncol Biol Phys. 2003; 57: 1210-1213Abstract Full Text Full Text PDF PubMed Scopus (66) Google Scholar). In the Uzsoki Hospital series it was practically impossible to cover such a target volume with single-plane implants. Furthermore, surgical clips or CT images were not used to delineate the tumor bed. This suggests that these suboptimal implants resulted in geographic miss for the vast majority (if not all) of the patients. The results obtained (a 17% rate of true recurrence/marginal miss) clearly demonstrate this. Regarding the dose prescription, the authors repeatedly contradict themselves; we confess that even after several readings we could not understand it. On the one hand, they state that the dose was calculated according to the Paris dosimetry system; on the other hand, it is written in the text that the 50 Gy dose was delivered at 5 mm from the sources. Finally, they state that for “radiobiologic considerations,” the CTV was calculated retrospectively with a 10-mm safety margin, resulting in a 28 Gy dose, 72 cm3 median CTV, and 1.3–2.8 Gy/h dose rate. Unfortunately, both of the latter dose prescriptions are very far from the Paris system's rules (7Pierquin B. Dutreix A. Paine C.H. et al.The Paris System in interstitial radiation therapy.Acta Radiol Oncol. 1978; 17: 33-48Crossref Scopus (45) Google Scholar). According to the Paris system, the thickness of the treated volume is around 0.6 times the separation between the needles for planar implants. For 10-mm spacing between the needles used in the study, the thickness of the treated volume is only 6 mm, which is much less than the 20-mm thickness of the retrospectively created CTV. Moreover, it is clearly not appropriate to redefine the CTV and recalculate the dose rate based on (otherwise not detailed) “radiobiologic considerations.” Definition of CTV and calculation of dose rate should always be based on clinical considerations. According to the original dose prescription, a total dose of 50 Gy was prescribed at 5 mm from the surface of the sources. This 50 Gy was administered during 10–22 h to the virtual lumpectomy plane. It means that in reality, the actual dose rate was in the range of 2.3 to 5.0 Gy/h, and the median volume covered by the reference isodose was significantly smaller (i.e., 36 cm3) than reported. Consequently, a high total dose of continuous medium-dose-rate (not low-dose-rate) treatment was delivered within a short overall treatment time. It has been proved by others that the implant dose rate (for continuous low-dose-rate BT) should be maintained between 0.3 and 0.7 Gy/h to maximize local tumor control and reduce late normal-tissue injury (8Deore S.M. Sarin R. Dinshaw K.A. et al.Influence of dose-rate and dose per fraction on clinical outcome of breast cancer treated by external beam irradiation plus iridium-192 implants Analysis of 289 cases.Int J Radiat Oncol Biol Phys. 1993; 26: 601-606Abstract Full Text PDF PubMed Scopus (31) Google Scholar). Based on radiobiologic calculations, the 50 Gy continuous medium-dose-rate irradiation within 10–22 h is equivalent to the late effects of 86 to 134 Gy of conventional low-dose-rate irradiation (using an alpha/beta ratio of 4 Gy for late effects and 0.5 Gy/h dose rate). Such a high radiobiologically equivalent dose inevitably causes serious late side effects, as demonstrated by the results of Póti et al. (1Póti Z. Nemeskéri C. Fekésházy A. et al.Partial breast irradiation with interstitial 60Co brachytherapy results in frequent grade 3 or 4 toxicity Evidence based on a 12-year follow-up of 70 patients.Int J Radiat Oncol Biol Phys. 2004; 58: 1022-1033Abstract Full Text Full Text PDF PubMed Scopus (49) Google Scholar). Unusual follow-up examinations including dynamic MRI, methoxy-isobutyl-isonitvile (MIBI) single-photon emission computed tomography (SPECT), [11C]methionine positron emission tomography, and [18F]fluorodeoxyglucose positron emission tomography were used by the authors to detect late radiation sequelae. Patients with palpable mass underwent these expensive, inconvenient, and time-consuming methods to decide between fibrosis and local tumor recurrence. We are convinced that these practically continuous diagnostic procedures (and not the palpable mass itself) might impose stress and significant inconvenience to the patients. On the other hand, these imaging methods can serve as tools for detection of otherwise clinically irrelevant “serious side effects” (i.e., small asymptomatic fat necroses and/or oil cysts). In a recent analysis (in revision to the Journal) of contemporary Hungarian studies of partial breast BT, we reevaluated all available follow-up mammography films for patients treated with either HDR BT or EBI, searching for visible signs of asymptomatic fat necroses. Noteworthy: we identified similar high incidence of asymptomatic fat necrosis in both HDR BT (20.0%) and EBI (20.6%) groups. It has also been stated by others that calcified suture materials and coarse calcifications owing to fat necrosis may develop in up to one-third of irradiated breasts (9Dershaw D.D. Evaluation of the breast undergoing lumpectomy and radiation therapy.Radiol Clin N Am. 1995; 33: 1147-1160PubMed Google Scholar). Dershaw (9Dershaw D.D. Evaluation of the breast undergoing lumpectomy and radiation therapy.Radiol Clin N Am. 1995; 33: 1147-1160PubMed Google Scholar) suggested avoiding open biopsy of these findings when possible, because percutaneous biopsy may be useful to differentiate benign lesions from malignant ones. As a summary, what can we conclude from the results of an out-of-date breast BT study? 1.Suboptimal surgical techniques applied after suboptimal diagnostic and pathologic workup should not be used for breast-conserving therapy.2.Poor patient selection, poor implant quality, and lack of quality assurance procedures, in addition to inadequately applied dose rate, inevitably lead to poor treatment outcome, and such BT should not be used in any setting.3.Whatever practice of dose prescription is used, the recommendations of the ICRU Report 58 should be applied for reporting dose and volume specification of interstitial implants to compare results and better relate outcome to treatment.4.The use of standard scoring systems is suggested for the objective documentation of side effects of any radiotherapy methods used in breast-conserving therapy.5.Unfortunately, the study of Póti et al. offers little useful information to assess the efficacy of contemporary studies using continuous LDR or fractionated HDR BT for partial breast irradiation.