Balloon Catheter Brachytherapy Research Articles

A PHASE II TRIAL OF BALLOON-CATHETER PARTIAL BREAST BRACHYTHERAPY OPTIMIZATION IN THE TREATMENT OF STAGE 0, I AND IIA BREAST CARCINOMA.

(a) To prospectively determine if multidwell position dose delivery can decrease skin dose and resultant toxicity over single dwell balloon-catheter partial breast irradiation, and (b) to evaluate whether specific skin parameters could be safely used instead of skin-balloon distance alone for predicting toxicity and treatment eligibility. A single-arm phase II study using a Simon two-stage design was performed on 28 women with stage 0-II breast cancer. All patients were treated with multiple dwell position balloon-catheter brachytherapy. The primary endpoint was ≥ grade 2 skin toxicity. Initial entry required a balloon-skin distance ≥ 7 mm. Based on the toxicity in the first 16 patients, additional patients were treated irrespective of skin-balloon distance as long as the Dmax to 1 mm skin thickness was < 130%. Compared to the phantom single dwell plans, multidwell planning yielded superior PTV coverage as per median V90, V95 and V100, but had slightly worse V150, V200 and DHI. Dmax to skin was decreased by multidwell planning at multiple skin thicknesses. The most common acute toxicity was grade 1 erythema (57%), and only two patients (7%) developed acute grade 2 toxicity (erythema). Late grade 1 fibrosis was seen in 32%. No patients experienced grade 3, 4, or 5 toxicity. Multidwell position planning for balloon-catheter brachytherapy results in lower skin doses with equal to superior PTV coverage and an overall low rate of initial skin toxicity. Our data suggest that limiting the Dmax to < 130% to 1 mm thick skin is achievable and results in minimal toxicity.

Brachytherapy in breast cancer: an effective alternative.

Breast conserving surgery (BCS) with following external beam radiation therapy (EBRT) of the conserved breast has become widely accepted in the last decades for the treatment of early invasive breast cancer. The standard technique of EBRT after BCS is to treat the whole breast up to a total dose of 42.5 to 50 Gy. An additional dose is given to treated volume as a boost to a portion of the breast. In the early stage of breast cancer, research has shown that the area requiring radiation treatment to prevent the cancer from local recurrence is the breast tissue that surrounds the area where the initial cancer was removed. Accelerated partial breast irradiation (APBI) is an approach that treats only the lumpectomy bed plus a 1-2 cm margin rather than the whole breast and as a result allows accelerated delivery of the radiation dose in four to five days. There has been a growing interest for APBI and various approaches have been developed under phase I-III clinical studies; these include multicatheter interstitial brachytherapy, balloon catheter brachytherapy, conformal external beam radiation therapy (3D-EBRT) and intra-operative radiation therapy (IORT). Balloon-based brachytherapy approaches include MammoSite, Axxent electronic brachytherapy, Contura, hybrid brachytherapy devices. Another indication for breast brachytherapy is reirradiation of local recurrence after mastectomy. Published results of brachytherapy are very promising. We discuss the current status, indications, and technical aspects of breast cancer brachytherapy.

Irradiación parcial acelerada en cáncer de mama: revisión de las diferentes técnicas

Breast conservation therapy is the procedure of choice of early-stage breast cancer. Accelerated partial breast irradiation is an approach that treats only the lumpectomy bed plus a 1-2cm margin, rather than the whole breast. Because of the small volume of irradiation, a higher dose can be delivered, thus reducing the total length of treatment. Growing interest in accelerated partial breast irradiation has prompted the development of phase i-iii clinical studies evaluating distinct techniques within this therapeutic modality; these techniques include multicatheter interstitial brachytherapy, balloon-catheter brachytherapy, conformal external beam radiation therapy, and intraoperative radiation therapy. Balloon-based brachytherapy approaches include MammoSite, Axxent and Contura electronic brachytherapy. Hybrid brachytherapy devices include SAVI and ClearPath. This article reviews the different techniques, identifying the weaknesses and strengths of each approach, and proposes a direction for future research and development. Although further follow-up and mature phase iii data are needed, it seems evident that accelerated partial breast irradiation will play a role in the management of a selected group of patients with early-stage breast cancer.

Comparative dosimetry in intracavitary balloon catheter brachytherapy with I-125 and in Cf-252 brachytherapy combined with BNCT for brain tumors

Objective Comparative analysis of dosimetry in intracavitary balloon catheter brachytherapy with I-125 and in Cf-252 brachytherapy combined with BNCT for treatment of brain tumors. Materials and Methods Simulations of intracavitary balloon catheter brachytherapy with I-125 and in Cf-252 brachytherapy combined with BNCT were performed with the MCNP5 code, modeling the treatment of a brain tumor on a voxel computational phantom representing a human head. Absorbed dose rates were converted into biologically weighted dose rates. Results Intracavitary balloon catheter brachytherapy with I-125 produced biologically weighted mean dose rates of 3.2E-11, 1.3E-10, 1.9E-11 and 6.9E-13 RBE.Gy.h-1.p-1.s, respectively, on the healthy tissue, on the balloon periphery and on the I 1 and I 2 tumor infiltration zones. On the other hand, Cf-252 brachytherapy combined with BNCT produced a biologically weighted mean dose rate of 5.2E-09, 2.3E-07, 8.7E-09 and 2.4E-09 RBE.Gy.h-1.p-1.s, respectively on the healthy tissue, on the target tumor and on the I 1 and I 2 infiltration zones. Conclusion Cf-252 brachytherapy combined with BNCT delivered a selective irradiation to the target tumor and to infiltration zones, while intracavitary balloon catheter brachytherapy with I-125 delivered negligible doses on the tumor infiltration zones.

Present standards and future concepts of surgery in breast cancer

Not so long ago, most breast cancer patients were treated with mastectomy (without reconstruction) and routine axillary lymph node dissection (ALND). With the increased emphasis on minimally invasive and less morbid surgical procedures, most patients today undergo breast-conserving surgery (BCS)without ALND. The surgical options for patients who require or desire mastectomy have dramatically expanded with the development of skin- and nipple-sparing mastectomies and better access to reconstructive options. Surprisingly, an increasing proportion of patients with unilateral breast cancer are undergoing bilateral mastectomy with contralateral prophylactic mastectomy. Today, surgeons are more involved in the delivery of partial breast irradiation therapy with the development of balloon-catheter brachytherapy and intraoperative radiation therapy. As a result of new technologies, improved surgical techniques and practice-changing studies, the surgeons’ role in breast cancer treatment has become increasingly more complex. The purpose of this review article is to outline the rapidly changing landscape of breast cancer management and to highlight the surgeons’ role in this multifaceted disease.

A Single-Institution Review of Accelerated Partial Breast Irradiation in Patients Considered “Cautionary” by the American Society for Radiation Oncology

The American Society for Radiation Oncology (ASTRO) issued a consensus statement in 2009 regarding patient selection for accelerated partial breast irradiation (APBI) following breast-conserving surgery (BCS) for breast cancer (BC). We reviewed our single-institution experience with APBI in patients considered "cautionary" by ASTRO to determine patterns of recurrence. An institutional review board-approved, retrospective chart review was conducted from January 2004 to November 2009. We identified 106 "cautionary" patients with 109 BC. All patients were treated with BCS followed by APBI via balloon catheter brachytherapy. "Cautionary" criteria include patients aged 50-59 years, tumor size 2.1-3.0 cm, close margins (<2 mm), focal lymphovascular invasion, estrogen receptor (ER)-negative tumors, invasive lobular carcinoma, or ductal carcinoma in situ (DCIS) ≤ 3 cm. Rates of recurrence at any site were evaluated. Median follow-up was 3 years. There were 3 IBTR (2.8%) at a median of 3.2 years. The 3-year actuarial IBTR rate was 1.8%. Patients with ER-negative invasive cancers had a higher IBTR rate compared with ER-positive patients (11.8% vs. 2.2%), although this did not reach statistical significance (P = 0.18). There were no IBTR in 46 patients with DCIS. On univariate analysis, there was no association between "cautionary" criteria and risk of local, regional, or distant recurrence. Patients considered "cautionary" for APBI based on ASTRO guidelines had low rates of IBTR. ER-negative patients trended toward a higher IBTR rate with APBI compared with ER-positive patients. Longer follow-up is needed to establish the safety of APBI in "cautionary" patients.

Abstract ES5-1: Emerging Radiation Techniques — The Fast and the Furious

Abstract The equivalence of breast conserving therapy (BCT) to mastectomy in the treatment of women with early-stage breast cancer has been demonstrated in several phase III trials with over 25 years of follow-up. Despite the undisputed efficacy of this treatment approach, recent investigations have explored methods to either reduce the overall time, inconvenience or toxicity of its application. These approaches have included (1) accelerating the dose delivery scheme, (2) reducing the treatment target to less than whole breast, or (3) identifying subgroups of women in which adjuvant radiation therapy (RT) following lumpectomy can be safely omitted Accelerated partial breast irradiation (APBI) has been investigated as a possible option that incorporates both a decrease in the overall treatment time and a reduction in the amount of normal tissue irradiated. Several different treatment techniques have been developed for the delivery of APBI. Within the United States, three ‘classic’ techniques dominate and include multicatheter interstitial brachytherapy, balloon catheter brachytherapy and three-dimensional conformal external beam radiotherapy (3D-CRT). In Europe, in addition to multicatheter brachytherapy, intraoperative radiotherapy has been central to their APBI experience. The majority of results with APBI to date have provided comparable 5 and 10-year outcomes to whole breast irradiation (WBI) in highly selected, low risk patients. In recognition of the success of these single institution experiences, nine phase III studies have now been initiated or completed in the United States and Europe. Despite limited long-term clinical data, the use of APBI outside of clinical trials has increased sharply. Given these concerns, the American Society of Therapeutic Radiology and Oncology (ASTRO) Health Services Research Committee convened a Task Force of breast cancer experts to develop a consensus statement addressing patient selection criteria and best practices for the application of APBI outside of clinical trials. These recently published recommendations were based on the results of a systematic literature review of the limited APBI data and were also supplemented by the expert opinions of the Task Force members using data applying WBI to treat patients. Accelerated whole breast irradiation (AWBI) has also been explored as a potential treatment option to deliver adjuvant irradiation after lumpectomy. Similar to APBI, the goals of this treatment approach are to theoretically increase the frequency that BCT is chosen as a treatment option, provide a logistically faster, convenient and more accessible method for BCT and potentially improve overall quality-of-life for early stage breast cancer patients. The data on AWBI include several phase III trials performed in Europe and North America with some trials reporting results at 10 years. In recognition of the concerns related to appropriate selection criteria for the application of this treatment approach, the ASTRO Health Services Research Committee also convened a Task Force of breast cancer experts to develop a consensus statement addressing patient selection criteria and best practices for the application of AWBI. Citation Information: Cancer Res 2010;70(24 Suppl):Abstract nr ES5-1.

Accelerated Partial Breast Irradiation (APBI): A review of available techniques.

Breast conservation therapy (BCT) is the procedure of choice for the management of the early stage breast cancer. However, its utilization has not been maximized because of logistics issues associated with the protracted treatment involved with the radiation treatment. Accelerated Partial Breast Irradiation (APBI) is an approach that treats only the lumpectomy bed plus a 1-2 cm margin, rather than the whole breast. Hence because of the small volume of irradiation a higher dose can be delivered in a shorter period of time. There has been growing interest for APBI and various approaches have been developed under phase I-III clinical studies; these include multicatheter interstitial brachytherapy, balloon catheter brachytherapy, conformal external beam radiation therapy and intra-operative radiation therapy (IORT). Balloon-based brachytherapy approaches include Mammosite, Axxent electronic brachytherapy and Contura, Hybrid brachytherapy devices include SAVI and ClearPath. This paper reviews the different techniques, identifying the weaknesses and strength of each approach and proposes a direction for future research and development. It is evident that APBI will play a role in the management of a selected group of early breast cancer. However, the relative role of the different techniques is yet to be clearly identified.

Measurements of dose discrepancies due to inhomogeneities and radiographic contrast in balloon catheter brachytherapy

Recently, a device called MammoSite, consisting of a balloon and a catheter, was developed to perform partial-breast irradiation using a high-dose-rate (HDR) brachytherapy unit with ease and reproducibility. However, the actual dose to the skin does not agree well with the calculated dose by the treatment planning system because of the difference between the calculation condition and the real treatment condition (i.e., homogeneous water and full scatter condition vs contrast solution and lack of full scatter condition). In this study, the authors experimentally estimated dose discrepancies due to contrast and lack of full scatter in breast HDR brachytherapy with MammoSite. Using metal-oxide-semiconductor field-effect transistor detectors and a breast phantom, the dose discrepancies between the calculation and the treatment conditions were measured according to contrast concentration (10% and 20% volume ratios), balloon size (35 and 60 cm3), and source to detector distance ranging from 25 to 50 mm. The source was an Ir-192 isotope from Nucletron HDR unit. The dose discrepancies from the calculation condition due to both contrast and lack of full scatter combined ranged from about -1.4 +/- 2.5% to -18.2 +/- 2.0% in the studied cases (error bound is in two sided confidence interval of 80% based on Student's t distribution). In all cases, the effect of lack of full scatter was dominant to that of contrast and significant dose discrepancies existed between the calculation and the real treatment conditions, indicating that the actual skin dose is less than that which is currently calculated.

Dose errors due to inhomogeneities in balloon catheter brachytherapy for breast cancer

PurposeTo evaluate dose errors in balloon catheter brachytherapy of breast cancer due to inhomogeneities, such as iodine-containing radiographic contrast medium in the balloon, the lack of scattering medium, and the low density of lung that are not considered by commercial treatment planning systems (TPS).Methods and materialsBy accounting for these inhomogeneities in breast/lung phantoms, Monte Carlo simulations were performed to calculate doses in the breast and lung. Doses were also calculated by a commercial TPS. The Monte Carlo doses and the TPS doses were compared along the transverse and longitudinal axes of the source.ResultsThe Monte Carlo doses were lower by 4–10% on the prescription line than the TPS doses, depending on the concentration (5–25% by volume) of the contrast medium, and on the direction from the source. The lack of scattering medium around the breast contributes to the differences more than the attenuation by the contrast medium. Attenuation contributed approximately 1.0–4.8% at the concentrations investigated in this study.ConclusionsCurrent treatment planning systems, which assume a source in a large homogeneous water-equivalent medium, significantly overestimate doses in breast brachytherapy. To evaluate dose errors in balloon catheter brachytherapy of breast cancer due to inhomogeneities, such as iodine-containing radiographic contrast medium in the balloon, the lack of scattering medium, and the low density of lung that are not considered by commercial treatment planning systems (TPS). By accounting for these inhomogeneities in breast/lung phantoms, Monte Carlo simulations were performed to calculate doses in the breast and lung. Doses were also calculated by a commercial TPS. The Monte Carlo doses and the TPS doses were compared along the transverse and longitudinal axes of the source. The Monte Carlo doses were lower by 4–10% on the prescription line than the TPS doses, depending on the concentration (5–25% by volume) of the contrast medium, and on the direction from the source. The lack of scattering medium around the breast contributes to the differences more than the attenuation by the contrast medium. Attenuation contributed approximately 1.0–4.8% at the concentrations investigated in this study. Current treatment planning systems, which assume a source in a large homogeneous water-equivalent medium, significantly overestimate doses in breast brachytherapy.

Dose errors due to inhomogeneities in balloon catheter brachytherapy for breast cancer

To evaluate dose errors in balloon catheter brachytherapy of breast cancer due to inhomogeneities, such as iodine-containing radiographic contrast medium in the balloon, the lack of scattering medium, and the low density of lung that are not considered by commercial treatment planning systems (TPS). By accounting for these inhomogeneities in breast/lung phantoms, Monte Carlo simulations were performed to calculate doses in the breast and lung. Doses were also calculated by a commercial TPS. The Monte Carlo doses and the TPS doses were compared along the transverse and longitudinal axes of the source. The Monte Carlo doses were lower by 4-10% on the prescription line than the TPS doses, depending on the concentration (5-25% by volume) of the contrast medium, and on the direction from the source. The lack of scattering medium around the breast contributes to the differences more than the attenuation by the contrast medium. Attenuation contributed approximately 1.0-4.8% at the concentrations investigated in this study. Current treatment planning systems, which assume a source in a large homogeneous water-equivalent medium, significantly overestimate doses in breast brachytherapy.

Dose overestimation in balloon catheter brachytherapy for breast cancer

Dose overestimation in balloon catheter brachytherapy for breast cancer

Dose overestimation in balloon catheter brachytherapy for breast cancer

Dose overestimation in balloon catheter brachytherapy for breast cancer