Radiation therapy commonly is used after lumpectomy to remove early-stage breast cancer. The radiation therapy destroys any cancer cells that may be left behind and reduces the risk of the cancer coming back. Still, whole-breast radiation can cause problems in women who have had implants inserted to increase breast size BEFORE breast cancer diagnosis. Whole-breast radiation therapy after lumpectomy can cause the capsule that naturally forms around a breast implant to contract. This contraction can cause cosmetic problems.
The small study reviewed here found that internal radiation therapy, also called brachytherapy, didn't cause the implant capsule to contract. The 70 women with implants in the study all had good cosmetic outcomes after lumpectomy and internal radiation therapy. None of the women had the breast cancer come back during the more than 2 years of follow-up after treatment.
External radiation, also called external beam radiation, is the most common type of radiation therapy. In external radiation, a machine called a linear accelerator aims a beam of high-energy radiation at the area affected by the cancer. This type of radiation is given 5 days a week, over 5 to 7 weeks, depending on each woman's particular situation. External radiation is given as an outpatient procedure.
Internal radiation usually uses very small bits of radioactive material, called seeds. The seeds are put into several small tubes (catheters) or into a balloon-catheter device called MammoSite. The seeds in the catheter are placed in the area around where the cancer was. The seeds emit radiation into the surrounding tissue. The area that's very close to the site of the original cancer is the area at highest risk for the cancer coming back. Internal radiation usually is given over 5 to 7 days, a much shorter time than external radiation. Still, internal radiation systems need a skilled and experienced medical team and available radioactive materials. Other research has shown that internal radiation therapy is safe and as effective as external radiation therapy.If you've been diagnosed with early-stage breast cancer and have breast implants, you and your doctor will talk about the types of surgery that make sense for your specific situation. Lumpectomy that preserves your existing implant followed by radiation therapy may be a good choice for you. Based on the results of this study, internal radiation may be good option to help ensure good cosmetic results after lumpectomy.
In the Breastcancer.org Radiation Therapy section, you can learn much more about how and when radiation therapy is used, the ways it is given, and what to expect during treatment.
CHICAGO, Dec. 1- A five-day course of partial breast irradiation by brachytherapy may be effective for women with early stage disease who have had augmentation mammoplasty, researchers reported here.
Breast augmentation is considered a contraindication for whole breast radiation because it is associated with an increased risk of capsular contracture, said Robert R. Kuske, Jr., M.D., of Advanced Providers of Breast Irradiation of Scottsdale, Ariz..
In a series of 70 women there were no cases of capsular contracture, cosmetic results were excellent in 91% of patients and good, meaning slight breast asymmetry, in 9%, he reported at the Radiological Society of North America Meeting.
No women had fair or poor results in what he said was the first study of image-guided brachytherapy in women with augmentation.
Moreover, there were no recurrences in up to 26 months of follow-up, he said.
Despite the relatively short follow-up, Dr. Kuske said he felt confident in the efficacy of the treatment. The reason, he said, is "because this technique has been studied for 18 years in women who don't have breast augmentation and in those studies the recurrence rate with brachytherapy is about 5%, which is comparable to the rate with whole breast irradiation."
Dr. Kuske said finding treatments for women with implants was an important clinical issue because about 350,000 American women have breast augmentation surgery annually.
While implants don't increase the risk of breast cancer, age does, he said. "We expect that 49,000 of those 350,000 women will develop breast cancer."
Joseph Tashjian, M.D., president of St. Paul Radiology in St. Paul, Minn., said the data from the studies of brachytherapy in women without implants did provide evidence of the safety of the procedure.
Image-guided brachytherapy was, Dr. Tashjian said, "a very good technique, but the real benefit is five days versus more than six weeks of radiation. That is a huge benefit."
Dr. Tashjian said that whole breast radiation, which is recommended following lumpectomy, has been associated with a 55% rate of capsular contracture, has other cosmetic problems as well. "It causes swelling, and a thickening of the skin," he said.
In Dr. Kuske's study, 70 women underwent lumpectomy to remove lesions less than 3 cm with nodal involvement in fewer than four lymph nodes. The mean age of the women was 50.
"Women with lesions larger than 3 cm or those with more extensive lymph node involvement are not candidates for this procedure," Dr. Kuske said.
Following surgery, Dr. Kuske used a template made by Nucletron, a Dutch company, to compress the breast tissue above the implant.
This same template is used for mammograms in women who have implants. The operator pulls the breast tissue out from the implant and then compresses the tissue between the templates.
The breast is then imaged with computerized tomography.
Using the CT image to guide the process, the radiologist then inserts brachytherapy capsules into the breast through catheters inserted into a series of pre-drilled holes that are used to guide the needles, and "avoid puncturing the implant."
Dr. Kuske said that he has not had a single capsule puncture using this procedure.
The goal, he said, was to irradiate an additional 2 cm margin around the lesion. The radiation seeds are placed in that 2 cm collar.
The dose prescription was 34 Gy in 10 twice-daily fractions (separated by more than six hours) over five treatment days, given with high dose rate Iridium-192.
Nancy A. Ellerbroek, M.D., medical director of radiation oncology at Holy Cross Cancer Center in Providence, R.I., told MedPage Today that while the results were interesting the study was limited by its small size and by the lack of randomization.
Also, she noted that it wasn't clear how Dr. Kuske "judged the cosmetic results."
The findings would have benefited from a "prospective companion study on quality of life in which the patients rated their own results."
Dr. Ellerbroek was not involved in the study but she has enrolled women in a large, prospective randomized study that is comparing partial breast irradiation to whole breast irradiation. The results of that cooperative trial-NSABPB-39/RTOG 0413 -- "will really provide evidence to answer the ongoing questions about partial breast irradiation."
Dr. Kuske disclosed that he designed the Nucletron template, but said he receives no royalties for its use. He said he was a paid consultant to Nucletron.
Dr. Kuske also disclosed that his new practice -- Advanced Providers of Breast Irradiation (APBI) -- would open January 1, 2009. He said he plans offer training in the brachytherapy technique used in this series, but he has not yet determined the price for the course.
Dr. Ellerbroek disclosed that her medical group is a participating center for the ongoing partial breast irradiation study. Dr. Tashjian said he had no relevant conflicts.
Primary source: Radiological Society of North America Source reference: Kuske, R. "Brachytherapy Improves Cosmetic Outcome and Reduces the Risk of Capsular Contracture in BREAST Conservation Therapy for Women with BREAST Cancer in the Presence of AUGMENTATION Mammoplasty" SSC19-0
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