The Surgeon's Role in Breast Brachytherapy

Abstract: Although two‐thirds of invasive breast cancers and half of non‐invasive breast cancers are amenable to lumpectomy, only about 70% of such patients choose breast conservation. Of that group, up to one‐third do not follow‐up with radiation therapy despite it being clinically indicated. The reasons include the patient’s and surgeon’s attitude toward breast conservation as well as the inconvenience and distance of a suitable radiation facility. The advent of shorter courses of radiation therapy may encourage more patients to seek adjuvant therapy. An increasingly popular and more convenient alternative to traditional whole‐breast radiation therapy in patients with early‐stage breast cancer is accelerated partial breast irradiation (APBI), for which the American Society of Breast Surgeons and the American Brachytherapy Society have promulgated guidelines for candidate selection. Although several methods are emerging, the most widely used brachytherapy technique utilizes the MammoSite single‐catheter balloon brachytherapy device. In a best practices symposium convened in 2006, breast surgeons from academic and community practices with extensive experience in balloon brachytherapy developed general guidelines for integrating APBI into a breast surgical practice. Important considerations include patient age, histology, tumor location and size, and breast size. Thoughtful lumpectomy planning is essential to optimize balloon placement. Real‐time sonographic guidance is essential as the surgeon should attend closely to volume excised and cavity shape. A cavity evaluation device can act as a place holder while patient suitability for APBI is considered. Many breast surgeons expert in this procedure insert the balloon catheter in the office either through a de novo skin entrance site removed from the lumpectomy incision or through the original incision. Optimally, insertion occurs within 2–3 weeks after lumpectomy. Close and continual communication with the radiation oncologist is essential to assure optimal outcomes. In this review, several key aspects of a successful APBI program from a surgeon’s perspective as well as a consensus panel from a best practices symposium on the topic herein are highlighted.     

Previous transurethral resection of the prostate is not a contraindication to high‐dose rate brachytherapy for prostate cancer

OBJECTIVE

To analyse retrospectively the morbidity and efficacy of high‐dose rate (HDR) brachytherapy in patients who had a previous transurethral resection of the prostate (TURP).

PATIENTS AND METHODS

Morbidities documented in the records of 32 patients with previous TURP and 106 with no previous TURP, treated with HDR brachytherapy for prostate cancer at our institution, were analysed and compared. All patients received HDR brachytherapy as a boost before conformal external beam radiotherapy. We recorded and analysed genitourinary complications, rectal morbidity, and the biochemical control rate as assessed by the prostate‐specific antigen (PSA) level.

RESULTS

All complications of patients who received HDR brachytherapy were recorded during the follow‐up. All gastrointestinal and genitourinary complications were not significantly different in patients with or without previous TURP. There was little incontinence or severe morbidity associated with HDR brachytherapy. The PSA‐based biochemical control rates were similar in patients with or without previous TURP in each risk group.

CONCLUSIONS

HDR brachytherapy is a reasonable treatment for localized prostate cancer in patients who have had a previous TURP, with the expectation of low morbidity and satisfactory biochemical control.     

Body mass index is not a prognostic marker for prostate‐specific antigen failure and survival in Dutch men treated with brachytherapy

Study Type – Prognosis (case series) Level of Evidence 4

OBJECTIVE

To examine the relationship between body mass index (BMI) and biochemical recurrence (BCR), cancer‐specific (CSS) and overall survival (OS) in men treated with permanent prostate brachytherapy (PPB), as there is limited information on the affect of obesity on treatment outcomes for prostate cancer.

PATIENTS AND METHODS

In all, 1530 patients with clinically localized prostate cancer who underwent PPB were studied. Clinical and pathological data were retrospectively obtained from medical records. The BMI was classified as normal (<25 kg/m²), overweight (25–30 kg/m²) and obese (≥30 kg/m²). BCR was defined as a rise in PSA levels of ≥2 ng/mL after the nadir had been reached. The cause of death was determined for each deceased patient. Patients with metastatic prostate cancer who died of any cause were classified as prostate cancer deaths.

RESULTS

In all, 617 (40%) patients were classified as having a normal weight, 754 (49%) overweight and 159 (10%) were obese. The Kaplan–Meier 8‐year risk of BCR (95% confidence interval) was 33.3% (27.2–39.4), 29.2% (23.5–34.9) and 29.3% (12.4–46.2) for patients with a BMI of <25 kg/m², 25–30 kg/m² and ≥30 kg/m², respectively. The 8‐year CSS was 88.2% (83.1–93.3), 88.6% (83.7–93.5) and 90.6% (79.9–101.4) and the 8‐year OS was 70.1% (63.6–76.6), 72.9% (66.6–79.2) and 81.8% (69.3–94.3) for these three groups, respectively. Multivariate proportional hazard regression analyses of BMI and established prognostic factors for BCR confirmed the absence of any prognostic value of BMI on BCR, CSS and OS.

CONCLUSIONS

BMI did not appear to have any prognostic value for BCR, CCS or OS in patients with clinically localized prostate cancer treated with PPB.     

~(32)P-磷酸铬-聚L-乳酸缓释粒子近距离治疗裸鼠前列腺癌的实验研究

目的:探讨32P-磷酸铬-聚L-乳酸(32P-CP-PLLA)缓释粒子局部植入对裸鼠前列腺癌的治疗作用。方法:建立裸鼠前列腺癌皮下移植瘤模型,然后将裸鼠进行如下分组,A、B、C为高、中、低剂量(14.8、7.4、3.7MBq)32P-CP-PLLA缓释粒子组,D、E、F为同等活度125I粒子组(14.8、7.4、3.7MBq),G为空白对照组,每组6只,植入粒子后观察:①32P缓释粒子和125I粒子对瘤体的病理形态学以及抑瘤率的影响;②外周血计数白细胞(WBC)和血小板(PLT)变化,观察血液毒性反应。结果:治疗21d后处死裸鼠,病理形态学显示实体瘤组织呈出血、坏死性改变,抑瘤率与给药剂量呈正相关,给药剂量为3.7、7.4、14.8MBq时,21d时各组抑瘤率[(65.72±6.95)%、(77.58±4.32)%、(82.64±4.03)%]、白细胞计数[(1.72±0.37)×109/L、(1.23±0.27)×109/L、(0.86±0.25)×109/L]、血小板计数[(1.18±0.11)×1011/L、(0.97±0.10)×1011/L、(0.72±0.11)×1011/L]、体重[(18.60±0.66)g、(17.60±0.39)g、(16.90±0.68)g]与相应各剂量的125I粒子组(3.7、7.4、14.8MBq)的抑瘤率[(35.61±5.61)%、(43.30±6.94)%、(69.01±4.98)%]、以及125I粒子组和空白对照组的白细胞计数[(1.45±0.40)×109/L、(0.51±0.24)×109/L、(0.37±0.26)×109/L、(3.96±0.26)×109/L]、血小板计数[(0.97±0.15)×1011/L、(0.76±0.16)×1011/L、(0.64±0.12)×1011/L、(2.89±0.21)×1011/L]、体重[(17.86±0.60)g、(15.56±0.39)g、(14.61±0.65)g、(19.95±0.73)g]比较差异有统计学意义(P均<0.01)。结论:32P-CP-PLLA缓释粒子瘤体植入治疗前列腺癌为一种安全、简便、有效的核素介入疗法。     

Relationship between prostate cancer mortality and number of unfavourable risk factors in men treated with definitive brachytherapy

Study Type – Therapy (case series)
Level of Evidence 4

OBJECTIVE

To explore whether the number of unfavourable pretreatment risk factors predicts cause‐specific mortality in men treated with prostate brachytherapy.

PATIENTS AND METHODS

Between April 1995 and March 2006, 739 patients were treated who had at least one of the following adverse risk factors: pretreatment prostate‐specific antigen (PSA) level of >10 ng/mL, a Gleason score of ≥7, clinical stage ≥T2b, or a PSA velocity (PSAV) of >2 ng/mL/year. Supplemental external beam radiotherapy (EBRT) was delivered to 464 (62.8%) men and 301 (40.7%) received androgen deprivation therapy (ADT). Of men with more than two risk factors, 87% received EBRT and 62% received ADT.

RESULTS

The biochemical progression‐free survival (bPFS), cause‐specific survival (CSS) and overall survival for all patients were 95.0%, 97.9% and 70.0% at 12 years. Men with three or four risk factors had a prostate cancer‐specific mortality (PCSM) at 12 years of 5.3%, vs 1.7% for men with one or two risk factors (P= 0.006). When ‘percentage of positive biopsy cores >50%’ replaced PSAV as a risk factor, men with two or more risk factors had a PCSM of 8.9%, vs 1.0% for men with one or two risk factors (P= 0.001). There was no difference in all‐cause mortality between the groups in either analysis.

CONCLUSION

Multimodal brachytherapy results in high rates of bPFS and CSS, even for men with several unfavourable risk factors. Men with two or more unfavourable risk factors had a slightly greater risk of PCSM and no difference in all‐cause mortality. The presence of three or four unfavourable intermediate‐risk factors does not appear to clearly identify a group that requires further treatment intensification, although the percentage of positive cores might be more predictive than PSAV.     

Impact of radiation dose on late clinical outcome after intracoronary radiation therapy: three-year follow-up of Long WRIST.

To determine the safety and efficacy, including the impact, on the late recurrence rate of an incremental gamma-radiation dose from 15 to 18 Gy, we report the 3-year clinical outcome of Washington Radiation for In-Stent Restenosis Trial for Long Lesions (Long WRIST). One hundred eighty patients with recurrent in-stent restenosis (ISR) were enrolled in the Long WRIST series and treated with (192)Ir with 1 month of antiplatelet therapy. Between 6 months and 3 years, the need for repeat revascularization was low and similar among the three groups. At 3 years, target lesion revascularization (TLR) and major adverse cardiac events (MACE) were less frequent in the 18 Gy group than in the 15 Gy group (P = 0.12 for TLR, P < 0.05 for MACE) and less frequent in the 15 Gy group as compared to the placebo group (P < 0.05 for TLR and MACE). At 3 years, a higher dose of 18 Gy with (192)Ir continues to improve the outcome of patients treated for ISR when compared to patients treated with 15 Gy or placebo.     

支气管腔内放疗治疗肺癌的疗效

目的：探讨支气管腔内后装近距离腔内放疗的方法、剂量和疗效。方法：用导丝导入法行支气管腔内放疗，可达亚段支气管。参考点20mm，单次剂量6-7GY，5-7日/间隔，2-4次/人。治疗中央型肺癌（均侵犯支气管）76例212人次。结果：病灶消失22例，缩小39例，稳定12例，进展3例，总有效率85.5％。起效时间均短于3周。结论：支气管腔内后装放疗是治疗腔内肿瘤及缓解伴随症状的有效方法。疗效及起效优于外照射和化疗。对复治患者仍然有效。     

Late stent thrombosis (> 1 year) following clopidogrel withdrawal after brachytherapy treatment: Need to assess aspirin resistance?

We report on a patient presenting with late thrombosis of a stent 15 months after being treated with intracoronary brachytherapy. It occurred 17 days after clopidogrel withdrawal while maintaining treatment with aspirin. At the time of stent thrombosis, evaluation of platelet aggregation was performed, revealing a suboptimal response to aspirin. Pathophysiological insights of aspirin resistance and clinical implications are reviewed.