High Dose Rate Brachytherapy

Good question. Advantages of HDR breast brachytherapy for partial breast irradiation (PBI) include shorter treatment time, radiation exposure to less normal tissue, and that may translate into fewer side effects (not yet proven). Anecdotally, external beam PBI has had an issue with rib fractures so I've leaned toward HDR for PBI, though it can occue with either.

That's a good lead-in to disadvantages. The dose each treatment is higher and given twice a day, so there is the potential for higher injury to that more focused area of tissue. The other issue is concern that by not irradiating the entire breast, some cancer cells might not be treated and lead to a higher risk of cancer coming back within that breast.

The conservative gold standard remains whole breast radiation because of the overall low toxicity and highly effective results to prevent cancer recurrence. The strongest current argument for HDR PBI is convenience, and many doctors want to wait for data from a clinical trial underway now, NSABP B-39/RTOG 0413, before being comfortable to offer it as an alternative standard option. Good question. Advantages of HDR breast brachytherapy for partial breast irradiation (PBI) include shorter treatment time, radiation exposure to less normal tissue, and that may translate into fewer side effects (not yet proven). Anecdotally, external beam PBI has had an issue with rib fractures so I've leaned toward HDR for PBI, though it can occue with either.

That's a good lead-in to disadvantages. The dose each treatment is higher and given twice a day, so there is the potential for higher injury to that more focused area of tissue. The other issue is concern that by not irradiating the entire breast, some cancer cells might not be treated and lead to a higher risk of cancer coming back within that breast.

The conservative gold standard remains whole breast radiation because of the overall low toxicity and highly effective results to prevent cancer recurrence. The strongest current argument for HDR PBI is convenience, and many doctors want to wait for data from a clinical trial underway now, NSABP B-39/RTOG 0413, before being comfortable to offer it as an alternative standard option.

The use of radiation therapy has been a standard treatment option for women undergoing lumpectomy since publication of NSABP B-06, a clinical trial conducted about 30 years ago. At that time external beam radiation (also called teletherapy) was used to treat the whole breast. While there have been some tweaks, whole breast radiation therapy remains the current evidence-based gold standard.

There has been interest if focusing radiation more on the surgivcal area only, the lumpectomy cavity. This is called partial breast irradiation and is currently under study, though promising results suggest it a reasonable option. High-dose rate brachytherapy (brachy meaning close) is a way to deliver higher doses to a more focused area.

Criteria for using HDR brachytherapy on clinical trials NSABP B-39 are listed here: http://bit.ly/r8rED1 . Currently, off study there are patients who are considered suitable based upon consensus guidelines from 2009:

Patient Factors: Women 60+ years; no BRCA mutations.
Tumor Factors: 2 cm or less invasive ductal cancer; ER+; negative margins (2mm or more); no lymphovascular invasion; no involved nodes.

Here's a link to a screenshot from the article. http://i.imgur.com/2YxQt.jpg
There are also some technical considerations.

However, not everyone agrees. William Beaumont has tended to be more willing to consider HDR brachytherapy and PBI for some patients deemed unsuitable in the 2009 consensus paper (link = http://1.usa.gov/qPYTv0). It's a controversial area that's still evolving, and varies beyond just the criteria above for each patient. So worth a long discussion if you're thinking about lumpectomy for the pros/cons of whole breast vs partial breast radiation. The use of radiation therapy has been a standard treatment option for women undergoing lumpectomy since publication of NSABP B-06, a clinical trial conducted about 30 years ago. At that time external beam radiation (also called teletherapy) was used to treat the whole breast. While there have been some tweaks, whole breast radiation therapy remains the current evidence-based gold standard.

There has been interest if focusing radiation more on the surgivcal area only, the lumpectomy cavity. This is called partial breast irradiation and is currently under study, though promising results suggest it a reasonable option. High-dose rate brachytherapy (brachy meaning close) is a way to deliver higher doses to a more focused area.

Criteria for using HDR brachytherapy on clinical trials NSABP B-39 are listed here: http://bit.ly/r8rED1 . Currently, off study there are patients who are considered suitable based upon consensus guidelines from 2009:

Patient Factors: Women 60+ years; no BRCA mutations.
Tumor Factors: 2 cm or less invasive ductal cancer; ER+; negative margins (2mm or more); no lymphovascular invasion; no involved nodes.

Here's a link to a screenshot from the article. http://i.imgur.com/2YxQt.jpg
There are also some technical considerations.

However, not everyone agrees. William Beaumont has tended to be more willing to consider HDR brachytherapy and PBI for some patients deemed unsuitable in the 2009 consensus paper (link = http://1.usa.gov/qPYTv0). It's a controversial area that's still evolving, and varies beyond just the criteria above for each patient. So worth a long discussion if you're thinking about lumpectomy for the pros/cons of whole breast vs partial breast radiation.