Radiation Treatment

Hi, I had two tumors one each in upper and lower right lobes. First, they did the tattoos and then the cast. The tattoo shows where the radiation is to be targeted. The cast is for your use only while receiving SRS so you don't move. You lay on the material and they wet it down, then shape it to your body. It dries quickly. Then you lay in it every time. I had 4 treatments for each tumor lasting 20 mins. each. They gave me a break in between. I did end up with esophagitis, very bad sore throat and hard to swallow. I used the magic mouthwash and it was gone within 10 days. I also used Prilosec for heartburn. I wasn't tired and never felt sick. My problem now is radiation scarring to the pectoral muscle and under the armpit. Though targeted, you have to remember that it has to go in and come back out somewhere. This was due to the location of the one tumor, so basically unavoidable. I have pain when I overdo it, but I'm doing very well overall. I started chemo within two weeks and I'm presently NED. Hi, I had two tumors one each in upper and lower right lobes. First, they did the tattoos and then the cast. The tattoo shows where the radiation is to be targeted. The cast is for your use only while receiving SRS so you don't move. You lay on the material and they wet it down, then shape it to your body. It dries quickly. Then you lay in it every time. I had 4 treatments for each tumor lasting 20 mins. each. They gave me a break in between. I did end up with esophagitis, very bad sore throat and hard to swallow. I used the magic mouthwash and it was gone within 10 days. I also used Prilosec for heartburn. I wasn't tired and never felt sick. My problem now is radiation scarring to the pectoral muscle and under the armpit. Though targeted, you have to remember that it has to go in and come back out somewhere. This was due to the location of the one tumor, so basically unavoidable. I have pain when I overdo it, but I'm doing very well overall. I started chemo within two weeks and I'm presently NED.

I see. I did not realize it was an individual plan related to autonomy. Very helpful. Patients who need radiation after reconstruction are at a risk of complications with regard to their reconstruction. A woman may have her reconstruction done at the time of surgery (immediate reconstruction) or at some point in the future (delayed reconstruction). Each carries with it different possible complications. Patients need to discuss all options with their surgeons – patient’s cancer and their anatomy play an important role in the determination of which type of reconstruction is appropriate. Regardless, it is essential that proper radiation planning take place and good dialogue between the treating radiation oncologist and the plastic surgeon.

"Internal" radiation or brachytherapy involves use of a variety of radioactive isotopes which are placed inside or near the tumor/cancer. By doing so, radiation does not have to go through the normal tissue between an external source and the target of radiation. Depending on whether the radioactive isotope is placed permanently or used temporarily, brachytherapy is categorized into two categories of permanent and temporary.

The most common form of permanent brachytherapy is prostate seed implant. In this form of treatment either Palladium (Pd-103) or Iodine (I-125) seeds are implanted inside the prostate. These seeds would irradiate the prostate gland and the cancer inside it as long as they are radioactive but eventually become inert.

Depending on the strength and therefore speed of delivery of radiation, temporary brachytherapy is categorized into Low Dose Rate and High Dose Rate brachytherapy. The most common example of temporary brachytherapy is the use of either Low Dose Rate (LDR) or High Dose Rate (HDR) forms of brachytherapy for the treatment of gynecological cancers specifically cervical and endometrial cancer. Through special catheters either cesium-137 (LDR) or iridium-192 (HDR) would be inserted nearby the tumor. During the period of time when the catheters remain in area, the prescribed dose of radiation would be delivered to the target. This would take about 48 hours in LDR but only a few minutes in HDR treatment.

HDR brachytherapy is also used in the treatment of breast cancer. This form of radiation for breast cancer is called Accelerated Partial Breast Irradiation or APBI. After a lumpectomy a special applicator such as Mammosite or Contura balloon catheter or a Savi applicator is placed inside the lumpectomy cavity. Using HDR technology an iridium-192 radioactive source is inserted into any of these catheters to deliver radiation to the wall of the lumpectomy cavity.

Intraluminal brachytherapy is also used for the treatment of endobronchial tumors, esophageal cancer and cancers of biliary tract. Other forms of temporary brachytherapy include radioactive eye plaque in treatment of choroidal melanoma and Strontium-90 applicators for treatment of pterygium. "Internal" radiation or brachytherapy involves use of a variety of radioactive isotopes which are placed inside or near the tumor/cancer. By doing so, radiation does not have to go through the normal tissue between an external source and the target of radiation. Depending on whether the radioactive isotope is placed permanently or used temporarily, brachytherapy is categorized into two categories of permanent and temporary.

The most common form of permanent brachytherapy is prostate seed implant. In this form of treatment either Palladium (Pd-103) or Iodine (I-125) seeds are implanted inside the prostate. These seeds would irradiate the prostate gland and the cancer inside it as long as they are radioactive but eventually become inert.

Depending on the strength and therefore speed of delivery of radiation, temporary brachytherapy is categorized into Low Dose Rate and High Dose Rate brachytherapy. The most common example of temporary brachytherapy is the use of either Low Dose Rate (LDR) or High Dose Rate (HDR) forms of brachytherapy for the treatment of gynecological cancers specifically cervical and endometrial cancer. Through special catheters either cesium-137 (LDR) or iridium-192 (HDR) would be inserted nearby the tumor. During the period of time when the catheters remain in area, the prescribed dose of radiation would be delivered to the target. This would take about 48 hours in LDR but only a few minutes in HDR treatment.

HDR brachytherapy is also used in the treatment of breast cancer. This form of radiation for breast cancer is called Accelerated Partial Breast Irradiation or APBI. After a lumpectomy a special applicator such as Mammosite or Contura balloon catheter or a Savi applicator is placed inside the lumpectomy cavity. Using HDR technology an iridium-192 radioactive source is inserted into any of these catheters to deliver radiation to the wall of the lumpectomy cavity.

Intraluminal brachytherapy is also used for the treatment of endobronchial tumors, esophageal cancer and cancers of biliary tract. Other forms of temporary brachytherapy include radioactive eye plaque in treatment of choroidal melanoma and Strontium-90 applicators for treatment of pterygium.

A patient may not be eligible to receive radiation treatment either because radiation therapy is not indicated for treatment of that particular cancer or stage of the disease or because, even though indicated, it would not be safe to receive radiation.

Contraindications to radiation therapy are often categorized as relative or absolute contraindications. Generally speaking autoimmune/connective tissue diseases increase the risk of acute and chronic side effects of radiation therapy. These patients may be at risk of severe skin reaction, severe scarring and even soft tissue necrosis. Depending on the type and level of activity of this form of diseases, radiation can be relatively or absolutely contraindicated. For example Scleroderma and active lupus are considered absolute contraindications to radiation therapy but an inactive, or limited Lupus such as Discoid Lupus and Rheumatoid Arthritis are considered relative contraindications to radiation therapy.

In recent years and with the invention of sophisticated radiation technology such as CyberKnife and Steroeotactic Radiosurgery, a traditional contraindication to radiation therapy due to previous radiation to the same target area, has been challenged. Without this precise form of targeting the tumor, a relatively significant dose of radiation was given to adjacent normal tissues. Each critical organ in our bodies has a certain tolerance to radiation. That is the dose an organ can safely receive without permanent and irreversible damage. Traditionally we could not reirraidate the same target area because we would have exceeded the safe dose an adjacent organ could tolerate. With this new technology, we can deliver additional doses of radiation to the same target without exceeding the safe dose to the adjacent organs. Despite this technology, at some point, we may reach a point when no additional radiation can be safely delivered and that would make a patient ineligible for additional radiation.

Patients' ineligibility for receiving radiation is a very compelling reason for a multidisciplinary approach to the treatment of cancer. As an example would it not be a shame to subject a patient ineligible for radiation therapy to a lumpectomy when radiation is a critical part of breast conservation therapy? That would sadly would subject the patient to a second operation, a mastectomy, because lumpectomy without radiation would not adequately address the risk of a recurrence in that breast. To avoid similar scenarios, consult all the members of a treatment team before initiating any form of treatment and undergoing any form of procedure. Be proactive! A patient may not be eligible to receive radiation treatment either because radiation therapy is not indicated for treatment of that particular cancer or stage of the disease or because, even though indicated, it would not be safe to receive radiation.

Contraindications to radiation therapy are often categorized as relative or absolute contraindications. Generally speaking autoimmune/connective tissue diseases increase the risk of acute and chronic side effects of radiation therapy. These patients may be at risk of severe skin reaction, severe scarring and even soft tissue necrosis. Depending on the type and level of activity of this form of diseases, radiation can be relatively or absolutely contraindicated. For example Scleroderma and active lupus are considered absolute contraindications to radiation therapy but an inactive, or limited Lupus such as Discoid Lupus and Rheumatoid Arthritis are considered relative contraindications to radiation therapy.

In recent years and with the invention of sophisticated radiation technology such as CyberKnife and Steroeotactic Radiosurgery, a traditional contraindication to radiation therapy due to previous radiation to the same target area, has been challenged. Without this precise form of targeting the tumor, a relatively significant dose of radiation was given to adjacent normal tissues. Each critical organ in our bodies has a certain tolerance to radiation. That is the dose an organ can safely receive without permanent and irreversible damage. Traditionally we could not reirraidate the same target area because we would have exceeded the safe dose an adjacent organ could tolerate. With this new technology, we can deliver additional doses of radiation to the same target without exceeding the safe dose to the adjacent organs. Despite this technology, at some point, we may reach a point when no additional radiation can be safely delivered and that would make a patient ineligible for additional radiation.

Patients' ineligibility for receiving radiation is a very compelling reason for a multidisciplinary approach to the treatment of cancer. As an example would it not be a shame to subject a patient ineligible for radiation therapy to a lumpectomy when radiation is a critical part of breast conservation therapy? That would sadly would subject the patient to a second operation, a mastectomy, because lumpectomy without radiation would not adequately address the risk of a recurrence in that breast. To avoid similar scenarios, consult all the members of a treatment team before initiating any form of treatment and undergoing any form of procedure. Be proactive!

The three common treatment modalities in treatment of breast cancer can be given in different sequences. The most common sequence is to start with surgery, continue with chemotherapy if indicated and finish with radiation therapy. But in some cases chemotherapy is delivered before surgery and is followed by radiation therapy. There is one exception to this general rule of radiation therapy being the last modality in the sequence of treatments and that is when Accelerated Partial Breast Irradiation (APBI) using brachytherapy balloons such as Mammosite, Contura or Savi applicator is the form of radiation utilized. In APBI, radiation is delivered immediately after surgery and chemotherapy, if recommended, would follow radiation.

Therefore a "delay" in beginning of radiation treatment can be a planned or an unplanned one. For example we often recommend 4-6 weeks between surgery and beginning of radiation in order to make sure that all the surgical incisions are completely healed. One of the potential side effects of radiation is delay in healing of wounds and that is the reason behind that planned delay. We also recommend about 2-4 weeks of gap between last chemotherapy administered and beginning of radiation therapy. This form of planned delay in beginning of radiation is due to the fact that some chemotherapy agents are radiosensitizers and may potentially increase the risk of side effects from radiation therapy.

The unplanned or undesired delays in beginning of radiation therapy may be due to an unhealed surgical incision or persistent seroma or a hematoma in the lumpectomy cavity or in soft tissue pouches after a mastectomy. Radiation therapy is based on very accurate measurements and calculations of the volumes of tissue irradiated and the doses delivered. If the calculations and radiation plan is based on a certain size of breast and certain size of lumpectomy cavity and this volume is changed due to an enlarging seroma or hematoma, our calculations and therefore radiation doses would be off. Therefore we would await resolution of a seroma or a hemtoma either by giving it some time to absorb or by aspirating it before planning the radiation treatment.

With increase in the use of tumor genetic assay tests such as Oncotype DX, often there is a delay in determining whether a patient requires chemotherapy or not. In this scenario, the radiation oncologist would need to await the test result before starting patient's radiation because if the Oncotype DX result indicates benefit from chemotherapy, this treatment should be delivered before beginning of radiation therapy. The three common treatment modalities in treatment of breast cancer can be given in different sequences. The most common sequence is to start with surgery, continue with chemotherapy if indicated and finish with radiation therapy. But in some cases chemotherapy is delivered before surgery and is followed by radiation therapy. There is one exception to this general rule of radiation therapy being the last modality in the sequence of treatments and that is when Accelerated Partial Breast Irradiation (APBI) using brachytherapy balloons such as Mammosite, Contura or Savi applicator is the form of radiation utilized. In APBI, radiation is delivered immediately after surgery and chemotherapy, if recommended, would follow radiation.

Therefore a "delay" in beginning of radiation treatment can be a planned or an unplanned one. For example we often recommend 4-6 weeks between surgery and beginning of radiation in order to make sure that all the surgical incisions are completely healed. One of the potential side effects of radiation is delay in healing of wounds and that is the reason behind that planned delay. We also recommend about 2-4 weeks of gap between last chemotherapy administered and beginning of radiation therapy. This form of planned delay in beginning of radiation is due to the fact that some chemotherapy agents are radiosensitizers and may potentially increase the risk of side effects from radiation therapy.

The unplanned or undesired delays in beginning of radiation therapy may be due to an unhealed surgical incision or persistent seroma or a hematoma in the lumpectomy cavity or in soft tissue pouches after a mastectomy. Radiation therapy is based on very accurate measurements and calculations of the volumes of tissue irradiated and the doses delivered. If the calculations and radiation plan is based on a certain size of breast and certain size of lumpectomy cavity and this volume is changed due to an enlarging seroma or hematoma, our calculations and therefore radiation doses would be off. Therefore we would await resolution of a seroma or a hemtoma either by giving it some time to absorb or by aspirating it before planning the radiation treatment.

With increase in the use of tumor genetic assay tests such as Oncotype DX, often there is a delay in determining whether a patient requires chemotherapy or not. In this scenario, the radiation oncologist would need to await the test result before starting patient's radiation because if the Oncotype DX result indicates benefit from chemotherapy, this treatment should be delivered before beginning of radiation therapy.

The best way to deal with fatigue from radiation therapy is creating a balance between getting enough rest and staying active enough. To succumb to the fatigue and give up physical activity would create a vicious cycle resulting in less energy and more fatigue. Yet you don't want to push yourself too much. It is all right to go to bed earlier, get up a little bit later or even take a nap during the day if one feels that tired but it is important to schedule a routine daily activity such as walking and stick with it throughout the course of radiation therapy. The other very important factor is to stay hydrated. Dehydration would negatively impact one's level of energy and may even interfere with their sleep pattern. This is particularly important during the warmer seasons and during the routine daily activity. Extremes of temperature should be avoided. A minimum of 8 cups of fluid per day will prevent dehydration. (That is 64 ounces, 2 quarts, or 1 half-gallon). Beverages containing caffeine do NOT count neither do alcoholic ones. Maintaining good nutrition can help you feel better and have more overall energy. Sticking to a regular schedules such as going to bed at a certain time and eating at regular hours would also be very helpful in creating that fine balance between resting and staying active. The best way to deal with fatigue from radiation therapy is creating a balance between getting enough rest and staying active enough. To succumb to the fatigue and give up physical activity would create a vicious cycle resulting in less energy and more fatigue. Yet you don't want to push yourself too much. It is all right to go to bed earlier, get up a little bit later or even take a nap during the day if one feels that tired but it is important to schedule a routine daily activity such as walking and stick with it throughout the course of radiation therapy. The other very important factor is to stay hydrated. Dehydration would negatively impact one's level of energy and may even interfere with their sleep pattern. This is particularly important during the warmer seasons and during the routine daily activity. Extremes of temperature should be avoided. A minimum of 8 cups of fluid per day will prevent dehydration. (That is 64 ounces, 2 quarts, or 1 half-gallon). Beverages containing caffeine do NOT count neither do alcoholic ones. Maintaining good nutrition can help you feel better and have more overall energy. Sticking to a regular schedules such as going to bed at a certain time and eating at regular hours would also be very helpful in creating that fine balance between resting and staying active.

Radiation therapy is a very technical treatment and takes a great deal
of work by the radiation oncologist, the dosimetrist and the radiation
physicist to create a radiation plan which would deliver the required
dose of radiation to the cancer while minimizing radiation dose to the
surrounding normal and critical organs. To create such a fine balance,
sophisticated technology and treatment planning software are utilized.

Traditional radiation therapy used plain X-ray films to map the target
area and radiation fields. This was a two-dimensional technique and
the exact dose of radiation to critical organs was not determined
carefully. Three-dimensional conformal radiation therapy uses CT scans
to carefully define each and every critical organ at risk of receiving
radiation as well as the tumor itself.

Over the past decade or so a more sophisticated form of
three-dimensional conformal radiation therapy called IMRT (Intensity
Modulated Radiation Therapy) has evolved. This technique utilizes
reverse planning. That is instead of learning how much of radiation
the critical organs would receive should we deliver a certain dose of
radiation to a tumor, we can set limits on how much of radiation these
organs can tolerate in advance.

Nowadays we also have the capability of fusing MRI and PET images with
our CT scan images to enhance the quality of our contours and mapping
of the target areas. By doing so we can be more precise in focusing
radiation on the areas requiring radiation.

So in general before starting radiation treatments a planning session
or simulation is required. During this session immobilization devices
are used prior to obtaining CAT scan of the area which requires
radiation. Once the images are obtained, a radiation oncologist would
define i.e. contour the target area as well as adjacent critical
organs. Radiation oncologist would set limits on how much of radiation
these organs can safely receive and also prescribes the required dose
of radiation to the tumor.

Using sophisticated treatment planning software, the dosimetrist would
generate one or more plan for the radiation treatment. Radiation
oncologist would review the plans and chooses the plan which has
optimized the dose of radiation to the target and adjacent organs.
Once the optimal plan is chosen, the physicist would review the plan
for quality assurance and subsequently approved by radiation
oncologist.

Prior to delivering the very first fraction of radiation, patient
would undergo another simulation consisting of obtaining films on the
radiation table (AKA Port Films). Radiation oncologist would review
these films to make sure that everything is aligned with what has been
planned. Once the radiation oncologist approves these films, the
actual treatments can begin.

Patients are anxious to begin radiation immediately but as you can
appreciate, a considerable amount of time and work is spent in
preparation for radiation. Our moto as radiation oncolgoists: safety
first! Radiation therapy is a very technical treatment and takes a great deal
of work by the radiation oncologist, the dosimetrist and the radiation
physicist to create a radiation plan which would deliver the required
dose of radiation to the cancer while minimizing radiation dose to the
surrounding normal and critical organs. To create such a fine balance,
sophisticated technology and treatment planning software are utilized.

Traditional radiation therapy used plain X-ray films to map the target
area and radiation fields. This was a two-dimensional technique and
the exact dose of radiation to critical organs was not determined
carefully. Three-dimensional conformal radiation therapy uses CT scans
to carefully define each and every critical organ at risk of receiving
radiation as well as the tumor itself.

Over the past decade or so a more sophisticated form of
three-dimensional conformal radiation therapy called IMRT (Intensity
Modulated Radiation Therapy) has evolved. This technique utilizes
reverse planning. That is instead of learning how much of radiation
the critical organs would receive should we deliver a certain dose of
radiation to a tumor, we can set limits on how much of radiation these
organs can tolerate in advance.

Nowadays we also have the capability of fusing MRI and PET images with
our CT scan images to enhance the quality of our contours and mapping
of the target areas. By doing so we can be more precise in focusing
radiation on the areas requiring radiation.

So in general before starting radiation treatments a planning session
or simulation is required. During this session immobilization devices
are used prior to obtaining CAT scan of the area which requires
radiation. Once the images are obtained, a radiation oncologist would
define i.e. contour the target area as well as adjacent critical
organs. Radiation oncologist would set limits on how much of radiation
these organs can safely receive and also prescribes the required dose
of radiation to the tumor.

Using sophisticated treatment planning software, the dosimetrist would
generate one or more plan for the radiation treatment. Radiation
oncologist would review the plans and chooses the plan which has
optimized the dose of radiation to the target and adjacent organs.
Once the optimal plan is chosen, the physicist would review the plan
for quality assurance and subsequently approved by radiation
oncologist.

Prior to delivering the very first fraction of radiation, patient
would undergo another simulation consisting of obtaining films on the
radiation table (AKA Port Films). Radiation oncologist would review
these films to make sure that everything is aligned with what has been
planned. Once the radiation oncologist approves these films, the
actual treatments can begin.

Patients are anxious to begin radiation immediately but as you can
appreciate, a considerable amount of time and work is spent in
preparation for radiation. Our moto as radiation oncolgoists: safety
first!

Palliative treatment are usually given either to palliate pain, remove compression of tumor on a vital organ such as spinal cord, preventing fracture if the cancer has spread to a weigh-bearing bone, or in the case of brain metastasis to relieve the life-threatening pressure inside the brain. Palliative treatments are often given in short courses of 2-3 weeks not only because the radiation dose per individual treatments (aka fractions) is usually higher but also because the total dose of radiation is lower. Palliative radiation is often used stage IV. That is when the cancer has spread to other organs and even though it might be treatable, it is not curable.

Definitive treatment is given when, based on the stage of the cancer, statistically there is a chance for its cure (i.e. stage I-III). Depending on the type of cancer, definitive radiation can take up to 9 weeks not only because the radiation dose per individual treatments (aka fractions) is usually lower but also because the total dose of radiation is higher. Definitive treatments are given to the primary site of cancer (i.e. original site where the cancer started). Palliative treatment are usually given either to palliate pain, remove compression of tumor on a vital organ such as spinal cord, preventing fracture if the cancer has spread to a weigh-bearing bone, or in the case of brain metastasis to relieve the life-threatening pressure inside the brain. Palliative treatments are often given in short courses of 2-3 weeks not only because the radiation dose per individual treatments (aka fractions) is usually higher but also because the total dose of radiation is lower. Palliative radiation is often used stage IV. That is when the cancer has spread to other organs and even though it might be treatable, it is not curable.

Definitive treatment is given when, based on the stage of the cancer, statistically there is a chance for its cure (i.e. stage I-III). Depending on the type of cancer, definitive radiation can take up to 9 weeks not only because the radiation dose per individual treatments (aka fractions) is usually lower but also because the total dose of radiation is higher. Definitive treatments are given to the primary site of cancer (i.e. original site where the cancer started).

Treatment options are dependent on a variety of factors including the stage, a patient's other medical conditions, and a patient's understanding of these options. For example, there are now certain conditions/situations where by stereotactic body radiation therapy (SBRT) may be an alternative to surgery. Our physicians always take their time in going through all modalities and side effects with our patients so that they can make the most educated decision for themselves, and be comfortable with the treatment they decided on. Treatment options are dependent on a variety of factors including the stage, a patient's other medical conditions, and a patient's understanding of these options. For example, there are now certain conditions/situations where by stereotactic body radiation therapy (SBRT) may be an alternative to surgery. Our physicians always take their time in going through all modalities and side effects with our patients so that they can make the most educated decision for themselves, and be comfortable with the treatment they decided on.

There are particular indications for using radiation therapy in the treatment in melanoma and broken down into three categories: primary disease, regional disease, and metastatic disease. For primary disease, radiation may be considered as adjuvant treatment (following surgery) for patients with desmoplastic type melanoma with extensive neurotrophism- findings determined by a pathologist examining the specimen under a microscope. For regional disease the following are indications after surgery: extracapsular extension, the involvement of 4 or more lymph nodes (two or more lymph nodes if cervical lymph nodes involved, size of the primary tumor >3 cm, and recurrent disease after prior complete lymph node dissection. Finally, for metastatic disease radiation therapy may be used to treat brain metastases alone or after surgical resection, and other symptomatic or impending symptomatic involvement of bony metastases or soft tissue resection. For more information please see The National Comprehensive Cancer Network (NCCN) Guidelines. Margins are determined by a pathologist reviewing the surgical specimen and measuring the distance from where tumor is seen to the nearest point of normal tissue. There are particular indications for using radiation therapy in the treatment in melanoma and broken down into three categories: primary disease, regional disease, and metastatic disease. For primary disease, radiation may be considered as adjuvant treatment (following surgery) for patients with desmoplastic type melanoma with extensive neurotrophism- findings determined by a pathologist examining the specimen under a microscope. For regional disease the following are indications after surgery: extracapsular extension, the involvement of 4 or more lymph nodes (two or more lymph nodes if cervical lymph nodes involved, size of the primary tumor >3 cm, and recurrent disease after prior complete lymph node dissection. Finally, for metastatic disease radiation therapy may be used to treat brain metastases alone or after surgical resection, and other symptomatic or impending symptomatic involvement of bony metastases or soft tissue resection. For more information please see The National Comprehensive Cancer Network (NCCN) Guidelines. Margins are determined by a pathologist reviewing the surgical specimen and measuring the distance from where tumor is seen to the nearest point of normal tissue.

Stereotactic radiosurgery is a type of external beam radiation therapy utilizes very precise and multiple beams in a small number of treatment fractions (one to five), and with a high dose delivered per treatment fraction. Often times radiosurgery is a terminology people refer to for a single fraction and stereotactic radiosurgery when it is more than one fraction- up to five, but the terms are relatively interchangeable. There is no surgery or cutting involved, as the treatment is non-invasive. Radiosurgery can be used to treat lesions in the brain, such as brain metastases, for spine metastases, and in the body for primary lung tumors, lung metastases, other organ metastases, and now to the prostate as primary treatment. Because of the ablative response of the tumor to this type of treatment it is now also known as stereotactic ablative radiotherapy, or SABR. Stereotactic radiosurgery is a type of external beam radiation therapy utilizes very precise and multiple beams in a small number of treatment fractions (one to five), and with a high dose delivered per treatment fraction. Often times radiosurgery is a terminology people refer to for a single fraction and stereotactic radiosurgery when it is more than one fraction- up to five, but the terms are relatively interchangeable. There is no surgery or cutting involved, as the treatment is non-invasive. Radiosurgery can be used to treat lesions in the brain, such as brain metastases, for spine metastases, and in the body for primary lung tumors, lung metastases, other organ metastases, and now to the prostate as primary treatment. Because of the ablative response of the tumor to this type of treatment it is now also known as stereotactic ablative radiotherapy, or SABR.

Brachytherapy for the treatment of melanoma is used for the treatment of choroidal or uveal (intraocular) melanoma as an eye-sparing technique. It is also referred to as plaque brachytherapy and can be performed with several isotopes including Iodine 125 (125I), gold 198 (198Au), palladium 103 (103Pd), and others. Guidelines are available by the American Brachytherapy Society: http://www.eyephysics.com/PS/PS5/UserGuide/References/PDF/Red_J_Articles/AmerBrachyRec03.pdf Brachytherapy for the treatment of melanoma is used for the treatment of choroidal or uveal (intraocular) melanoma as an eye-sparing technique. It is also referred to as plaque brachytherapy and can be performed with several isotopes including Iodine 125 (125I), gold 198 (198Au), palladium 103 (103Pd), and others. Guidelines are available by the American Brachytherapy Society: http://www.eyephysics.com/PS/PS5/UserGuide/References/PDF/Red_J_Articles/AmerBrachyRec03.pdf

Radiation therapy is used in the palliative settings for nearly all types of cancers. For example, it can be used to treat pain related to bone metastases from different primary sites, improve respiratory symptoms from a tumor blocking airways, improve swallowing conditions related to esophageal tumors. Radiation therapy can also be used in the prophylactic palliative setting for brain metastases, lesions in vertebral bodies before they cause pain or neurological symptoms, or impending bone fractures. For the majority of times a tumor causes symptoms there is often a role for radiation to address and improve them palliatively. Radiation therapy is used in the palliative settings for nearly all types of cancers. For example, it can be used to treat pain related to bone metastases from different primary sites, improve respiratory symptoms from a tumor blocking airways, improve swallowing conditions related to esophageal tumors. Radiation therapy can also be used in the prophylactic palliative setting for brain metastases, lesions in vertebral bodies before they cause pain or neurological symptoms, or impending bone fractures. For the majority of times a tumor causes symptoms there is often a role for radiation to address and improve them palliatively.

Radiation therapy treatment schedules and the doses delivered per treatment vary depending on the intent to treat (definitive or curative intent versus palliative intent), the tumor type (breast, prostate, lung, etc), a patient's overall condition, and the accessibility of patient to receive radiation treatment. Furthermore, centers with more state-of-the-art equipment can offer different treatment options because of the capability of the technology. There are treatment guidelines within the radiation community, as well. We encourage patients to do their homework, know that often times there are multiple treatment options available (even if the first place they go to doesn't have them), and to even call some of our patients who have completed treatment for other opinions. Radiation therapy treatment schedules and the doses delivered per treatment vary depending on the intent to treat (definitive or curative intent versus palliative intent), the tumor type (breast, prostate, lung, etc), a patient's overall condition, and the accessibility of patient to receive radiation treatment. Furthermore, centers with more state-of-the-art equipment can offer different treatment options because of the capability of the technology. There are treatment guidelines within the radiation community, as well. We encourage patients to do their homework, know that often times there are multiple treatment options available (even if the first place they go to doesn't have them), and to even call some of our patients who have completed treatment for other opinions.

Acute side effects from radiation typically last anywhere from 3-6 weeks following completion of radiation therapy. Depending on the extent of the skin-related side effects, which may be related to a person's individual anatomy, side effects may persist on the longer side of this time scale. Acute side effects from radiation typically last anywhere from 3-6 weeks following completion of radiation therapy. Depending on the extent of the skin-related side effects, which may be related to a person's individual anatomy, side effects may persist on the longer side of this time scale.

I'm not a surgeon, so my answer is more based on my own experience that anything else, because what Dr. Kline said was also said to me. However, I have mastectomy with skin sparing breast reconstruction, although it was known I would have radiotherapy afterwards. I don't regret this decision in the least. Although the radiated breast feels slightly firmer than the other one, both implants are perfect in shape and size, and without touch there isn't much difference. Just because I did it in one surgery meant for me I didn't have to be operated on again once tx was done. With two toddlers that was a bonus. It depends on what type of reconstruction you have chosen. If you choose implant reconstruction, radiation doesn’t hurt the tissue expander or implant, although it significantly decreases the chance of achieving an acceptable result. If you have had an immediate flap reconstruction, then learn (unexpectedly) that you need radiation, then the flap may be in serious jeopardy. Experienced oncologic breast surgeons are usually pretty good at anticipating whether a patient will need radiation or not. If significant doubt exists, however, and a flap reconstruction is planned, it is best either place temporary tissue expanders at the time of mastectomy, or delay all reconstruction until after radiation.

Richard M. Kline Jr., M.D.

The study presented by Dr. Grace Smith at the San Antonio Breast Cancer Symposium entitled Partial Breast Brachytherapy is Associated with Inferior Effectiveness and Increased Toxicity Compared with Whole Breast Irradiation in Older Patients has garnered a tremendous amount of print and internet media attention. After reading the abstract (paper not in press yet), seeing the talk live in San Antonio, and discussing the study with many colleagues in the breast surgery and radiation oncology fields, it has become necessary to try to clarify the data on APBI, discuss the 'information' in the abstract and the hyperbole in the lay press that is distressing our patients.

First and unequivocally, Acellerated Partial Breast Irradiation is a safe and effective form of treating the breast after appropriately performed lumpectomy in patients over age 45-50 with early stage invasive (typically <3cm primaries and lymph node negative) and non-invasive breast cancer. Numerous retrospective studies and 2 prospective randomized (the gold standard) studies have shown no difference in survival, local-regional recurrence rates or complications between APBI and Whole Breast Irradiation (WBI). The American Society of Breast Surgeons Mammosite Registry has published more than 16 papes showing the safety and efficacy (comparable to WBI) of Mammosite APBI.

The abstract and presentation is drawn from the Medicare claims-SEER database which is a large database with cancer patient data linked to Medicare claims data. The database is managed by the NCI and sold to institutions to do research. The linked database has information about cancer type and treatments but no specific data on margin status, prognostic factors such as ER/PR and Her2Neu, or even local, regional or distant recurrence. The study stated that 'subsequent mastectomy' is a 'validated surrogate for local failure' although I am unaware of any literature that states this. The 'two-fold increased risk for subsequent mastectomy' is misleading (and inaccurate - it's 4.0% for APBI vs. 2.2% for Whole Breast Irradiation in their study). Both of these rates are quite small and questionable whether there is any clinical significance between the two. Not emphasized but equally (?more) important is the overall survival rates which were equivalent. The study also stated that infections were higher for APBI (not surprising since it involves the insertion of one or more catheters in the breast) but there is no statement regarding severity (were the APBI patients just placed on prophylactic antiobiotics and that is how an infection was defined?). Fat necrosis and breast pain were also significantly higher in the APBI group although there is absolutely no uniform definition of what fat necrosis is nor a statement about the severity or the fat necrosis or breast pain. Lastly, they state there was a 9.6% hospitalization rate for APBI patients vs 5.7% for WBI patients. This is quizzical since no diagnosis was given for hospitalization nor the time period over which they were hospitalized (was it APBI related[doubtful] or related to first chemotherapy cycle [perhaps] or other unrelated health issues [APBI often used in older, sicker patients who may not be candidates for 6-7 weeks of WBI]). In summary, this retrospective study of an inherently inacurate (no data on tumor characteristics and margin status - both known to be significant determiners of local recurrence) database with questionable outcomes (admission rate) and non-validated 'surrogate endpoints' (subsequent mastectomy=local recurrence) should be looked at with appropriate skepticism in the face of 20 years of retrospective studies and 2 prospective randomized trial to the contrary.
Thanks for the question! The San Antonio Breast Cancer Symposium is one of the largest and most prestigious breast cancer conferences, and often exciting and innovative research is presented. However at the recent meeting, a study was presented by a group from MD Anderson, questioning the safety and effectiveness of accelerated partial breast irradiation (APBI) for early-stage breast cancer - specifically they noted that patients undergoing this treatment have a higher rate of complications and eventual mastectomy. Unfortunately before the study was even presented, it received national media attention, leading to significant anxiety and confusion among women. This stresses the importance of reading the study, not just listening to the sound bite - here are some facts:
- The study used retrospective (after the fact) "claims data" to do their evaluation. That means they took Medicare billing information, not actual patient data, and drew some conclusions. It is NOT possible to accurately determine complication rates from claims data as they are not always reported. It is also not possible (and the authors admitted this) to determine why the women treated with APBI subsequently underwent mastectomy - it could have been for an entirely different cancer, even one in the other breast!
- The absolute increased risk of mastectomy was 1.8% which is quite low, and again we have no way to know why the women underwent mastectomy
- APBI has been the subject of multiple prospective (going-forward) and peer-reviewed studies, and has been shown to have an equivalent or in some cases better rate of breast cancer control compared to whole-breast irradiation; the complication rate is also equivalent.

3 respected professional medical societies published responses critical of the MD Anderson study, and I expect more criticism will come. The responses are from the American Society of Breast Surgeons: https://www.breastsurgeons.org/news/article.php?id=122, the American Brachytherapy Society: http://campaign.r20.constantcontact.com/render?llr=kdofiegab&v=001rj64Pj8NTf4ISgwN4cSdZYtZBR53GjAi73j4En_qeygPzWmSUe1qgGI7U-jt8HRV7NouL9sMViv1IOOeGT2QHMAaDWrfEuOApREAHj-8Z60%3D and the American Society for Radiation Oncology: https://astro.org/News-and-Media/News-Releases/2011/ASTRO--APBI-safe,-effective-for-some-breast-cancer-patients.aspx

It is again unfortunate that this poorly designed study with no real valid clinical data was allowed to be presented at such a prestigious meeting, and that it received immense national media attention before the scientific community was allowed to interpret the study and respond. I am hopeful that this will not happen in the future, as many women (and many physicians) were caused unnecessary anxiety regarding their breast cancer treatment options.

Our patients have had a lot of success with Udderly Smooth cream - it comes in a big tub - good for elbows and feet, too! There are several skin care options. Some of the topical creams and lotions we recommend include Aquaphor, Biafine, Mederma, and Jean's Cream. We also recommend the use of Aloe Vera (plant or gel) or vitamin E cream. Much of this is individualistic and a matter of comfort.

Radiation oncologists, like other cancer doctors, use evidence-based medicine to advise patients on appropriate treatment recommendations. This means we use results of big studies to guide our management recommendations. For example, several big studies compared lumpectomy alone versus lumpectomy plus radiation. The results showed a much higher risk of local recurrence with lumpectomy alone. Therefore, based on these studies, the addition of radiation after lumpectomy is considered standard of care based. Often times, patient's individual circumstances call for a discussion amongst the treating physicians to determine the specifics of a patient's treatment — whether or not we radiate lymph nodes, if a patient can get partial breast irradiation, if a patient needs a 'boost', if a patient is eligible for the "short-course" of radiation, etc. Dialogue between the surgeon, medical oncologist, and radiation oncologist is imperative for these decisions. Radiation oncologists, like other cancer doctors, use evidence-based medicine to advise patients on appropriate treatment recommendations. This means we use results of big studies to guide our management recommendations. For example, several big studies compared lumpectomy alone versus lumpectomy plus radiation. The results showed a much higher risk of local recurrence with lumpectomy alone. Therefore, based on these studies, the addition of radiation after lumpectomy is considered standard of care based. Often times, patient's individual circumstances call for a discussion amongst the treating physicians to determine the specifics of a patient's treatment — whether or not we radiate lymph nodes, if a patient can get partial breast irradiation, if a patient needs a 'boost', if a patient is eligible for the "short-course" of radiation, etc. Dialogue between the surgeon, medical oncologist, and radiation oncologist is imperative for these decisions.