Radiation Treatments

Even though the new radiation technology has given us the capability to spare patients from significant skin burns, depending on the type of cancer and its location, sometimes either the skin itself is the target of radiation or it is impossible to spare it completely. Skin burn from radiation in many ways is similar to a sunburn. There are a number of products that radiation oncologists may recommend to alleviate the discomfort from the skin burn. These include but are not limited to Aquaphor ointment, Miaderm Lotion, Aloe Vera gel, Calendu, RadX Radiation Therapy cream, Radia-Guard lotion and many other products. If the skin has blistered or the shiny and moist part of skin is exposed Silvadene cream and/or a variety of gel wound dressings may be recommended. In worst case scenarios, your radiation oncologist may decide to advise a break in the course of treatment but this has to be weighed carefully against the negative impact of breaks during radiation on the final outcome of treatment. Avoiding sun exposure and products containing alcohol is advisable. Cleaning the area with mild and fragrance-free soap and water to prevent infection is essential. If the affected area is in perineal area, sitz baths with water and Hydrogen Peroxide would be helpful. Women should avoid wearing wired bras if the treatment area includes the chest. Please do not use any product without consulting your radiation oncologist first. Even though the new radiation technology has given us the capability to spare patients from significant skin burns, depending on the type of cancer and its location, sometimes either the skin itself is the target of radiation or it is impossible to spare it completely. Skin burn from radiation in many ways is similar to a sunburn. There are a number of products that radiation oncologists may recommend to alleviate the discomfort from the skin burn. These include but are not limited to Aquaphor ointment, Miaderm Lotion, Aloe Vera gel, Calendu, RadX Radiation Therapy cream, Radia-Guard lotion and many other products. If the skin has blistered or the shiny and moist part of skin is exposed Silvadene cream and/or a variety of gel wound dressings may be recommended. In worst case scenarios, your radiation oncologist may decide to advise a break in the course of treatment but this has to be weighed carefully against the negative impact of breaks during radiation on the final outcome of treatment. Avoiding sun exposure and products containing alcohol is advisable. Cleaning the area with mild and fragrance-free soap and water to prevent infection is essential. If the affected area is in perineal area, sitz baths with water and Hydrogen Peroxide would be helpful. Women should avoid wearing wired bras if the treatment area includes the chest. Please do not use any product without consulting your radiation oncologist first.

Traditionally the indications for post-mastectomy radiation have been as following:
- A tumor 5cm (2 inches) or larger
- 4 or more lymph nodes involved by cancer
- Inflammatory Breast Cancer
- when the surgical margins of the mastectomy specimen are grossly or closely involved with cancer

About a decade ago, studies from Denmark and Canada revealed benefit of post-mastectomy radiation for women with 1-3 involved lymph nodes. Even though initially in the US we were slow to accepting these data, independent studies in US have convinced most of radiation oncologists in the US to recommend post-mastectomy radiation not only to post-menopausal but also premenopausal women with less than 4 lymph nodes involved.

Even though the above-mentioned factors continue to be indications for radiation after mastectomy a few challenges have been introduced to these seemingly straightforward indications in the past decade. This is mainly due to sentinel lymph node biopsy replacing most of complete axillary lymph node dissections, introductions of PET imaging and also increase in use of neoadjuvant chemotherapy.

The challenge sentinel lymph node biopsy has introduced is that often the number of lymph nodes removed are less than 4. The question of whether additional nodes need to be removed if one or more of these sentinel lymph nodes are involved, has been subject of debate amongst surgical, radiation and medical oncology experts for years. The recent publication of the results of the American College of Surgeons Oncology Group trial (Z0011) put this issue to rest because it showed that completion axillary dissection in these patients did not add local control or survival benefit. But it also left radiation oncologists in a dilemma regarding the necessity for irradiating the lymph nodes for patients with positive SLNs who do not undergo ALND is uncertain. So this issue is often addressed by assessing the individual's risk of having residual disease in the axilla.

When chemotherapy is administered prior to mastectomy, it can potentially completely destroy the cancer cells. That is an ideal outcome but would not eliminate the need for mastectomy. In such a scenario, the challenge for the radiation oncologist is whether postmastectomy radiation is necessary or not. If a sentinel node biopsy is performed prior to the administration of chemotherapy, the status of the lymph nodes prior to chemotherapy may provide helpful information regarding this dilemma, otherwise the radiation oncologist does not have such a basis for making the recommendation. The jury is still out on this issue and individualized recommendations must be based on taking other factors predictive of risk of local recurrence.

PET scans might suggest involvement of internal mammary nodes. Because of the risk of false-positivity and the fact that these nodes are not normally sampled or dissected, the decision regarding treating these potential positive lymph nodes by irradiating them becomes another subject of discussion at tumor boards.

So as you can appreciate, practice of radiation oncology, like many other fields in medicine is moving away from one size fits all towards individualized medicine. Traditionally the indications for post-mastectomy radiation have been as following:
- A tumor 5cm (2 inches) or larger
- 4 or more lymph nodes involved by cancer
- Inflammatory Breast Cancer
- when the surgical margins of the mastectomy specimen are grossly or closely involved with cancer

About a decade ago, studies from Denmark and Canada revealed benefit of post-mastectomy radiation for women with 1-3 involved lymph nodes. Even though initially in the US we were slow to accepting these data, independent studies in US have convinced most of radiation oncologists in the US to recommend post-mastectomy radiation not only to post-menopausal but also premenopausal women with less than 4 lymph nodes involved.

Even though the above-mentioned factors continue to be indications for radiation after mastectomy a few challenges have been introduced to these seemingly straightforward indications in the past decade. This is mainly due to sentinel lymph node biopsy replacing most of complete axillary lymph node dissections, introductions of PET imaging and also increase in use of neoadjuvant chemotherapy.

The challenge sentinel lymph node biopsy has introduced is that often the number of lymph nodes removed are less than 4. The question of whether additional nodes need to be removed if one or more of these sentinel lymph nodes are involved, has been subject of debate amongst surgical, radiation and medical oncology experts for years. The recent publication of the results of the American College of Surgeons Oncology Group trial (Z0011) put this issue to rest because it showed that completion axillary dissection in these patients did not add local control or survival benefit. But it also left radiation oncologists in a dilemma regarding the necessity for irradiating the lymph nodes for patients with positive SLNs who do not undergo ALND is uncertain. So this issue is often addressed by assessing the individual's risk of having residual disease in the axilla.

When chemotherapy is administered prior to mastectomy, it can potentially completely destroy the cancer cells. That is an ideal outcome but would not eliminate the need for mastectomy. In such a scenario, the challenge for the radiation oncologist is whether postmastectomy radiation is necessary or not. If a sentinel node biopsy is performed prior to the administration of chemotherapy, the status of the lymph nodes prior to chemotherapy may provide helpful information regarding this dilemma, otherwise the radiation oncologist does not have such a basis for making the recommendation. The jury is still out on this issue and individualized recommendations must be based on taking other factors predictive of risk of local recurrence.

PET scans might suggest involvement of internal mammary nodes. Because of the risk of false-positivity and the fact that these nodes are not normally sampled or dissected, the decision regarding treating these potential positive lymph nodes by irradiating them becomes another subject of discussion at tumor boards.

So as you can appreciate, practice of radiation oncology, like many other fields in medicine is moving away from one size fits all towards individualized medicine.

The duration of radiation treatments are also determined by the type and stage of the courses. Before prescribing any dose of radiation, a radiation oncologist has to first determine what the intention of the treatment would be. Treatment intent is either palliative or definitive.

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).

Radiation is normally given five days a week Monday through Friday. In some instances twice a day radiation may be recommended. In this case the two treatments are at least six hours apart. How long each individual treatment would take depends on many factors including the dose per fraction, the number of fields used to treat a target, the technology used and the energy and form of radiation.

Brachytherapy (aka "internal radiation") is usually given in much fewer number of treatments. For example prostate seed implant requires one procedure to place the seeds in the prostate. In treatment of gynecological cancers depending on whether Low Dose Radiation (LDR) or High Dose Rate (HDR) radiation is used anywhere between 2 to 6 treatments often one to two weeks apart is given. In a similar manner systemic radiation, in the form of an injection or oral intake, would require much fewer number of treatments. For example treatment of thyroid cancer using I-131 often requires only one treatment. The duration of radiation treatments are also determined by the type and stage of the courses. Before prescribing any dose of radiation, a radiation oncologist has to first determine what the intention of the treatment would be. Treatment intent is either palliative or definitive.

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).

Radiation is normally given five days a week Monday through Friday. In some instances twice a day radiation may be recommended. In this case the two treatments are at least six hours apart. How long each individual treatment would take depends on many factors including the dose per fraction, the number of fields used to treat a target, the technology used and the energy and form of radiation.

Brachytherapy (aka "internal radiation") is usually given in much fewer number of treatments. For example prostate seed implant requires one procedure to place the seeds in the prostate. In treatment of gynecological cancers depending on whether Low Dose Radiation (LDR) or High Dose Rate (HDR) radiation is used anywhere between 2 to 6 treatments often one to two weeks apart is given. In a similar manner systemic radiation, in the form of an injection or oral intake, would require much fewer number of treatments. For example treatment of thyroid cancer using I-131 often requires only one treatment.

In general, no. However, there may be reasons to avoid certain foods depending upon where the radiation is being directed. Your radiation oncology physician or nurse would be the best source of information for your particular situation. Although anti-oxidants interfere with radiation, there is no evidence that the anti-oxidants found in whole foods (not dehydrated, concentrated versions of what was once a whole food) are harmful during treatment. In general, no. However, there may be reasons to avoid certain foods depending upon where the radiation is being directed. Your radiation oncology physician or nurse would be the best source of information for your particular situation. Although anti-oxidants interfere with radiation, there is no evidence that the anti-oxidants found in whole foods (not dehydrated, concentrated versions of what was once a whole food) are harmful during treatment.

Throughout the past two decades, the role of radiation therapy in treatment of ovarian cancer has been consistently diminishing. This is due to two major factors. The first factor is the increasing knowledge that most of ovarian cancers, especially the ones which are not localized and require more than surgical intervention i.e. adjuvant treatment, are considered either systemic disease or at least putting the entire abdominal cavity at risk of recurrence. The second factor is the advances made in chemotherapy, not only by having better supportive care so that the patients can tolerate chemotherapy better but also in the number new chemotherapy agents.

When radiation therapy was routinely used for ovarian cancer, it was given in the form of whole abdominal radiation. That is the radiation was covering all and every tissue below diaphragm down to the pelvis. These large radiation fields were very difficult to tolerate. Large does could not be delivered to these large fields and patients had to endure many side effects particularly nausea, vomiting, and diarrhea. Later on injection of Phosphorus-32, a radioactive isotope of phosphorus into the abdominal cavity replaced the external radiation to the whole abdomen. Nowadays even that has been mostly replaced by injection of chemotherapy agents into the abdominal cavity.

Currently surgery and chemotherapy are the mainstays of treatment of ovarian cancer and as opposed to many other cancers, repeating surgery either in the form of debulking the disease or for second look, takes place before considering radiation therapy. That has limited the role of radiation therapy in treatment of ovarian cancer to treating the metastatic areas. That is if the cancer spreads to the bone, brain or other organs, radiation may be used to address those areas in a palliative manner. Also if disease becomes resistant to second and third line chemotherapy agents, and surgery is not an option either, radiation can be used to locally treat the residual or progressive disease at the primary site. Throughout the past two decades, the role of radiation therapy in treatment of ovarian cancer has been consistently diminishing. This is due to two major factors. The first factor is the increasing knowledge that most of ovarian cancers, especially the ones which are not localized and require more than surgical intervention i.e. adjuvant treatment, are considered either systemic disease or at least putting the entire abdominal cavity at risk of recurrence. The second factor is the advances made in chemotherapy, not only by having better supportive care so that the patients can tolerate chemotherapy better but also in the number new chemotherapy agents.

When radiation therapy was routinely used for ovarian cancer, it was given in the form of whole abdominal radiation. That is the radiation was covering all and every tissue below diaphragm down to the pelvis. These large radiation fields were very difficult to tolerate. Large does could not be delivered to these large fields and patients had to endure many side effects particularly nausea, vomiting, and diarrhea. Later on injection of Phosphorus-32, a radioactive isotope of phosphorus into the abdominal cavity replaced the external radiation to the whole abdomen. Nowadays even that has been mostly replaced by injection of chemotherapy agents into the abdominal cavity.

Currently surgery and chemotherapy are the mainstays of treatment of ovarian cancer and as opposed to many other cancers, repeating surgery either in the form of debulking the disease or for second look, takes place before considering radiation therapy. That has limited the role of radiation therapy in treatment of ovarian cancer to treating the metastatic areas. That is if the cancer spreads to the bone, brain or other organs, radiation may be used to address those areas in a palliative manner. Also if disease becomes resistant to second and third line chemotherapy agents, and surgery is not an option either, radiation can be used to locally treat the residual or progressive disease at the primary site.

The presentation by Dr. 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 breast surgery and radiation oncology, I want to try to clarify the data on APBI, and discuss the “information” in the abstract and the hyperbole in the lay press that is distressing our patients.

First and unequivocally, accelerated 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 two prospective randomized studies (the gold standard) have shown no difference in survival, local-regional cancer recurrence rates and complications between APBI and whole breast irradiation (WBI). The American Society of Breast Surgeons’ MammoSite Registry has published more than 16 papers showing the safety and efficacy (comparable to WBI) of Mammosite APBI.

The San Antonio abstract and presentation were 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 National Cancer Institute and sold to institutions to do research. The linked database has information about cancer type and treatments, but it has no specific data on margin status, prognostic factors such as estrogen receptor/progesterone receptor (ER/PR) and HER2/Neu receptor -- or even local, regional or distant recurrence.

The study stated that “subsequent mastectomy” is a “validated surrogate for local failure,” but 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 WBI in their study). Both of these rates are quite small, and it is questionable whether there is any clinical significance between the two. Not emphasized but equally important are the overall survival rates for APBI vs. WBI, 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 antibiotics and is that 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 of the fat necrosis or breast pain.

Lastly, the researchers state there was a 9.6% hospitalization rate for APBI patients vs. 5.7% for WBI patients. This is puzzling since no diagnosis was given for hospitalization nor was there information on the time period over which patients were hospitalized. Was hospitalization APBI-related (doubtful) or related to first chemotherapy cycle (perhaps) or other unrelated health issues? (It’s worth noting that APBI is often used in older, sicker patients who may not be candidates for six to seven weeks of WBI).

In summary, this retrospective study of an inherently inaccurate database (no data on tumor characteristics and margin status -- both known to be significant determiners of local recurrence), 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 two prospective randomized trials to the contrary.
The presentation by Dr. 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 breast surgery and radiation oncology, I want to try to clarify the data on APBI, and discuss the “information” in the abstract and the hyperbole in the lay press that is distressing our patients.

First and unequivocally, accelerated 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 two prospective randomized studies (the gold standard) have shown no difference in survival, local-regional cancer recurrence rates and complications between APBI and whole breast irradiation (WBI). The American Society of Breast Surgeons’ MammoSite Registry has published more than 16 papers showing the safety and efficacy (comparable to WBI) of Mammosite APBI.

The San Antonio abstract and presentation were 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 National Cancer Institute and sold to institutions to do research. The linked database has information about cancer type and treatments, but it has no specific data on margin status, prognostic factors such as estrogen receptor/progesterone receptor (ER/PR) and HER2/Neu receptor -- or even local, regional or distant recurrence.

The study stated that “subsequent mastectomy” is a “validated surrogate for local failure,” but 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 WBI in their study). Both of these rates are quite small, and it is questionable whether there is any clinical significance between the two. Not emphasized but equally important are the overall survival rates for APBI vs. WBI, 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 antibiotics and is that 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 of the fat necrosis or breast pain.

Lastly, the researchers state there was a 9.6% hospitalization rate for APBI patients vs. 5.7% for WBI patients. This is puzzling since no diagnosis was given for hospitalization nor was there information on the time period over which patients were hospitalized. Was hospitalization APBI-related (doubtful) or related to first chemotherapy cycle (perhaps) or other unrelated health issues? (It’s worth noting that APBI is often used in older, sicker patients who may not be candidates for six to seven weeks of WBI).

In summary, this retrospective study of an inherently inaccurate database (no data on tumor characteristics and margin status -- both known to be significant determiners of local recurrence), 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 two prospective randomized trials to the contrary.

Brachytherapy is radiation therapy delivered at a close distance - brachy means arm's length. Many cancers can be treated with brachytherapy including prostate cancer (implanted seeds), cervical cancer, and breast cancer. There any many techniques but most involve a shortened course (intra-operative single dose to two treatments per day for 5 days) and only treat the part of the breast at highest risk (the lumpectomy cavity). The term for this is Accelerated Partial Breast Irradiation (APBI) and is most commonly done with a device inserted into the lumpectomy cavity through a small skin nick. These devices (Contura, Mammosite Multi-Lumen, and SAVI) have multiple catheters bundled together that separate within the lumpectomy cavity (think egg beater). A small radiation seed (~size of a grain of rice) is inserted into each catheter and 'dwells' at a certain position for a certain amount of time to deliver the radiation dose prescribed by the radiation oncologist. Brachytherapy is radiation therapy delivered at a close distance - brachy means arm's length. Many cancers can be treated with brachytherapy including prostate cancer (implanted seeds), cervical cancer, and breast cancer. There any many techniques but most involve a shortened course (intra-operative single dose to two treatments per day for 5 days) and only treat the part of the breast at highest risk (the lumpectomy cavity). The term for this is Accelerated Partial Breast Irradiation (APBI) and is most commonly done with a device inserted into the lumpectomy cavity through a small skin nick. These devices (Contura, Mammosite Multi-Lumen, and SAVI) have multiple catheters bundled together that separate within the lumpectomy cavity (think egg beater). A small radiation seed (~size of a grain of rice) is inserted into each catheter and 'dwells' at a certain position for a certain amount of time to deliver the radiation dose prescribed by the radiation oncologist.

Let me start by saying that brachytherapy is safe and effective in properly selected patients. We have 20 years of studies that have analyzed patient outcome data and 2 prospective randomized trials (the true gold standard) that have shown that brachytherapy (accelerated partial breast irradiation [APBI]) is equally effective to whole breast irradiation (WBI).

There was a recent presentation at the San Antonio Breast Cancer Symposium from radiation oncologists from MDAnderson Cancer Center that has creasted some controversy. They retorspectively analyzed a large Medicare Claims-SEER database that showed equivalent survival rates between APBI and WBI. The controversial part of their presentation that they chose to emphasize was the slightly higher breast cancer local recurrence rate (as assessed by mastectomy rates) for APBI patients (4%) compared to WBI patients (2.2%). The difficulty with emphasizing this one point was that it struck fear in many patients. Frankly, both rates are very low and acceptible but to make a 'big deal' out of this clinically very small difference is unfair to APBI. Let me start by saying that brachytherapy is safe and effective in properly selected patients. We have 20 years of studies that have analyzed patient outcome data and 2 prospective randomized trials (the true gold standard) that have shown that brachytherapy (accelerated partial breast irradiation [APBI]) is equally effective to whole breast irradiation (WBI).

There was a recent presentation at the San Antonio Breast Cancer Symposium from radiation oncologists from MDAnderson Cancer Center that has creasted some controversy. They retorspectively analyzed a large Medicare Claims-SEER database that showed equivalent survival rates between APBI and WBI. The controversial part of their presentation that they chose to emphasize was the slightly higher breast cancer local recurrence rate (as assessed by mastectomy rates) for APBI patients (4%) compared to WBI patients (2.2%). The difficulty with emphasizing this one point was that it struck fear in many patients. Frankly, both rates are very low and acceptible but to make a 'big deal' out of this clinically very small difference is unfair to APBI.

Brachytherapy is a more inclusive name for radiation that is delivered at a 'short distance' (the name 'brachy' means arm's length). Brachytherapy techniques include the Mammosite balloon technique. Mammosite is a balloon with a single catheter running down the middle. http://www.mammosite.com/ A small radiation seed (about the size of a grain of rice) is then run down the catheter and stops at various positions along the way to deliver the prescribed radiation dose. Other brachytherapy techniques include using multiple catheters that pierce the skin (interstial brachytherapy - used rarely now but was the original technique pioneered by Robert Kuske, MD) and single entry/multiple catheter devices (SAVI, Mammosite Multi-Lumen, and Contura). The radiation seed goes down each catheter (just as in the single catheter Mammosite) for a set time to deliver the prescribed dose.

I feel very comfortable offering properly selected patients - accelerated partial breast irradiation (5 days instead of 6-7 weeks) usually with one of the single entry/multicatheter devices. Brachytherapy is a more inclusive name for radiation that is delivered at a 'short distance' (the name 'brachy' means arm's length). Brachytherapy techniques include the Mammosite balloon technique. Mammosite is a balloon with a single catheter running down the middle. http://www.mammosite.com/ A small radiation seed (about the size of a grain of rice) is then run down the catheter and stops at various positions along the way to deliver the prescribed radiation dose. Other brachytherapy techniques include using multiple catheters that pierce the skin (interstial brachytherapy - used rarely now but was the original technique pioneered by Robert Kuske, MD) and single entry/multiple catheter devices (SAVI, Mammosite Multi-Lumen, and Contura). The radiation seed goes down each catheter (just as in the single catheter Mammosite) for a set time to deliver the prescribed dose.

I feel very comfortable offering properly selected patients - accelerated partial breast irradiation (5 days instead of 6-7 weeks) usually with one of the single entry/multicatheter devices.

There is always some leeway in these criteria including discussing all radiation options with the patient but generally
age >45
tumor size < 3 cm
Margins - neg
Lymph nodes - neg

Here is the link to the American Society of Breast Surgeons Offical Statment.
https://www.breastsurgeons.org/statements/PDF_Statements/APBI.pdf There is always some leeway in these criteria including discussing all radiation options with the patient but generally
age >45
tumor size < 3 cm
Margins - neg
Lymph nodes - neg

Here is the link to the American Society of Breast Surgeons Offical Statment.
https://www.breastsurgeons.org/statements/PDF_Statements/APBI.pdf

Radiation therapy is the use of high energy X-rays to kill cancer cells. It works by destroying or damaging rapidly growing cells, such as cancer cells, that may have been left behind by even the best surgeon. It damages cells only in the area of the body where the radiation is given. Before patients begin receiving radiation therapy, the radiation oncology team will carefully tailor their plan to make sure she receives safe and accurate treatment. Treatment will be carefully planned to target the cancer while avoiding healthy organs in the area - like the heart and lungs. Special computers are also used to monitor and double–check the treatment machines to make sure the proper treatment is given. Radiation beams come out of a machine called a linear accelerator. The beams are aimed at the target (breast, chest wall, +/- lymph node regions). The actual radiation treatments are painless — they take only a few minutes to deliver. Radiation therapy is the use of high energy X-rays to kill cancer cells. It works by destroying or damaging rapidly growing cells, such as cancer cells, that may have been left behind by even the best surgeon. It damages cells only in the area of the body where the radiation is given. Before patients begin receiving radiation therapy, the radiation oncology team will carefully tailor their plan to make sure she receives safe and accurate treatment. Treatment will be carefully planned to target the cancer while avoiding healthy organs in the area - like the heart and lungs. Special computers are also used to monitor and double–check the treatment machines to make sure the proper treatment is given. Radiation beams come out of a machine called a linear accelerator. The beams are aimed at the target (breast, chest wall, +/- lymph node regions). The actual radiation treatments are painless — they take only a few minutes to deliver.

Many patients who have breast implants may still be able to undergo breast conservation surgery (lumpectomy or partial mastectomy) followed by radiation therapy. There are many determining factors to this, including, the type of tumor, stage of tumor, and extent of cancer within the breast. Many patients who have breast implants may still be able to undergo breast conservation surgery (lumpectomy or partial mastectomy) followed by radiation therapy. There are many determining factors to this, including, the type of tumor, stage of tumor, and extent of cancer within the breast.

how you feel about the treatment is the key. i use drawings to get patients to display themselves receiving treatment and when a purple beam comes from god and another draws a body in a trapped box or a gas chamber they have side effects even when there is no radiation given. others say i get out of the way and let it go to my tumor and have no side effects.
when a radiation machine had no radioactive material in it the radiation therapist did not realize it for 30 days when machine was inspected. because people acted as if they were being treated. their mind created what they expected. how you feel about the treatment is the key. i use drawings to get patients to display themselves receiving treatment and when a purple beam comes from god and another draws a body in a trapped box or a gas chamber they have side effects even when there is no radiation given. others say i get out of the way and let it go to my tumor and have no side effects.
when a radiation machine had no radioactive material in it the radiation therapist did not realize it for 30 days when machine was inspected. because people acted as if they were being treated. their mind created what they expected.

Some of the practices that we employ to minimizing damage to normal cells during breast radiation treatment includes precise target acquisition and minimization of movement along with patient monitoring. With regard to target acquisition, we use one of the best treatment machines, the Elekta Infinity which gives great images of the patient; one of the best CT-simulators, the new Toshiba large bore, which acquires very clear anatomical images; and we also use AccuBoost, the most precise way of locating the patient's lumpectomy cavity and treating that area (http://www.thefarbercenter.com/cancers/breast.php_).
To monitor patients we utilize c-rad sentinel, which gives a laser topography image of the patient real time during treatment.
Some of the practices that we employ to minimizing damage to normal cells during breast radiation treatment includes precise target acquisition and minimization of movement along with patient monitoring. With regard to target acquisition, we use one of the best treatment machines, the Elekta Infinity which gives great images of the patient; one of the best CT-simulators, the new Toshiba large bore, which acquires very clear anatomical images; and we also use AccuBoost, the most precise way of locating the patient's lumpectomy cavity and treating that area (http://www.thefarbercenter.com/cancers/breast.php_).
To monitor patients we utilize c-rad sentinel, which gives a laser topography image of the patient real time during treatment.

Partial breast techniques include: AccuBoost (as protocol or off-label) non-invasive high dose rate (HDR) brachytherapy technique, balloon-based invasive HDR: MammoSite, Contura, Savi, and external beam radiation therapy. Partial breast techniques include: AccuBoost (as protocol or off-label) non-invasive high dose rate (HDR) brachytherapy technique, balloon-based invasive HDR: MammoSite, Contura, Savi, and external beam radiation therapy.