Partial Breast Irradiation for Boost Using Image-Guided Brachytherapy: Florida Community Experience and Review of the Literature

Research Article

Austin J Radiat Oncol & Cancer. 2016; 2(1): 1016.

Partial Breast Irradiation for Boost Using Image-Guided Brachytherapy: Florida Community Experience and Review of the Literature

Kuruvilla A¹*, Paryani S¹, Paryani N¹, Simmons D¹, Shah N¹, Caudill J², Stillword J² and Sullivan JW³

1First Radiation & Oncology Group, Cancer Center of Putnam, Palatka, Florida, USA

2General Surgery, Putnam Community Medical Center,USA

3Medical Oncology, Cancer Center of Putnam, Palatka, Florida, USA

*Corresponding author: Kuruvilla A, Cancer Center of Putnam, 600 Zeagler Drive, Palatka, Florida, USA

Received: May 07, 2016; Accepted: May 27, 2016; Published: May 30, 2016


Purpose: To evaluate the feasibility of implementing non-invasive, imageguided breast brachytherapy (NIBB) in a community setting.

Materials & Methods: We reviewed our experience of treating 91 patients with early stage breast cancer since 2011. All patients were seen at a community cancer center serving about 100,000 people. Of the total number of patients seen, 7 elected to undergo modified radical mastectomy. 71 women underwent breast conserving surgery (BCS) followed by whole breast radiation therapy (WBRT) to a total dose of 45Gy along with a NIBB boost of 16Gy. 13 patients received WBRT with either an electron beam or photon boost. Most patients received NIBB at the initiation of their therapy followed by WBRT. All patients were followed at our center for toxicity and cosmesis by a single physician.

Results: All patients completed therapy as prescribed. Grade 2 or higher acute skin toxicity was observed in less than 10% of our patients. There was no grade 4 toxicity. Cosmesis at minimum of 6 months follow-up was judged to be excellent or good in 90% of women.

Conclusion: NIBB can be delivered safely and effectively in a community setting. The results presented here are the first single center, community results using NIBB. The results compare favorably with previously reported results.

Keywords: Brachytherapy; NIBB; Breast conserving surgery; Low dose rate; High dose rate


This article details the First Radiation & Oncology Group’s experience at the Cancer Center of Putnam, Palatka, Florida. Whenever feasible, Non Invasive Breast Brachytherapy (NIBB) has been used as the preferential breast tumor bed boost technique for patients receiving irradiation after Breast Conserving Surgery (BCS) since initial implementation of this technology in 2011. At this center we have not yet offered NIBB as monotherapy following BCS.

Multiple randomized studies support the use of whole breast with external beam radiation therapy along with a boost after BCS [1,2]. Boost therapy has been reported to improve local control after lumpectomy and whole breast radiotherapy. Initial attempts to define a boost target involved scar-based palpation, but this practice has diminished with realization that the scar often did not correlate with the tumor bed. Interstitial Low Dose Rate (LDR) brachytherapy boosts, initially felt to be a promising technique for accurate localization of the boost volume, have also been decreasing in popularity, due to the availability of less invasive boosts [3]. The current standard of care is to boost with electrons or photons, and the modality chosen is usually dictated by the location and depth of the tumor bed [4]. Photon irradiation may be either via 3-dimensional conformal radiation therapy or intensity modulated radiation therapy. In some patients, it can be challenging to identify the tumor bed, particularly when surgical clips have not been placed. This difficulty is compounded in patients who undergo neoadjuvant chemotherapy. Attempts to localize the tumor bed on treatment planning Computed Tomography (CT), which is often inaccurate, result in unnecessarily large volumes of normal breast being targeted as part of the boost. A more novel technique involves NIBB, which utilizes High Dose Rate (HDR) brachytherapy incorporated with real time mammography for target localization and delineation.

All of the studies currently reported using NIBB were conducted at multi-center trials or academic facilities [5,6]. This is the first study examining the results of patients treated in a community setting serving a population of about 100,000 people.

Materials and Methods

Since implementation of NIBB in 2011, 91 breast cancer patients have been referred to the Cancer Center of Putnam. Of these, 84 (92%) chose BCS. 71 (78%) of these patients were boosted using NIBB.

Our protocol has been to treat the tumor bed with 4 fields. It takes a physicist approximately 30 minutes to perform daily Quality Assurance (QA) on the HDR. As such, we allocate a 60 minute slot per patient and treating all 4 fields is generally accomplished in this window. Once the patient is in the room, set up, including compression and images acquisition, is accomplished within 15 minutes. The physician is called to select the appropriate applicator and positioning coordinates. Treatment planning mammogram is correlated with pre-surgical mammogram (Figure 1 and 2) and referencing margin proximity in all dimensions from the pathology report. This typically takes the physician less than 5 minutes. The physician also verifies the plate separation required and from the Surface to Center Dose (SCD) the appropriate applicator is selected. The radiation therapists then attach the selected pair of applicators using the coordinates provided by the physician. Prior to commencing treatment, applicator coordinates used, final separation, and cable attachments are checked before treatment begins. The above procedure is then repeated for the next field. Depending on source strength, the treatment time is usually under 10 minutes per axis.