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 Table of Contents  
ORIGINAL ARTICLE
Year : 2019  |  Volume : 10  |  Issue : 1  |  Page : 24-26

High-dose interstitial brachytherapy for accelerated partial-breast irradiation in clinical practice: Preliminary results from a tertiary cancer center in India


1 Department of Radiation Oncology, HCG Manavata Cancer Centre, Nashik, Maharashtra, India
2 Department of Surgical Oncology, HCG Manavata Cancer Centre, Nashik, Maharashtra, India
3 Department of Clinical Research, HCG Manavata Cancer Centre, Nashik, Maharashtra, India

Date of Web Publication22-May-2019

Correspondence Address:
Dr. Vijay Palwe
Department of Radiation Oncology, HCG Manavata Cancer Centre, Nashik, Maharashtra
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/jrcr.jrcr_19_18

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  Abstract 


Introduction: Over the past several years, there has been growing interest in the use of accelerated partial-breast irradiation (APBI) as an alternative to whole-breast radiation in properly selected patients. The use of multicatheter interstitial brachytherapy (MIB) for APBI is increasing due to better availability of expertise and experience than other forms of APBI. The use of APBI outside the framework of a clinical trial has markedly increased. We report the efficacy and safety of APBI through high-dose-rate (HDR) MIB for early-stage breast cancer. Materials and Methods: Between 2008 and 2017, 20 prospectively selected patients with early-stage breast cancer received APBI using MIB following breast-conserving surgery. The mean age was 62.85 years (range: 41–80). Mean size of the tumor was 2.04 cm. The dose of 34 Gy in 10 fractions given twice daily (3.4 Gy) over 5 days was delivered to the tumor bed plus a 2-cm margin. The mean follow-up was 57.75 months (range: 12–100). Ten (50%) patients received adjuvant chemotherapy. Thirteen (65%) patients received hormonal therapy. Results: A total of 18 (90%) patients reported having excellent-to-good cosmesis, while 2 (10%) had fair-to-poor cosmesis. All patients (100%) were clinically controlled at follow-up, i.e., no locoregional recurrence. Only three (15%) had distant metastasis on follow-up. Conclusion: APBI using HDR-MIB was associated with excellent local control, acceptable toxicity, and cosmesis for early-stage breast cancer patients.

Keywords: Accelerated partial-breast irradiation, breast cancer, cosmesis


How to cite this article:
Palwe V, Pandit P, Nagarkar R, Paleja N. High-dose interstitial brachytherapy for accelerated partial-breast irradiation in clinical practice: Preliminary results from a tertiary cancer center in India. J Radiat Cancer Res 2019;10:24-6

How to cite this URL:
Palwe V, Pandit P, Nagarkar R, Paleja N. High-dose interstitial brachytherapy for accelerated partial-breast irradiation in clinical practice: Preliminary results from a tertiary cancer center in India. J Radiat Cancer Res [serial online] 2019 [cited 2019 Oct 23];10:24-6. Available from: http://www.journalrcr.org/text.asp?2019/10/1/24/258712




  Introduction Top


Breast cancer has become one of the most common malignancies in females worldwide. Breast cancer accounts for nearly 23% of all cancers diagnosed in women.[1] The global burden of breast cancer is estimated to increase exponentially, i.e., over 2 million by 2030.[2] The age-standardized incidence rates in India are comparatively low as compared to the United Kingdom (25.8 against 95 per 100,000). However, the mortality rates are nearly as high to those of the UK (12.7 as against 17.1 per 100,000).[1] There is a need to develop and implement effective treatment approaches to reduce overall breast cancer burden.


  Materials and Methods Top


A total of 20 patients with early-stage breast cancer were included for prospective analysis between November 2008 and August 2018. All patients received accelerated partial-breast irradiation (APBI) using multicatheter interstitial brachytherapy following breast-conserving surgery. All patients underwent APBI with high-dose-rate (HDR) iridium-192 brachytherapy. A dose of 34 Gy in 10 fractions was prescribed to the clinical target volume (CTV), which was delivered over a period of 5–7 days with two fractions delivered daily with a gap of 6 h in between the two fractions. The Harvard scale/criteria were used for the assessment of cosmesis in all patients. The Harvard criteria are based on four cosmetic outcomes, i.e., excellent, good, fair, and poor. In our case, the results were dichotomized into excellent/good and fair/poor.

Accelerated partial-breast irradiation with interstitial brachytherapy procedure details

Postresection of the primary breast tumor, stainless steel needles (implants) are inserted through the tumor bed and postoperative cavity surrounding the lumpectomy. The catheters are inserted in several plans at 1–1.5-cm intervals. The overall process ensures adequate coverage of the lumpectomy cavity and the margins. As per our experience, the procedure requires 12–20 catheters to assure proper dose coverage. The exact number of catheters is dependent on the size and shape of the target. In our case, the template-guided approach was used to place multiple catheters in the breast. The stainless steel needles are replaced by flexible after loading catheters. HDR is an outpatient procedure wherein each treatment lasts for 3–5 min. Patients are fractionated over the course of a week. In our case, 34 Gy in 10 fractions twice daily was used for HDR.


  Results Top


The mean age of the sample population was 62.85 years. All patients presented with breast lump at the time of initial evaluation. A total of 6 (30%) of patients had hypertension. Three patients (15%) had diabetes mellitus. One (5%) patient had a history of breast lumpectomy, multiple cancers, and bilateral cataract surgery, respectively. Two (10%) of patients had a history of hysterectomy. A total of six (30%) of patients had a lump in the right breast, while a total of 14 (70%) of patients had a lump in the left breast at the time of presentation.

The tumor size ranged from 1.7 to 2.5 cm. The mean size of the tumor was 2.04 cm. A total of 11 (55%) of patients had a tumor in the upper outer quadrant, while four (20%) had a tumor in the upper inner quadrant. A total of three (15%) had a tumor in the lower outer quadrant, while two (10%) had a tumor in the lower inner quadrant. In context to biomarkers, a total of 13 (65%) patients were positive for estrogen receptor, 13 (65%) for progesterone receptor, and 3 (15%) for human epidermal growth factor receptor-2,. A total of 5 (25%) patients were triple negative. At our hospital, triple-negative patients with no nodal involvement underwent high-dose interstitial brachytherapy accelerated partial-breast irradiation (ABPI). Eleven (55%) patients received adjuvant chemotherapy. A total of 3 (15%) patients received cyclophosphamide, doxorubicin hydrochloride (adriamycin), and fluorouracil. Two patients received doxorubicin (adriamycin)/cyclophosphamide (AC). Two patients received endoxan and methotrexate. One patient received four cycles of epirubicin and cyclophosphamide (EC) chemotherapy followed by trastuzumab. One patient received four cycles of AC. One patient receives cyclophosphamide, methotrexate, and fluorouracil regimen. One patient received fluorouracil and EC chemo regimen. All 13 (60%) patients received hormonal therapy. The number of implants ranged from 9 to 19 in all patients. The mean number of implants required for the procedure was 12.6.

In context to toxicities, a total of 13 (60%) of patients had erythema, 3 (15%) patients had desquamation, 2 (10%) patients had telangiectasia, and 2 (10%) patients had fibrosis. A single patient reported having lymphangitis and lymphedema of the right upper limb. A total of 18 (90%) patients reported having excellent-to-good cosmesis, while 2 (10%) had fair cosmesis. All patients (100%) were clinically controlled at follow-up, i.e., patients had no locoregional recurrence at the time of the last follow-up. Only 3 (15%) had distant metastasis on follow-up. One patient had metastasis in the liver and lung, one patient had metastasis in the brain and cervical node, and one patient had metastasis in the brain. The mean follow-up was 57.75 months (range: 12–100).


  Discussion Top


The report is based from a tertiary cancer center in a Tier-2 city in India. Most of our patients come from socially and economically backward classes. The number of patients presenting to our hospital with early-stage disease is low. A large number of patients present with locally advanced breast cancer which are unsuitable for APBI with interstitial brachytherapy. Thus, we have an extremely low number of patients in our prospective study.

The incidence rates of breast cancer in India vary significantly. The highest rates of breast cancer have been observed in the northeast followed by major metropolitan cities such as Mumbai and New Delhi.[3] Some of the most common factors for these variations include lifestyle (example: alcohol use or tobacco smoking), anthropometric (example: adiposity), reproductive (example: age at first child and number of children), and demographic (example: education).[3] Cancer has emerged as a major public health issue considering the ongoing epidemiological and demographic transition in India. As per the World Health Organization, the cancer mortality rate has reached 79 per 100,000 deaths in India. It accounts for over 6% of total deaths.[4] These figures are close to those of high-income nations. The cancer mortality is projected to increase to over 900,000 deaths in India by the end of 2020.[4]

Early-stage breast cancer is defined as Stage II or less. It is based on the lack of lymph node involvement, distant metastasis, and/or a clinical lesion size of 2 cm or less.[5] Considering the increased use of breast cancer screening such as mammography, more patients are expected to be diagnosed with breast cancer at an early stage. Thus, there is a need to develop and implement efficient clinical management strategies for patients with early-stage breast cancer. Women presenting with newly diagnosed early-stage breast cancer may have an effective choice of breast-conserving surgery such as lumpectomy or mastectomy (also referred as modified radical mastectomy), radiation therapy, or other systemic treatments.[6]

Breast conservation therapy (BCT) is a choice of treatment for patients with early-stage breast cancer. BCT comprises resection of primary breast tumor such as lumpectomy, segmental mastectomy, or wide local excision. It is followed by whole-breast irradiation.[7] In such cases, radiation therapy could be delivered in a short time, making BCT a potentially feasible and attractive for women. This is the basic principle of APBI. In our case, we included such patients for HDR interstitial brachytherapy for ABPI. Our cosmesis results were based on the Harvard criteria which have four outcomes, i.e., excellent, good, fair, and poor. These outcomes were later dichotomized as excellent/good and fair/poor as observed in our results.[8],[9] Our study results had similar cosmesis outcomes, local disease control (recurrence), and satisfactory toxicity profile as compared to previously published literature.[10],[11],[12],[13],[14]


  Conclusion Top


Brachytherapy APBI can be considered as a valuable alternative considering reduced treatment time and the volume of irradiated normal tissue. However, it is suitable for a selected population of women with clinically defined early-stage breast cancer.[15] Our results reflect positive cosmesis with minimal toxicities and no locoregional recurrence. Although the sample size was small, our objective was to report positive cosmetic results and excellent clinical outcomes in early-stage breast cancer patients in a tertiary cancer center in India.

Acknowledgment

We would like to thank Mr. Lyndon Fernandes for his editorial assistance.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Gupta A, Shridhar K, Dhillon PK. A review of breast cancer awareness among women in India: Cancer literate or awareness deficit? Eur J Cancer 2015;51:2058-66.  Back to cited text no. 1
    
2.
Jemal A, Bray F, Center MM, Ferlay J, Ward E, Forman D, et al. Global cancer statistics. CA Cancer J Clin 2011;61:69-90.  Back to cited text no. 2
    
3.
National Cancer Registry Programme. National Centre for Disease Informatics and Research and Indian Council of Medical Research. Three Year Report of Population Based Cancer Registries 2009–2011 National Cancer Registry Programme. National Cancer Registry; 2013.  Back to cited text no. 3
    
4.
Rajpal S, Kumar A, Joe W. Economic burden of cancer in India: Evidence from cross-sectional nationally representative household survey, 2014. PLoS One 2018;13:e0193320.  Back to cited text no. 4
    
5.
Suzuki T, Toi M, Saji S, Horiguchi K, Aruga T, Suzuki E, et al. Early breast cancer. Int J Clin Oncol 2006;11:108-19.  Back to cited text no. 5
    
6.
Njeh CF, Saunders MW, Langton CM. Accelerated partial breast irradiation (APBI): A review of available techniques. Radiat Oncol 2010;5:90.  Back to cited text no. 6
    
7.
Liu G, Dong Z, Huang B, Liu Y, Tang Y, Li Q, et al. Efficacy and safety of accelerated partial breast irradiation: A meta-analysis of published randomized studies. Oncotarget 2017;8:59581-91.  Back to cited text no. 7
    
8.
Harris JR, Levene MB, Svensson G, Hellman S. Analysis of cosmetic results following primary radiation therapy for stages I and II carcinoma of the breast. Int J Radiat Oncol Biol Phys 1979;5:257-61.  Back to cited text no. 8
    
9.
Aaronson NK, Bartelink H, van Dongen JA, van Dam FS. Evaluation of breast conserving therapy: Clinical, methodological and psychosocial perspectives. Eur J Surg Oncol 1988;14:133-40.  Back to cited text no. 9
    
10.
Aliyev JA, Isayev IH, Akbarov KS, Qurbanov SS, Huseynov RR, Aliyeva NS, et al. High-dose-rate interstitial brachytherapy for accelerated partial breast irradiation – Trial results of Azerbaijan National Center of Oncology. J Contemp Brachytherapy 2017;9:106-11.  Back to cited text no. 10
    
11.
Garsa AA, Ferraro DJ, DeWees T, Margenthaler JA, Naughton M, Aft R, et al. Cosmetic analysis following breast-conserving surgery and adjuvant high-dose-rate interstitial brachytherapy for early-stage breast cancer: A prospective clinical study. Int J Radiat Oncol Biol Phys 2013;85:965-70.  Back to cited text no. 11
    
12.
Latorre JA, Galdós P, Buznego LA, Blanco AG, Cardenal J, Ferri M, et al. Accelerated partial breast irradiation in a single 18 Gy fraction with high-dose-rate brachytherapy: Preliminary results. J Contemp Brachytherapy 2018;10:58-63.  Back to cited text no. 12
    
13.
Cozzi S, Laplana M, Najjari D, Slocker A, Encinas X, Pera J, et al. Advantages of intraoperative implant for interstitial brachytherapy for accelerated partial breast irradiation either frail patients with early-stage disease or in locally recurrent breast cancer. J Contemp Brachytherapy 2018;10:97-104.  Back to cited text no. 13
    
14.
Ott OJ, Strnad V, Hildebrandt G, Kauer-Dorner D, Knauerhase H, Major T, et al. GEC-ESTRO multicenter phase 3-trial: Accelerated partial breast irradiation with interstitial multicatheter brachytherapy versus external beam whole breast irradiation: Early toxicity and patient compliance. Radiother Oncol 2016;120:119-23.  Back to cited text no. 14
    
15.
Akhtari M, Abboud M, Szeja S, Pino R, Lewis GD, Bass BL, et al. Clinical outcomes, toxicity, and cosmesis in breast cancer patients with close skin spacing treated with accelerated partial breast irradiation (APBI) using multi-lumen/catheter applicators. J Contemp Brachytherapy 2016;8:497-504.  Back to cited text no. 15
    




 

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