Brachytherapy

Course of Therapy

This initial part of therapy is unchanged.

Diagnosis: Most women are diagnosed by routine screening annual mammography or by feeling a mass. The mass discovery is by Breast Self Examination (BSE) or on examination by her physician. At any rate, either will lead to a Stereotactic (3-D guided) biopsy.

Stereotactic Biopsies can be accomplished with a special mammographic machine or under ultrasound guidance.

After the diagnosis of cancer is made, the lady is scheduled for appropriate consultations.

Pre-Operative Consultation with Dr Tokita (Radiation Oncologist): It is imperative that the patients have the opportunity to consult with Dr Tokita, before surgery. From the mammogram and initial evaluation, it will be quite clear to the surgeon that Brachy-therapy is an option. If the patient also wishes this approach, it will be very advantageous to review the treatment, risks and benefits with each participating physician. This will allow the surgeon to proceed in an orderly fashion, within the wishes and guidelines of the patients.

Surgery is then scheduled.

Lumpectomy: At surgery, the mass is removed (lumpectomy) with as wide a surgical margin as needed to get clear (free of cancer) margins.

Sentinel Lymph Node (SLN): In an attempt to

Cut down on the number of lymph nodes needing removal,
Decrease the incidence of lymphedema (postoperative arm swelling, which may never completely go away),
Decrease the pain post operatively, and also to
Increase the accuracy of evaluating whether the cancer has spread to the lymph nodes.

In the early to mid 1990s, Dr Tokita was Director of the St John’s Radiation Department and worked with Dr Guiliano. During that time, Dr Guiliano invented the ‘Blue dye” sentinel lymph node (SLN) procedure. It is now the standard and involves the injection of a blue dye around the tumor before surgery (and now also a radioactive label) to guide the surgeon to the set of nodes “draining” the cancer site. Its accuracy is superb.

So again, who is a candidate? If the tumor is small 2 cm or less, margins are clear of cancer, the cancer cells are not overly nasty, and the lady does not want 7 weeks of radiation, she is a reasonable candidate for Brachytherapy. There are several other criteria mentioned above, but these are the most important.

Catheter Implantation: Since Brachytherapy has already been reviewed with the patient; the surgeon can comfortably prepare or “size” the lumpectomy cavity to accept the Mammosite or Interstitial catheters.

Under direct visual exam, the surgeon can free up the surrounding skin and tissue and allow for later “deep and superficial closure” to give a margin over the catheter of over 7mm (ideally over 1cm or 10mm). The balloon on the catheter will be filled or “inflated” to a minimum of 35cc (diameter of 4cm) or a maximum of 70cc (diameter of 5 cc). The bulb is filled with dilute x-ray contrast (3%) and saline. The lumpectomy site is closed leaving the catheter handle exiting the breast at a separate site.

For Interstitial Tube placement, there is less need for re-exploring the previous surgical site. A series of needles are inserted through the cancer site in a pre-planned pattern. Dr Tokita and his staff determine this pattern preoperatively. The patient is left with a series of plastic green tubes in the breast.

If the lumpectomy had been accomplished at an earlier surgery, the catheters may be placed with an ultrasound-guided placement or a second surgery. This is up to the discretion of the surgeon.

Radiation: Post-operatively; the patients will go to The Cancer Center of Irvine, Radiation Therapy Department under the direction of Dr Kenneth Tokita. In general this appointment will be the day after surgery, or the first working day, if the surgery was done on a Friday.

Examination: Dr Tokita will examine the wound site and check the catheter.

Drainage: One would expect a thin pink to reddish colored drainage as long as the catheter is inplace. Be aware, that there should not be a lot of blood, pus, or foul odor.

Bandages: Dr Tokita or his staff will teach the patient and family how to change the bandages.

Symptoms: there should be no fever, chills, or sweats. There will be some discomfort at the surgical site, from the incision and some tightness from the inflated balloon on the catheter.

Simulation and 3-D Conformational CT Scan: At the Cancer Center, a CT scan will be done of the breast and chest. This will allow a very detailed look at the catheters; it’s placement and can be used to plan the actual radiation delivery.

The CT will also be used to evaluate the patient’s situation and help Dr Tokita to achieve the treatment objectives.

Important parameters are:

Balloon Diameter (as large as possible, maximum being 5 cm)

Tissue Conformance

Separation from the Skin (> 5mm, preferably >7mm)

Balloon or Catheter array Symmetry (circular and not oblong or squashed)

Establish a Baseline CT for monitoring

Treatment Planning: The CT images will be electronically forwarded to the Prowess and Nucletron Treatment planning computers. From these images, a coherent treatment plan will be developed. The physicist and Dr.Tokita accomplish this planning and review. A computer program will be then provide the necessary commands for the High Dose Rate After-Loader to accomplish the “prescribed” treatment.

This complex and time intensive process will take from 8-12 combined hours of the physicist and Dr Tokita.

Radiation Machine: The machine used is called a High Dose Rate (HDR) Remote Afterloader. This is a computer controlled Iridium-192 applicator. It allows the remote, computer controlled insertion of a very strong Ir-192 source into the Mammosite or Interstitial catheters. The Ir-192 will be allowed to “dwell” for several minutes at specific points in the catheters. This machine allows us to deliver a dose in minutes, which in the older Low Dose Rate applications would take many hours. At The Cancer Center of Irvine, we use a Nucletron HDR Remote Afterloader. There are 3 companies in the world making this type of machine.

Nucletron HDR Remote Afterloader

Orange County: The Cancer Center of Irvine is the only facility in Orange County with this capability. There are only 15-20 centers in the United States with this capability and experience.

Treatments: The radiation treatments are delivered at the Cancer Center on an appointment basis..

Personnel:

Dr Tokita will be directing the therapy at all times

CT Technologist will take the initial CT scans and establish a protocol for daily and pre-treatment confirmatory quality assurance CT scans.

Radiation Therapist and a Radiation Physicist will all assist Dr Tokita at each treatment.

Frequency: Brachytherapy treatments will be delivered twice a day, separated by at least 6 hour, for a total of 5 days or 10 treatments.

Transportation: Patient will feel fine, so she may drive herself to the treatments

Pre-Procedure: Prior to each treatment, a CT scan of the breast will be taken to verify balloon inflation and position.

Examination: The bandages and drainage will be checked before each treatment. If necessary, the bandages will be changed.

Pre-Treatment Checks: Prior to the patient coming in, the therapist, physicist and Dr Tokita accomplish a stringent checklist of equipment, safety precautions, emergency procedures, and quality assurance on the planned treatment.

Treatment: Patient will then be taken to the HDR room.

A 3 foot long “transfer tube” will be attached to the “red tip” on the Mammosite and white cap on the catheters, and the other end attached to the HDR Remote Afterloader.
The room will be evacuated (patient will be in constant contact with the staff by 2 remote closed circuit TV cameras and room audio system).
We can always see the patient and hear her at all times and can respond in seconds to any eventuality.
The computer controlling the HDR Remote Afterloader is at the outside control console and has been programmed by the radiation physicist and checked by the Radiation Therapist and Dr Tokita.
A final checklist of steps is taken, and the treatment started.
The patient will first feel a slight motion in the catheter, as a test wire will go through the machine, transfer tube and into the catheter. This checks for any obstructions to the wire and to be sure there aren’t any tight turns.
The test wire will retract and be followed by the actual treatment wire. It will be left in place for several minutes. The time will vary slightly from each treatment as the Ir-192 source continues to decay and get weaker.
Post-treatment, the physicist or technologists confirm that the Ir-192 source has retracted into the Nucletron Afterloader.
The transfer tube will be removed and the “ cap” replaced.
Patient can now go home and return in 6 hours or the next day for treatment.

Number of Treatments: Ten treatments will be given over five days. This could be

*Monday through Friday or may be broken up by a weekend.

Time in Department: patient should anticipate being in the department from an hour to an hour and a half for each treatment.

Post Implantation Care:

Wear a cotton support bra, even while sleeping for comfort and protection of the catheter.

Ok to shower after 24 hours, but no baths.

Maintain normal activity as tolerated.

No heavy lifting with the arm on the treatment side

Oral pain medication such as Tylenol #3 or Vicodin is acceptable

Antibiotics may be prescribed

Post implant Education:

There may be breast tenderness

A small amount of red colored drainage is expected

There is usually a mild breast swelling

There may be bruising from the surgery

Do not remove any of the caps on the catheter

Do not change the dressings until instructed by your surgeon or Dr Tokita. Once instructed, one can change the dressings, if there is too much drainage.

Call us if:

There is a sudden discharge of a large amount of clear or red drainage

Signs of Breast infect

Breast becomes warm, red, swollen,

Patient notices moderate to severe breast pain or fever (above 100.5)

Removal of the Mammosite Catheter or Interwstitial Tubes (Dr Tokita will remove The Catheter on the last day after the last treatment. There may be some pain, and if the patient wishes, she can take Tylenol #3 or Vicodin before the last treatment.

Post Treatment Education:

There may be temporary side effects after treatment.

There may be mild breast redness

Possible infection

Breast swelling

Skin area of breast may become dry/flaky. She can apply any personal choice of hand cream.

Tiredness; this is very common after any treatment for an illness as serious as cancer and may be the normal let-down and "recharging of the patient's energy battery".

Follow Up:

The patient followup will follow the Cancer Center’s routine pattern.

The first followup will be within 1-2 weeks and every other week if there are problems that need checking.

Usually this will be followed by a one-month followup

Then every three months thereafter for two years. This schedule may be shared with your surgeon or medical oncologist, so as not to overburden the patient with appointments.

Assessments: Checks will include

Toxicity or Side Effects

Exit Site evaluation

Cosmesis

Possible cancer recurrence

Overall well-being

Possible Complications:

Serious:

Abscess (has occurred in about 3%, can go as high as 11%)

Seroma (Fluid filled cavity occurs in about 3%, may go as high as 15%)

Fat Necrosis (None has been seen so far, but may go as high as 4-27%)

Skin scarring over Catheter Bulb site (unknown, expected 5%)

Device Related Adverse Events

Breast edema Skin Irritation

Dry skin slough (Desquamation) Eschar (Scab Formation)

Dry skin Moist Skin slough (Desquamation)

Seroma (Fluid filled cavity) Serosanguineous leak (Red drainage)

Pruritis (itching) Fibrocystic Breast

Skin Discoloration Mastitis (Inflammation of breast)

Induration (firmness) Eccymosis (Bruise)

Rash Dimpling of skin over tumor site

Blister Infection

Cosmetic Evaluation Results

One Month Excellent 90% Fair 10% Poor 0%

Eight Months Excellent 96% Fair 4% Poor 0%

Most Common Breast Related Adverse Events

Erythema (Red inflamed Breast) 57%

Breast Tenderness/Pain 48%

Catheter Site Drainage 42%