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Accelerated Partial Breast Irradiation
Sushil Beriwal, MD; Zachary D. Horne, MD
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KEY FACTS

  • Terminology

    • Imaging

      • Clinical Issues

        TERMINOLOGY

        • Abbreviations

          • Accelerated partial breast irradiation (APBI)
          • Ipsilateral breast tumor recurrence (IBTR)
        • Definitions

          • APBI: Short course of intraoperative &/or postoperative radiation lasting 1-10 days
          • Radiation focused on lumpectomy cavity plus 1- to 2-cm margin surrounding postsurgical cavity
            • Goal is to provide equal local control as in conventional adjuvant XRT following breast-conserving surgery
            • Minimize radiation to normal tissue
            • Rationale: ~ 90% of tumor recurrences occur at or within 1-2 cm of lumpectomy site
              • Focusing radiation treatment to this vulnerable region may be beneficial
          • Brachytherapy: Therapeutic range in mm
            • Radioisotope delivers XRT at short distance from source, limiting dose to normal tissue
              • Radioactive materials are placed directly at or near operated site
              • 1 or a few fractions
                • Variable dose rates, energies, shielding
          • Interstitial (within tissue) brachytherapy
            • Multiple catheters placed in operating room 1 cm apart, encompassing postlumpectomy area to be treated
              • Advantage: Most conformal, best control of skin and chest wall dose
                • Suitable for all breast shapes and types
              • Disadvantage: Requires higher level of skill, training, and OR time (~ 45 minutes) and is most invasive
          • Single lumen intracavitary, balloon brachytherapy (MammoSite)
            • Ease of insertion: At surgery or under US guidance
            • Requires good conformance and at least 7 mm skin-to-balloon-surface distance to avoid skin toxicity
          • Multilumen intracavitary devices [Contoura, strut-adjusted volume implant (SAVI)]
            • Advantage: Ease of insertion like MammoSite plus dosimetric advantages of interstitial brachytherapy
            • Limits dose to chest wall and skin without compromising target coverage; preferred devices
            • Device usually placed under US guidance postoperatively in lumpectomy cavity
              • Satisfactory device placement confirmed by CT
              • 3D planning to optimize dose-to-target volume and reduce dose to skin and chest wall
              • 2 daily doses of 3.4 Gy each, separated by at least 6 hours for total of 5 days = 34 Gy in 10 fractions
          • Accelerated external beam with 3D conformal (3DCRT) or intensity-modulated radiation therapy (IMRT)
            • External beam restricted to lumpectomy site and immediate surrounding tissue
              • Advantage: Noninvasive, easily available in most radiation departments
              • Disadvantage: Higher dose to normal breast tissue and to greater volume of normal breast tissue vs. brachytherapy → sometimes poor cosmetic results
          • Intraoperative radiation therapy (IORT)
            • Single fraction in operating room immediately following lumpectomy with either 3 or 9 MeV electrons or 50 kVp x-ray intrabeam device
            • Requires careful lesion selection: Unifocal T1N0, ER(+) disease
            • Treated before final pathologic assessment; if margins or nodes positive, need whole-breast irradiation (WBI) (~ 15% of TARGIT trial)
          • External beam with protons (investigational)
            • May be able to ↓ volume of normal breast tissue included in high-dose region vs. photon 3DCRT

        IMAGING

        • General Features

          • Mammographic Findings

            • Ultrasonographic Findings

              • MR Findings

                • Imaging Recommendations

                  DIFFERENTIAL DIAGNOSIS

                    PATHOLOGY

                    • Microscopic Features

                      CLINICAL ISSUES

                      • Presentation

                        • Natural History & Prognosis

                          • Treatment

                            DIAGNOSTIC CHECKLIST

                            • Consider

                              Selected References

                              1. Paudel N et al: Impact of breast MRI in women eligible for breast conservation surgery and intra-operative radiation therapy. Surg Oncol. 27:95-99, 2018
                              2. Coles CE et al: Partial-breast radiotherapy after breast conservation surgery for patients with early breast cancer (UK IMPORT LOW trial): 5-year results from a multicentre, randomised, controlled, phase 3, non-inferiority trial. Lancet. ePub, 2017
                              3. Correa C et al: Accelerated partial breast irradiation: Executive summary for the update of an ASTRO Evidence-Based Consensus Statement. Pract Radiat Oncol. 7(2):73-79, 2017
                              4. Morrow M et al: Society of Surgical Oncology-American Society for Radiation Oncology-American Society of Clinical Oncology Consensus Guideline on Margins for Breast-Conserving Surgery With Whole-Breast Irradiation in Ductal Carcinoma in Situ. Pract Radiat Oncol. 6(5):287-95, 2016
                              5. Strnad V et al: 5-year results of accelerated partial breast irradiation using sole interstitial multicatheter brachytherapy versus whole-breast irradiation with boost after breast-conserving surgery for low-risk invasive and in-situ carcinoma of the female breast: a randomised, phase 3, non-inferiority trial. Lancet. 387(10015):229-38, 2016
                              6. Ibrahim NB et al: Radiographic findings after treatment with balloon brachytherapy accelerated partial breast irradiation. Radiographics. 35(1):6-13, 2015
                              7. Livi L et al: Accelerated partial breast irradiation using intensity-modulated radiotherapy versus whole breast irradiation: 5-year survival analysis of a phase 3 randomised controlled trial. Eur J Cancer. 51(4):451-63, 2015
                              8. Buchholz TA et al: Margins for breast-conserving surgery with whole-breast irradiation in stage I and II invasive breast cancer: American Society of Clinical Oncology endorsement of the Society of Surgical Oncology/American Society for Radiation Oncology consensus guideline. J Clin Oncol. 32(14):1502-6, 2014
                              9. Vaidya JS et al: Risk-adapted targeted intraoperative radiotherapy versus whole-breast radiotherapy for breast cancer: 5-year results for local control and overall survival from the TARGIT-A randomised trial. Lancet. 383(9917):603-13, 2014
                              10. Lei RY et al: Four-year clinical update from a prospective trial of accelerated partial breast intensity-modulated radiotherapy (APBIMRT). Breast Cancer Res Treat. 140(1):119-33, 2013
                              11. Olivotto IA et al: Interim cosmetic and toxicity results from RAPID: a randomized trial of accelerated partial breast irradiation using three-dimensional conformal external beam radiation therapy. J Clin Oncol. 31(32):4038-45, 2013
                              12. Leonardi MC et al: How do the ASTRO consensus statement guidelines for the application of accelerated partial breast irradiation fit intraoperative radiotherapy? A retrospective analysis of patients treated at the European Institute of Oncology. Int J Radiat Oncol Biol Phys. 83(3):806-13, 2012
                              13. Vaidya J et al: Targeted intraoperative radiotherapy for early breast cancer: TARGIT-a trial-updated analysis of local recurrence and first analysis of survival [abstract]. Cancer Res. 72 (Suppl. 3), S4-2, 2012
                              14. Ivanov O et al: Twelve-month follow-up results of a trial utilizing Axxent electronic brachytherapy to deliver intraoperative radiation therapy for early-stage breast cancer. Ann Surg Oncol. 18(2):453-8, 2011
                              15. Monticciolo DL et al: Breast conserving therapy with accelerated partial breast versus external beam whole breast irradiation: comparison of imaging sequela and complications in a matched population. Breast J. 17(2):187-90, 2011
                              16. Ahmed HM et al: Mammographic appearance following accelerated partial breast irradiation by using MammoSite brachytherapy. Radiology. 255(2):362-8, 2010
                              17. Shaitelman SF et al: Five-year outcome of patients classified using the American Society for Radiation Oncology consensus statement guidelines for the application of accelerated partial breast irradiation: an analysis of patients treated on the American Society of Breast Surgeons MammoSite Registry Trial. Cancer. 116(20):4677-85, 2010
                              18. Smith BD et al: Accelerated partial breast irradiation consensus statement from the American Society for Radiation Oncology (ASTRO). Int J Radiat Oncol Biol Phys. 74(4):987-1001, 2009
                              19. Esserman LE et al: Imaging findings after breast brachytherapy. AJR Am J Roentgenol. 187:57-64, 2006
                              20. Evans SB et al: Persistent seroma after intraoperative placement of MammoSite for accelerated partial breast irradiation: incidence, pathologic anatomy, and contributing factors. Int J Radiat Oncol Biol Phys. 65(2):333-9, 2006
                              21. Vicini F et al: A phase I/II trial to evaluate three-dimensional conformal radiation therapy confined to the region of the lumpectomy cavity for Stage I/II breast carcinoma: initial report of feasibility and reproducibility of Radiation Therapy Oncology Group (RTOG) Study 0319. Int J Radiat Oncol Biol Phys. 63(5):1531-7, 2005
                              22. TARGIT-B
                              Related Anatomy
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                              Related Differential Diagnoses
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                              References
                              Tables

                              Tables

                              KEY FACTS

                              • Terminology

                                • Imaging

                                  • Clinical Issues

                                    TERMINOLOGY

                                    • Abbreviations

                                      • Accelerated partial breast irradiation (APBI)
                                      • Ipsilateral breast tumor recurrence (IBTR)
                                    • Definitions

                                      • APBI: Short course of intraoperative &/or postoperative radiation lasting 1-10 days
                                      • Radiation focused on lumpectomy cavity plus 1- to 2-cm margin surrounding postsurgical cavity
                                        • Goal is to provide equal local control as in conventional adjuvant XRT following breast-conserving surgery
                                        • Minimize radiation to normal tissue
                                        • Rationale: ~ 90% of tumor recurrences occur at or within 1-2 cm of lumpectomy site
                                          • Focusing radiation treatment to this vulnerable region may be beneficial
                                      • Brachytherapy: Therapeutic range in mm
                                        • Radioisotope delivers XRT at short distance from source, limiting dose to normal tissue
                                          • Radioactive materials are placed directly at or near operated site
                                          • 1 or a few fractions
                                            • Variable dose rates, energies, shielding
                                      • Interstitial (within tissue) brachytherapy
                                        • Multiple catheters placed in operating room 1 cm apart, encompassing postlumpectomy area to be treated
                                          • Advantage: Most conformal, best control of skin and chest wall dose
                                            • Suitable for all breast shapes and types
                                          • Disadvantage: Requires higher level of skill, training, and OR time (~ 45 minutes) and is most invasive
                                      • Single lumen intracavitary, balloon brachytherapy (MammoSite)
                                        • Ease of insertion: At surgery or under US guidance
                                        • Requires good conformance and at least 7 mm skin-to-balloon-surface distance to avoid skin toxicity
                                      • Multilumen intracavitary devices [Contoura, strut-adjusted volume implant (SAVI)]
                                        • Advantage: Ease of insertion like MammoSite plus dosimetric advantages of interstitial brachytherapy
                                        • Limits dose to chest wall and skin without compromising target coverage; preferred devices
                                        • Device usually placed under US guidance postoperatively in lumpectomy cavity
                                          • Satisfactory device placement confirmed by CT
                                          • 3D planning to optimize dose-to-target volume and reduce dose to skin and chest wall
                                          • 2 daily doses of 3.4 Gy each, separated by at least 6 hours for total of 5 days = 34 Gy in 10 fractions
                                      • Accelerated external beam with 3D conformal (3DCRT) or intensity-modulated radiation therapy (IMRT)
                                        • External beam restricted to lumpectomy site and immediate surrounding tissue
                                          • Advantage: Noninvasive, easily available in most radiation departments
                                          • Disadvantage: Higher dose to normal breast tissue and to greater volume of normal breast tissue vs. brachytherapy → sometimes poor cosmetic results
                                      • Intraoperative radiation therapy (IORT)
                                        • Single fraction in operating room immediately following lumpectomy with either 3 or 9 MeV electrons or 50 kVp x-ray intrabeam device
                                        • Requires careful lesion selection: Unifocal T1N0, ER(+) disease
                                        • Treated before final pathologic assessment; if margins or nodes positive, need whole-breast irradiation (WBI) (~ 15% of TARGIT trial)
                                      • External beam with protons (investigational)
                                        • May be able to ↓ volume of normal breast tissue included in high-dose region vs. photon 3DCRT

                                    IMAGING

                                    • General Features

                                      • Mammographic Findings

                                        • Ultrasonographic Findings

                                          • MR Findings

                                            • Imaging Recommendations

                                              DIFFERENTIAL DIAGNOSIS

                                                PATHOLOGY

                                                • Microscopic Features

                                                  CLINICAL ISSUES

                                                  • Presentation

                                                    • Natural History & Prognosis

                                                      • Treatment

                                                        DIAGNOSTIC CHECKLIST

                                                        • Consider

                                                          Selected References

                                                          1. Paudel N et al: Impact of breast MRI in women eligible for breast conservation surgery and intra-operative radiation therapy. Surg Oncol. 27:95-99, 2018
                                                          2. Coles CE et al: Partial-breast radiotherapy after breast conservation surgery for patients with early breast cancer (UK IMPORT LOW trial): 5-year results from a multicentre, randomised, controlled, phase 3, non-inferiority trial. Lancet. ePub, 2017
                                                          3. Correa C et al: Accelerated partial breast irradiation: Executive summary for the update of an ASTRO Evidence-Based Consensus Statement. Pract Radiat Oncol. 7(2):73-79, 2017
                                                          4. Morrow M et al: Society of Surgical Oncology-American Society for Radiation Oncology-American Society of Clinical Oncology Consensus Guideline on Margins for Breast-Conserving Surgery With Whole-Breast Irradiation in Ductal Carcinoma in Situ. Pract Radiat Oncol. 6(5):287-95, 2016
                                                          5. Strnad V et al: 5-year results of accelerated partial breast irradiation using sole interstitial multicatheter brachytherapy versus whole-breast irradiation with boost after breast-conserving surgery for low-risk invasive and in-situ carcinoma of the female breast: a randomised, phase 3, non-inferiority trial. Lancet. 387(10015):229-38, 2016
                                                          6. Ibrahim NB et al: Radiographic findings after treatment with balloon brachytherapy accelerated partial breast irradiation. Radiographics. 35(1):6-13, 2015
                                                          7. Livi L et al: Accelerated partial breast irradiation using intensity-modulated radiotherapy versus whole breast irradiation: 5-year survival analysis of a phase 3 randomised controlled trial. Eur J Cancer. 51(4):451-63, 2015
                                                          8. Buchholz TA et al: Margins for breast-conserving surgery with whole-breast irradiation in stage I and II invasive breast cancer: American Society of Clinical Oncology endorsement of the Society of Surgical Oncology/American Society for Radiation Oncology consensus guideline. J Clin Oncol. 32(14):1502-6, 2014
                                                          9. Vaidya JS et al: Risk-adapted targeted intraoperative radiotherapy versus whole-breast radiotherapy for breast cancer: 5-year results for local control and overall survival from the TARGIT-A randomised trial. Lancet. 383(9917):603-13, 2014
                                                          10. Lei RY et al: Four-year clinical update from a prospective trial of accelerated partial breast intensity-modulated radiotherapy (APBIMRT). Breast Cancer Res Treat. 140(1):119-33, 2013
                                                          11. Olivotto IA et al: Interim cosmetic and toxicity results from RAPID: a randomized trial of accelerated partial breast irradiation using three-dimensional conformal external beam radiation therapy. J Clin Oncol. 31(32):4038-45, 2013
                                                          12. Leonardi MC et al: How do the ASTRO consensus statement guidelines for the application of accelerated partial breast irradiation fit intraoperative radiotherapy? A retrospective analysis of patients treated at the European Institute of Oncology. Int J Radiat Oncol Biol Phys. 83(3):806-13, 2012
                                                          13. Vaidya J et al: Targeted intraoperative radiotherapy for early breast cancer: TARGIT-a trial-updated analysis of local recurrence and first analysis of survival [abstract]. Cancer Res. 72 (Suppl. 3), S4-2, 2012
                                                          14. Ivanov O et al: Twelve-month follow-up results of a trial utilizing Axxent electronic brachytherapy to deliver intraoperative radiation therapy for early-stage breast cancer. Ann Surg Oncol. 18(2):453-8, 2011
                                                          15. Monticciolo DL et al: Breast conserving therapy with accelerated partial breast versus external beam whole breast irradiation: comparison of imaging sequela and complications in a matched population. Breast J. 17(2):187-90, 2011
                                                          16. Ahmed HM et al: Mammographic appearance following accelerated partial breast irradiation by using MammoSite brachytherapy. Radiology. 255(2):362-8, 2010
                                                          17. Shaitelman SF et al: Five-year outcome of patients classified using the American Society for Radiation Oncology consensus statement guidelines for the application of accelerated partial breast irradiation: an analysis of patients treated on the American Society of Breast Surgeons MammoSite Registry Trial. Cancer. 116(20):4677-85, 2010
                                                          18. Smith BD et al: Accelerated partial breast irradiation consensus statement from the American Society for Radiation Oncology (ASTRO). Int J Radiat Oncol Biol Phys. 74(4):987-1001, 2009
                                                          19. Esserman LE et al: Imaging findings after breast brachytherapy. AJR Am J Roentgenol. 187:57-64, 2006
                                                          20. Evans SB et al: Persistent seroma after intraoperative placement of MammoSite for accelerated partial breast irradiation: incidence, pathologic anatomy, and contributing factors. Int J Radiat Oncol Biol Phys. 65(2):333-9, 2006
                                                          21. Vicini F et al: A phase I/II trial to evaluate three-dimensional conformal radiation therapy confined to the region of the lumpectomy cavity for Stage I/II breast carcinoma: initial report of feasibility and reproducibility of Radiation Therapy Oncology Group (RTOG) Study 0319. Int J Radiat Oncol Biol Phys. 63(5):1531-7, 2005
                                                          22. TARGIT-B