Annals of Surgical Oncology Sign the Guestbook
HOME HELP FEEDBACK SUBSCRIPTIONS ARCHIVE SEARCH TABLE OF CONTENTS
Originally published as Ann Surg Oncol Early Release 10.1245/ASO.2004.02.009 on July 12, 2004

Annals of Surgical Oncology 11:739-746 (2004)
© 2004 Society of Surgical Oncology
This Article
Right arrow Abstract Freely available
Right arrow Full Text (PDF)
Right arrow Alert me when this article is cited
Right arrow Alert me if a correction is posted
Services
Right arrow Similar articles in this journal
Right arrow Similar articles in PubMed
Right arrow Alert me to new issues of the journal
Right arrow Download to citation manager
Citing Articles
Right arrow Citing Articles via HighWire
Right arrow Citing Articles via Google Scholar
Google Scholar
Right arrow Articles by Richards, G. M.
Right arrow Articles by Mills, C.
Right arrow Search for Related Content
PubMed
Right arrow PubMed Citation
Right arrow Articles by Richards, G. M.
Right arrow Articles by Mills, C.

ORIGINAL ARTICLES

Acute Toxicity of High-Dose-Rate Intracavitary Brachytherapy With the MammoSite Applicator in Patients With Early-Stage Breast Cancer

Gregory M. Richards, MD, Anthony M. Berson, MD, John Rescigno, MD, Seema Sanghavi, MD, Beth Siegel, MD, Deborah Axelrod, MD, Stephanie Bernik, MD, Vincent Scarpinato, MD and Christopher Mills, MD

From the Departments of Radiation Oncology (GMR, AMB, JR, SS) and Surgical Oncology (BS, DA, SB), St. Vincent’s Comprehensive Cancer Center, New York, New York; the Department of Surgery (VS, CM), St. Vincent’s Hospital-Manhattan, New York, New York; and New York Medical College (AMB, JR, SS, BS, DA, SB, VS, CM), Valhalla, New York.

Correspondence: Address correspondence and reprint requests to: Anthony M. Berson, MD, Department of Radiation Oncology, St. Vincent’s Comprehensive Cancer Center, 325 W. 15th St., New York, NY 10011; Fax: 212-367-1742; E-mail: aberson{at}salick.com


   ABSTRACT
TOP
 ABSTRACT
INTRODUCTION
 METHODS
 RESULTS
 DISCUSSION
 REFERENCES
 
Background: Intracavitary brachytherapy with the MammoSite applicator as the sole radiation treatment in breast-conserving therapy is an option for women with early-stage breast cancer; we evaluated the acute toxicities associated with this treatment method.

Methods: Thirty-one patients with 32 stage I or II breast carcinomas underwent breast-conserving therapy, which included lumpectomy with negative margins, sentinel node biopsy, or axillary dissection, followed by brachytherapy with the MammoSite applicator. Acute radiation skin complications were graded on the day of radiotherapy completion and at weeks 2, 4, 6, and 12 after radiation treatment. Cosmesis was graded on the Harvard Scale at all follow-ups.

Results: The median follow-up was 11 months (range, 4–15 months). Twenty-seven of the 31 patients were treated with the device as the sole method of radiotherapy. No acute toxicities occurred during the 5 days of treatment. Nineteen patients (68%) had no to mild acute skin reactions, and 25% developed bright erythema and patchy moist desquamation. Two patients (7%) developed confluent moist desquamation within the first 4 weeks (grade 3); this healed by week 12. All skin reactions were localized to the area overlying the balloon. Sixteen percent (5 of 32) of all breasts with implants developed infection. Cosmesis was good to excellent in 86% of cases.

Conclusions: Most acute skin toxicities were mild. Our infection rate was higher than in prior studies that used interstitial brachytherapy. Cosmesis was good to excellent in most patients. Breast brachytherapy with the MammoSite catheter was well tolerated; further investigations of breast brachytherapy with this system are warranted.

Key Words: Brachytherapy • Breast cancer • Breast-conserving therapy • Lumpectomy • Radiation


   INTRODUCTION
TOP
 ABSTRACT
 INTRODUCTION
METHODS
 RESULTS
 DISCUSSION
 REFERENCES
 
For the past three decades, breast-conserving therapy (BCT), which consists of breast-conserving surgery and radiotherapy (RT), has been compared with mastectomy as an alternative treatment for appropriately selected women with early-stage breast cancer. During that time, multiple retrospective studies and several randomized prospective trials have consistently shown equivalent survival data between BCT and mastectomy for this patient population. In 2002, two of those studies published their 20-year follow-up data, which continued to demonstrate no significant differences in disease-free survival, distant disease-free survival, and overall survival.1–6

Despite the overwhelming evidence in support of BCT, studies have indicated that ≥50% of patients with early-stage breast cancer continue to undergo mastectomy and that medical contraindications to BCT are not the major factors that result in the high rate of mastectomies. Factors related to the temporal and logistical nature of external beam RT, such as patient age, geographical location, distance from an RT facility, and transportation availability, have a substantial effect on the choice of treatment.7–11 This seems logical considering that standard external beam RT consists of 5 weeks of daily treatment to the whole breast followed by up to 2 weeks of boost therapy delivered to the tumor bed.

These disadvantages to external beam whole-breast RT have led to the investigation of accelerated regimens of partial-breast RT,12 including those using low-dose-rate (LDR) or high-dose-rate (HDR) interstitial brachytherapy delivered to the tumor bed. Early reports have demonstrated that brachytherapy is similar to external beam RT with respect to cosmetic results, local control, and complication rates in appropriately selected patient populations.13–17 However, because interstitial brachytherapy can be technically challenging, it is not offered at many radiation oncology centers.

In May 2002, the Food and Drug Administration approved a new treatment device, the MammoSite applicator (Proxima Therapeutics, Alpharetta, GA, U.S.A.), intended to provide brachytherapy to deliver intracavitary radiation to the surgical margins after lumpectomy,18 thus simplifying the delivery of HDR breast brachytherapy. This device is easy to implant and has demonstrated improved dose coverage and reproducibility compared with interstitial implantation.19,20 In this report we describe our initial experience and evaluate the acute toxicities associated with iridium-192 (192Ir) HDR brachytherapy with the MammoSite applicator as the sole RT in BCT in early-stage breast cancer patients.


   METHODS
TOP
 ABSTRACT
 INTRODUCTION
 METHODS
RESULTS
 DISCUSSION
 REFERENCES
 
Between May 2002 and June 2003, at Saint Vincent’s Comprehensive Cancer Center (New York, NY), 31 patients with 32 stage I or II breast cancers were entered onto a protocol that used the MammoSite applicator to deliver 192Ir HDR intracavitary brachytherapy as the sole source of radiation after lumpectomy. Initially the patients were entered onto an in-house protocol according to American Brachytherapy Society guidelines21,22; subsequently, we implemented an institutional review board–approved protocol. Patients qualified for intracavitary brachytherapy if they met the following criteria: (1) age ≥45 years, (2) tumor ≤2 cm, (3) nodal status N1 or less (maximum of three nodes), (4) no distant metastasis, and (5) ≥2-mm microscopically negative margins after final surgery. Patients were considered ineligible if any of the following were present: (1) tumor histology with an extensive intraductal component, (2) pregnant or breast-feeding state, and (3) collagen vascular disease. Informed consent was obtained from all patients, and all cases were entered onto the Proxima Therapeutics national registry.

All patients underwent lumpectomy with the goal of gross total resection of the primary tumor. If the pathologic margins were <2 mm microscopically, surgical re-excision of the biopsy cavity was performed. Lymph node assessment consisted of sentinel lymph node identification by using 99mTc-labeled sulfur colloid and isosulfan blue dye, level I/II dissection, or both.

The MammoSite device was placed either at the time of lumpectomy/re-excision or during a separate open or ultrasonically guided closed procedure within 10 weeks of the last surgery. The device’s balloon was inflated with a saline/contrast mixture (maximum of 25% contrast) to fill the entire cavity and ensure conformance to the surrounding tissue. Before treatment began, the location and registration of the device was checked with a computed tomography (CT) scan to ensure acceptable conformity and an absence of air pockets between the balloon and the surrounding tissue, as well as to measure the balloon diameter, symmetry, and proximity to the skin and chest wall.

The treatment protocol was to deliver 3.4 Gy x 10 (34 Gy) prescribed 1 cm from the surface of the device’s balloon twice daily (morning and evening doses were 6 hours apart) over 5 to 7 days. CT imaging was performed before each fraction to ensure that the position of the device and the diameter and symmetry of the balloon remained unchanged.

Acute skin complications were graded according to Radiation Therapy Oncology Group guidelines23 on the day of RT completion and at weeks 2, 4, 6, and 12 after RT. Cosmesis was graded on the Harvard Scale.


   RESULTS
TOP
 ABSTRACT
 INTRODUCTION
 METHODS
 RESULTS
DISCUSSION
 REFERENCES
 
Patient and tumor characteristics are listed in Table 1. The median follow-up for all patients was 11 months (range, 4–15 months). Eight different surgeons placed the catheters, and four different radiation oncologists planned and delivered the RT. The breakdown of cases per physician is listed in Table 2. Two additional radiation oncologists covered individual brachytherapy sessions when necessary. Most catheters (91%) were placed with an open procedure. Nine percent were placed with a closed technique under ultrasound guidance. Forty-seven percent were placed perioperatively during the initial lumpectomy or re-excision. The median interval between surgery and the start of treatment in these patients was 7 days (range, 3–12 days; SD, 3 days). Fifty-three percent had a delayed (nonperioperative) placement of the catheter. The median interval between the prior surgery and placement of the catheter in these patients was 35 days (range, 18–70 days; SD, 15 days). Sixteen patients underwent re-excision of the lumpectomy cavity; all patients had microscopically negative surgical margins after their final surgery. Table 3 contains more complete treatment characteristics.


View this table:
[in this window]
[in a new window]
  		TABLE 1. Patient and tumor characteristics
 

View this table:
[in this window]
[in a new window]
  		TABLE 2. Distribution of cases per physician
 

View this table:
[in this window]
[in a new window]
  		TABLE 3. Treatment characteristics
 
Twenty-seven of the 31 patients enrolled were treated with 192Ir HDR brachytherapy with the MammoSite applicator as the sole RT in BCT. Twenty-six of these patients received the protocol dosing as outlined previously. One patient with bilateral disease received 3.0 Gy x 10 (30 Gy) prescribed 1 cm from the surface of the catheter balloon twice daily (morning and evening doses were 6 hours apart) over 5 days to the right breast and 3.4 Gy x 5 (17 Gy) followed by 3.0 Gy x 4 (12 Gy) for a total of 29.0 Gy prescribed 1 cm from the surface of the balloon twice daily (morning and evening doses were 6 hours apart) over 5 days to the left breast.

The device was explanted before treatment in three cases (9%). One of the patients had poor conformance (Fig. 1A), the second patient had evidence of vascular invasion in the final pathology report, and the third had poor conformance and a minimum skin distance of only 3 mm (Fig. 1B). All three of these catheters were placed perioperatively: one at the initial lumpectomy and two at re-excision. A fourth patient was found to have an extensive intraductal component in the final pathology report. This patient was treated with a boost dose of 10.2 Gy in three fractions of 3.4 Gy twice daily over 2 days by using the applicator followed by 50.4 Gy of external beam RT.



View larger version (99K):
[in this window]
[in a new window]
  		FIG. 1. Computed tomographic image of the MammoSite applicator in two patients who had the device explanted because of (A) poor conformance to the lumpectomy cavity, with multiple air pockets between the surface of the balloon and the lumpectomy cavity wall, and (B) poor conformance with 3 mm between the balloon surface and breast skin.

 
The median implant duration was 10 days (range, 7–18 days), during which patients had excellent tolerance of the catheter. Only 1 (3%) of the 31 patients reported moderate discomfort requiring acetaminophen with codeine while the catheter was in place. Removal of the device, which is rapidly and easily performed in an examination room, was also well tolerated. Nineteen of the 31 patients received mild analgesia consisting of one or more of the following: acetaminophen/codeine, acetaminophen/oxycodone, lorazepam, or ibuprofen, administered 1 hour before removal. All other removal procedures were performed without analgesia and with minimal discomfort.

Eighty-one percent of patients were given adjuvant hormonal therapy. Thirteen patients received tamoxifen, 11 patients received anastrozole, and 1 patient with bilateral disease received letrozole after experiencing side effects from anastrozole. Three patients received chemotherapy. One received four cycles of cyclophosphamide, methotrexate, and 5-fluorouracil beginning 2 weeks after completing brachytherapy, and this was completed within 2.5 months of finishing brachytherapy. The second patient received three cycles of docetaxel, doxorubicin, and cyclophosphamide beginning 4 weeks after completing brachytherapy. This was followed by one cycle of 5-fluorouracil, doxorubicin, and cyclophosphamide and then one final cycle of docetaxel alone. She completed all chemotherapy within 4 months of finishing brachytherapy. The third patient had the catheter explanted before treatment because of vascular involvement. She received four cycles of doxorubicin and cyclophosphamide before 60.8 Gy of external beam radiation.

The acute skin toxicities of the 27 patients (28 catheters) treated with brachytherapy alone were graded as detailed previously. No acute skin toxicities occurred during the 5 days of treatment. Five (18%) had no appreciable skin reactions (grade 0) within the first 12 weeks, and 14 (50%) had grade 1 dull erythema. There were seven cases (25%) of grade 2 bright erythema and patchy moist desquamation; however, six of those subsided to grade 0 or 1 by 12 weeks. The seventh patient had a small area of moist desquamation at 12 weeks, which resolved (grade 0) by 20 weeks. Two patients (7%) developed confluent moist desquamation within the first 4 weeks (grade 3), but this healed by week 12. There were no grade 4 or 5 skin complications. The mean skin reaction grade per week is shown in Figure 2. Complete skin toxicity grades are listed in Table 4. All skin reactions were localized to the area overlying the balloon. The minimum skin distance, measured on CT slices, between the balloon and the skin ranged from .4 to 2.8 cm (mean, 1.0 cm). The correlation between minimum skin distance and maximum skin reaction grade, calculated by using the Spearman correlation test, was weak (rs = –.19). Figure 3 displays the number of cases of each acute skin toxicity grade per skin-distance interval.



View larger version (39K):
[in this window]
[in a new window]
  		FIG. 2. Mean skin toxicity grade per week.

 

View this table:
[in this window]
[in a new window]
  		TABLE 4. Skin toxicity grades
 


View larger version (40K):
[in this window]
[in a new window]
  		FIG. 3. The number of cases of each acute skin toxicity grade per balloon-to-skin distance interval.

 
Four patients developed erythema and warmth at the surgical site before, during, or shortly after completing RT. The patients were empirically placed on oral antibiotics for cellulitis. One required incision and drainage and oral antibiotics; the second resolved with antibiotics alone. A third patient developed cellulitis of the biopsy site 10 days after removal of the catheter. Despite multiple courses of oral antibiotics, an abscess developed that required incision and drainage, as well as hospitalization for intravenous antibiotics. Blood and wound cultures were consistently negative. Ultimately, re-excision of the skin and biopsy cavity was performed, the patient was discharged home on oral antibiotics, and the infection resolved completely. A fourth case initially responded to antibiotics, but approximately 2 months later a cystic collection was detected on ultrasound. This developed into an abscess that formed a communication with the skin and required oral antibiotics and drainage. A fifth patient developed cellulitis at the site of the treatment 2 months after completion. A seroma was detected and drained, and the patient was placed on antibiotics, with complete resolution. Table 5 provides more detailed information regarding the five cases that were complicated with infection.


View this table:
[in this window]
[in a new window]
  		TABLE 5. Characteristics and management of cases complicated with infection
 
Cosmesis at last follow-up, graded on the Harvard Scale, was excellent in 43%, good in 43%, and fair in 14% of cases treated with intracavitary brachytherapy alone. The difference in the balloon-to-skin spacing among the excellent, good, and fair cosmesis groups was not statistically significant (Kruskal-Wallis test). The effects of treatment parameters on cosmesis at last follow-up are listed in Table 6. The most recent cosmesis results in the cases complicated with infection are listed in Table 5.


View this table:
[in this window]
[in a new window]
  		TABLE 6. The effects of treatment parameters on cosmetic results
 

   DISCUSSION
TOP
 ABSTRACT
 INTRODUCTION
 METHODS
 RESULTS
 DISCUSSION
REFERENCES
 
In May 2002, the Food and Drug Administration approved the MammoSite Radiation Therapy System (RTS) to provide brachytherapy to deliver intracavitary radiation to the surgical margins after lumpectomy for breast cancer.18 Because of the likelihood of off-label use, it was determined at that time that the device would come with the following warning on the package insert: "The safety and effectiveness of the MammoSite RTS as a replacement for whole breast irradiation in the treatment of breast cancer has not been established."18 This study describes our initial experience with the MammoSite applicator as the sole modality of radiation to deliver HDR RT to 28 early-stage breast cancers in 27 patients. All patients were explicitly informed that the effectiveness of this form of therapy as a replacement for whole-breast irradiation had not been established.

We focused on the acute toxicities associated with this new form of therapy, which were mild in most patients. Most (68%) experienced no reaction or dull erythema and dry desquamation. Twenty-five percent experienced grade 2 skin reactions, and 7% experienced grade 3 reactions. All skin reactions were treated and resolved with topical therapy.

In a series of 54 patients implanted with the MammoSite (43 received brachytherapy) with a median follow-up of 1 month after treatment, Keisch et al.24 reported mild to moderate erythema without desquamation as the most common side effects, dry desquamation in 7 patients, and moist desquamation in only 3 patients. In our experience, with a minimum follow-up of 4 months (median, 11 months), we found that the maximum acute skin toxicity peaked at approximately 6 weeks after completion of brachytherapy (Fig. 2). Between posttreatment weeks 4 and 6, the number of patients experiencing moist desquamation increased by 50%.

Implantation of the device was relatively simple and quick. Most cases were performed in the operating room during lumpectomy, during re-excision of the lumpectomy cavity, or as the sole procedure; three implantations were performed under ultrasound guidance. Patients had excellent tolerance of the catheter before and during treatment. Only one patient (3%) reported moderate breast discomfort that required acetaminophen with codeine for relief during the duration of the implant. All other patients required either no analgesia or mild nonnarcotic analgesia throughout the duration of the implant. This seems to be a superior tolerance compared with interstitial HDR brachytherapy, considering the study by Baglan et al.,15 in which 24% of the patients reported moderate discomfort that necessitated acetaminophen with codeine for control. Removal of the MammoSite catheter was well tolerated.

It has been established that BCT and mastectomy have equivalent survival rates in patients with early-stage breast cancer, and recent publication of 20-year follow-up data1–6 should help to dismiss any remaining uncertainty regarding long-term safety and efficacy. Yet many patients with early-stage breast cancers still undergo mastectomy. Possible reasons for the underuse of BCT may be related to the extended length of time it takes to complete a full course of external beam RT.

Several groups have evaluated BCT with an accelerated course of RT consisting of interstitial brachytherapy to the tumor bed alone. A study from the Ochsner Clinic compared complication rates, local recurrence rates, and cosmesis scores among 50 patients who were treated with either LDR or HDR brachytherapy and 94 patients who were eligible for brachytherapy but were concurrently treated with external beam RT.13 At a median follow-up of >6 years, a significantly higher rate of mild to moderate treatment toxicities was found in the group treated with external beam RT (80% vs. 22%; P < .001). There was no significant difference in severity of treatment toxicities, local recurrence rates, or cosmesis scores.13 Another recent study from the William Beaumont Hospital showed that there was no significant difference in locoregional failure or ipsilateral breast treatment failure between patients with early-stage breast cancer treated with brachytherapy compared with external beam RT.17 Although these studies have had promising results, the technical complexities of interstitial brachytherapy implantation and treatment planning have limited the number of facilities that offer this therapeutic modality.

A study by Edmundson et al.19 of the dosimetric characteristics, comparing intracavitary brachytherapy using the MammoSite with interstitial brachytherapy, demonstrated improved coverage and reproducibility but decreased dose homogeneity. It also described the relative simplicity of placing the MammoSite catheter compared with the interstitial brachytherapy catheters. Through our experience, we confirm the simplicity of using this device. The implantation procedure, whether performed at the time of lumpectomy/re-excision, as a separate open procedure, or under ultrasound guidance, was relatively uncomplicated.

Although our study did not show a correlation between the minimum distance from the treatment balloon to the skin and the severity of skin toxicity, the current guideline is to maintain ≥7 mm between the two. The distance from balloon to skin in the patients treated in this study ranged from .4 to 2.8 cm. We explanted three catheters (9%) before treatment because of inadequate skin spacing, poor conformity, and histology incompatible with treatment; this is similar to the previously published rates of 9% to 20%.24–26 One of the three patients who had the catheter removed before treatment had a distance of only 3 mm. This patient had a small amount of breast tissue relative to the size of the lumpectomy cavity. In this respect, the breast surgeon will play an important role in selecting patients both before and during surgery who will have favorable distances between the lumpectomy cavity and the overlying skin when the catheter balloon is inflated.

Cosmesis was good to excellent in 86% of cases and was fair in the remaining 14%. Our data are consistent with recently published early cosmetic data showing good to excellent cosmesis in 88%–90% of patients treated with the MammoSite.24,26,27 However, we did not find an association between balloon-to-skin distance and cosmetic result, as demonstrated in prior reports.27

We reported five patients (16%) who developed infection: four within 2 weeks of the implantation and one approximately 2 months after completing RT. Three of these catheters were placed with an open procedure, and two were placed with a closed technique. Two were placed perioperatively, and three were placed between 28 and 35 days after surgery. Although most of these infections were successfully treated without complications, one patient had a prolonged course of recurrent bouts of cellulitis despite multiple courses of antibiotics. She ultimately required surgical debridement of the lumpectomy cavity. The reported rate of surgical site infection after breast surgery—which is highly variable because of the variations in infection definition, surgical procedure, and radiation modality, as well as patient characteristics—has been reported as 3% to 33%,15,24,28–33 including a 17% infection rate in patients treated with lumpectomy and RT.32 Our infection rate of 16% is higher than that reported in other studies that used intracavitary or interstitial brachytherapy. Keisch et al.24 reported a 3.7% infection rate within the first 4 weeks after treatment, and we experienced a 12.5% infection rate during the same period. Vicini et al.33 reported no cases of perioperative infection and four cases of mild, transient infection that developed from 2 to 4 months after removal of the implant in a series of 60 patients treated with LDR interstitial brachytherapy. These resolved with oral antibiotic treatment. Baglan et al.15 reported 3 cases of mild cellulitis out of 38 HDR interstitial implants; all resolved with oral antibiotics. In that study, patients were maintained on prophylactic antibiotics while the implant was in place and for several days after removal. Of note, administration of prophylactic antibiotics was not mandatory in our protocol during or after implantation of the catheter. Whether prophylactic antibiotics would reduce the rate of infection is unknown and warrants further investigation.

Given that the MammoSite is a new device, the follow-up of this study was short. Continued follow-up of these patients and additional patients will be necessary to accumulate the recurrence data necessary to validate this new approach to treating early breast cancers after breast-conserving surgery. However, if data from previous brachytherapy studies can be extrapolated to the MammoSite device, it may prove to be a more tolerable way to deliver accelerated RT to those wishing to undergo breast conservation. We will continue to enroll patients for this treatment on an institutional review board–approved protocol and report our toxicity and control data periodically. We have now included in our protocol the use of intravenous antibiotics at the time of catheter implantation and a 10-day course of prophylactic oral antibiotics after the implantation procedure.


   FOOTNOTES
 
In this article, we describe our initial experience with the MammoSite catheter as a part of breast-conserving therapy to treat women with early-stage breast cancer. We focus on the acute skin toxicity and infection rate associated with this form of therapy.

Received for publication February 13, 2004. Accepted for publication May 11, 2004.


   REFERENCES
TOP
 ABSTRACT
 INTRODUCTION
 METHODS
 RESULTS
 DISCUSSION
 REFERENCES
 

  1. Fisher B, Anderson S, Bryant J, et al. Twenty-year follow-up of a randomized trial comparing total mastectomy, lumpectomy, and lumpectomy plus irradiation for the treatment of invasive breast cancer. N Engl J Med 2002; 347: 1233–41.[Abstract/Free Full Text]
  2. Veronesi U, Cascinelli N, Mariani L, et al. Twenty-year follow-up of a randomized study comparing breast-conserving surgery with radical mastectomy for early breast cancer. N Engl J Med 2002; 347: 1227–32.[Abstract/Free Full Text]
  3. van Dongen JA, Voogd AC, Fentiman IS, et al. Long-term results of a randomized trial comparing breast-conserving therapy with mastectomy: European Organization for Research and Treatment of Cancer 10801 trial. J Natl Cancer Inst 2000; 92: 1143–50.[Abstract/Free Full Text]
  4. Arriagada R, Le MG, Rochard F, Contesso G. Conservative treatment versus mastectomy in early breast cancer: patterns of failure with 15 years of follow-up data. J Clin Oncol 1996; 14: 1558–64.[Abstract/Free Full Text]
  5. Jacobson JA, Danforth DN, Cowan KH, et al. Ten-year results of a comparison of conservation with mastectomy in the treatment of stage I and II breast cancer. N Engl J Med 1995; 332: 907–11.[Abstract/Free Full Text]
  6. Blichert-Toft M, Rose C, Andersen JA, et al. Danish randomized trial comparing breast conservation therapy with mastectomy: six years of life-table analysis. Danish Breast Cancer Cooperative Group. J Natl Cancer Inst Monogr 1992; 11: 19–25.
  7. Morrow M, White J, Moughan J, et al. Factors predicting the use of breast-conserving therapy in stage I and II breast carcinoma. J Clin Oncol 2001; 19: 2254–62.[Abstract/Free Full Text]
  8. Nattinger AB, Kneusel RT, Hoffmann RG, Gilligan MA. Relationship of distance from a radiotherapy facility and initial breast cancer treatment. J Natl Cancer Inst 2001; 93: 1344–6.[Free Full Text]
  9. Vlastos G, Mirza NQ, Meric F, et al. Breast conservation therapy as a treatment option for the elderly. Cancer 2001; 92: 1092–100.[CrossRef][Medline]
  10. Morrow M, Bucci C, Rademaker A. Medical contraindications are not a major factor in the underutilization of breast conserving therapy. J Am Coll Surg 1998; 186: 269–74.[CrossRef][Medline]
  11. Lazovich D, Solomon C, Thomas D, Moe RE, White E. Breast conservation therapy in the United States following the 1990 National Institutes of Health Consensus Development Conference on the treatment of patients with early stage invasive breast carcinoma. Cancer 1999; 86: 628–37.[CrossRef][Medline]
  12. Kuerer HM, Julian TB, Strom EA, et al. Accelerated partial breast irradiation after conservative surgery for breast cancer. Ann Surg 2004; 239: 338–51.[CrossRef][Medline]
  13. King TA, Bolton JS, Kuske RR, Fuhrman GM, Scroggins TG, Jiang XZ. Long-term results of wide-field brachytherapy as the sole method of radiation therapy after segmental mastectomy for Tis,1,2 breast cancer. Am J Surg 2000; 180: 299–304.[CrossRef][Medline]
  14. Vicini FA, Baglan KL, Kestin LL, et al. Accelerated treatment of breast cancer. J Clin Oncol 2001; 19: 1993–2001.[Abstract/Free Full Text]
  15. Baglan KL, Martinez AA, Frazier RC, et al. The use of high-dose brachytherapy alone after lumpectomy in patients with early-stage breast cancer treated with breast-conserving therapy. Int J Radiat Oncol Biol Phys 2001; 50: 1003–11.[CrossRef][Medline]
  16. Wazer DE, Lowther DL, Boyle T, et al. Clinically evident fat necrosis in women treated with high-dose-rate brachytherapy alone for early-stage breast cancer. Int J Radiat Oncol Biol Phys 2001; 50: 107–11.[CrossRef][Medline]
  17. Vicini FA, Kestin L, Chen P, Benitez P, Goldstein NS, Martinez A. Limited-field radiation therapy in the management of early-stage breast cancer. J Natl Cancer Inst 2003; 95: 1205–11.[Abstract/Free Full Text]
  18. Food and Drug Administration 510(k) approval, No. K011690. Available at: http://www.fda.gov/cdrh/pdf/k011690.pdf. Accessed: May 20, 2004.
  19. Edmundson GK, Vicini FA, Chen PY, Mitchell C, Martinez AA. Dosimetric characteristics of the MammoSite RTS, a new breast brachytherapy applicator. Int J Radiat Oncol Biol Phys 2002; 52: 1132–9.[CrossRef][Medline]
  20. Edmundson GK, Weed D, Vicini F, Chen P, Martinez A. Accelerated treatment of breast cancer: dosimetric comparisons between interstitial HDR brachytherapy, MammoSite balloon brachytherapy, and external beam quadrant radiation. Int J Radiat Oncol Biol Phys 2003; 57 (Suppl 2): S307–8.
  21. Nag S, Kuske RR, Vicini F, Arthur DW, Zwicker RD. Brachytherapy in the treatment of breast cancer. Oncology 2001; 15: 195–207.[Medline]
  22. Arthur DW, Vicini FA, Kuske RR, Wazer DE, Nag S. Accelerated partial breast irradiation: an updated report from the American Brachytherapy Society. Brachytherapy 2002; 1: 184–90.[CrossRef][Medline]
  23. Radiation Therapy Oncology Group. Acute radiation morbidity scoring criteria. Available at: http://www.rtog.org/members/toxicity/acute.html. Accessed: May 21, 2004.
  24. Keisch M, Vicini F, Kuske RR, et al. Initial clinical experience with the MammoSite breast brachytherapy applicator in women with early-stage breast cancer treated with breast-conserving therapy. Int J Radiat Oncol Biol Phys 2003; 55: 289–93.[CrossRef][Medline]
  25. Zannis VJ, Walker LC, Barclay-White B, Quiet CA. Postoperative ultrasound-guided percutaneous placement of a new breast brachytherapy balloon catheter. Am J Surg 2003; 186: 383–5.[CrossRef][Medline]
  26. Gittleman M, Vigneri P, Carlson DJ, et al. Clinical evaluation of the MammoSite breast brachytherapy catheter: an analysis of technical reproducibility, acute toxicity, and patient demographics. Int J Radiat Oncol Biol Phys 2003; 57 (2 Suppl): S365–6.[CrossRef][Medline]
  27. Keisch M, Vicini F, Kuske R, et al. Two-year outcome with the MammoSite breast brachytherapy applicator: factors associated with optimal cosmetic results when performing partial breast irradiation. Int J Radiat Oncol Biol Phys 2003; 57 (Suppl 2): S315.
  28. Bertin ML, Crowe J, Gordon SM. Determinants of surgical site infection after breast surgery. Am J Infect Control 1998; 26: 61–5.[CrossRef][Medline]
  29. Bundred N, Maguire P, Reynolds J, et al. Randomised controlled trial of effects of early discharge after surgery for breast cancer. BMJ 1998; 317: 1275–9.[Abstract/Free Full Text]
  30. Platt R, Zaleznik DF, Hopkins CC, et al. Perioperative antibiotic prophylaxis for herniorrhaphy and breast surgery. N Engl J Med 1990; 322: 153–60.[Abstract]
  31. Vilar-Compte D, Jacquemin B, Robles-Vidal C, Volkow P. Surgical site infections in breast surgery: case-control study. World J Surg 2004; 28: 242–6.[CrossRef][Medline]
  32. Nieto A, Lozano M, Moro MT, Keller J, Carralafuente C. Determinants of wound infections after surgery for breast cancer. Zentralbl Gynakol 2002; 124: 429–33.[CrossRef][Medline]
  33. Vicini FA, Chen PY, Fraile M, et al. Low-dose rate brachytherapy as the sole radiation modality in the management of patients with early-stage breast cancer treated with breast-conserving therapy: preliminary results of a pilot trial. Int J Radiat Oncol Biol Phys 1997; 38: 301–10.[CrossRef][Medline]



This article has been cited by other articles:


Home page
 Ann. Surg. Oncol.Home page
J. S. Jeruss, F. A. Vicini, P. D. Beitsch, B. G. Haffty, C. A. Quiet, V. J. Zannis, A. J. Keleher, D. M. Garcia, H. C. Snider, M. A. Gittleman, et al.
Initial Outcomes for Patients Treated on the American Society of Breast Surgeons MammoSite Clinical Trial for Ductal Carcinoma-In-Situ of the Breast
Ann. Surg. Oncol., July 1, 2006; 13(7): 967 - 976.
[Abstract] [Full Text] [PDF]

Home page
 Arch SurgHome page
L. A. DiFronzo, P. I. Tsai, J. M. Hwang, J. J. Lee, M. C. Ryoo, J. Rahimian, M. Tome, J. K. Takasugi, and P. I. Haigh
Breast Conserving Surgery and Accelerated Partial Breast Irradiation Using the MammoSite System: Initial Clinical Experience
Arch Surg, August 1, 2005; 140(8): 787 - 794.
[Abstract] [Full Text] [PDF]

Home page
 JCOHome page
D. W. Arthur and F. A. Vicini
Accelerated Partial Breast Irradiation As a Part of Breast Conservation Therapy
J. Clin. Oncol., March 10, 2005; 23(8): 1726 - 1735.
[Full Text] [PDF]

This Article
Right arrow Abstract Freely available
Right arrow Full Text (PDF)
Right arrow Alert me when this article is cited
Right arrow Alert me if a correction is posted
Services
Right arrow Similar articles in this journal
Right arrow Similar articles in PubMed
Right arrow Alert me to new issues of the journal
Right arrow Download to citation manager
Citing Articles
Right arrow Citing Articles via HighWire
Right arrow Citing Articles via Google Scholar
Google Scholar
Right arrow Articles by Richards, G. M.
Right arrow Articles by Mills, C.
Right arrow Search for Related Content
PubMed
Right arrow PubMed Citation
Right arrow Articles by Richards, G. M.
Right arrow Articles by Mills, C.

HOME HELP FEEDBACK SUBSCRIPTIONS ARCHIVE SEARCH TABLE OF CONTENTS