Portal de Periódicos da CAPES

In response to Drs. Kuerer, Pawlik, and Strom

2003; Elsevier BV; Volume: 57; Issue: 3 Linguagem: Inglês

10.1016/s0360-3016(03)00424-3

1879-355X

Martin Keisch, Frank A. Vicini,

Cancer and Skin Lesions

The letter from Drs Kuerer, Pawlik, and Strom raises several important questions about balloon brachytherapy for early-stage breast cancer patients. The primary concerns raised by Kuerer et al. relate to the size and shape of the lumpectomy cavity and the implications they may have for treatment with balloon brachytherapy techniques. The initial point regarding the limitations of usefulness because of the applicator's size (maximum 70 cc fill volume) is one of the main areas of concern with the use of the balloon. In the initial series of 70 patients enrolled, 10 patients were not implanted and 7 more had devices pulled because of conformance or cavity size issues. The article stresses this point in the discussion section. Regardless, the points raised in the letter are interesting and worth comment. Dr. Kuerer stated that his tumors were rarely positioned in the center of the lumpectomy specimen, with margins that might be 3 to 4 cm on one side and only a few millimeters on the other. Tumor localization has long been a challenge in smaller tumors and it seems unlikely that the additional tissue over that required to achieve a clear margin is of any clinical benefit to the patient. Additional marginal tissue may, however, decrease the cosmetic result because of missing tissue effect. This has clearly been demonstrated in most large studies addressing the factors responsible for suboptimal cosmetic results after breast cancer therapy where the extent of the surgical resection (>70 cm3 in the Harvard study) has the most profound detrimental effect on cosmesis ( 1 Olivotto I.A. Rose M.A. Osteen R.T. et al. Late cosmetic outcome after conservative surgery and radiotherapy Analysis of causes of cosmetic failure. Int J Radiat Oncol Biol Phys. 1989; 17: 747-753 Abstract Full Text PDF PubMed Scopus (243) Google Scholar ). Still, most of the lumpectomy cavities that were created during our study were elliptical in shape and some were quite a bit larger than 50 cm3. In most cases, the 4–5 cm balloon fit these cavities with excellent conformance. In our study, the largest lumpectomy specimen came from a T1c patient with a lumpectomy volume of 176 cm3. This patient's cavity conformed well to the MammoSite and she completed treatment without complication. Her cosmetic outcome was rated as excellent. Images are shown in Fig. 1 taken 22 months after radiation therapy. The only obvious cosmetic decrement is breast size resulting from missing tissue.