Gildy Babiera, M.D., F.A.C.S.
What are the advantages of using the SAVI Prep™ Catheter as opposed to doing a percutaneous implant?
The prep catheter can facilitate a more efficient device placement in the clinic. Using the catheter gives you an idea of how your cavity will look and conform to the device, and it can help you determine what size you’re going to need. You know your long axis and you already have a tract formed, so the exchange is very quick – if you don’t have to do any resizing, I estimate the exchange of the prep catheter for a SAVI device takes no more than a minute, compared to the 5-10 minutes required for a percutaneous implant.
What are the disadvantages of using a prep catheter?
There are two disadvantages. One disadvantage would be the possibility of causing more persistent seroma formation after APBI, which tends to happen when you have a balloon pressed up against the cavity wall. However, this may be minimized by deflating the balloon to half its size so the balloon is not pressing up against the cavity. The other disadvantage is the potential for a higher risk of infection because you have a foreign body in the breast. You definitely want to go with a percutaneous implant for patients who have a high risk of infection, like women with implants, chronic UTIs or who have had a recent infection. You have to consider the ease of placement versus the risk of infection, and for some patients the risk may be relatively high to do anything other than a pecutaneous implant.
What should surgeons consider before making a decision between the prep catheter and a percutaneous implant?
They basically need to take a look at their practice and determine how comfortable they are with ultrasound. In my opinion, you have to have ultrasound skills to place SAVI percutaneously. I’ve seen implants performed without it, but I wouldn’t feel comfortable using a trocar and placing a device relying solely on palpation without any ultrasound guidance.
The prep catheter provides better visualization of where the long axis should be, which may help surgeons as they’re figuring how to design the cavity. It also provides an alternative for surgeons who want to offer the benefits of SAVI but don’t have the required ultrasound equipment. It’s a good mechanism to start with, and as surgeons gain more experience with office-based procedures, the implants become easier, allowing them to become more comfortable with the procedure.
How much do you collaborate with radiation oncologists on selecting the appropriate devices for APBI patients?
The radiation oncologist should be involved from the very beginning. Most of our radiation oncologists wouldn’t appreciate a patient coming in with a catheter already in place, saying “Ok, time to do partial breast radiation.” They want to be involved in the decision, particularly about which catheter to use. If there are problems with skin toxicity or conformance, the radiation oncologist is most often the one who has to do the device exchange, so they should have a say in which device is used. At MD Anderson, it’s typically the radiation oncology who will decide what size catheter is most appropriate, but I’ll offer my opinion following the surgery.
Communication is key. Before a patient even goes in for surgery, I communicate with the radiation oncologist a minimum of four times. I alert the radiation oncologist that I am sending a patient and that I think she’s a candidate for breast brachytherapy. Then they’ll contact me after they’ve seen the patient and we’ll discuss their observations. We communicate about surgery dates, schedules for CT simulations, when we can expect to receive the pathology back. Post-operatively, the radiation oncologist will contact me after the CT cavity evaluation with a recommendation for the particular size of device, and again prior to treatment to ensure we achieved proper conformance. I truly believe this level of collaboration is essential in order to provide a higher quality of care for our patients.
Dr. Babiera is an associate professor of surgical oncology at The University of Texas M.D. Anderson Cancer Center in Houston, Texas. In 2009, she was named one of America’s Top Doctors for Cancer by Castle Connolly.
Which do you prefer – prep catheter or percutaneous implant? Why?
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