Mary Brian, MD, FACS
Christy Kesslering, MD
Although there is still a need for long-term data on the risks and benefits of all forms of APBI, anecdotal evidence suggests that use of the accelerated treatment reduces the physical toll on patients undergoing radiation therapy. The most common side effects of APBI include redness, bruising and soreness. However, many patients still experience more long-term, chronic effects such as persistent seroma and fibrosis.
Breast surgeon Mary Brian, MD, FACS, and radiation oncologist Christy Kesslering, MD, discuss their clinical experiences and how the risk of side effects influences their selection of brachytherapy catheters.
Some physicians say the occurrence of seroma is a non-issue and that it is a natural part of healing after breast cancer surgery. Do you agree with that?
Dr. Brian: Not necessarily. I agree that any time you do a lumpectomy the cavity will initially fill with fluid – that certainly is a natural part of healing. But typically the fluid will reabsorb and the seroma disappears with time. But persistent seroma is much different than the normal fluid collection that results from doing surgery. I think persistent seroma occurs because necrosis develops in the tissue around the cavity where radiation was delivered. The tissue isn’t able to collapse, so fluid just collects and cannot be reabsorbed by the body.
As physicians, what challenges do you face as a result of side effects – like persistent seroma or fibrosis – that can occur after APBI?
Dr. Brian: Although it certainly has a typical appearance, the presence of a persistent seroma can impact post-lumpectomy surveillance. It makes physical examination more challenging and creates difficulty when evaluating the area with a mammogram.
Dr. Kesslering: I agree – these side effects can have a serious impact on follow-up. When a patient has large amounts of fibrosis, the dense tissue can limit visualization of the area around the cavity on mammograms and ultrasounds, making it more challenging to see if there is a recurrence. The increased thickness also limits the amount of compression you can obtain on a mammogram, which might cause you to miss something in a different location of the breast.
How do these side effects impact your patients?
Dr. Kesslering: One of the advancements of brachytherapy is that a majority of the patient’s breast will have no fibrosis, unlike with whole breast radiation. However, when fibrosis occurs at the lumpectomy site patients can experience increased tenderness. Not necessarily in their day-to-day activities, but certainly with a mammogram or palpation, there is some discomfort. But I’ve also had patients who developed chronic pain as a result of fibrosis/fat necrosis at the lumpectomy site or in the chest wall musculature.
Dr. Brian: The impact on patients is both physical and emotional. Persistent seromas can be uncomfortable and sometimes painful. Typically the pain can be lessened by draining the fluid, but it often fills back up. I’ve had cases that could only be resolved with additional surgery to remove the cavity because of the persistent pain. And then there’s the anxiety that’s caused by having a palpable mass at the lumpectomy site, which makes patients concerned about recurrence.
Do you think the occurrence of fibrosis is somehow linked with the incidence of persistent seroma?
Dr. Kesslering: There certainly seems to be. I have noticed significantly more fibrosis in patients with persistent seroma, while those who do not develop persistent seroma tend to have very little fibrosis. I’ve especially noticed this correlation with the SAVI applicator. While a small number of patients may still experience mild fibrosis, the tissue isn’t as thick or inflamed as patients who are treated with balloon catheters. At the same time, based on my experience it’s exceedingly rare to have a patient treated with SAVI who develops one of those chronic persistent seromas. I can’t definitively say whether one causes the other, but there definitely appears to be a connection.
Does the potential for side effects affect your choice of APBI catheters?
Dr. Brian: It certainly does. As a surgeon, I don’t like to see my patients coming to me after their treatment because they have a palpable mass, and I’ve had to remove several cavities because of the chronic discomfort caused by seromas. Persistent seroma seems to occur less often with SAVI, which I attribute at least partially to the device’s open architecture. We’ve had a few patients who developed seromas with SAVI, but we don’t see the same persistence of the abnormality. The seromas are smaller and easier to treat – after a few aspirations, they tend to go away for good. We use SAVI almost exclusively, and that’s due in part to the persistent seroma issue.
Dr. Kesserling: Absolutely. All I know is that from my clinical experience of eight years of doing breast brachytherapy and trying every available catheter, we’ve seen a dramatic difference with SAVI. At first, I was hesitant to try SAVI. I waited until data was available and I talked to Dr. [Catheryn] Yashar at UCSD. But after treating the first few patients, I was absolutely convinced it was a better option for women. Even if I have more than a centimeter to the skin or the chest wall, even if I can treat the patient with a single channel – I use SAVI every time.
Mary Brian, MD, FACS is a breast surgeon at the Breast Care Center of North Texas in Bedford, Texas. Christy Kesslering, MD is the Medical Director of Radiation Oncology at Central DuPage Hospital and Alexian Brothers Medical Center in Chicago.