In Parts 1 and 2 of our Oncoplastic Surgery series, breast surgeon Gail Lebovic, MD, and radiation oncologist Robert Kuske, MD, shared their views on oncoplastic surgery and the role of brachytherapy in this increasingly popular surgical approach.
In the final installment of our series, surgeon Jane Kakkis, MD, discusses her surgical techniques for combining a single-entry brachytherapy device with oncoplastic surgery, how SAVI works better than a balloon, and why localized radiation should be offered to women traditionally considered to be “high-risk.”
How do you define oncoplastic breast surgery?
Oncoplastic surgery is the integration of removing a cancer and restoring the breast, whether through breast conservation, or mastectomy with reconstruction. When people talk about oncoplastic surgery, they’re often referring to lifts, or the more aesthetic procedures on the opposite breast for symmetry. But that’s not all there is to it – those are the much more elective portions of oncoplastic surgery.
Perhaps one of the biggest misconceptions about oncoplastic surgery is that brachytherapy – particularly with single-entry devices – is not possible. The truth is the two modalities can be a successful pairing when done on the properly selected patient using the appropriate catheter.
The use of single-entry brachytherapy devices obviously requires a cavity to be left behind after surgery, but is it ever necessary to eliminate the cavity?
It’s never absolutely necessary to eliminate the cavity. The goal of oncoplastic surgery is to restore the contour of the breast, not to simply fill a hole by moving tissue from one area of the breast to another. In fact, doing so might have a negative impact on the cosmesis. Tissue is limited, so moving it from one area to completely fill another will leave a defect in the first area.The only way to truly eliminate a cavity is to suture it down, and I’ve found that while that looks great when the woman is lying down, it can lead to serious cosmetic issues when she is upright.
By moving tissue in order to restore contouring, I typically end up with several smaller potential spaces – some of which are related to the cancer and some of which are not – rather than one, large fluid-filled pocket. But if the patient is a candidate for APBI, then I leave a potential space that has the ability to be expanded with the insertion of a single-entry catheter. If I don’t insert a catheter in that space, eventually the tissue will heal and the space will disappear
Are there specific techniques you utilize in order to accommodate a single-entry brachytherapy device following oncoplastic surgery?
I create tissue flaps and sew at the periphery to construct a small but identifiable temporary cavity that is designed to hold a catheter. I design the area to be able to collapse down following catheter removal. If I know I’m going to put a catheter in postoperatively, I’ll plan for the cavity and the catheter entrance site to a small potential space, which always fills with fluid and naturally distends itself in the early post-op period. If we end up not placing a catheter, the fluid would simply reabsorb and the cavity would collapse.
When combining oncoplastic surgery with a single-entry brachytherapy device, how does the SAVI applicator differ from a balloon?
When utilizing oncoplastic techniques, SAVI is easier to use, provides more options, and causes less discomfort for patients. The problem with a balloon is that requires a spherical potential space of 40 cc. It’s difficult to create that with proper conformance and adequate distance from the skin, while also ensuring it will collapse and have a nice restored contour following treatment. Since SAVI can be put in much smaller cavities,I have many more options for how to restore the breast and my oncoplastic technique is much closer to what I would do if a patient was having external beam. In addition, there are more options for placement with SAVI, which minimizes the need to resort to interstitial brachytherapy if the patient desires a 5-day treatment option.
Creating a cavity than can hold a 40 cc sphere is very difficult, and inflating the balloon causes a lot of tension on the edges of the advancement flaps. Not only is it difficult for the tissue flaps to maintain adequate blood supply through that tension, but it causes a great deal of discomfort during insertion for the patient, particularly when inflating the final 10-20 cc of the balloon. I insert the catheter in my office with local anesthesia; it is difficult to completely anesthetize when inserting the balloon because when the tissue is stretched that much the pain is perceived at a significant distance from the insertion site. The SAVI device doesn’t require as much expansion, so it’s much more comfortable for the patient.
The biggest difference following treatment is that use of the balloon frequently led to symptomatic seromas. It seems to create a rind of radiated tissue that prevented the potential fluid space from collapsing like it was supposed to. Sometimes the seroma was visible, but even if it didn’t visibly deform the breast, the seroma was palpable, which in some cases is uncomfortable to the patient and makes clinical exam difficult. With balloons, I’ve seen a lot of encapsulated seromas that took a long time to resolve, if they resolved at all. I haven’t seen that with SAVI.
Do you prefer to offer brachytherapy if a patient is eligible for localized radiation therapy?
The advantage of using localized radiation is that it preserves options for the patient in the future. If she’s already had whole breast radiation and something were to happen in the future, whether it’s a recurrence or a second cancer, she can no longer have radiation and her options for mastectomy reconstruction are limited.
In fact, I would like to see the use of brachytherapy extended to patient populations that are currently considered “high-risk,” like younger women. In general, a younger woman has a greater risk of developing a second cancer simply due to her life expectancy, so why not use localized radiation at the first occurrence, so we can provide her with broader options in the future, like mastectomy and reconstruction, if a second occurrence were ever to happen. For younger patients who choose breast conservation therapy, I’d love to see a study evaluate if we can do brachytherapy safely, so that at a future date if they should either electively decide to do a risk reduction with mastectomy, or if a second event were to occur, they would have as many options open to them as possible.
Why is the interdisciplinary approach to patient care so important when it comes to oncoplastic breast surgery, particularly when brachytherapy is involved?
When a patient is a potential candidate for APBI, the patient has to be advised about her options prior to surgery – that’s just essential. She has to see the radiation oncologist to evaluate her candidacy and discuss all the options she has for radiation so that before surgery, we have an understanding of the ideal goals for therapy. That treatment pathway may change when the pathology comes back, but at least the surgeon has an idea that the patient would like to do APBI. The radiation oncologist and surgeon have to have a good close working relationship – with communication starting from before the surgery, through treatment and after completion of therapy.
When it comes to choosing a treatment pathway for breast cancer, it’s a very complicated decision-making process. Within the treatment pathway, we have medical treatment, radiation treatment, and surgical treatment. You have to integrate all the treatments she can expect to have, now and in the future, with her personal history and her goals for therapy. Each team member has to understand the whole picture to help guide the patient and help her see the appropriate people at the right time in order to make this complicated decision.
Dr. Jane Kakkis is an oncoplastic surgeon who specializes and treats cancer of the breast, other conditions of the breast and related diseases exclusively. She currently serves as the Surgical Director of the Breast Center at Orange Coast Memorial Medical Center and is Vice Chair of the Department of Surgery at Orange Coast Memorial Medical Center in Fountain Valley, Calif. Dr. Kakkis has been named one of the “Best Doctors in America” and given the “Orange County Physician of Excellence” award multiple times, and has been honored with the inaugural “Fight with Grace” award.