Pat Whitworth, MD
In the past decade, oncoplastic breast surgery has gained widespread acceptance within the United States. The term applies to a variety of techniques that combine the principles of surgical oncology with plastic surgery techniques in order to control cancer while producing a desirable cosmetic result. Due to the variance in techniques, there is often a misconception that brachytherapy – particularly with single-entry devices – is not compatible with oncoplastic breast surgery.
Breast surgeon Pat Whitworth, MD, of the Nashville Breast Center, shares his approach to oncoplastic surgery, including why a majority of women benefit from a combination of what he calls “minor” oncoplastic techniques and targeted radiation like brachytherapy.
Describe your oncoplastic technique for breast-conserving surgery.
In my practice, we do a periareolar crescent mammoplasty in the majority of lumpectomy cases. Our goal is simple – to reset the nipple-areolar complex and lift the breast in a way that compensates for the distortion that can be caused by a standard lumpectomy technique. In addition, we always offer the opportunity to do the contralateral breast to ensure symmetry.
The vast majority of women I see don’t require a formal reduction mammoplasty, which is a major oncoplastic procedure performed in conjunction with a plastic surgeon. Instead, I promote and encourage other breast surgeons to adopt what are essentially minor oncoplastic techniques that are quite easy for them to master and perform on their own.
What radiation options do you and your radiation oncologist offer to patients who desire oncoplastic breast conservation?
While we offer both whole breast irradiation (WBI) and brachytherapy-based accelerated partial breast irradiation (APBI), we believe brachytherapy is the preferable approach for most women. Although the oncoplastic surgical techniques decrease the size of the cavity by shifting breast tissue upward, there is still a sufficient cavity to accommodate a brachytherapy catheter. Particularly for women with lower risk cancers, we recommend the more targeted course of radiation with brachytherapy – we see no reason to put them through WBI.
I warn physicians to be on the lookout for papers linking APBI with bad cosmetic results. Without exception, those reports are coming from studies where a majority or all of the patients were treated with external APBI via 3D conformal radiation therapy (3DCRT). There’s mounting evidence that external APBI leads to poor cosmetic outcomes – even compared to WBI – but this does not apply in any way to brachytherapy.
What kinds of outcomes have you seen in patients who receive brachytherapy compared to those who receive WBI?
The patients who receive brachytherapy tend to have fewer side effects and better cosmetic results. We generally see less shrinkage, less hardening of the breast and less hyperpigmentation with brachytherapy. Since we began using strut-based brachytherapy with the SAVI applicator, we’ve also noticed fewer symptomatic seromas. These outcomes are important, as women who desire an oncoplastic approach are clearly concerned with both the oncologic outcome and the cosmetic results of their treatment. And in general, women are thrilled with the outcomes.
Which patients are the best candidates for oncoplastic surgery with brachytherapy?
In general, lower-risk patients are the ideal candidates for brachytherapy with oncoplastic breast conservation. We typically follow the American Society of Breast Surgeons (ASBrS) and the American Brachytherapy Society (ABS) guidelines. The American Society for Radiation Oncology (ASTRO) guidelines are a little too restrictive – many of the concerns that existed when the guidelines were initially published have been addressed. For instance, we now have data that shows no increased risk of recurrence for DCIS patients, or patients between 50 and 60 years of age. Several studies, including the MammoSite ASBrS Registry, have looked at these populations and reported excellent outcomes with a ≤5 percent risk of local recurrence.
How does an oncoplastic placement of a SAVI device differ from a routine SAVI placement?
There’s really no difference. Again, the cavity may be slightly smaller since we’ve shifted the nipple-areolar complex northward, but otherwise it’s a routine placement. We don’t typically use a spacer balloon, unless the cavity is in the upper-inner quadrant of the breast where we think we might have trouble getting the catheter in. In a majority of cases, it’s a standard routine placement like we always do.
Are there special considerations you take into account when planning for surgery knowing you have a patient who desires an oncoplastic approach with brachytherapy?
Unless it’s a patient who might be a candidate for a formal lumpectomy with a reduction mammoplasty – which would be done in coordination with the plastic surgeon – I initially approach every case as if we’re going to do a periareolar crescent mammoplasty, combined with radiation. I tell the patient they’ll be a candidate for brachytherapy if the pathology shows negative lymph nodes, clear margins and so forth, and so I approach the lumpectomy with that assumption in mind. We make the final radiation decision when the pathology report confirms their eligibility for brachytherapy, at which point we do an ultrasound to confirm that we have a sufficient cavity – which we essentially always do – and send the patient for a consultation with the radiation oncologist.
How do you respond to physicians who say oncoplastic surgery is incompatible with brachytherapy?
Generally, physicians who say that are referring to a more advanced kind of oncoplastic surgery that is based on reduction mammoplasty or major tissue rearrangement techniques. One of the major tenets of those techniques is to rearrange the tissue in a way that leaves no open space – meaning there’s no cavity to accommodate a brachytherapy device. So for patients with larger breasts who would benefit from a reduction mammoplasty or a reduction with major tissue rearrangement, brachytherapy is not a good option.
However, a majority of patients don’t require that extreme oncoplastic surgery. Most patients will benefit from the minor oncoplastic techniques that require shifting the nipple-areolar complex to compensate for any damage but still enable us to leave a cavity as with any standard lumpectomy. I believe advocates of the major oncoplastic techniques will agree that brachytherapy is compatible with the more minor oncoplastic approach that most breast surgeons can easily learn do to on their own.
A majority of the patients I see will get the most benefit out of this minor oncoplastic approach to surgery, combined with an accelerated, targeted form of radiation like brachytherapy.
Dr. Whitworth is a breast surgical oncologist and Director of the Nashville Breast Center in Tennessee.