This is a very interesting case of a 38 year-old female, with bilateral breast invasive

ductal carcinoma, with extensive cutaneous involvement.

1
A double mastectomy was done after
irradiation because of the lack of dermal response to chemotherapy. In order to reduce normal
tissue irradiation, patient was initially treated with Tomotherapy-based intensity modulated
radiation (IMRT) technique.
2
According to Quantitative Analysis of Normal Tissue Effects in the
Clinic (QUANTEC) guidelines for limiting doses for heart and lung, a IMRT boost would not be
recommended for this case. An electron boost treatment was considered as a boost but when
compared to a high-dose (HDR) surface applicator-based brachytherapy (BRT) a superior
coverage of scar and homogeneity was noted.
3, 4
The initial phase of radiation therapy (RT) a
dose of 50 Gy in 25 fractions was delivered, figure 1, followed by HDR boost with patient
receiving an additional 10 Gy in 5 fractions. A customized surface mold of the contour of
patients breasts was created using thermoplastic mold with 17 interstitial HDR catheters placed
at 1 cm intervals, figure 2. Catheters were added to the mold, figure 3. Figure 4 shows a digital
representation of the target volume, in red, with positioning of catheters, in blue, against patients
surface anatomy. Figure 5 demonstrates the plan isodose distribution. The brachytherapy dose
was prescribed to points at 7mm underneath the skin surface.
IMRT treatment followed by surface-mold BRT boost is an ideal option for this rare and
complex clinical case. By using surface-mold BRT all the guidelines recommended by
QUANTEC were meet.

Figure 1

Figure 2


Figure 3



Figure 4


Figure 5









References
1. Mohindra P, Das R. Anderson B. Surface mold brachytherapy: a means to achieve
therapeutic skin irradiation in a case of synchronous bilateral breast cancer with extensive
cutaneous involvement. App Radiat Oncol. 2013; 2(2): 2530.
http://appliedradiationoncology.com/radiation-therapy-clinical-application-volumetric-
modulated-arc-therapy/. Published June 12, 2013. Accessed April 20, 2014.
2. Arthur DW, Morris MM, Vicini FA. Breast Cancer: new radiation treatment options.
Oncology. 2004; 18: 1621-1629; discussion 1629-1630, 1636-1638.
3. Fritz P, Hensley FW, Berns C, Schraube P, Wannemacher M. First experiences with
superfractionated skin irradiations using large afterloading molds. Int J Radiat Oncol Biol
Phys. 1996; 36: 147-157.
4. Harms W, Krempien R, Hensley FW, Berns C, et al. Results of chest wall reirradiation
using pulsed-dose-rate (PDR) brachytherapy molds for breast cancer local recurrences.
Int J Radiat Oncol Biol Phys. 2001; 49: 205:210.