When it comes to organ preservation, the other very important factor to keep in mind is that one should not preserve an organ just for the sake of preserving it if that organ is not going to function as result of organ-preserving treatments! For example, what good is preserving a cervix would do to fertility of a woman if their ovaries are going to be non-functional as result of receiving radiation to their pelvis? Therefore, every patient’s case has to be discussed individually. One has to know the stage of the disease, the baseline function of the organ to begin with, how the treatments would affect the function of the organ one is trying to preserve but above all, how successful the treatments are going to be in eliminating the disease without compromising the outcomes.

With the invention of CAT scans, three-dimensional radiation therapy was developed. This technology was a CT-based radiation planning system which allowed sparing of normal tissues to some extent. Later on a sophisticated form of 3D conformal radiation therapy, called Intensity Modulated Radiation Therapy or IMRT was developed. This form of radiation planning software is an inverse planning system which begins with a desired dose distribution and arrives at a specification of the required fluence modulation to create it.

Obviously the more sophisticated these technologies get, the more successfully we can spare the normal tissues surrounding the target of radiation.

Nowadays an even more sophisticated technology called RapidArc Therapy, not only improves dose conformity but also significantly shortens treatment times. Volumetric modulated arc therapy differs from existing techniques like IMRT because it delivers dose to the whole volume, rather than slice by slice and the treatment planning algorithm ensures the treatment precision, helping to spare normal healthy tissue.

With the invention of CAT scans, three-dimensional radiation therapy was developed. This technology was a CT-based treatment planning system which allowed sparing of adjacent normal tissues to some extent. Later on a sophisticated form of 3D conformal radiation therapy, called Intensity Modulated Radiation Therapy or IMRT was developed. This form of radiation planning software is an inverse planning system which begins with a desired dose distribution and arrives at a specification of the required fluence modulation to create it.

Obviously the more sophisticated these technologies get, the more successfully we can spare the normal tissues surrounding the target of radiation.

Radiation to the bowel can cause chronic diarrhea, bowel obstruction and fistula formation. A fistula is an abnormal connection or passageway between two organs that normally do not connect and requires surgical repair. Radiation to the bowel may also cause thinning of the blood vessels in the bowel which may cause bleeding even with the normal passage of the stool. This may require laser ablation to stop the bleeding.

Radiation to the bladder can cause stiffening of the bladder and therefore frequency of urination. Internal and/or external radiation to the vagina can cause narrowing of the vagina which would be progressive and would only be prevented by using a vaginal dilator. This is usually provided by the radiation oncologist after completion of radiation treatments.

Even though statistically the risk is relatively small, radiation would increase the risk of a secondary malignancy in the irradiated field. Therefore the above mentioned organs are potentially at risk of developing another cancer. Particularly in case of endometrial cancer one has to be aware of HNPCC or Hereditary nonpolyposis colorectal cancer. This is a syndrome with increased risk of colorectal and endometrial cancer but unfortunately two major factors in this syndrome are overlooked even by medical professionals. One is the fact that individuals affected by this syndrome do not have increased number of polyps in their colon or rectum. The second one is the fact that women with HNPCC are at higher risk for endometrial cancer that they are for colorectal cancer. Therefore often when a woman is diagnosed with endometrial cancer nobody is alarmed about their risk of colorectal cancer regardless of whether they get radiation therapy or not and they should be!

If a radiation oncologist determines that the lymph nodes in the pelvis are also at risk of recurrence, then he/she would recommend addition of five weeks of daily external beam radiation therapy as well.

The exception to all of the the above is a patient who can not undergo surgery. In that scenario, radiation therapy would become the primary treatment. A combination of internal and external radiation would be indicated. For internal radiation, a double tandem intrauterine catheter and High Dose Rate (HDR) machine would be utilized. In the absence of HDR machine, one may use Hayman Capsule catheters and Low Dose Rate Brachytherapy technique.

Generally speaking the most common sites of recurrence after a mastectomy are mastectomy scar, followed by supraclavicular nodes, followed by the axillary nodes. So the minimum area covered by radiation would be the chest wall including the mastectomy scar. Whether the regional lymph nodes including supraclavicular nodes and axillary nodes need to be irradiated or not depends on individual patient and subject to review of each patient’s clinical presentation and review of pathology and details of surgical procedure including whether the patient had undergone sentinel lymph node biopsy or a full axillary dissection and many other factors including biological markers defining level of aggression of the disease, etc. One size does not fit all and multidisciplinary conferences are where medical teams discuss the best approach for each patient and offer individualized care.

If no chemotherapy has been recommended, as a rule of thumb we would like to leave at least four weeks between surgical procedure and the beginning of radiation therapy but it is all right to delay it up to eight weeks for invasive cancer and up to twelve weeks for DCIS. But once the interval is increased more than that, one would be concerned that the efficacy of radiation would begin to decrease.

Please bear in mind that the above is in regards to external beam radiation therapy because in APBI or Accelerated Partial Breast Irradiation using a variety of catheters such as The SAVI Applicator, MammoSite or Contura Balloon radiation can begin within a couple of days after insertion of these applicators and as soon as the pathology report is finalized.