Previous mantle radiotherapy for HD is considered a contraindication to BCS and radiotherapy [
17]. This is based on concerns about possible severe sequelae arising from a high total cumulative dose, exceeding normal tissue tolerance, being delivered to the portions of the breast that have presumably already received radiation for the lymphoma, even though modifications of the breast gland over time render the exact calculation of the dose infeasible many years after radiation delivery. Most authors consider these patients at significant risk of complications (fibrosis, skin and soft tissue necrosis, rib fractures, potential lung and heart toxicities) [
6] and do not candidate them for BCS and adjuvant radiotherapy. In contrast, other reports [
18,
19] support BCS followed by PFR when breast cancer develops many years after radiotherapy for HD. At present, no consensus exists regarding the correct management of breast cancer after mantle irradiation for HD and, given the discordant results and the small number of women treated with BCS, mastectomy continues to be recommended as the standard treatment. To avoid a high total cumulative dose to portions of the breast or soft tissues of the thoracic wall, one of the conservative options is to treat just the tumor bed: the irradiation of a small volume of the breast and adjacent structures could allow the risk of complications to be minimized [
7‐
10]. Therefore, over the past decade there has been increasing interest in a variety of radiation techniques designed to treat only the portion of the breast deemed to be at high risk for local recurrence [
20]: these include brachytherapy implants, MammoSite applicator, intraoperative orthovoltage device, and 3D conformal or intensity-modulated external radiotherapy (partial-breast irradiation (PBI)). All these techniques have similar indications but different applications [
21,
22]. In particular, they differ in the source of radiation (for example, X-ray, Iridium, photons) and the amount of breast volume treated. Although 5 to 7 year outcome data on patients treated with PBI are now becoming available, many issues remain unresolved, including the clinical and pathological selection criteria of patients, radiation dose and fractionation, and how these relate to the standard fractionation for whole breast irradiation, appropriate target volume, local control within the untreated ipsilateral breast tissue, and overall survival. With a view to furnishing guidelines and clarifying the issues of major controversy, a workshop on PBI was held in Bethesda, in December 2002. The workshop report emphasized the importance of education and training with regard to the results of PBI as it becomes an emerging clinical treatment [
23]. In particular, ELIOT, a new radiotherapeutic technique that delivers a single dose of radiation directly to the tumor bed during the conservative surgical treatment of early breast cancer, has been proposed for evaluation in randomized clinical trials as a possible alternative to standard PFR.
When in July 1999 we focused our interest on the use of intraoperative radiotherapy as an exclusive treatment in small unifocal infiltrating breast carcinomas, we considered that ELIOT could be specifically applied in all those situations in which PFR was not considered safe or feasible for various reasons (for example, severe cardiopathy, large hypertrophic scarring from skin burns, vitiligo, geographic or social obstacles) [
24] and, in particular, in patients irradiated for HD. After our first preliminary report [
25], ELIOT was proposed in six patients previously irradiated for HD. In all cases, the dose delivered and the energy of electron beams from ELIOT did not differ from those in the other 549 patients submitted to ELIOT; in one patient a total dose of 17 Gy (prescribed at 100% isodose) using electron beams at 7 MeV energy and in five patients doses of 21 Gy (90% isodose, 7 and 9 MeV of energy) were delivered. The different electron energies administrated (7 or 9 MeV) are related to the different breast gland thickness.
The radio-surgical technique of the six ELIOT procedures did not differ from the 'classic' technique used for previously non-irradiated patients [
14]. In particular, to ensure a good coverage of the target by the radiation dose and maximal protection of the normal tissues in the operative area, adequate preparation for irradiation of the portion of breast gland to undergo ELIOT is necessary. Protective devices are placed between the gland and the pectoral muscle; a dedicated lead disk 5 mm thick and an aluminium disk 4 mm thick, available in various diameters (4, 5, 6, 8, 10 cm) are commonly used. The wall protection is guaranteed both by the absorption properties of the lead and aluminium and the 9 mm outdistance created by the disks.
We scored the radiation morbidity according to the RTOG/EORTC criteria [
15]. ELIOT was well tolerated without any unusual acute reactions despite previous breast irradiation. We did not observe any ischemic or necrotic problems of the skin flap due to the careful sparing of the subcutaneous vessels during the mobilization of the residual breast around the tumor bed. No increased post-operative complications (pain, seroma, emathoma, infection) were observed in these six patients when compared to the overall group of ELIOT patients. The length of hospital stay was therefore not prolonged. The cosmetic outcome was also very good in all patients: no skin erythema was observed as a result of the complete removal of the skin from the radiation beam.
The follow up is too short (average 30.8 months) to evaluate late sequelae in these six re-irradiated patients but no complications were observed in the four patients with more than 2 years of follow up.