SAVI Brachytherapy

Structural design/Insertion into Patient

A lumpectomy is the removal of a tumor from the breast. This is done in efforts to
preserve the breast and avoid a complete mastectomy (removal of the entire breast). However,
post-operative lumpectomy sites have been found to contain residual disease. The SAVI
brachytherapy applicator was developed to treat this residual disease. The SAVI has unique
advantages of being able to modulate dose to the chest wall and skin surface when compared to
other treatment techniques.
Seven to eleven catheters (depending on SAVI size) are placed together in a near straight
line for insertion into the lumpectomy cavity (see the top of Figure 1).1 Once inside the
lumpectomy cavity, the SAVI is expanded to fill the site. At this point the SAVI takes on its
whisk-like shape (see the bottom of Figure 1). Tubes fill the catheters in between treatments to
maintain the integrity of the tubes shape (see Figure 2). The removable expansion tool is what
expands/retracts the SAVI and holds the position.

Figure 1: Unexpanded (top) and expanded (bottom) SAVI.

Figure 2: Components of SAVI.

Simulation
A CT simulation is performed after the surgeon places the SAVI in the operating room
(OR). The SAVI remains in the patient throughout the course of treatment. Vac lock
immobilization devices can be used to assist with patient positioning. The patients arms can be
over their head or at their side. The CT scan with SAVI placed is sent over for treatment
planning, at McLaren site the physicist do the planning (see treatment planning section). Patients
are treated twice daily at our facility, 6 hours apart. Prior to each treatment a simulation is done
to verify proper device positioning.
1

Treatment Planning
Once the TPCT has been sent over, the catheters must be identified on the scan.
Radiopaque markers (see Figure 2). Are placed on catheter 2 (most distal), catheter 4 (middle)
and catheter 6 (most proximal) so that they may be more easily identified.1 Each catheter must be
contoured and identified, it is crucial that this is done correctly because the entire treatment
planning process revolves around proper dwell times/positions (see Figure 3). Contours that
must be drawn include: the SAVI, PTV (1cm expansion of cavity), body, lung, chest wall,
PTV_Eval (PTV-SAVI-Body (lungs if needed)), air pockets, and skin. The treatment planning
process can be done in a few ways. The first way typically involves a geometric calculation
which gives all lines a general dwell time, the next way is similar to IMRT objective based
planning, and the final way is to manually adjust the dwell times. It is also possible to drag the
isodose lines using a planning tool that will automatically adjust the dwell times. Typically
3.4Gy per fraction is given over 10 fractions for a total of 34Gy. Typically 95% of the volume is

required to get 95% of the dose, no more than 20cc can receive greater than 200% dose and no
more than 50cc can receive more than 150% dose.

Figure 3: Catheters identified for dwell time/position calculation.

Source/Treatment
Traditionally only the HDR source Iridium is used for SAVI treatment. We have the
ability to increase the specific activity of Iridium in labs.1 With a higher specific activity a

smaller source can deliver a higher dose. The sources are delivered to the patient through a
remote afterloader, which feeds the sources through a wire. Each catheter is connected to the
appropriate number on the HDR afterloader. The HDR afterloader feeds the sources through the
catheters based on the dwell time and positions developed on the treatment planning system. The
actual treatment time takes about 10 minutes, but patients can expect to be at the clinic for about
an hour to do the CT scan with other pre and post treatment procedures.

References:
1. Cianna Medical, SAVI Physics Training. [PowerPoint]. Aliso Viejo, CA; 2009