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DEGRO practical guidelines: radiotherapy of breast cancer II

Radiotherapy of non-invasive neoplasia of the breast

DEGRO-Leitlinien für die Radiotherapie des Mammakarzinoms II

Radiotherapie nicht-invasiver Neoplasien der Brust

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Abstract

Purpose

To complement and update the 2007 practice guidelines of the breast cancer expert panel of the German Society of Radiation Oncology (DEGRO) for radiotherapy (RT) of breast cancer. Owing to its growing clinical relevance, in the current version, a separate paper is dedicated to non-invasive proliferating epithelial neoplasia of the breast. In addition to the more general statements of the German interdisciplinary S3 guidelines, this paper is especially focused on indication and technique of RT in addition to breast conserving surgery.

Methods

The DEGRO expert panel performed a comprehensive survey of the literature comprising recently published data from clinical controlled trials, systematic reviews as well as meta-analyses, referring to the criteria of evidence-based medicine yielding new aspects compared to 2005 and 2007. The literature search encompassed the period 2008 to September 2012 using databases of PubMed and Guidelines International Network (G-I-N). Search terms were “non invasive breast cancer”, “ductal carcinoma in situ, “dcis”, “borderline breast lesions”, “lobular neoplasia”, “radiotherapy” and “radiation therapy”. In addition to the more general statements of the German interdisciplinary S3 guidelines, this paper is especially focused on indications of RT and decision making of non-invasive neoplasia of the breast after surgery, especially ductal carcinoma in situ.

Results

Among different non-invasive neoplasia of the breast only the subgroup of pure ductal carcinoma in situ (DCIS; synonym ductal intraepithelial neoplasia, DIN) is considered for further recurrence risk reduction treatment modalities after complete excision of DCIS, particularly RT following breast conserving surgery (BCS), in order to avoid a mastectomy. About half of recurrences are invasive cancers. Up to 50 % of all recurrences require salvage mastectomy. Randomized clinical trials and a huge number of mostly observational studies have unanimously demonstrated that RT significantly reduces recurrence risks of ipsilateral DCIS as well as invasive breast cancer independent of patient age in all subgroups. The recommended total dose is 50 Gy administered as whole breast irradiation (WBI) in single fractions of 1.8 or 2.0 Gy given on 5 days weekly. Retrospective data indicate a possible beneficial effect of an additional tumor bed boost for younger patients. Prospective clinical trials of different dose–volume concepts (hypofractionation, accelerated partial breast irradiation, boost radiotherapy) are still ongoing.

Conclusion

Postoperative radiotherapy permits breast conservation for the majority of women by halving local recurrence as well as reducing progression rates into invasive cancer. New data confirmed this effect in all patient subsets—even in low risk subgroups (LoE 1a).

Zusammenfassung

Ziel

Aktualisierung und Ergänzung der 2007 von der DEGRO-Expertengruppe Mammakarzinom publizierten Leitlinie zur Radiotherapie (RT) des Mammakarzinoms. Aufgrund der zunehmenden klinischen Relevanz nicht-invasiver epithelialer Neoplasien der Brust wurde diesen in der aktuellen Version ein eigenes Kapitel gewidmet. Schwerpunkte der hier vorgelegten Empfehlungen sind – in Ergänzung zu den S3-Leitlinien der Deutschen Krebsgesellschaft von 2012 – die Indikation und Technik der postoperativen RT nach brusterhaltender Operation.

Methoden

Die DEGRO-Expertengruppe führte eine Literaturrecherche aktueller klinisch kontrollierter Studien, systematischer Reviews und Metaanalysen, orientiert an den Kriterien der evidenzbasierten Medizin, im Hinblick auf neue Aspekte gegenüber 2005 und 2007 durch. Die Recherche umfasst die Zeitspanne 2008 bis September 2012 und erstreckte sich auf in PubMed und Guidelines International Network (G-I-N) gelisteten Publikationen. Suchbegriffe waren „non invasive breast cancer“, „ductal carcinoma in situ“, „dcis“, „borderline breast lesions“, „lobular neoplasia“, „radiotherapy“ und „radiation therapy“. Ergänzend zu den allgemeineren Statements der S3-Leitlinie zielt diese Arbeit auf Entscheidungsprozesse für das Vorgehen nach chirurgischer Exstirpation und speziell auf die Indikationsstellung zur RT von nicht-invasiven Mammaneoplasien.

Ergebnisse

Unter den verschiedenen nicht-invasiven Neoplasien der Brust erfordert nur die Subgruppe der duktalen In-situ-Karzinome (DCIS; Synonym für „ductal intraepithelial neoplasia“, DIN) Therapiemodalitäten zur Senkung des Rückfallrisikos nach kompletter Exzision des DCIS, speziell eine RT nach brusterhaltender operativer Therapie (BCS) als Alternative zur Mastektomie. Die Hälfte aller Erkrankungsrückfälle sind invasive Karzinome. Etwa 50 % der Patientinnen benötigen beim Rezidiv eine Salvage-Mastektomie. Randomisierte klinische Studien und eine große Anzahl von Beobachtungsstudien belegten übereinstimmend, dass eine RT das Risiko invasiver und nicht-invasiver Rückfälle signifikant, altersunabhängig und in allen Subgruppen senkt. Allgemein empfohlen wird eine Gesamtdosis von 50 Gy, appliziert als perkutane RT der gesamten Brust (WBI) in Fraktionen von 1,8–2,0 Gy an 5 Tagen pro Woche. Retrospektiv erhobene Daten weisen auf einen zusätzlichen Benefit durch eine Boost-RT der Tumorregion für junge Patientinnen hin. Prospektiv randomisierte klinische Studien verschiedener Dosis-Volumen-Konzepte (Hypofraktionierung, akzelerierte Teilbrust-RT) werden dazu derzeit durchgeführt.

Schlussfolgerung

Eine postoperative RT ermöglicht eine brusterhaltende Therapie für die Mehrzahl der Patientinnen, da hierdurch die Rezidivrate halbiert und das Risiko einer Progression vom DCIS zu invasiven Karzinomen vermindert werden. Daten neuer Studien bestätigen diese Effekte für sämtliche Patientinnengruppen – also auch für die Niedrig-Risikogruppe (LoE 1a).

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Conflict of interest. R. Souchon, M.-L. Sautter-Bihl, W. Budach, J. Dunst, P. Feyer, R. Fietkau, W. Haase, W. Harms, and R. Sauer state that there are no conflicts of interest. F. Wenz declares the following: research cooperation, speaker’s fees, and travel reimbursement received from Elektra and Carl Zeiss Meditec. F. Sedlmayer declares the following: research cooperation with Elektra, study sponsorship and travel reimbursement received from IntraOp Medical.

The accompanying manuscript does not include studies on humans or animals.

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Authors and Affiliations

  1. Klinik für Radioonkologie, University Hospital Tübingen, Hoppe-Seyler-Str. 3, 72076, Tübingen, Germany

    R. Souchon

  2. Municipal Hospital Karlsruhe, Karlsruhe, Germany

    M.-L. Sautter-Bihl

  3. LKH Salzburg, Paracelsus Medical University Hospital, Salzburg, Austria

    F. Sedlmayer

  4. University Hospital Duesseldorf, Duesseldorf, Germany

    W. Budach

  5. University Hospital Schleswig-Holstein, Luebeck, Germany

    J. Dunst

  6. Klinikum Neukoelln, Berlin, Germany

    P. Feyer

  7. University Hospital Erlangen, Erlangen, Germany

    R. Fietkau & R. Sauer

  8. Formerly St.-Vincentius-Kliniken, Karlsruhe, Germany

    W. Haase

  9. St. Clara Hospital, Basel, Switzerland

    W. Harms

  10. University Hospital Mannheim, Mannheim, Germany

    F. Wenz

Authors
  1. R. Souchon
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  2. M.-L. Sautter-Bihl
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  3. F. Sedlmayer
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  4. W. Budach
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  5. J. Dunst
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  6. P. Feyer
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  7. R. Fietkau
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  8. W. Haase
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  9. W. Harms
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  10. F. Wenz
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  11. R. Sauer
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Consortia

Breast Cancer Expert Panel of the German Society of Radiation Oncology (DEGRO)

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Correspondence to R. Souchon.

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Souchon, R., Sautter-Bihl, ML., Sedlmayer, F. et al. DEGRO practical guidelines: radiotherapy of breast cancer II. Strahlenther Onkol 190, 8–16 (2014). https://doi.org/10.1007/s00066-013-0502-3

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  • DOI: https://doi.org/10.1007/s00066-013-0502-3

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