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Radiotherapy after skin-sparing mastectomy with immediate breast reconstruction in intermediate-risk breast cancer

Indication and technical considerations

Strahlentherapie nach hautschonender Mastektomie mit sofortiger Brustrekonstruktion bei Brustkrebs mit intermediärem Risiko

Indikation und technische Überlegungen

  • Review Article
  • Published:
Strahlentherapie und Onkologie Aims and scope Submit manuscript

Abstract

Background

Skin-sparing (SSME) and nipple-sparing mastectomy (NSME) were developed to improve the cosmetic results for breast cancer (BC) patients, both allowing for immediate breast reconstruction. Recommendations for post-mastectomy radiotherapy (PMRT) are primarily derived from trials where patients were treated by standard mastectomies. Due to their more conservative character, SSME and especially NSME potentially leave more glandular tissue at risk for subclinical disease.

Methods

Rates and sites of locoregional failures following SSME and NSME plus/minus reconstruction were analyzed regarding tumor stage and biological risk factors. In particular, the role of PMRT in “intermediate”-risk and early stage high-risk breast cancer patients was revisited. Implications on targeting and dose delivery of PMRT were critically reviewed.

Results

The value of PMRT in stage III BC remains undisputed. For node-negative BC patients, the majority of reports classify clinical and biological features such as tumor size, close surgical margins, premenopausal status, multicentricity, lymphangiosis, triple-negativity, HER2-overexpression, and poor tumor grading as associated with higher rates of locoregional relapse, thus, building an “intermediate” risk group. Surveys revealed that the majority of radiation oncologists use risk-adaptive models also considering the number of coinciding factors for the estimation of recurrence probability following SSME and NSME. Constellations with a 10-year locoregional recurrence risk of >10% are usually triggering the indication for PMRT. There was no common belief that the amount of residual tissue, e.g., tissue thickness over flaps, serves as additional decision aid. Modern treatment planning can ensure optimal dose distribution for PMRT in almost all patients with SSME. There are no reliable data supporting a reduction of the treatment volume from the CTV chest wall, e.g., to the nipple-areola complex, to the dorsal aspect behind the implant volume, the pectoralis muscle, nor the regional interpectoral, axillary, or complete regional lymph nodes only. The omission of a skin bolus in intermediate-risk BC does not compromise oncological safety.

Conclusions

For intermediate-risk as well as early stage high-risk BC patients, the DEGRO Breast Cancer Expert Panel recommends the use of PMRT following SSME and NSME when a 10-year locoregional recurrence risk is likely to be greater than 10%, as estimated by clinical and biological risk factors. Subvolume-only radiation is discouraged outside of trials. The impact of adequate systemic treatment and the value of radiotherapy on optimal locoregional tumor control, with the goal of less than 5% LRR at 10-years follow-up, has to be verified in prospective trials.

Zusammenfassung

Hintergrund

Für Brustkrebs(BC)-Patientinnen mit Indikation zur Brustentfernung können die hautschonende („skin sparing“, SSME) und die brustwarzenschonende Mastektomie („nipple sparing“, NSME) die kosmetischen Ergebnisse verbessern und eine sofortige Brustrekonstruktion ermöglichen. Empfehlungen zur Strahlentherapie nach Mastektomie (PMRT) basieren in erster Linie auf Studien von Patientinnen ohne sofortige Brustrekonstruktion. Wegen des weniger radikalen operativen Vorgehens mit verbleibendem Drüsengewebe bei der SSME und NSME ist ein erhöhtes Risiko für subklinischen Tumorbefall zu erwarten.

Methoden

Das lokoregionäre Rückfallrisiko und die Lokalisation der Rezidive nach SSME und NSME mit/ohne Rekonstruktion wurden in Abhängigkeit vom Tumorstadium und biologischen Risikofaktoren analysiert. Insbesondere der Stellenwert einer PMRT bei BC-Patientinnen im Stadium II mit „intermediärem“ Rückfallrisiko sowie im Stadium I mit hohem Rückfallrisiko wurden überprüft. Auswirkungen einer sofortigen Brustrekonstruktion auf das Zielvolumen und die Dosisverteilung der PMRT werden kritisch bewertet.

Ergebnisse

Die Indikation zur PMRT im BC-Stadium III ist unbestritten. Für BC-Patientinnen ohne Lymphknotenmetastasen werden in den überwiegenden Studien klinische und biologische Merkmale mit einem erhöhten lokoregionären Rückfallrisiko beschrieben: Tumorgröße, knappe Resektionsgrenzränder, prämenopausaler Status, Multizentrizität, Lymphangiosis, triple-negative Tumoren, Her2-Überexpression und ein undifferenziertes Tumorgrading, wodurch eine „intermediäre“ Rückfallrisikogruppe beschrieben werden kann. Umfragen zeigen, dass die überwiegende Anzahl erfahrener Strahlentherapeuten zur Abschätzung des Rückfallrisikos auch die Anzahl der Risikofaktoren nach SSME und NSME berücksichtigt. Eine Risikofaktorenkonstellation mit einem 10-Jahres-Rückfallrisiko von >10 % begründet typischerweise die Indikation zur PMRT. Aus radioonkologischer Sicht werden weitere Faktoren, wie z. B. das subkutan verbliebene Gewebevolumen nach SSME und NSME, nicht als Entscheidungskriterien herangezogen. Die aktuellen Bestrahlungsplanungssysteme können bei nahezu allen Patientinnen nach SSME und NSME eine optimale Zielvolumenerfassung und Dosisverteilung sicherstellen. Es liegen keine validen Daten vor, die Reduktionen des Zielvolumens „Brustwand“ auf z. B. den Nipple-Areola-Komplex, das Volumen hinter dem Brustimplantat, den M. pectoralis oder auf die interpektoralen, axillären oder kompletten Lymphabflusswege erlauben. Der Verzicht auf einen Bolus auf der Haut bei „intermediärem“ Rückfallrisiko beeinträchtigt die onkologische Sicherheit der PMRT nicht.

Schlussfolgerungen

Für BC-Patientinnen mit „intermediate-risk“ und „early stage high-risk“ empfiehlt das Expertenpanel Mamma der DEGRO den Einsatz der PMRT nach SSME und NSME, sobald klinische und biologische Faktoren ein 10-Jahres-Rückfallrisiko >10% erwarten lassen. Außerhalb klinischer Studien wird eine Reduktion der PMRT auf Subvolumina der Brustwand nicht empfohlen. Der Einfluss einer adäquaten Systemtherapie und der Stellenwert einer PMRT für eine optimale lokoregionäre Tumorkontrolle mit dem Ziel einer lokoregionären 10-Jahres-Rezidivrate <5% sollten in prospektiven Studien überprüft werden.

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Authors and Affiliations

  1. Marienhospital Stuttgart, Stuttgart, Germany

    Thomas Hehr

  2. St. Marien-Krankenhaus Siegen, Siegen, Germany

    René Baumann

  3. Heinrich-Heine-University Hospital Düsseldorf, Düsseldorf, Germany

    Wilfried Budach

  4. Universitätsklinikum Jena, Jena, Germany

    Marciana-Nona Duma

  5. University Hospital Schleswig-Holstein, Kiel, Germany

    Jürgen Dunst & David Krug

  6. Vivantes Hospital Neukoelln, Berlin, Germany

    Petra Feyer

  7. University Hospital Erlangen, Erlangen, Germany

    Rainer Fietkau & Rolf Sauer

  8. St.-Vincentius-Hospital Karlsruhe, Karlsruhe, Germany

    Wulf Haase

  9. St. Claraspital Basel, Basel, Switzerland

    Wolfgang Harms

  10. Helios University Hospital Wuppertal, Witten/Herdecke University, Wuppertal, Germany

    Marc D. Piroth

  11. Paracelsus Medical University Hospital Salzburg, Salzburg, Austria

    Felix Sedlmayer

  12. University Hospital, Tübingen, Germany

    Rainer Souchon

  13. Universitätsklinikum Freiburg, Freiburg, Germany

    Frederick Wenz

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T. Hehr, R. Baumann, W. Budach, M.-N. Duma, J. Dunst, P. Feyer, R. Fietkau, W. Haase, W. Harms, D. Krug, M.D. Piroth, F. Sedlmayer, R. Souchon, F. Wenz and R. Sauer declare that they have no competing interests.

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Hehr, T., Baumann, R., Budach, W. et al. Radiotherapy after skin-sparing mastectomy with immediate breast reconstruction in intermediate-risk breast cancer. Strahlenther Onkol 195, 949–963 (2019). https://doi.org/10.1007/s00066-019-01507-9

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  • DOI: https://doi.org/10.1007/s00066-019-01507-9

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