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Heart-sparing radiotherapy techniques in breast cancer patients: a recommendation of the breast cancer expert panel of the German society of radiation oncology (DEGRO)

Herzschonende Strahlentherapietechniken bei Brustkrebspatientinnen: Eine Stellungnahme des Brustkrebs-Expertenpanels der Deutschen Gesellschaft für Radioonkologie (DEGRO)

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

Abstract

Purpose

The aim of this review was to analyze the respective efficacy of various heart-sparing radiotherapy techniques.

Material and methods

Heart-sparing can be performed in three different ways in breast cancer radiotherapy: by seeking to keep the heart out of treated volumes (i.e. by prone position or specific breathing techniques such as deep inspiration breath-hold [DIBH] and/or gating), by solely irradiating a small volume around the lumpectomy cavity (partial breast irradiation, PBI), or by using modern radiation techniques like intensity-modulated radiation therapy (IMRT), volumetric modulated arc therapy (VMAT) or protons. This overview presents the available data on these three approaches.

Results

Studies on prone position are heterogeneous and most trials only refer to patients with large breasts; therefore, no definitive conclusion can be drawn for clinical routine. Nonetheless, there seems to be a trend toward better sparing of the left anterior descending artery in supine position even for these selected patients. The data on the use of DIBH for heart-sparing in breast cancer patients is consistent and the benefit compared to free-breathing is supported by several studies. In comparison with whole breast irradiation (WBI), PBI has an advantage in reducing the heart dose. Of note, DIBH and PBI with multicatheter brachytherapy are similar with regard to the dose reduction to heart structures. WBI by IMRT/VMAT techniques without DIBH is not an effective strategy for heart-sparing in breast cancer patients with “standard” anatomy. A combination of DIBH and IMRT may be used for internal mammary radiotherapy.

Conclusion

Based on the available findings, the DEGRO breast cancer expert panel recommends the use of DIBH as the best heart-sparing technique. Nonetheless, depending on the treatment volume and localization, other techniques may be employed or combined with DIBH when appropriate.

Zusammenfassung

Zielsetzung

Das Ziel dieser Übersichtsarbeit ist eine Darstellung der verfügbaren Strahlentherapietechniken zur Herzschonung bezüglich ihrer Effektivität.

Material und Methoden

Im Rahmen der postoperativen Radiotherapie von Patienten mit Mammakarzinom gibt es drei wesentliche Möglichkeiten zur Herzschonung: Durch eine Verlagerung des Herzens aus dem Bestrahlungsvolumen (z. B. durch eine Bestrahlung in Bauchlage oder eine Bestrahlung in tiefer Inspiration [DIBH] mit oder ohne Gating), durch eine Reduktion des Bestrahlungsvolumens auf das Tumorbett mit einem geringen Sicherheitssaum im Sinne einer Teilbrustbestrahlung (PBI) oder durch die Verwendung moderner Bestrahlungstechniken wie der intensitätsmodulierten Radiotherapie (IMRT), der volumenmodulierten Rotationsbestrahlung (VMAT) oder Protonen. Es wird ein Überblick über die Datenlage zu diesen drei Ansätzen präsentiert.

Ergebnisse

Die Studien zur Bestrahlung in Bauchlage liefern heterogene Ergebnisse und beziehen sich zumeist auf Patientinnen mit großen Mammae, sodass keine klare Empfehlung für die klinische Routine gegeben werden kann. Selbst für diese ausgewählten Patientinnen zeigt sich bezogen auf die Schonung des Ramus interventricularis anterior (LAD, „left anterior descending artery“) eher ein Vorteil zugunsten der Bestrahlung in Rückenlage. Die Datenlage zur Bestrahlung in DIBH ist konsistent und zeigt über viele Studien hinweg einen Vorteil gegenüber der Bestrahlung in freier Atmung. Im Vergleich zur Ganzbrustbestrahlung kann durch eine PBI die Strahlendosis am Herzen gesenkt werden. Bemerkenswert ist, dass durch PBI und DIBH vergleichbare Dosisreduktionen am Herzen gegenüber einer Ganzbrustbestrahlung erreicht werden können. Für Patientinnen ohne anatomische Besonderheiten stellen die IMRT oder VMAT keine effektiven Strategien zur Herzschonung dar. Im Fall einer Bestrahlung der Mammaria-interna-Lymphabflusswege kann eine Kombination aus DIBH und IMRT angewendet werden.

Schlussfolgerung

Auf Grundlage der vorliegenden Studiendaten wird die Verwendung von DIBH zur Herzschonung empfohlen. Nichtsdestotrotz können in Abhängigkeit individueller Faktoren wie Behandlungsvolumen und -lokalisation alternative Verfahren, ggf. in Kombination mit DIBH, zum Einsatz kommen.

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Authors and Affiliations

  1. Department of Radiotherapy and Radiation Oncology, University Hospital, Friedrich-Schiller-University, Bachstr. 18, 07745, Jena, Germany

    Marciana-Nona Duma

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

    René Baumann

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

    Wilfried Budach

  4. University Hospital Schleswig-Holstein, Kiel, Germany

    Jürgen Dunst & David Krug

  5. Vivantes Hospital Neukoelln, Berlin, Germany

    Petra Feyer

  6. University Hospital Erlangen, Erlangen, Germany

    Rainer Fietkau & Rolf Sauer

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

    Wulf Haase

  8. St. Claraspital Basel, Basel, Switzerland

    Wolfgang Harms

  9. Marienhospital Stuttgart, Stuttgart, Germany

    Thomas Hehr

  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

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  1. Marciana-Nona Duma
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  2. René Baumann
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  3. Wilfried Budach
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  4. Jürgen Dunst
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  5. Petra Feyer
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  7. Wulf Haase
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  8. Wolfgang Harms
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  9. Thomas Hehr
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  10. David Krug
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  11. Marc D. Piroth
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  12. Felix Sedlmayer
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  13. Rainer Souchon
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  14. Rolf Sauer
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Consortia

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

Corresponding author

Correspondence to Marciana-Nona Duma.

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Conflict of interest

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

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Duma, MN., Baumann, R., Budach, W. et al. Heart-sparing radiotherapy techniques in breast cancer patients: a recommendation of the breast cancer expert panel of the German society of radiation oncology (DEGRO). Strahlenther Onkol 195, 861–871 (2019). https://doi.org/10.1007/s00066-019-01495-w

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