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Strahlentherapeutische Konzepte nach Neoadjuvanz

Radiotherapy after neoadjuvant chemotherapy

  • Leitthema
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Die Gynäkologie Aims and scope

Zusammenfassung

Hintergrund

Die neoadjuvante Chemotherapie (NACT) wird gegenüber der adjuvanten Chemotherapie mittlerweile in vielen Situationen bevorzugt. Das Therapieansprechen ist ein wichtiger Prognosefaktor und wird zunehmend zur Individualisierung der (post-neo-)adjuvanten Therapie eingesetzt.

Fragestellung

Was ist der Stellenwert der adjuvanten Radiotherapie bei Patientinnen mit Mammakarzinom, die eine NACT erhalten haben?

Material und Methode

Halbstrukturiere Literaturrecherche.

Ergebnisse

Das Therapieansprechen auf die NACT ist neben der bekannten Assoziation zu krankheitsfreiem und Gesamtüberleben auch ein wichtiger Prognosefaktor für das lokoregionäre Rezidiv. Nach brusterhaltender Operation ist die adjuvante Radiotherapie der Brust weiterhin empfohlen, eine Teilbrustbestrahlung sollte nicht angewendet werden. Bezüglich einer Bestrahlung der Lymphabflusswege sowie der Thoraxwand nach Mastektomie liegen für Patientinnen mit cT1–2-cN1-Stadium erste prospektive Daten zur Anpassung der Zielvolumina anhand des ypN-Stadiums vor. Bei lokal fortgeschrittenen Erkrankungen sollte eine Bestrahlung auf Basis des klinischen Ausgangsstadiums und unabhängig vom Therapieansprechen erfolgen.

Diskussion

Die adjuvante Radiotherapie ist auch nach NACT regelhaft indiziert. Zur Indikationsstellung sind sowohl das klinische Stadium vor, als auch das pathologische Stadium nach NACT relevant. Insbesondere bei Patientinnen mit pathologischer Komplettremission nach NACT besteht Potenzial für eine Deeskalation der Bestrahlungsvolumina – Ergebnisse aus randomisierten kontrollierten Studien wie NSABP B-51/RTOG 1304 stehen jedoch noch aus und werden erst in mehreren Jahren vorliegen.

Abstract

Background

Neoadjuvant chemotherapy (NACT) is favored over adjuvant chemotherapy in many situations for patients with breast cancer. Treatment response is an important prognostic factor and is increasingly used for individualization of (post-neo)adjuvant treatment.

Objective

This article aims to give an overview of current changes and controversies regarding adjuvant radiotherapy for patients with breast cancer who have received NACT.

Materials and methods

A semi-structured literature review was performed.

Results

Treatment response to NACT is not only associated with disease-free and overall survival, but also with the risk of locoregional recurrence. After breast-conserving surgery, adjuvant whole-breast radiotherapy is recommended, partial-breast irradiation should not be performed. Regarding regional nodal irradiation and post-mastectomy radiotherapy, first prospective data show that target volumes may be adapted according to nodal treatment response for patients with cT1–2 cN1 breast cancer. In patients with locally advanced breast cancer, radiotherapy should be performed based on clinical staging before NACT, regardless of treatment response.

Conclusion

Adjuvant radiotherapy remains the standard of care for most patients after NACT. Both the clinical stage as well as the pathological stage after NACT should inform the clinical decision-making. For patients with pathological complete response, there is potential for de-escalation of radiotherapy target volumes; however, results from randomized controlled trials such as NSABP B‑51/RTOG 1304 are still pending and will not be available for several years.

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Authors and Affiliations

  1. Klinik für Strahlentherapie, Campus Kiel, Universitätsklinikum Schleswig-Holstein (UKSH), Arnold-Heller-Str. 3, 24105, Kiel, Deutschland

    David Krug &  Jürgen Dunst

  2. Klinik für Gynäkologie und Geburtshilfe, Universitätsklinikum Schleswig-Holstein (UKSH) Campus Kiel, Kiel, Deutschland

    Nicolai Maass &  Marion van Mackelenbergh

Authors
  1. David Krug
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  2. Nicolai Maass
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  3. Marion van Mackelenbergh
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  4. Jürgen Dunst
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Corresponding author

Correspondence to David Krug.

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Interessenkonflikt

D. Krug erhielt Vortragshonorare von Merck Sharp & Dohme und Pfizer sowie Forschungsunterstützung von Merck KGaA. N. Maass, M. van Mackelenbergh und J. Dunst geben an, dass kein Interessenkonflikt besteht.

Für diesen Beitrag wurden von den Autor/-innen keine Studien an Menschen oder Tieren durchgeführt. Für die aufgeführten Studien gelten die jeweils dort angegebenen ethischen Richtlinien.

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Wolfgang Janni, Ulm

Tanja Fehm, Düsseldorf

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Krug, D., Maass, N., van Mackelenbergh, M. et al. Strahlentherapeutische Konzepte nach Neoadjuvanz. Gynäkologie 56, 325–329 (2023). https://doi.org/10.1007/s00129-023-05079-9

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