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Bestrahlung der Mamma nach brusterhaltender Operation

Aktuelle Standards

Irradiation of the breast after breast conserving surgery

Current medical practice

  • Leitthema
  • Published:
Der Onkologe Aims and scope

Zusammenfassung

Hintergrund

Nach brusterhaltender Operation ist eine Nachbestrahlung indiziert. Es stellt sich die Frage, wie stark ausgeprägt die Effekte der Bestrahlung auf das Lokalrezidivrisiko und Überleben sind und ob nicht bei bestimmten Subgruppen auf eine Bestrahlung verzichtet werden kann. Außerdem ist interessant, ob auch kürzere Fraktionierungsschemata angewendet werden können sowie in welchen Fällen und in welcher Technik ein Boost appliziert wird. Des Weiteren sollte eine Stellungsnahme zur Rebestrahlung erfolgen.

Ziel

Evidenzbasierter Review zur Klärung von Indikation, Fraktionierung, Technik von adjuvanter Homogenbestrahlung der Brust und Boost sowie Möglichkeit der Rebestrahlung.

Material und Methode

Mittels systematischer Literaturrecherche von Pubmed und manueller Suche wurden relevante Publikationen zwischen 1985 (tierexperimentelle Daten) und 2013 untersucht. Der Publikation wurde insbesondere die Metaanalyse der Early Breast Cancer Trialists Collaborative Group (EBCTCG) mit 10.801 Patientinnen aus randomisierten Studien und bis zu 15 Jahren Nachbeobachtungszeit zugrunde gelegt.

Ergebnisse

Nach brusterhaltender Operation ist eine Nachbestrahlung der Brust in allen Subgruppen indiziert. Zusätzlich kann zur Senkung des Lokalrezdivrisikos ein Boost appliziert werden. Langzeitergebnisse weisen darauf hin, dass neben der normofraktionierten Strahlentherapie auch hypofraktionierte Bestrahlungsschemata bei Patientinnen mit niedrigem Rückfallrisiko (ältere Patientinnen ohne lokoregionären Lymphknotenbefall, die keine Chemotherapie benötigen, mit < 5 cm großen Tumoren) zum Einsatz kommen können. Von einem gehäuften Auftreten einer koronaren Herzerkrankung nach linksseitiger Bestrahlung ist nach der aktuellen Datenlage nicht mehr auszugehen, wobei Langzeitergebnisse > 15 Jahre fehlen. Rebestrahlungen sind möglich; allerdings sollte ein Zeitabstand von mindestens 6 Monaten eingehalten werden.

Schlussfolgerungen

Grundsätzlich handelt es sich bei der adjuvanten Strahlentherapie nach brusterhaltender Operation um eine gut untersuchte, nebenwirkungsarme Therapie mit der Möglichkeit, das Lokalrezidivrisiko um den Faktor 3 zu senken und mit 4 verhinderten Lokalrezidiven statistisch einen Todesfall zu vermeiden.

Abstract

Background

After breast-conserving surgery additional postoperative irradiation of breasts is indicated. The question is raised how extensive the benefit concerning local recurrence rate and overall survival is. Additionally it is interesting to know if a hypofractionated radiotherapy schedule can be safely used and in which cases a boost is indicated. Furthermore, an appraisal is made concerning re-irradiation.

Objective

This was an evidence-based review for clarification of the indications, fractionation schedules, techniques for whole breast irradiation and boost as well as re-irradiation.

Materials and methods

A systematic literature research of PubMed, Medline was carried out for relevant publications between 1985 (animal data) and 2013 was performed. The results of the early breast cancer trialists’ collaborative group (EBCTCG) meta-analysis of 10,801 patients from randomized trials with up to 15 years follow-up was also included in the review

Results

After breast-conserving surgery, adjuvant radiotherapy is indicated in all subgroups. In addition, to reduce the local tumor recurrence rate a boost can be applied. Long-term results indicated that besides the normofractionated radiotherapy regime a hypofractionated radiotherapy in patients with a low risk of relapse (elderly patients without locoregional lymph node involvement which does not require chemotherapy and tumor size < 5 cm) can be used. An increased rate of coronary heart disease after left-sided irradiation can no longer be assumed according to the current data although long-term results > 15 years are pending. Re-irradiation is possible but an interval of at least 6 months is mandatory.

Conclusions

Adjuvant radiotherapy after breast-conserving surgery is a well-studied therapy with less side effects. There is an opportunity to reduce the risk of local recurrence by a factor of 3 and statistically to prevent one death with four prevented local recurrences.

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Interessenkonflikt

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Authors and Affiliations

  1. Medizinische Fakultät, Klinik für Strahlentherapie und Radiologische Onkologie, Heinrich-Heine-Universität Düsseldorf, Moorenstraße 5, 40225, Düsseldorf, Deutschland

    C. Matuschek, E. Bölke & W. Budach

  2. Klinik für Allgemein-, Viszeral- und Thoraxchirurgie, Harzklinik Goslar, Goslar, Deutschland

    K. Orth

  3. Medizinische Fakultät, Frauenklinik, Heinrich-Heine-Universität Düsseldorf, Düsseldorf, Deutschland

    K. Zwiefel

  4. Klinik für Senologie, Krankenhaus Gerresheim, Gerresheim, Deutschland

    C. Nestle-Krämling

Authors
  1. C. Matuschek
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  2. E. Bölke
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  3. K. Orth
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  4. K. Zwiefel
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  5. C. Nestle-Krämling
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  6. W. Budach
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Correspondence to C. Matuschek.

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Matuschek, C., Bölke, E., Orth, K. et al. Bestrahlung der Mamma nach brusterhaltender Operation. Onkologe 19, 471–480 (2013). https://doi.org/10.1007/s00761-013-2452-x

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  • DOI: https://doi.org/10.1007/s00761-013-2452-x

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