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DEGRO Practice Guidelines for Palliative Radiotherapy of Metastatic Breast Cancer

Bone Metastases and Metastatic Spinal Cord Compression (MSCC)

DEGRO-Handlungsleitlinie zur palliativen Radiotherapie bei metastasiertem Mammakarzinom. Knochenmetastasen und metastatisch bedingtes spinales Kompressionssyndrom (MSCC)

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Purpose:

To provide practice guidelines and clinical recommendations on preferred standard palliative radiation therapy of bone metastases as well as metastatic spinal cord compression (MSCC) for metastatic breast cancer patients.

Methods:

The breast cancer expert panel of the German Society of Radiation Oncology (DEGRO) performed a comprehensive survey of the literature comprising recently published data from clinical controlled trials. The literature search encompassed the period 1995–2008 using databases of PubMed and Guidelines International Network (G-I-N). Search terms were “breast cancer”, “bone metastasis”, “osseous metastasis”, “metastatic spinal cord compression” as well as “radiotherapy” and “radiation therapy”. Clinical recommendations were formulated based on the panel’s interpretation of the level of evidence referring to the criteria of evidence-based medicine.

Results:

Different therapeutic goals (pain relief, local tumor control, prevention or improvement of motor deficits, stabilization of the spine or other bones) require complex approaches considering individual factors (i.e., life expectancy, tumor progression at other sites). Best results are achieved by close interdisciplinary cooperation minimizing the interval between diagnosis and onset of treatment. Most important criteria for prognosis and choice of treatment (mostly combined multimodal therapy) are neurologic status at diagnosis of MSCC, time course of duration and progression of the neurologic symptoms. Radiation therapy is effective and regarded as treatment of choice for MSCC with or without motor deficits and/or bone metastases, which do not need immediate surgical intervention. It may be used either postoperatively or as primary treatment in case of inoperability. An optimal dose fractionation schedule or optimal standard dose for treatment of bone metastases has not been established. With regard to different therapeutic goals, different dose concepts and fractionation schedules, single- versus multifraction palliative radiation therapy (1 × 8, 5 × 4, 10 × 3, 15 × 2.5, 20 × 2 Gy), should be adapted individually.

Conclusion:

Bone metastases as well as MSCC should be managed in an interdisciplinary approach mostly as combined-modality treatment according to the specific clinical situation. The present practice guidelines offer criteria and recommendations for different radiooncologic treatment schedules based on the best available levels of evidence. Preferred technique, targeting and different dose schedules are described in detail.

Ziel:

In dieser Arbeit werden praktische Handlungsleitlinien und klinische Hinweise zur empfohlenen palliativen radioonkologischen Therapie bei ossärer Metastasierung und bei tumorbedingtem spinalen Kompressionssyndrom (MSCC) bei Patientinnen mit Mammakarzinom gegeben.

Methodik:

Das Expertengremium der Organgruppe Mamma der Deutschen Gesellschaft für Radioonkologie (DEGRO) erarbeitete diese Empfehlungen auf der Grundlage einer intensiven Literaturrecherche unter Einbeziehung von Daten aktuell publizierter kontrollierter klinischer Studien. Entsprechend den Kriterien der evidenzbasierten Medizin erfasste die systematische Suche in den Datenbanken von PubMed und Guidelines International Network (G-I-N) den Zeitraum von 1995 bis 2008. Suchbegriffe waren „breast cancer“, „bone metastasis“, „osseous metastasis“, „metastatic spinal cord compression“, „radiation therapy“ und „radiotherapy“.

Ergebnisse:

Unterschiedliche Therapieziele (Schmerzlinderung, lokale Tumorkontrolle, Prävention und Rückbildung neurologischer Ausfälle, ossäre Stabilisierung) erfordern auf den individuellen Fall abgestimmte differenzierte Behandlungskonzepte (Berücksichtigung von Lebenserwartung und Tumoraktivität an weiteren Orten). Die besten Ergebnisse werden bei enger interdisziplinärer Zusammenarbeit und kurzem Zeitintervall zwischen Diagnose und Therapiebeginn erreicht. Beim MSCC sind neurologischer Ausgangsbefund bei Diagnose, Dauer und zeitlicher Verlauf der neurologischen Symptomatik die wichtigsten Kriterien zur Beurteilung der Prognose und Therapieauswahl (bei mehrheitlich kombiniertem multimodalen Behandlungsansatz). Die Radiotherapie ist wirksam und – sofern keine sofortige chirurgische Intervention erforderlich ist – dringlich indiziert zur Therapie des MSCC und bei Knochenbefall mit oder ohne motorische Ausfälle, unabhängig vom Effekt einer initialen Kortikoidtherapie. Sie wird postoperativ oder primär bei Inoperabilität eingesetzt. Ein optimales Dosisfraktionierungsschema oder optimale Standarddosierungen sind für die Therapie von Knochenmetastasen nicht etabliert. Im Hinblick auf differierende Therapieziele kommen unterschiedliche Dosiskonzepte und Fraktionierungsschemata in Form von Einzel- oder Multifraktionierungsradiotherapie (1 × 8, 5 × 4, 10 × 3, 15 × 2,5, 20 × 2 Gy) entsprechend den verschiedenen klinischen Situationen zur Anwendung.

Schlussfolgerung:

Im interdisziplinären Management bei ossären Metastasen und beim MSCC ist der Entscheidungsprozess für die multimodale Kombinationstherapie an der individuellen Patientensituation auszurichten. Die hier vorgelegten Handlungsleitlinien liefern dazu Kriterien auf der Basis der jeweils höchsten Evidenzstufe („level of evidence“ [LoE]).

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Authors and Affiliations

  1. Department of Radiation Oncology, UKT Tübingen, Tübingen, Germany

    Rainer Souchon

  2. University Hospital Mannheim, Mannheim, Germany

    Frederik Wenz

  3. University Hospital, Salzburger Landeskliniken, Salzburg, Austria

    Felix Sedlmayer

  4. University Hospital Duesseldorf, Duesseldorf, Germany

    Wilfried Budach

  5. University Hospital Schleswig-Holstein, Luebeck, Germany

    Jürgen Dunst

  6. Klinikum Neukoelln, Berlin, Germany

    Petra Feyer

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

    Wulf Haase

  8. St. Clara Hospital, Basel, Switzerland

    Wolfgang Harms

  9. Municipal Hospital, Karlsruhe, Germany

    Marie-Luise Sautter-Bihl

  10. University Hospital Erlangen, Erlangen, Germany

    Rolf Sauer

  11. Department of Radiation, Oncology UKT Tübingen, Hoppe-Seyler-Straße 3, 72079, Tübingen, Germany

    Rainer Souchon

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  1. Rainer Souchon
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Souchon, R., Wenz, F., Sedlmayer, F. et al. DEGRO Practice Guidelines for Palliative Radiotherapy of Metastatic Breast Cancer. Strahlenther Onkol 185, 417–424 (2009). https://doi.org/10.1007/s00066-009-2044-2

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