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DEGRO practical guidelines for radiotherapy of breast cancer IV

Radiotherapy following mastectomy for invasive breast cancer

DEGRO Leitlinien für die Radiotherapie des Mammakarzinoms IV

Radiotherapie nach Mastektomie beim invasiven Mammakarzinom

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Strahlentherapie und Onkologie Aims and scope Submit manuscript

Abstract

Background and purpose

Since the last recommendations from the Breast Cancer Expert Panel of the German Society for Radiation Oncology (DEGRO) in 2008, evidence for the effectiveness of postmastectomy radiotherapy (PMRT) has grown. This growth is based on updates of the national S3 and international guidelines, as well as on new data and meta-analyses. New aspects were considered when updating the DEGRO recommendations.

Methods

The authors performed a comprehensive survey of the literature. Data from recently published (meta-)analyses, randomized clinical trials and international cancer societies’ guidelines yielding new aspects compared to 2008 were reviewed and discussed. New aspects were included in the current guidelines. Specific issues relating to particular PMRT constellations, such as the presence of risk factors (lymphovascular invasion, blood vessel invasion, positive lymph node ratio > 20 %, resection margins < 3 mm, G3 grading, young age/premenopausal status, extracapsular invasion, negative hormone receptor status, invasive lobular cancer, size > 2 cm or a combination of ≥ 2 risk factors) and 1–3 positive lymph nodes are emphasized.

Results

The evidence for improved overall survival and local control following PMRT for T4 tumors, positive resection margins, > 3 positive lymph nodes and in T3 N0 patients with risk factors such as lymphovascular invasion, G3 grading, close margins, and young age has increased. Recently identified risk factors such as invasive lobular subtype and negative hormone receptor status were included. For patients with 1–3 positive lymph nodes, the recommendation for PMRT has reached the 1a level of evidence.

Conclusion

PMRT is mandatory in patients with T4 tumors and/or positive lymph nodes and/or positive resection margins. PMRT should be strongly considered in patients with T3 N0 tumors and risk factors, particularly when two or more risk factors are present.

Zusammenfassung

Hintergrund und Ziel

Seit der letzten Aktualisierung der 2008 publizierten Leitlinie der „Expertengruppe Mammakarzinom“ der Deutschen Gesellschaft für Radioonkologie (DEGRO) zur Strahlentherapie nach Mastektomie (PMRT) hat sich die Evidenz für die Effektivität der PMRT aufgrund von Überarbeitungen der nationalen S3- und internationaler Leitlinien sowie neuer Daten und Metaanalysen verstärkt. Hieraus resultierende neue Erkenntnisse wurden bei der Aktualisierung der DEGRO-Leitlinien berücksichtigt.

Methode

Die Autoren führten eine umfassende Literaturrecherche durch. Es wurden Daten aktueller (Meta-)Analysen, randomisierter klinischer Studien und Leitlinien internationaler Krebsgesellschaften auf Neuerungen gegenüber 2008 überprüft und diskutiert. Daraus abgeleitete Änderungen wurden in die aktuellen Empfehlungen eingearbeitet. Es wurden spezielle Fragestellungen in Bezug auf eine PMRT bei speziellen Konstellationen wie dem Vorliegen von Risikofaktoren (lymphovaskuläre Invasion, vaskuläre Invasion, positive „lymph node ratio“ > 20 %, Resektionsränder < 3 mm, Grading G3, junges Alter/Prämenopausalstatus, extrakapsuläre Invasion, negative Hormonrezeptoren, invasive lobuläre Tumoren, Tumorgröße > 2 cm oder eine Kombination von ≥ 2 Risikofaktoren) und von 1–3 positiven Lymphknoten untersucht.

Ergebnisse

Die Evidenz für verbesserte Überlebenswahrscheinlichkeit und lokoregionale Kontrolle nach PMRT bei T4-Tumoren, positivem Resektionsstatus, > 3 positiven Lymphknoten und zusätzlich bei Patientinnen mit T3 N0-Situation und Risikofaktoren wie lymphovaskulärer Invasion, G3-Tumoren, kleinem Sicherheitssaum und jungem Alter hat sich verstärkt. Neue Risikofaktoren wie invasiver lobulärer Subtyp und negativer Hormonrezeptorstatus wurden eingeschlossen. Für Patientinnen mit 1–3 positiven Lymphknoten hat die PMRT ein Evidenzlevel („level of evidence“) 1a erreicht.

Schlussfolgerung

PMRT ist obligat bei Patientinnen mit einem T4-Tumor und/oder positiven Lymphknoten und/oder positiven Schnitträndern. Eine PMRT sollte auch bei Patientinnen mit T3 N0-Tumoren und Risikofaktoren erfolgen, vor allem wenn 2 oder mehr Risikofaktoren vorliegen.

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Conflict of interest

F. Wenz, E. Sperk, W. Budach, J. Dunst, P. Feyer, R. Fietkau, W. Haase, W. Harms, M. D. Piroth, M.-L. Sautter-Bihl, F. Sedlmayer, R. Souchon, C. Fussl, and R. Sauer state that there are no conflicts of interest.

The accompanying manuscript does not include studies on humans or animals.

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Authors and Affiliations

  1. Klinik für Strahlentherapie und Radioonkologie, Universitätsmedizin Mannheim, Theodor-Kutzer-Ufer 1-3, 68167, Mannheim, Germany

    Frederik Wenz & Elena Sperk

  2. Heinrich-Heine-University, Duesseldorf, Germany

    Wilfried Budach

  3. University Hospital Schleswig-Holstein, Luebeck, Germany

    Jürgen Dunst

  4. Vivantes Hospital Neukoelln, Berlin, Germany

    Petra Feyer

  5. University Hospital Erlangen, Erlangen, Germany

    Rainer Fietkau & Rolf Sauer

  6. Formerly St.-Vincentius-Hospital, Karlsruhe, Germany

    Wulf Haase

  7. St. Clara Hospital, Basel, Switzerland

    Wolfgang Harms

  8. Helios Hospital, Wuppertal, Germany

    Marc D. Piroth

  9. Municipal Hospital, Karlsruhe, Germany

    Marie-Luise Sautter-Bihl

  10. Paracelsus Medical University Hospital, Salzburg, Germany

    Felix Sedlmayer & Christoph Fussl

  11. Formerly University Hospital Tuebingen, Tuebingen, Germany

    Rainer Souchon

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  1. Frederik Wenz
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  14. Rolf Sauer
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Breast Cancer Expert Panel of the German Society of Radiation Oncology (DEGRO)

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Correspondence to Frederik Wenz.

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Frederik Wenz and Elena Sperk contributed equally to this work.

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Wenz, F., Sperk, E., Budach, W. et al. DEGRO practical guidelines for radiotherapy of breast cancer IV. Strahlenther Onkol 190, 705–714 (2014). https://doi.org/10.1007/s00066-014-0687-0

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