Strahlentherapie beim Mammakarzinom – State of the Art

Die Bestrahlung einer Brustkrebserkrankung hat eine lange Tradition. Eine entsprechende Behandlung wurde bereits im Jahre 1907 durch Georges Chicotot in Paris beschrieben [1]. Noch heute stellt die Strahlentherapie einen wesentlichen Bestandteil moderner multimodaler Therapiekonzepte beim Mammakarzinom und dessen Vorstufen dar. Durch kontinuierliche Verbesserungen der technischen Möglichkeiten ist die Strahlentherapie heutzutage sehr zielgenau und in der Regel nebenwirkungsarm durchzuführen. Ihre Rolle in den verschiedenen Erkrankungssituationen konnte durch zahlreiche Studien mittlerweile gut charakterisiert werden.

Postoperatively irradiation will be applied in the situation of DCIS after conservative resection and risk adapted also after mastectomy. Today, irradiation is an integral component of the total therapy of mamma carcinoma. During the last years new technique developments have emerged and therefore irradiation has become more efficient with minor side effects. The recurrence rate and the overall survival rate will be improved both after conservative resection and mastectomy. The lymph areas should be irradiated only in the case of higher risk. The beginning of irradiation should be in the range between 6 and 8 weeks after surgery. But because chemotherapy is interposed in most cases, irradiation will start after a lot of months after surgery and therefore the results could be compromised.

An alternative to this problem could be seen in the so-called intraoperative or accelerated radiotherapy of the mamma which can be realized within one week or one treatment day. Actually, results concerning recurrence rate and overall survival are unclear.

Key words

irradiation - mamma carcinoma - side effects - new techniques - intraoperative therapy - accelerated radiotherapy of the mamma

• Literatur

• 1 Chicotot Georges. Premiers essais du traitement du cancer par les rayons X. Musée de l'Assistance Publique, Hopitaux de Paris
• 2 Veronesi U, Saccozzi R, Del Vecchio M et al. Comparing radical mastectomy with quadrantectomy, axillary dissection, and radiotherapy in patients with small cancer of the breast. N Engl J Med 1981; 305: 6-11
• 3 Fisher B, Redmond C, Poisson R et al. Eight-year results of a randomized clinical trial comparing total mastectomy and lumpectomy with or without irradiation in the treatment of breast cancer. N Engl J Med 1989; 320: 8282-8283
• 4 Fisher B, Anderson S, Redmond C et al. Reanalysis and results after twelve years of follow-up in a randomized clinical trial comparing total mastectomy with lumpectomy with or without irradiation in the treatment of breast cancer. N Engl J Med 1995; 333: 1456-1461
• 5 Kreienberg R, Kopp I Lorenz et al. Interdisziplinäre S 3-Leitlinie für die Diagnostik und Therapie des Mammakarzinoms der Frau. München-Wien-New York: ISTO, Zuckschwerdt Verlag; 2004
• 6 Boyages J, Delaney G, Taylor R. Predictors of local recurrences after treatment of ductal carcinoma in situ. A meta-analysis. Cancer 1999; 85: 616-628
• 7 NIH State of the Science Conference Diagnosis and Management of Ductal Carcinoma In Situ (DCIS). September 22–24, 2009, Bethesda, Maryland. Accessed http://www.consensus.nih.gov/2009/dcis.htm. 15.12.2009
• 8 Schaffer PM, Dühmke E. Postoperative adjuvante Strahlentherapie des DCIS und des invasiven Mammakarzinoms bei Brusterhaltung. München-Wien-New York: Verlag W. Zuckschwerdt; 2002: 227-235
• 9 Cuzick J, Sestak I, Pinder SE et al. Effect of tamoxifen and radiotherapy in women with locally excised ductal carcinoma in situ: long-term results from the UK/ANZ DCIS trial. Lancet Oncol 2011; 12: 21-29
• 10 Veronesi U, Salvadori B, Luini A et al. Breast-conservation is a safe method in patients with small cancer of the breast. Longterm results of three randomized trials on 1973 patients. Eur J Cancer 1995; 31: 1574-1579
• 11 Whelan T, Darby S, Taylor C, McGale P, Ewertz M. Overviews of randomized trials of radiotherapy in early breast cancer.: 43rd Annual Meeting ASCO 2007, ASCO Annual Meeting Educational Book. 2007: 3-6
• 12 Antonini N, Jones H, Horiot JC et al. Effect of age and radiation dose on local control after breast conserving treatment: EORTC trail 2281–10882. Radiother Oncol 2007; 82: 265-271
• 13 Sauer R Dunst Müller et al. Leitlinien in der Radioonkologie: Radiotherapie des Mammakarzinoms. 1999;
• 14 Ragaz J, Jackson SM, Lee N et al. Adjuvant radiotherapy and chemotherapie in node positive premenopausal women with breast cancer. N Engl J Med 1997; 337: 956-962
• 15 Auquier A, Rutqvist LE, Host H et al. Postmastectomy megavoltage radiotherapy: the Oslo and Stockholm trials. Eur J Cancer 1992; 28: 433-437
• 16 Yang PS, Chen CM, Liu MC et al. Radiotherapy can decrease locoregional recurrence and increase survival in mastectomy patients with T1 to T2 breast cancer and one to three positive nodes with negative estrogen receptor and positive lymphovascular invasion status. Int J Radiat Oncol Biol Phys 2010; 77: 516-522
• 17 Fowble B, Hanlon A, Freedman G et al. Internal mammary node irradiation neither decreases distant metastases nor improves survivel in stage I and II brest cancer. Int J Radiat oncol Biol Phys 2000; 47: 883-894
• 18 Recht A, Gray R, Davidson NE et al. Locoregional failure 10 years after mastectomy and adjuvant chemotherapie with or without tamoxifen without irradiation: experience of the Eastern Cooperative Oncology Group. J Clin Oncol 1999; 17: 1689-1700
• 19 Hughes KS, Schnaper LA, Berry D et al. Lumpectomy plus tamoxifen with or without irradiation in women 70 years of age or older with early breast cancer. N Engl J Med 2004; 351: 971-977
• 20 Huang J, Barbera L, Brouwers M et al. Does delay in starting treatment affect the outcomes of radiotherapy? A systematic review. J Clin Oncol 2003; 21: 555-563
• 21 Foster SF, Farwell ME, Costanza MC. Breast-conserving surgery for breast cancer: Patterns of care in a geographical region and estimation of potential applicability. Ann Surg Oncol 1995; 2: 275-280
• 22 Engel J, Nagel G, Breuer E et al. Primary breast cancer therapy in six regions of Germany. Eur J Cancer 2002; 38: 578-585
• 23 Overgaard M, Jensen MB, Overgaard J et al. Postoperative radiotherapy in high-risk postmenopausal breast-cancer patients given adjuvant tamoxifen: Danish Breast Cancer Cooperative Group DBCG 82c randomised trial. Lancet 1999; 353: 1641-1648
• 24 Overgaard M, Hansen PS, Overgaard J et al. Postoperative radiotherapy in high-risk premenopausal women with breast cancer who receive adjuvant chemotherapy. N Engl J Med 1997; 337: 949-955
• 25 Recht A, Edge SB, Solin LJ et al. Postmastectomy radiotherapy: clinical practice guidelines of the American Society of Clinical Oncology. J Clin Oncol 2001; 19: 1539-1569
• 26 Truong PT, Olivotto IA, Kader HA et al. Selecting breast cancer patients with T1-T2 tumors and one to three positive axillary nodes at high postmastectomy locoregional recurrence risk for adjuvant radiotherapy. Int J Radiat Oncol Biol Phys 2005; 61: 1337-1347
• 27 Von der Assen A. Welche Möglichkeiten gibt es bei der Brustrekonstruktion und was sind die Vor- und Nachteile der unterschiedlichen Methoden?. Krebsmagazin.de 2003; 1: 26-27
• 28 Lucas FV, Perez-Mesa C. Inflammatory carcinoma of the breast. (DKG-N). Cancer 1978; 41: 1595-1605
• 29 Fisher B, Anderson S, Bryant J et al. Twenty year follow-up of a randomized trial comparing total mastectomy, lumpectomy and lumpectomy plus irradiation for the treatment of invasive breast cancer. (NCCN, ICSI-Class A, CANADA, AGO). N Engl J Med 2002; 347: 1233-1241
• 30 Katz A, Strom EA, Buchholz TA et al. The influence of pathologic tumor characteristics on locoregional recurrence rates following mastectomy. (ICSI Class B, AGO). Int J Radiat Oncol Biol Phys 2001; 50: 735-742
• 31 Taghian AG, Assaad SI, Niemierko A et al. Risk of pneumonitis in breast cancer patients treated with radiation therapie and combination chemotherapy with pactlitaxel. J Natl Cancer Inst 2001; 93: 1806-1811
• 32 Würschmidt F, Molls M. Strahlentherapie nach Mastektomie und rekonstruktiven Verfahren. München-Wien-New York: Zuckschwerdt Verlag; 2002: 236-245
• 33 Hojris I, Overgaard M, Christensen JJ et al. Morbidity and mortality of ischemic heart disease in high-risk breast-cancer patients after adjuvant postmastectomy systemic treatment with or without radiotherapy: analysis of DBCG 82b and 82c randomised trials. Lancet 1999; 354: 1425-1430
• 34 Rutqvist LE, Liedberg A, Hammar N et al. Myocardial infarction among women with early-stage breast cancer treated with conservative surgery and breast irradiation. Int J Radiat Oncol Biol Phys 1998; 40: 359-363
• 35 McGale P, Darby SC, Hall P et al. Incidence of heart disease in 35,000 women treated with radiotherapy for breast cancer in Denmark and Sweden. Radiother Oncol 2011; 100: 167-175
• 36 Vikstrom J, Hjelstuen MH, Mjaaland I, Dybvik KI. Cardiac and pulmonary dose reduction for tangentially irradiated breast cancer, utilizing deep inspiration breath-hold with audio–visual guidance, without compromising target coverage. Acta Oncol 2011; 50: 42-50
• 37 Taghian A, De Vathaire F, Terrier P et al. Long-term risk of sarcoma following radiation treatment for breast cancer. Int J Radiat Oncol Biol Phys 1991; 21: 361-367
• 38 Kuske RR, Schuster R, Klein E et al. Radiotherapy and breast reconstruction: clinical results and dosimetry. Int J Radiat Oncol Biol Phys 1991; 21: 339-346
• 39 Schuster RH, Kuske RR, Young VL et al. Breast reconstruction in women treated with radiation therapy for breast cancer: cosmesis, complications, and tumor control. Plast Reconstr Surg 1992; 90: 445-452
• 40 Orecchia R, Ciocca M, Lazzari R et al. Intraoperative radiation therapy with electrons (ELIOT) in early stage breast cancer. Breast 2003; 12: 483-490
• 41 Vaidya JS, Joseph D, Tobias JS et al. Targeted intraoperative radiotherapy versus whole breast radiotherapy for breast cancer (TARGIT-A trial): an international, prospective, randomised, non-inferiority phase 3 trial. Lancet 2010; 376: 91-102
• 42 Budach W, Dunst J, Engenhart-Cabillic R et al. DEGRO-Stellungnahme Oktober 2010 Ellis DL Teitelbaum SL (1974) Inflammatory carcinoma of the breast: a pathologic definition. Cancer http://www.degro.org 2010; 33: 1045-1047
• 43 Krauss DJ, Kestin LL, Mitchell C et al. Changes in temporal patterns of local failure after breast conserving therapy and their prognostic implications. Int J Radiat Oncol Biol Phys 2004; 60: 731-740
• 44 Smith BD, Arthur DW, Buchholz TA et al. Accelerated partial breast irradiation consensus statement from the American Society for Radiation Oncology (ASTRO). Int J Radiat Oncol Biol Phys 2009; 74: 987-1001
• 45 Ott O, Strnad V, Poetter R et al. Partial breast irradiation with 192-iridium implants after breast conserving surgery: perioperative morbididy toxicity and cosmetic results. The Breast 2003; 12 (Suppl. 01)
• 46 Kauer-Dorner D, Pötter R, Resch A. Partial breast irradiation for locally recurrent breast cancer within a second breast conserving treatment: Alternative to mastectomy? Results from a prospective trial. Radiother Oncol epub ahed of print DOI: 10.1016/j.radonc.2011.07.020.
• 47 Vaidya JS, Baum M, Tobias JS et al. Long-term results of targeted intraoperative radiotherapy (TARGIT) boost during breast-conserving surgery. Int J Radiat Oncol Biol Phys 2011; 81: 1091-1097
• 48 Kuten A, Leitzin L, Rosenblatt E, Tamir A et al. Short fractionation schedule in breast irradiation: Preliminary results. The Breast (Suppl. 01) 2003; 12
• 49 FAST Trailists group. First results of the randomised UK FAST Trial of radiotherapy hypofractionation for treatment of early breast cancer (CRUKE/04/015). Radiother Oncol 2011; 100: 93-100
• 50 Herbert C, Nichol A, Olivotto I, Weir L et al. The impact of hypofractionated whole breast radiotherapy on local relapse in patients with grade 3 early breast cancer: A population-based cohort study. Int J Radiat Oncol Biol Phys (epub ahead of print) 2011;