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DEGRO Practical Guidelines for Palliative Radiotherapy of Breast Cancer Patients: Brain Metastases and Leptomeningeal Carcinomatosis

DEGRO-Handlungsleitlinie zur Strahlentherapie von Hirnmetastasen und der leptomeningealen Karzinomatose bei Mammakarzinompatientinnen

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Purpose:

To provide recommendations for palliative treatment of brain metastases (BM) and leptomeningeal carcinomatosis (LC) in breast cancer patients with specific emphasis on radiooncologic aspects.

Methods:

The breast cancer expert panel of the German Society of Radiation Oncology (DEGRO) performed a comprehensive survey of the literature comprising national and international guidelines, lately published randomized trials, and relevant retrospective analyses. The search included publications between 1995–2008 (PubMed and Guidelines International Network [G-I-N]). Recommendations were devised according to the panel’s interpretation of the evidence referring to the criteria of EBM.

Results:

Aim of any treatment of BM and LC is to alleviate symptoms and improve neurologic deficits. Close interdisciplinary cooperation facilitates rapid diagnosis and onset of therapy, tailored to the individual and clinical situation.

Treatment decisions for BM should be based on the allocation to three prognostic groups defined by recursive partitioning analysis (RPA). Karnofsky Performance Score (KPS) is the strongest prognostic parameter. Together with the extent of the disease, KPS determines whether excision or radiosurgery/stereotactic radiotherapy is feasible and if exclusive or additional whole-brain radiotherapy (WBRT) is indicated. With adequate therapy, survival may be up to 3 years.

For LC, treatment is mostly indicated for patients with positive cytology or in case of strongly indicative signs and symptoms. Radiotherapy (WBRT and involved-field irradiation of bulky spinal lesions) and chemotherapy (systemically or intrathecally applied methotrexate, thiotepa and cytarabine) are both effective and may prolong survival from several weeks to 4–6 months.

Conclusion:

Radiotherapy is an effective tool for palliative treatment of BM and LC.

Ziel:

Erstellung einer klinischen Leitlinie zur palliativen Therapie von Hirnmetastasen und Leptomeningeosis carcinomatosa beim Mammakarzinom unter spezieller Berücksichtigung radioonkologischer Aspekte. Diese soll eine Vereinheitlichung des Vorgehens und somit eine Verbesserung der Behandlungsqualität ermöglichen.

Methodik:

Die Expertengruppe Mammakarzinom der Deutschen Gesellschaft für Radioonkologie (DEGRO) führte eine umfassende Literaturrecherche durch, die nationale und internationale Leitlinien, randomisierte Studien und relevante retrospektive Analysen im Publikationszeitraum von 1995 bis 2008 berücksichtigte (PubMed, Guidelines International Network [G-I-N]). Die Empfehlungen wurden entsprechend den jeweils vorliegenden Evidenzen nach EBM-Kriterien gewichtet.

Ergebnisse:

Ziele jeglicher Behandlung von Hirnmetastasen und Leptomeningeosis carcinomatosa sind die Linderung entsprechender Symptome und Verminderung neurologischer Defizite. Eine enge interdisziplinäre Zusammenarbeit ermöglicht eine rasche Diagnose und den umgehenden Beginn einer Therapie, die individuell auf die persönliche und klinische Situation zugeschnitten sein sollte.

Bei Hirnmetastasen orientiert sich die Therapieentscheidung an der Zuordnung zu drei prognostischen Gruppen, die mit dem Verfahren der „recursive partitioning analysis (RPA)“ der RTOG definiert wurden. Hier ist der Karnofsky-Performance-Status wichtigster prognostischer Parameter, der zusammen mit der Tumorausdehnung zur Entscheidung beiträgt, ob eine Exzision, eine radiochirurgische/stereotaktische Strahlentherapie oder eine alleinige bzw. zusätzliche Ganzhirnbestrahlung sinnvoll ist. Mit adäquater Behandlung kann ein Überleben bis zu 3 Jahren erzielt werden.

Die Behandlung der Meningeosis carcinomatosa ist zumeist bei positiver Liquorzytologie oder im Fall einer eindeutigen klinischen Symptomatik indiziert. Eine Ganzhirnbestrahlung und eine umschriebene Strahlentherapie befallener spinaler Manifestationen sowie eine entweder systemisch oder intrathekal applizierte Chemotherapie (Methotrexat, Thiotepa, Cytarabin [DepoCyte®]) sind wirksam. Mit einer effektiven Behandlung kann das Überleben von wenigen Wochen auf 4–6 Monate verlängert werden.

Schlussfolgerung:

Die Strahlentherapie stellt eine effektive Palliativmaßnahme in der Therapie von Hirnmetastasen und Meningeosis carcinomatosa dar.

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Authors and Affiliations

  1. Klinikum Neukölln, Berlin, Germany

    Petra Feyer

  2. Municipal Hospital, Karlsruhe, Germany

    Marie-Luise Sautter-Bihl

  3. University Hospital, Düsseldorf, Germany

    Wilfried Budach

  4. University Hospital Schleswig-Holstein, Lübeck, Germany

    Jürgen Dunst

  5. Formerly St. Vincentius Kliniken, Karlsruhe, Germany

    Wulf Haase

  6. St. Clara Hospital, Basel, Switzerland

    Wolfgang Harms

  7. University Hospital, Landeskrankenhaus Salzburg, Salzburg, Austria

    Felix Sedlmayer

  8. University Hospital Tübingen, Tübingen, Germany

    Rainer Souchon

  9. Department of Radiation Oncology, University Medical Center Mannheim, Mannheim, Germany

    Frederik Wenz

  10. University Hospital Erlangen, Erlangen, Germany

    Rolf Sauer

  11. Klinik für Strahlentherapie, Radioonkologie und Nuklearmedizin, Vivantes Klinikum Neukölln, Rudower Straße 48, 12351, Berlin, Deutschland

    Petra Feyer

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Feyer, P., Sautter-Bihl, ML., Budach, W. et al. DEGRO Practical Guidelines for Palliative Radiotherapy of Breast Cancer Patients: Brain Metastases and Leptomeningeal Carcinomatosis. Strahlenther Onkol 186, 63–69 (2010). https://doi.org/10.1007/s00066-010-2100-y

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