Niedrige Fibroserate bei adäquatem Zeitintervall zwischen intraoperativem Tumorbettboost und perkutaner Nachbestrahlung

Zusammenfassung

Die intraoperative Radiotherapie (IORT) kommt zunehmend als Boost bei Brustkrebspatientinnen zum Einsatz. Wir haben den Einfluss des Zeitintervalls zwischen IORT und der anschließenden perkutanen Mammahomogenbestrahlung (EBRT) auf die Spättoxizität analysiert. Hierzu wurden 91 Patientinnen im Median 24 Monate (= Gruppe 1) und 48 Patientinnen im Median 36 Monate (= Gruppe 2) nachgesorgt. Intraoperativ wurden 20 Gy mit 50 kV Röntgenstrahlen (INTRABEAM, Carl Zeiss Surgical, Oberkochen) und perkutan 46–50 Gy appliziert. Das mediane Zeitintervall zwischen IORT und EBRT betrug 37 Tage in Gruppe 1 und 36 Tage in Gruppe 2. Die Toxizität wurde anhand der modifizierten LENT SOMA Skala ­bewertet. In Gruppe 1 und 2 hatten 54 bzw. ­30 Patientinnen keine höhergradigen Spätfolgen. In Gruppe 1 entwickelten 27 Patientinnen eine höhergradige Fibrose (II–III°), 13 Retraktionen, 8 Schmerzen II°, 8 ein Brustödem und 4 Teleangiektasien. Ein Lymphödem II° und Hyperpigmentierung II° traten einmal auf. In Gruppe 2 hatten 12 Patientinnen Fibrosen (II–III°), 6 Retraktionen, 5 Schmerzen (II–III°), 4 Hyperpigmentierungen, 3 Teleangiektasien und 1 ein Brustödem II°. 2 / 3 der höhergradigen Fibrosen (Gruppe 1: n = 18, Gruppe 2: n = 8) lagen unterhalb des medianen Zeitintervalls zwischen IORT und EBRT. Im Vergleich zeigte sich bei den Patientinnen mit ­Spättoxizität sowohl in Gruppe 1 (n = 37) als auch in Gruppe 2 (n = 18) ein signifikant kürzeres Intervall zwischen IORT und EBRT (Gruppe 1: 34 vs. 40 Tage, p = 0,044; Gruppe 2: 29,5 vs. 39,5 Tage, p = 0,023; Mann-Whitney-U-Test). Bei adäquatem Zeitintervall zwischen IORT und EBRT konnte eine niedrige Fibroserate beobachtet werden. Die EBRT sollte frühestens ca. 5–6 Wochen nach der IORT eingeleitet werden.

Abstract

Intraoperative radiotherapy (IORT) during breast conserving surgery is increasingly used. When ­given as a boost, the sequencing of IORT, systemic therapy and external beam radiotherapy (EBRT) may be of importance to normal tissue damage. We analyzed the influence of the interval be­tween IORT and EBRT on the development of late toxicity in breast cancer patients. No higher grade toxicity was seen in 54 and 30 patients in group 1 and 2, respectively. 91 patients were followed for a median of 24 months (= group 1) and 48 patients for a median of 36 months (= group 2) after IORT and EBRT. 20 Gy IORT were given with 50 kV x-rays (INTRABEAM, Carl Zeiss Surgical, Oberkochen, Germany) followed by 46–50 Gy EBRT with a median interval of 37 days in group 1 and 36 days in group 2. Toxicity was assessed with the modified LENT SOMA score. 27 patients devel­oped a higher grade fibrosis (II–III°). There were 13 patients with retractions, 8 with pain II°, 8 with edema I°, 4 with teleangiectases, 1 with lymphedema II°, and 1 patient with hyperpigmentation II°. In group 2, 12 patients developed fibrosis II–III°, 6 retractions, 5 pain II–III°, 4 hyperpigmentation, 3 teleangiectases and 1 patient had edema II°. In both groups most fibroses II–III° (group 1: n = 18; group 2: n = 8) were noticed ­under the median interval between IORT and EBRT. Finally the interval in patients with higher grade toxicity (group 1: n = 37; group 2: n = 18) was significantly shorter in both groups than in the patients without chronic late effects (group 1: 34 vs. 40 d, p = 0.044; group 2: 29.5 vs. 39.5 d, p = 0.023; Mann-Whitney-U-Test). A low fibrosis rate was seen after delayed initiation of external beam radiotherapy. Starting EBRT about 5–6 weeks after IORT appears safe.

Schlüsselwörter

Mammakarzinom - intraoperative ­Bestrahlung - Tumorbettboost - Fibrose - Spätfolgen

Key words

breast cancer - intraoperative radiotherapy - tumorbed boost - fibrosis - late effects

Literatur

• 1 Kraus-Tiefenbacher U, Bauer L, Kehrer T et al. Intraoperative radiotherapy (IORT) as a boost in patients with early-stage breast cancer – acute toxicity.  Onkologie. 2006;  29 77-82
• 2 Kraus-Tiefenbacher U, Bauer L, Scheda A et al. Long-term toxicity of an intraoperative radiotherapy boost using low energy X-rays during breast-conserving surgery.  Int J Radiat Oncol Biol Phys. 2006;  66 377-381
• 3 Kraus-Tiefenbacher U, Scheda A, Steil V et al. Intraoperative radiotherapy (IORT) for breast cancer using the Intrabeam system.  Tumori. 2005;  91 339-345
• 4 Kraus-Tiefenbacher U, Steil V, Bauer L et al. A novel mobile device for ­intraoperative radiotherapy (IORT).  Onkologie. 2003;  26 596-598
• 5 Reitsamer R, Sedlmayer F, Kopp M et al. The Salzburg concept of intraoperative radiotherapy for breast cancer: results and considerations.  Int J Cancer. 2006;  118 2882-2887
• 6 Sauer R, Wenz F, Strnad V et al. [Partial breast irradiation after breast-conserving surgery for breast cancer].  Strahlenther Onkol. 2005;  181 417-423
• 7 Vaidya J S, Baum M, Tobias J S et al. Targeted intraoperative radiotherapy (TARGIT) yields very low recurrence rates when given as a boost.  Int J Radiat Oncol Biol Phys. 2006;  66 1335-1338
• 8 Vaidya J S, Tobias J S, Baum M et al. Intraoperative radiotherapy for breast cancer.  Lancet Oncol. 2004;  5 165-173
• 9 Intra M, Luini A, Gatti G et al. Surgical technique of intraoperative radia­tion therapy with electrons (ELIOT) in breast cancer: a lesson learned by over 1 000 procedures.  Surgery. 2006;  140 467-471
• 10 Vaidya J S, Tobias J S, Baum M et al. TARGeted Intraoperative radiotherapy (TARGIT): an innovative approach to partial-breast irradiation.  Semin Radiat Oncol. 2005;  15 84-91
• 11 Veronesi U, Orecchia R, Luini A et al. Full-dose intraoperative radiotherapy with electrons during breast-conserving surgery: experience with 590 cases.  Ann Surg. 2005;  242 101-106
• 12 Goldhirsch A, Wood W, Gelber R et al. Progress and promise: highlights of the international expert consensus on the primary therapy of early breast cancer 2007.  Ann Oncol. 2007;  18 1133-1144
• 13 LENT SOMA tables.  Radiother Oncol. 1995;  35 17-60
• 14 Seegenschmiedt M H. Interdisciplinary documentation of treatment side effects in oncology. Present status and perspectives.  Strahlenther Onkol. 1998;  174 Suppl 3 25-29
• 15 Lilla C, Ambrosone C B, Kropp S et al. Predictive factors for late normal tissue complications following radiotherapy for breast cancer.  Breast cancer research and treatment. 2007;  106 143-150
• 16 Hoeller U, Tribius S, Kuhlmey A et al. Increasing the rate of late toxicity by changing the score? A comparison of RTOG / EORTC and LENT / SOMA scores.  Int J Radiat Oncol Biol Phys. 2003;  55 1013-1018
• 17 Antonini N, Jones H, Horiot J C et al. Effect of age and radiation dose on local control after breast conserving treatment: EORTC trial 22881-10882.  Radiother Oncol. 2007;  82 265-271
• 18 Bartelink H, Horiot J C, Poortmans P et al. Recurrence rates after treatment of breast cancer with standard radiotherapy with or without ­additional radiation.  N Engl J Med. 2001;  345 1378-1387
• 19 Vrieling C, Collette L, Fourquet A EORTC Radiotherapy and Breast Cancer Cooperative Groups et al. The influence of patient, tumor and treatment factors on the cosmetic results after breast-conserving therapy in the EORTC ‘boost vs. no boost’ trial.  Radiother Oncol. 2000;  55 219-232
• 20 Chen P Y, Vicini F A, Benitez P et al. Long-term cosmetic results and toxicity after accelerated partial-breast irradiation: a method of radiation delivery by interstitial brachytherapy for the treatment of early-stage breast carcinoma.  Cancer. 2006;  106 991-999
• 21 Shah N M, Tenenholz T, Arthur D et al. MammoSite and interstitial brachytherapy for accelerated partial breast irradiation: factors that affect toxicity and cosmesis.  Cancer. 2004;  101 727-734
• 22 Herskind C, Schalla S, Hahn E W et al. Influence of different dose rates on cell recovery and RBE at different spatial positions during protracted conformal radiotherapy.  Radiat Prot Dosimetry. 2006;  122 498-505
• 23 Herskind C, Steil V, Kraus-Tiefenbacher U et al. Radiobiological aspects of intraoperative radiotherapy (IORT) with isotropic low-energy X rays for early-stage breast cancer.  Radiat Res. 2005;  163 208-215
• 24 Ott O J, Schulz-Wendtland R, Uter W et al. Fat necrosis after conserving surgery and interstitial brachytherapy and / or external-beam irradiation in women with breast cancer.  Strahlenther Onkol. 2005;  181 638-644
• 25 Wasser K, Schoeber C, Kraus-Tiefenbacher U et al. Early mammographic and sonographic findings after intraoperative radiotherapy (IORT) as a boost in patients with breast cancer.  Eur Radiol. 2007;  17 1865-1874