Klinik für Radioonkologie und Strahlentherapie, Städtisches Klinikum Karlsruhe, Karlsruhe, Germany,
Strahlenther Onkol. 2014 Apr;190(4):342-51. doi: 10.1007/s00066-013-0543-7. Epub 2014 Mar 5.
The purpose of this work is to update the practical guidelines for adjuvant radiotherapy of the regional lymphatics of breast cancer published in 2008 by the breast cancer expert panel of the German Society of Radiation Oncology (DEGRO).
A comprehensive survey of the literature concerning regional nodal irradiation (RNI) was performed using the following search terms: "breast cancer", "radiotherapy", "regional node irradiation". Recent randomized trials were analyzed for outcome as well as for differences in target definition. Field arrangements in the different studies were reproduced and superimposed on CT slices with individually contoured node areas. Moreover, data from recently published meta-analyses and guidelines of international breast cancer societies, yielding new aspects compared to 2008, provided the basis for defining recommendations according to the criteria of evidence-based medicine. In addition to the more general statements of the German interdisciplinary S3 guidelines updated in 2012, this paper addresses indications, targeting, and techniques of radiotherapy of the lymphatic pathways after surgery for breast cancer.
International guidelines reveal substantial differences regarding indications for RNI. Patients with 1-3 positive nodes seem to profit from RNI compared to whole breast (WBI) or chest wall irradiation alone, both with regard to locoregional control and disease-free survival. Irradiation of the regional lymphatics including axillary, supraclavicular, and internal mammary nodes provided a small but significant survival benefit in recent randomized trials and one meta-analysis. Lymph node irradiation yields comparable tumor control in comparison to axillary lymph node dissection (ALND), while reducing the rate of lymph edema. Data concerning the impact of 1-2 macroscopically affected sentinel node (SN) or microscopic metastases on prognosis are conflicting.
Recent data suggest that the current restrictive use of RNI should be scrutinized because the risk-benefit relationship appears to shift towards an improvement of outcome.
本研究旨在更新德国放射肿瘤学会（DEGRO）乳腺癌专家组 2008 年发布的乳腺癌区域淋巴结辅助放疗的实用指南。
采用“乳腺癌”“放疗”“区域淋巴结照射”等检索词，对区域淋巴结照射（RNI）相关文献进行全面检索。分析了近期随机试验的结果，并对目标定义的差异进行了分析。对不同研究中的射野排布进行了复制，并将其叠加到单独勾画的淋巴结区域的 CT 切片上。此外，最近发表的国际乳腺癌协会的荟萃分析和指南的数据提供了依据，与 2008 年相比，这些数据提供了新的方面，并根据循证医学的标准为定义建议提供了依据。除了 2012 年更新的德国跨学科 S3 指南的更一般性陈述外，本文还述及了乳腺癌手术后淋巴结途径放疗的适应证、靶区和技术。
国际指南在 RNI 的适应证方面存在显著差异。与单独全乳（WBI）或胸壁照射相比，1-3 个阳性淋巴结的患者似乎从 RNI 中获益，无论在局部区域控制还是无病生存方面。在最近的随机试验和一项荟萃分析中，照射区域淋巴结，包括腋窝、锁骨上和内乳淋巴结，可带来微小但显著的生存获益。淋巴结照射在肿瘤控制方面与腋窝淋巴结清扫（ALND）相当，但可降低淋巴水肿的发生率。关于 1-2 个宏观受累的前哨淋巴结（SN）或微观转移对预后的影响的数据存在争议。
最近的数据表明，目前对 RNI 的限制使用应该受到审查，因为风险效益关系似乎朝着改善结果的方向转变。
