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Moser R, Pfeiffer S, Cala L, Klein E, Kiechle M, Behzadi ST, Fallenberg E, Combs SE, Weber W, Borm KJ. Detecting Metastatic Patterns of Oligometastatic Breast Cancer: A Comparative Analysis of 18F-FDG PET/CT and Conventional CT Imaging. J Nucl Med 2024:jnumed.123.266925. [PMID: 38637138 DOI: 10.2967/jnumed.123.266925] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/23/2023] [Revised: 03/05/2024] [Indexed: 04/20/2024] Open
Abstract
Metastasis-directed therapy has the potential to improve progression-free and overall survival in oligometastatic disease (OMD). For breast cancer, however, randomized trials have failed so far to confirm this finding. Because the concept of metastasis-directed therapy in OMD is highly dependent on the accuracy of the imaging modality, we aimed to assess the impact of 18F-FDG PET/CT on the definition of OMD in breast cancer patients. Methods: Eighty patients with a total of 150 18F-FDG PET/CT images (between October 2006 and January 2022) were enrolled in this retrospective study at the Technical University of Munich. The inclusion criteria were OMD, defined as 1-5 distant metastases, at the time of 18F-FDG PET/CT. For the current study, we systemically compared the metastatic pattern on 18F-FDG PET/CT with conventional CT. Results: At the time of 18F-FDG PET/CT, 21.3% of patients (n = 32) had a first-time diagnosis of metastatic disease, 40.7% (n = 61) had a previous history of OMD, and 38% (n = 57) had a previous history of polymetastatic disease. In 45.3% of cases, the imaging modality (18F-FDG PET/CT vs. conventional CT) had an impact on the assessment of whether OMD was present. An identical metastatic pattern was observed in only 32% of cases.18F-FDG PET/CT detected additional metastases in 33.3% of cases, mostly in the nonregional lymph node system. Conclusion: The use of 18F-FDG PET/CT had a substantial impact on the definition of OMD and detection of metastatic pattern in breast cancer. Our results emphasize the importance of establishing a standardized definition for imaging modalities in future trials and clinical practices related to metastasis-directed therapy in breast cancer patients.
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Affiliation(s)
- Rebecca Moser
- Department of Radiation Oncology, Klinikum Rechts der Isar, TUM School of Medicine and Health, Technical University Munich, Munich, Germany
| | - Sophie Pfeiffer
- Department of Radiation Oncology, Klinikum Rechts der Isar, TUM School of Medicine and Health, Technical University Munich, Munich, Germany
| | - Lisena Cala
- Department of Nuclear Medicine, Klinikum Rechts der Isar, TUM School of Medicine and Health, Technical University Munich, Munich, Germany
| | - Evelyn Klein
- Department of Obstetrics and Gynecology, Klinikum Rechts der Isar, TUM School of Medicine and Health, Technical University Munich, Munich
| | - Marion Kiechle
- Department of Obstetrics and Gynecology, Klinikum Rechts der Isar, TUM School of Medicine and Health, Technical University Munich, Munich
| | - Sophie T Behzadi
- Department of Radiation Oncology, Klinikum Rechts der Isar, TUM School of Medicine and Health, Technical University Munich, Munich, Germany
| | - Eva Fallenberg
- Department of Obstetrics and Gynecology, Klinikum Rechts der Isar, TUM School of Medicine and Health, Technical University Munich, Munich
| | - Stephanie E Combs
- Department of Radiation Oncology, Klinikum Rechts der Isar, TUM School of Medicine and Health, Technical University Munich, Munich, Germany
- Department of Radiation Sciences, Germany Institute of Innovative Radiotherapy, Helmholtz Zentrum München, Oberschleißheim, Germany; and
- German Consortium for Translational Cancer Research, Munich, Germany
| | - Wolfgang Weber
- Department of Nuclear Medicine, Klinikum Rechts der Isar, TUM School of Medicine and Health, Technical University Munich, Munich, Germany
| | - Kai J Borm
- Department of Radiation Oncology, Klinikum Rechts der Isar, TUM School of Medicine and Health, Technical University Munich, Munich, Germany;
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Borm KJ, Behzadi ST, Hörner-Rieber J, Krug D, Baumann R, Corradini S, Duma MN, Dunst J, Fastner G, Feyer P, Fietkau R, Haase W, Harms W, Hehr T, Matuschek C, Piroth MD, Schmeel LC, Souchon R, Strnad V, Budach W, Combs SE. DEGRO guideline for personalized radiotherapy of brain metastases and leptomeningeal carcinomatosis in patients with breast cancer. Strahlenther Onkol 2024; 200:259-275. [PMID: 38488902 DOI: 10.1007/s00066-024-02202-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/03/2024] [Accepted: 01/07/2024] [Indexed: 03/17/2024]
Abstract
PURPOSE The aim of this review was to evaluate the existing evidence for radiotherapy for brain metastases in breast cancer patients and provide recommendations for the use of radiotherapy for brain metastases and leptomeningeal carcinomatosis. MATERIALS AND METHODS For the current review, a PubMed search was conducted including articles from 01/1985 to 05/2023. The search was performed using the following terms: (brain metastases OR leptomeningeal carcinomatosis) AND (breast cancer OR breast) AND (radiotherapy OR ablative radiotherapy OR radiosurgery OR stereotactic OR radiation). CONCLUSION AND RECOMMENDATIONS Despite the fact that the biological subtype of breast cancer influences both the occurrence and relapse patterns of breast cancer brain metastases (BCBM), for most scenarios, no specific recommendations regarding radiotherapy can be made based on the existing evidence. For a limited number of BCBM (1-4), stereotactic radiosurgery (SRS) or fractionated stereotactic radiotherapy (SRT) is generally recommended irrespective of molecular subtype and concurrent/planned systemic therapy. In patients with 5-10 oligo-brain metastases, these techniques can also be conditionally recommended. For multiple, especially symptomatic BCBM, whole-brain radiotherapy (WBRT), if possible with hippocampal sparing, is recommended. In cases of multiple asymptomatic BCBM (≥ 5), if SRS/SRT is not feasible or in disseminated brain metastases (> 10), postponing WBRT with early reassessment and reevaluation of local treatment options (8-12 weeks) may be discussed if a HER2/Neu-targeting systemic therapy with significant response rates in the central nervous system (CNS) is being used. In symptomatic leptomeningeal carcinomatosis, local radiotherapy (WBRT or local spinal irradiation) should be performed in addition to systemic therapy. In patients with disseminated leptomeningeal carcinomatosis in good clinical condition and with only limited or stable extra-CNS disease, craniospinal irradiation (CSI) may be considered. Data regarding the toxicity of combining systemic therapies with cranial and spinal radiotherapy are sparse. Therefore, no clear recommendations can be given, and each case should be discussed individually in an interdisciplinary setting.
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Affiliation(s)
- Kai J Borm
- TUM School of Medicine, Department of Radiation Oncology, Technical University of Munich, Ismaninger Straße 22, 81675, Munich, Germany
| | - Sophie T Behzadi
- TUM School of Medicine, Department of Radiation Oncology, Technical University of Munich, Ismaninger Straße 22, 81675, Munich, Germany
| | - Juliane Hörner-Rieber
- Department of Radiation Oncology, Heidelberg University Hospital, Heidelberg, Germany
| | - David Krug
- Department of Radiation Oncology, University Hospital Schleswig-Holstein, Kiel, Germany
| | - Rene Baumann
- Department of Radiation Oncology, St. Marien-Krankenhaus, Siegen, Germany
| | - Stefanie Corradini
- Department of Radiation Oncology, University Hospital, LMU Munich, Munich, Germany
| | - Marciana Nona Duma
- Department of Radiation Oncology, Helios Clinics of Schwerin-University Campus of MSH Medical School Hamburg, Schwerin, Germany
- Department for Human Medicine, MSH Medical School Hamburg, Hamburg, Germany
| | - Jürgen Dunst
- Department of Radiation Oncology, University Hospital Schleswig-Holstein, Kiel, Germany
| | - Gerd Fastner
- Department of Radiotherapy and Radio-Oncology, University Hospital Salzburg, Landeskrankenhaus, Paracelsus Medical University, Salzburg, Austria
| | - Petra Feyer
- Formerly Department of Radiation Oncology, Vivantes Hospital Neukölln, Berlin, Germany
| | - Rainer Fietkau
- Department of Radiation Oncology, University Hospital Erlangen, Erlangen, Germany
| | - Wulf Haase
- Formerly Department of Radiation Oncology, St.-Vincentius-Hospital Karlsruhe, Karlsruhe, Germany
| | - Wolfgang Harms
- Department of Radiation Oncology, St. Claraspital, Basel, Switzerland
| | - Thomas Hehr
- Department of Radiation Oncology, Marienhospital Stuttgart, Stuttgart, Germany
| | - Christiane Matuschek
- Department of Radiation Oncology, University Hospital Düsseldorf, Düsseldorf, Germany
| | - Marc D Piroth
- Department of Radiation Oncology, HELIOS University Hospital Wuppertal, Witten/Herdecke University, Wuppertal, Germany
| | | | - Rainer Souchon
- Formerly Department of Radiation Oncology, University Hospital Tübingen, Tübingen, Germany
| | - Vratislav Strnad
- Department of Radiation Oncology, University Hospital Erlangen, Erlangen, Germany
| | - Wilfried Budach
- Department of Radiation Oncology, University Hospital Düsseldorf, Düsseldorf, Germany
| | - Stephanie E Combs
- TUM School of Medicine, Department of Radiation Oncology, Technical University of Munich, Ismaninger Straße 22, 81675, Munich, Germany.
- Partner Site Munich, Deutsches Konsortium für Translationale Krebsforschung (DKTK), Munich, Germany.
- Department of Radiation Medicine (IRM), Helmholtz Zentrum München (HMGU), Neuherberg, Germany.
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Behzadi ST, Moser R, Kiesl S, Nano J, Peeken JC, Fischer JC, Fallenberg EM, Huber T, Haller B, Klein E, Kiechle M, Combs SE, Borm KJ. Tumor Contact With Internal Mammary Perforator Vessels as Risk Factor for Gross Internal Mammary Lymph Node Involvement in Patients With Breast Cancer. Int J Radiat Oncol Biol Phys 2024:S0360-3016(24)00339-0. [PMID: 38458496 DOI: 10.1016/j.ijrobp.2024.02.030] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/29/2023] [Revised: 02/12/2024] [Accepted: 02/16/2024] [Indexed: 03/10/2024]
Abstract
PURPOSE The identification of internal mammary lymph node metastases and the assessment of associated risk factors are crucial for adjuvant regional lymph node irradiation in patients with breast cancer. The current study aims to investigate whether tumor contact with internal mammary perforator vessels is associated with gross internal mammary lymph node involvement. METHODS AND MATERIALS We included 297 patients with primary breast cancer and gross internal mammary (IMN+) and/or axillary metastases as well as 230 patients without lymph node metastases. Based on pretreatment dynamic contrast-enhanced magnetic resonance imaging, we assessed contact of the tumor with the internal mammary perforating vessels (IMPV). RESULTS A total of 59 patients had ipsilateral IMN+ (iIMN+), 10 patients had contralateral IMN+ (cIMN+), and 228 patients had ipsilateral axillary metastases without IMN; 230 patients had node-negative breast cancer. In patients with iIMN+, 100% of tumors had contact with ipsilateral IMPV, with 94.9% (n = 56) classified as major contact. In iIMN- patients, major IMPV contact was observed in only 25.3% (n = 116), and 36.2% (n = 166) had no IMPV contact at all. Receiver operating characteristic analysis revealed that "major IMPV contact" was more accurate in predicting iIMN+ (area under the curve, 0.85) compared with a multivariate model combining grade of differentiation, tumor site, size, and molecular subtype (area under the curve, 0.65). Strikingly, among patients with cIMN+, 100% of tumors had contact with a crossing contralateral IMPV, whereas in cIMN- patients, IMPVs to the contralateral side were observed in only 53.4% (iIMN+) and 24.8% (iIMN-), respectively. CONCLUSIONS Tumor contact with the IMPV is highly associated with risk of gross IMN involvement. Further studies are warranted to investigate whether this identified risk factor is also associated with microscopic IMN involvement and whether it can assist in the selection of patients with breast cancer for irradiation of the internal mammary lymph nodes.
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Affiliation(s)
- Sophie T Behzadi
- Department of Radiation Oncology, TUM School of Medicine and Health, Technical University Munich (TUM), Klinikum rechts der Isar, Munich, Germany
| | - Rebecca Moser
- Department of Radiation Oncology, TUM School of Medicine and Health, Technical University Munich (TUM), Klinikum rechts der Isar, Munich, Germany
| | - Sophia Kiesl
- Department of Radiation Oncology, TUM School of Medicine and Health, Technical University Munich (TUM), Klinikum rechts der Isar, Munich, Germany
| | - Jana Nano
- Department of Radiation Oncology, TUM School of Medicine and Health, Technical University Munich (TUM), Klinikum rechts der Isar, Munich, Germany
| | - Jan C Peeken
- Department of Radiation Oncology, TUM School of Medicine and Health, Technical University Munich (TUM), Klinikum rechts der Isar, Munich, Germany
| | - Julius C Fischer
- Department of Radiation Oncology, TUM School of Medicine and Health, Technical University Munich (TUM), Klinikum rechts der Isar, Munich, Germany
| | - Eva M Fallenberg
- Department of Radiology, TUM School of Medicine and Health, Technical University Munich (TUM), Klinikum rechts der Isar, Munich, Germany
| | - Thomas Huber
- Department of Radiology, TUM School of Medicine and Health, Technical University Munich (TUM), Klinikum rechts der Isar, Munich, Germany
| | - Bernhard Haller
- Institute of AI and Informatics in Medicine, TUM School of Medicine and Health, Technical University Munich (TUM), Klinikum rechts der Isar, Munich, Germany
| | - Evelyn Klein
- Department of Gynecology and Obstetrics, TUM School of Medicine and Health, Technical University Munich (TUM), Klinikum rechts der Isar, Munich, Germany
| | - Marion Kiechle
- Department of Gynecology and Obstetrics, TUM School of Medicine and Health, Technical University Munich (TUM), Klinikum rechts der Isar, Munich, Germany
| | - Stephanie E Combs
- Department of Radiation Oncology, TUM School of Medicine and Health, Technical University Munich (TUM), Klinikum rechts der Isar, Munich, Germany; Deutsches Konsortium für translationale Krebsforschung (DKTK) - Partner Site Munich, Munich, Germany; Institute of Radiation Medicine, Helmholtz Zentrum München, Munich, Germany
| | - Kai J Borm
- Department of Radiation Oncology, TUM School of Medicine and Health, Technical University Munich (TUM), Klinikum rechts der Isar, Munich, Germany.
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