title: DEGRO practice guidelines for palliative radiotherapy of metastatic breast cancer: bone metastases and metastatic spinal cord compression (MSCC).
abstract: OBJECTIVE
  To provide practice guidelines and clinical recommendations on preferred standard palliative radiation therapy of bone metastases as well as metastatic spinal cord compression (MSCC) for metastatic breast cancer patients.
  
  
  METHODS
  The breast cancer expert panel of the German Society of Radiation Oncology (DEGRO) performed a comprehensive survey of the literature comprising recently published data from clinical controlled trials. The literature search encompassed the period 1995-2008 using databases of PubMed and Guidelines International Network (G-I-N). Search terms were "breast cancer", "bone metastasis", "osseous metastasis", "metastatic spinal cord compression" as well as "radiotherapy" and "radiation therapy". Clinical recommendations were formulated based on the panel's interpretation of the level of evidence referring to the criteria of evidence-based medicine.
  
  
  RESULTS
  Different therapeutic goals (pain relief, local tumor control, prevention or improvement of motor deficits, stabilization of the spine or other bones) require complex approaches considering individual factors (i.e., life expectancy, tumor progression at other sites). Best results are achieved by close interdisciplinary cooperation minimizing the interval between diagnosis and onset of treatment. Most important criteria for prognosis and choice of treatment (mostly combined multimodal therapy) are neurologic status at diagnosis of MSCC, time course of duration and progression of the neurologic symptoms. Radiation therapy is effective and regarded as treatment of choice for MSCC with or without motor deficits and/or bone metastases, which do not need immediate surgical intervention. It may be used either postoperatively or as primary treatment in case of inoperability. An optimal dose fractionation schedule or optimal standard dose for treatment of bone metastases has not been established. With regard to different therapeutic goals, different dose concepts and fractionation schedules, single- versus multifraction palliative radiation therapy (1 x 8, 5 x 4, 10 x 3, 15 x 2.5, 20 x 2 Gy), should be adapted individually.
  
  
  CONCLUSIONS
  Bone metastases as well as MSCC should be managed in an interdisciplinary approach mostly as combined-modality treatment according to the specific clinical situation. The present practice guidelines offer criteria and recommendations for different radiooncologic treatment schedules based on the best available levels of evidence. Preferred technique, targeting and different dose schedules are described in detail.
authors.affiliation: Department of Radiation Oncology, UKT Tübingen, Tübingen, Germany. rainer.souchon@med.uni-tuebingen.de
authors.forename: Rainer
authors.initials: R
authors.lastname: Souchon
authors.forename: Frederik
authors.initials: F
authors.lastname: Wenz
authors.forename: Felix
authors.initials: F
authors.lastname: Sedlmayer
authors.forename: Wilfried
authors.initials: W
authors.lastname: Budach
authors.forename: Jürgen
authors.initials: J
authors.lastname: Dunst
authors.forename: Petra
authors.initials: P
authors.lastname: Feyer
authors.forename: Wulf
authors.initials: W
authors.lastname: Haase
authors.forename: Wolfgang
authors.initials: W
authors.lastname: Harms
authors.forename: Marie-Luise
authors.initials: ML
authors.lastname: Sautter-Bihl
authors.forename: Rolf
authors.initials: R
authors.lastname: Sauer
mesh_terms: D001859:Bone Neoplasms / Q000175:diagnosis / Q000532:radiotherapy* / Q000556:secondary*; D001943:Breast Neoplasms / Q000175:diagnosis / Q000532:radiotherapy*; D003131:Combined Modality Therapy; D003661:Decision Support Techniques; D019583:Dose Fractionation, Radiation; D005260:Female; D005598:Fractures, Spontaneous / Q000175:diagnosis / Q000532:radiotherapy; D006801:Humans; D033183:Interdisciplinary Communication; D008279:Magnetic Resonance Imaging; D009460:Neurologic Examination; D010166:Palliative Care; D010348:Patient Care Team; D011879:Radiotherapy Dosage; D011880:Radiotherapy Planning, Computer-Assisted; D019233:Retreatment; D013117:Spinal Cord Compression / Q000175:diagnosis / Q000532:radiotherapy*; D016103:Spinal Fractures / Q000175:diagnosis / Q000532:radiotherapy; D013125:Spinal Neoplasms / Q000175:diagnosis / Q000532:radiotherapy* / Q000556:secondary*; D014057:Tomography, X-Ray Computed