title: Hypofractionated irradiation in elderly patients with breast cancer after breast conserving surgery and mastectomy : Analysis of 205 cases.
abstract: BACKGROUND
  Several randomized trials and meta-analyses confirmed a wide benefit of radiotherapy (RT), both after breast conserving surgery (BCS) and mastectomy. However, many elderly women don't receive RT. Hypofractionated (HF) RT allows « simplified » and more accessible treatments with equivalent results to classic RT in three large randomized trials. However, there are few available data on HF-RT for nodal irradiation, as well as for the boost.
  
  
  METHODS
  We evaluated patients treated for IBC by HF-RT between 2004 and 2012 in two regional cancer centres. We used an original scheme delivering 45 Gy in 15 fractions three times a week, both after BCS or mastectomy, with or without nodal irradiation. After BCS, a 9 Gy boost in 3 fractions was delivered. Local, regional and distant recurrences were assessed, as well as acute and late cutaneous, cardiac or pulmonary toxicities.
  
  
  RESULTS
  205 patients were analysed, 116 after BCS (57 %) and 89 after mastectomy (43 %). Median age was 81 years (range: 52-91); 44 % had axillary nodal involvement (pN+). The Nottingham Prognostic Index (NPI) scored 0, 1, 2 and 3 in 10 %, 27 %, 44 % and 19 % of the cases. A nodal HF-RT was delivered in 65 patients (32 %) and boost in 98 patients (84 % of BCS) by 9 Gy/3 fr scheme. Fifty (24 %) patients underwent chemotherapy and 156 (75 %) hormonal treatment. With a 49-month median follow-up, 3/116 (2.6 %) patients and 4/89 (4.5 %) had local recurrence (LR) after BCS and mastectomy, respectively. The overall 5-year LR rate was 4.4 %. In univariate and multivariate analysis, LR risk factors were: high NPI (HR 5.46; p = 0.028), and triple negative tumour (HR 9.78; p = 0.006). Only 8 (4.5 %) patients had grade III skin toxicity; 29 (14 %) late fibrosis and 16 (8 %) telangiectasia. No pulmonary or cardiac toxicity was observed.
  
  
  CONCLUSIONS
  Our HF-RT scheme (with or without nodal irradiation) confirms in elderly patients the data from randomized trials, both after BCS or mastectomy. Toxicity seems very acceptable but requires a longer follow-up. A larger evaluation is still ongoing in several other centres in France.
authors.affiliation: Radiation Oncology Department, Institut de Cancérologie de l'Ouest, Nantes, France. meladore@gmail.com.
authors.forename: Mélanie
authors.initials: M
authors.lastname: Doré
authors.affiliation: Radiation Oncology Department, Institut de Cancérologie de Courlancy, Reims, France. bcutuli@iccreims.fr.
authors.forename: Bruno
authors.initials: B
authors.lastname: Cutuli
authors.affiliation: Radiation Oncology Department, Institut de Cancérologie de l'Ouest, Angers, France. patrice.cellier@ico.unicancer.fr.
authors.forename: Patrice
authors.initials: P
authors.lastname: Cellier
authors.affiliation: Radiation Oncology Department, Institut de Cancérologie de l'Ouest, Nantes, France. loic.campion@ico.unicancer.fr.
authors.forename: Loïc
authors.initials: L
authors.lastname: Campion
authors.affiliation: Radiation Oncology Department, Institut de Cancérologie de l'Ouest, Nantes, France. magali.le-blanc@ico.unicancer.fr.
authors.forename: Magali
authors.initials: M
authors.lastname: Le Blanc
mesh_terms: D000368:Aged; D000369:Aged, 80 and over; D000971:Antineoplastic Combined Chemotherapy Protocols / Q000627:therapeutic use; D001943:Breast Neoplasms / Q000188:drug therapy / Q000532:radiotherapy* / Q000601:surgery; D009202:Cardiomyopathies / Q000209:etiology; D003131:Combined Modality Therapy; D005260:Female; D005355:Fibrosis; D006801:Humans; D008171:Lung Diseases / Q000209:etiology; D015182:Lymphatic Irradiation / Q000009:adverse effects; D008207:Lymphatic Metastasis / Q000532:radiotherapy; D008408:Mastectomy / Q000379:methods*; D008875:Middle Aged; D009364:Neoplasm Recurrence, Local / Q000453:epidemiology; D017698:Postmenopause; D000069473:Radiation Dose Hypofractionation; D011855:Radiodermatitis / Q000209:etiology; D018714:Radiotherapy, Adjuvant / Q000009:adverse effects / Q000379:methods*; D011882:Radiotherapy, High-Energy / Q000009:adverse effects / Q000379:methods*; D013684:Telangiectasis / Q000209:etiology; D064726:Triple Negative Breast Neoplasms / Q000628:therapy