Marchal C, Spaeth D, Verhaeghe J L, Depardieu C, Netter E, Luporsi E, Bernou A
Département de Radiothérapie, Centre Alexis Vautrin, Vandoeuvre-lès-Nancy.
Presse Med. 1996 Nov 9;25(34):1636-42.
Because of its high incidence and the high number of deaths induced, breast cancers in elderly women is a major health problem. The diagnosis is often clinical and the tumors are often at advanced stage with many initial metastases due to some neglect. Breast cancer in elderly women has no specific radiological form and is more often infiltrating ductal carcinoma of SBR grade I. Hormonal receptors are generally higher in elderly than in young women. Surgery of breast cancers with equal anesthetic risks factors does not induce more complications in elderly women than in the general population. In 12% of cases, an associated pathology influences the decision (degradation of the respiratory or cardiovascular function or reduction of the renal function). Between 70 and 80 years, provided that life expectancy is compatible with radiotherapy, corollary to conservative treatments in the present state of our knowledge for tumors under 3 to 4 cm, there is an alternative between radiosurgical conservative treatment and modified mastectomy associated with axillary dissection. In case of bulky tumors (> 3 to 4 cm) and failure of the hormonal treatment or impossibility to perform a complementary radiotherapy treatment (for instance, senile dementia), of axillary node involvement, a fortiori if the tumor has no hormonal receptors, the modified mastectomy with axillary dissection remains the therapeutic standard. In case of bulky tumor, the hormonal status can be used to induce the patient to accept an operation and, if necessary, to perform a conservative surgery. However, despite hormonosensitivity of breast cancer, a tumoral progression after a mean duration of hormonosensitivity of 25 months is to be expected in 93% of the cases, included 25% in whom a complete response to hormonotherapy was observed. A fractionated irradiation delivering 2 Gy per fraction and 5 fractions per week with a total number of sessions of 25 gives better esthetical results. This optimal treatment lasts 5 weeks and the patients often get tired since they are old and their radiotherapy centre is far from their house. Therefore hypofractionated treatment (once a week) should be proposed. The adjuvant medical treatment of reference for menopausal women is hormonotherapy by tamoxifen. Breast cancer in elderly women reduces life expectancy at 5 years by 50%; the theoretical therapeutic indications are the same as for young women, but their application is adapted to the patient. It would be dangerous and illusive to undertreat such a disease when the life expectancy is longer than 3 years.
由于老年女性乳腺癌发病率高且致死人数众多，它成为一个主要的健康问题。诊断通常依靠临床检查，并且由于一些疏忽，肿瘤往往处于晚期且伴有多处初始转移。老年女性乳腺癌没有特定的放射学表现，更常见的是SBR I级浸润性导管癌。老年女性的激素受体水平通常高于年轻女性。在麻醉风险因素相同的情况下，老年女性乳腺癌手术引发的并发症并不比普通人群更多。在12%的病例中，相关的病理状况会影响治疗决策（呼吸或心血管功能退化或肾功能减退）。在70到80岁之间，倘若预期寿命适合放疗，就目前我们对3至4厘米以下肿瘤的认知而言，在放射外科保守治疗与改良乳房切除术加腋窝淋巴结清扫术之间存在选择。对于体积较大的肿瘤（>3至4厘米）、激素治疗失败或无法进行辅助放疗（例如老年痴呆）、腋窝淋巴结受累的情况，尤其是肿瘤没有激素受体时，改良乳房切除术加腋窝淋巴结清扫术仍是治疗标准。对于体积较大的肿瘤，激素状态可用于促使患者接受手术，如有必要，可进行保守手术。然而，尽管乳腺癌具有激素敏感性，但预计93%的病例在平均25个月的激素敏感持续时间后会出现肿瘤进展，其中25%的病例对激素治疗有完全反应。每次分割剂量为2 Gy、每周5次分割、总共25次分割的分割照射能取得更好的美学效果。这种最佳治疗持续5周，而且由于患者年老且放疗中心离家远，他们常常会感到疲惫。因此，应建议采用大分割治疗（每周一次）。绝经后女性的标准辅助药物治疗是他莫昔芬激素治疗。老年女性乳腺癌使5年预期寿命降低50%；理论上的治疗指征与年轻女性相同，但应用时需根据患者情况调整。当预期寿命超过3年时，对这种疾病治疗不足既危险又盲目。
