Hypofractionation for Regional Nodal Irradiation in breast cancer: Best of both the worlds

Purpose : Locoregional radiotherapy play an important role in controlling the disease after surgery in patients with breast cancer. Radiotherapy schedules vary from conventional fraction to hypofractionation. The purpose of this review is to get an insight into the data on regional nodal irradiation (RNI) with hypofractionation in patients with breast cancer. Methods and materials : This systematic review was constructed in accordance with Preferred Reporting Items for Systematic reviews and Meta-analysis (PRISMA) framework (Figure 1). Electronic databases such as PubMed, Cochrane and EMBASE were searched from 1st January 2023 to 31st March 2023 to identify studies published in English language on hypofractionated RNI in post mastectomy patients. The search was carried out with the National Library of Medicine's Medical Subject Heading (MeSH) terms like ‘regional nodal irradiation’, ‘hypofractionated’ and ‘hypofractionation in breast cancer’ with different Boolean operators (and/or). A manual search of reference lists of included articles was also performed to make sure there were no additional cases unidentified from the primary search. Studies deemed potentially eligible were identified and assessed by same independent reviewers to confirm eligibility. Results : RNI data are mainly from a randomised study from Beijing and pooled data from START trials. There are also data from retrospective and single institutional studies and a few phase II studies with limited number of patients using different dose fractionations and techniques of radiotherapy. Doses used in these trials ranged from 26-47.7Gy in 5-19 fractions over 1-4 weeks. Grade ≥2 pulmonary fibrosis and lymphedema rate ranged from 2-7.9% and 3-19.8% respectively. Grade ≥2 shoulder dysfunction and brachial plexopathy ranged from 0.2-28% and 0-<1%, respectively. Late effects with a dose range of 26-40Gy delivered in 5 to 15 fractions over 1-3 weeks were less/similar to conventional fraction. Conclusions : Current data showed lower/similar rates of toxicity with hypofractionated RNI compared with conventional fractionation RNI. Doses of 26Gy to 40Gy delivered in 5 to 15 fractions over 1-3 weeks are safe for RNI. With limited data, ultra-hypofractionation 26Gy/5 fractions/ 1 week also seems to be safe. However, long-term outcome is awaited and many trials are going on to address its efficacy and safety.