Abstract
Background/PurposeShoulder/arm morbidity is a late complication of breast cancer treatment with surgery and regional nodal irradiation (RNI). We set to analyze the impact of radiation technique [intensity modulated radiation therapy (IMRT) or 3D conformal radiation therapy (3DCRT)] on radiation dose to the shoulder with a hypothesis that IMRT use results in smaller volume of shoulder receiving radiation. We explored the relationship of treatment technique on long-term patient-reported outcomes using the quick disabilities of the arm, shoulder, and hand (q-DASH) questionnaire.Materials/MethodsWe identified patients treated with adjuvant RNI (50 Gy/25 fractions) from 2013 to 2018. We retrospectively contoured the shoulder organ-at-risk (OAR) from 2 cm above the ipsilateral supraclavicular (SCL) planning target volume (PTV) to the inferior SCL PTV slice and calculated the absolute volume of shoulder OAR receiving 5–50 Gy (V5–V50). We identified patients that completed a q-DASH questionnaire ≥6 months from the end of RNI.ResultsWe included 410 RNI patients: 54% stage III, 72% mastectomy, 35% treated with IMRT. IMRT resulted in significant reductions in the shoulder OAR volume receiving 20–50 Gy vs. 3DCRT. In total, 82 patients completed the q-DASH. The mean (SD) q-DASH=25.4 (19.1) and tended to be lower with IMRT vs. 3DCRT: 19.6 (16.4) vs. 27.8 (19.8), p=0.078.ConclusionWe found that IMRT reduces radiation dose to the shoulder and is associated with a trend toward reduced q-DASH scores ≥6 months post-RNI in a subset of our cohort. These results support prospective evaluation of IMRT as a technique to reduce shoulder morbidity in breast cancer patients receiving RNI.
Highlights
Regional nodal irradiation (RNI) in breast cancer patients is expanding based on clinical trials and meta-analyses [1,2,3]
Intensity modulated radiation therapy (IMRT) resulted in significant reductions in the shoulder OAR volume receiving 20–50 Gy vs. 3D conformal radiation therapy (3DCRT)
We found that IMRT reduces radiation dose to the shoulder and is associated with a trend toward reduced q-DASH scores ≥6 months post-RNI in a Shoulder Dose and Morbidity in RNI
Summary
Regional nodal irradiation (RNI) in breast cancer patients is expanding based on clinical trials and meta-analyses [1,2,3]. Shoulder and arm morbidity include impairments of shoulder/arm movement, chest wall discomfort, lymphedema, and upper extremity weakness [6] which negatively impact quality of life [9, 13]. These morbidities are common with as many as 2/3 of patients reporting decreased shoulder mobility and nearly 20% of patients experiencing persistent shoulder/arm pain more than 2.5 years out from the end of radiation [10]. IMRT may reduce the volume of shoulder musculature exposed to high/ moderate radiation doses relative to 3D conformal radiation therapy (3DCRT), but this has not been previously characterized
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