Axillary Radiotherapy Research Articles

The 21-gene recurrence score in node-positive, hormone receptor-positive, HER2-negative breast cancer: a cautionary tale from an NCDB analysis.

The 21-gene recurrence score assay (RS) has not been prospectively validated to predict adjuvant chemotherapy benefit in hormone receptor-positive (HR+), HER2-negative (HER2-), node-positive breast cancer patients. Nevertheless, de-escalation based on RS has been demonstrated and partially advocated by retrospective data. The purpose of this study was to identify subgroups of node-positive patients with low to intermediate RS who still benefit from adjuvant chemotherapy. The National Cancer Database was used to identify 28,591 women with stage I-III, T1-T3, N1, HR+, HER2- breast cancer and a RS ≤ 25 between 2010 and 2016. Univariate and multivariate analyses were used to identify variables correlating with chemotherapy use and 5-year survival. Subgroup analysis was performed to discern patients in whom the use of adjuvant chemotherapy correlated with better survival. A 35% decline in chemotherapy use was observed from 2010 to 2016. Patients with younger age, higher RS, larger tumors and more positive lymph nodes, and those treated by mastectomy, axillary lymph node dissection and radiation, were more likely to receive chemotherapy. Chemotherapy use was associated with an improved 5-year survival (HR = 1.63, 95% CI 1.28-2.07). Upon subgroup analysis, this association was lost in patients > 70years and those with a RS ≤ 11, while patients ≤ 70 with a RS of 12-25 treated with chemotherapy had an absolute 5-year survival advantage of 3.0% (HR = 1.91, 95% CI 1.42-2.57). Clinicians should be cautious when considering omission of adjuvant chemotherapy in patients ≤ 70years, with HR+, HER2-, N1 tumors and a RS 12-25, at least until the results of the anticipated RxPONDER trial become available.

Molecular analysis of sentinel lymph nodes in patients with breast cancer using one-step nucleic acid amplification (OSNA): Does not lead to overtreatment in the current era of de-escalating axillary management

PurposeOSNA is a molecular technique for sentinel lymph node (SN) analysis in breast cancer. Compared to histology, OSNA may yield more (micro)metastases and thereby result in more axillary lymph node dissections or radiotherapy. We investigated whether axillary treatments increase when using OSNA, applying current guidelines for de-escalating axillary management. MethodsAll patients treated for cT1-3N0 breast cancer in our hospital between December 2013 and February 2016 were included. In 148 prospectively included patients (January 2015–February 2016), SN's were examined with OSNA. In a retrospective cohort of 123 patients (December 2013–December 2014), SN's were examined with conventional histology. Outcomes were: number of macro and micrometastases, amount of patients receiving axillary dissection or irradiation, number of patients receiving adjuvant systemic therapy. Data were analyzed using Mann-Whitney and Pearson Chi-square test. P < 0.05 was considered statistically significant. Results230 SN's from 123 patients were examined with conventional histology. 229 SN's from 148 patients were evaluated with OSNA. Amount of macrometastases was equal between groups (histology 17.9% versus OSNA 16.2%, p = 0.715). We found significantly more micrometastases when using OSNA (histology 11.4% versus OSNA 25.0%, p = 0.004). Total number of axillary lymph node dissections was comparable in both groups (histology 12.2%, OSNA 12.2%, p = 0.993), as well as number of axillary radiations (histology 8.9%, OSNA 11.5%, p = 0.493). Also, the number of patients receiving adjuvant systemic therapy was similar between conventional histology and OSNA (histology 53.7% versus OSNA 58.1%, p = 0.462). ConclusionOSNA analysis for SN in breast cancer is a highly sensitive technique, detecting more micrometastases than standard histology. When applying current guidelines, OSNA analysis does not lead to overtreatment with more axillary dissections or irradiation.

Determination of the Minimum Detectable Change in the Total and Segmental Volumes of the Upper Limb, Evaluated by Perimeter Measurements.

Among female breast cancer survivors, there is a high prevalence of lymphedema subsequent to axillary lymph node dissection and axillary radiation therapy. There are many methodologies available for the screening, diagnosis and follow-up of breast cancer survivors with or without lymphedema, the most common of which is the measurement of patients’ arm circumference. The purpose of this study was to determine the intra-rater minimal detectable change (MDC) in the volume of the upper limb, both segmentally and globally, using circumference measurements for the evaluation of upper limb volume. In this study, 25 women who had received a unilateral mastectomy for breast cancer stage II or III participated. On two occasions separated by 15 min, the same researcher determined 11 perimeters for each arm at 4 cm intervals from the distal crease of the wrist in the direction of the armpit. The MDC at the segmental level ranged from 3.37% to 7.57% (2.7 to 14.6 mL, respectively) and was 2.39% (42.9 mL) at the global level of the arm; thus, minor changes in this value result in a high level of uncertainty in the interpretation of the results associated with the diagnosis of lymphedema and follow-up for presenting patients.

Axillary reverse mapping in patients undergoing axillary dissection -a short review of the literature

Axillary lymph node dissection (ALND) can be avoided not only in patients with negative sentinel lymph nodes (SLNs) but also in those with one or two positive SLNs receiving breast or axillary radiation. However, ALND has remained the standard treatment for patients with clinically positive nodes (cN+). Although axillary reverse mapping (ARM) was developed to map and preserve arm lymphatic drainage during ALND, it could not be indicated for cN + patients because metastatic rate of ARM nodes is high. However, a new type of conservative ALND with ARM attempts to preserve ARM lymphatics and nodes except SLNs and other suspicious palpable nodes, including suspicious ARM nodes. This procedure allowed reduction of the rate of arm lymphedema without increasing axillary recurrence, although patients received postoperative chemotherapy and high-risk patients underwent axillary radiation. Thus, a traditional full ALND may not be necessary for cN + patients in the era of effective multimodality therapy.

Conserving the axilla in breast cancer.

It is recognised that surgical conservatism is the most effective way of managing the axilla in breast cancer patients undergoing primary breast conserving surgery. The extended clinical scenarios in which a less aggressive approach can be safely adopted warrant consideration—including a group of patients who potentially could bypass surgical staging of the axilla altogether. The application of omission of further surgical management and axillary radiotherapy in the primary surgical and neoadjuvant chemotherapy settings are considered.

Low-Energy Extracorporeal Shockwave Therapy as a Therapeutic Option for Patients with a Secondary Late-Stage Fibro-Lymphedema After Breast Cancer Therapy: A Pilot Study.

Background: Secondary lymphedema (LE) can occur after breast cancer (BC) therapy with axillary lymph node surgery and/or radiotherapy. Reported incidence varies around 20%. The aim of this study was to see whether low-energy extracorporeal shockwave therapy (ESWT) is a therapeutic option in end-stage secondary upper limb fibro-LE. Methods and Results: A pilot study was performed on 10 adult patients who presented with an end-stage LE after BC treatment. They were all treated with usual physical therapy and all had lymphatic surgery before. Eight sessions of ESWT were applied, 2600 shocks at 0.1 mJ/mm2, 2/week during 4 weeks. Upper limb volume decreased nonsignificantly, from 3086.4 ± 539.47 to 2909.1 ± 471.60 mL. Mean circumference of the upper limb was significantly decreased from 32.3 ± 3.01 to 31.4 ± 2.71 cm at the height of the upper arm, from 29.1 ± 2.89 to 28.1 ± 2.71 cm at the height of the elbow, and from 27.5 ± 4.08 to 26.8 ± 3.75 cm at the height of the forearm. Subjective measurements by visual analog scale showed significant decrease in both hardness from 57.3 ± 15.84 to 24.4 ± 21.89 mm and subjective feeling of edema from 44.2 ± 16.90 to 23.2 ± 21.16 mm. No adverse features were reported. Conclusion: We added some evidence that low-energy ESWT is well supported and has additional benefits also in longstanding fibro-lipo-LE on swelling of the arm leading to more subjective comfort for the patients.

Neo‐Adjuvant chemotherapy and its affects to the axilla—Can we safely downgrade axillary surgery to mirror the approach in the breast

The use of neo-adjuvant chemotherapy (NACT) to downgrade surgery in the breast from mastectomy to breast-conserving surgery is well-established. In certain patients, the use of adjuvant axillary radiotherapy can be safe and effective in place of axillary node clearance. What remains less clear are the alternative surgical options to the axilla following NACT. The aim of this study was to examine the effects of NACT in the axilla and whether downgrading axillary node clearance to axillary conserving surgery to mirror the approach in the breast may be a viable and safe practice. Patients undergoing neo-adjuvant chemotherapy were identified over a seven-year period between 2010 and 2017. Surgical plans were compared with pre- and post-chemotherapy. Histological information at the time of diagnosis was compared to surgical excision specimens. 349 patients were included for analysis, and 264 had axillary status documented at diagnosis. The average patient age was 51years, and Grade 3, ER-positive, and Her2-negative cancers made the biggest histological subgroups. Complete pathological response (CPR) was seen in the breast in 27% of cases. 19% of patients requiring mastectomy had their surgery downgraded. Following NACT, axillary CPR was seen in 42% of patients and residual axillary nodal burden was limited to four nodes in 73% of patients. Axillary conserving surgery may be a safe alternative surgical approach in the downstaged axilla following neo-adjuvant chemotherapy. Advances in perioperative identification of suspicious nodes may be needed to facilitate progress.

Quantifying the Impact of Axillary Surgery and Nodal Irradiation on Breast Cancer-Related Lymphedema and Local Tumor Control: Long-Term Results From a Prospective Screening Trial.

To independently evaluate the impact of axillary surgery type and regional lymph node radiation (RLNR) on breast cancer-related lymphedema (BCRL) rates in patients with breast cancer. From 2005 to 2018, 1,815 patients with invasive breast cancer were enrolled in a lymphedema screening trial. Patients were divided into the following 4 groups according to axillary surgery approach: sentinel lymph node biopsy (SLNB) alone, SLNB+RLNR, axillary lymph node dissection (ALND) alone, and ALND+RLNR. A perometer was used to objectively assess limb volume. All patients received baseline preoperative and follow-up measurements after treatment. Lymphedema was defined as a ≥ 10% relative increase in arm volume arising > 3 months postoperatively. The primary end point was the BCRL rate across the groups. Secondary end points were 5-year locoregional control and disease-free-survival. The cohort included 1,340 patients with SLNB alone, 121 with SLNB+RLNR, 91 with ALND alone, and 263 with ALND+RLNR. The overall median follow-up time after diagnosis was 52.7 months for the entire cohort. The 5-year cumulative incidence rates of BCRL were 30.1%, 24.9%, 10.7%, and 8.0% for ALND+RLNR, ALND alone, SLNB+RLNR, and SLNB alone, respectively. Multivariable Cox models adjusted for age, body mass index, surgery, and reconstruction type showed that the ALND-alone group had a significantly higher BCRL risk (hazard ratio [HR], 2.66; P = .02) compared with the SLNB+RLNR group. There was no significant difference in BCRL risk between the ALND+RLNR and ALND-alone groups (HR, 1.20; P = .49) and between the SLNB-alone and SLNB+RLNR groups (HR, 1.33; P = .44). The 5-year locoregional control rates were similar for the ALND+RLNR, ALND-alone, SLNB+RLNR, and SLNB-alone groups (2.8%, 3.8%, 0%, and 2.3%, respectively). Although RLNR adds to the risk of lymphedema, the main risk factor is the type of axillary surgery used.

Evolution Of Subclinical Systemic Lymphedema In-Patient With Lipedema And Axillary Dissection

Background: The surgical treatments of breast cancer associated or not with axillary drainage and radiotherapy constitute the main cause of secondary upper limb lymphedema. Obesity is a particularly aggravating aspect in patients with lymphedema. Novel concepts of subclinical systemic lymphedeman and clinical systemic lymphedema have recently been described. The aim of the present study was to evaluate the evolution of subclinical systemic lymphedema to upper limb lymphedema following treatment for breast cancer. Case: A 36-year-old female patient had been submitted to treatment for breast cancer involving left-side mastectomy and lymph node drainage during a pregnancy three years earlier. She had undergone both chemotherapy and radiotherapy. The patient had a portacath in the right arm for chemotherapy, which was removed after the first evaluation. She was submitted to bioelectrical impedance analysis, which revealed an increase in intracellular and extracellular water and body water in all limbs and the trunk above the normal range. The patient returned approximately two years after the initial evaluation, complaining of edema in the left arm. Conclusion: The treatment of breast cancer in patients with lipedema could lead to the development of subclinical lymphedema in patients with a BMI less than 30 kg/m2. Therefore, such conditions constitute a warning sign for the development of lymphedema.

Shoulder Dysfunction in Breast Cancer Survivors: Can Treatment Type or Musculoskeletal Factors Identify Those at Higher Risk?

Background and Objective: Breast cancer is the most commonly diagnosed cancer in Canadian women. Breast cancer survivors are known to experience shoulder dysfunction, but the influence of musculoskeletal and treatment factors has yet to be investigated in a Saskatchewan population, which was the purpose of this study. Methods: Two study designs were used to assess risk factors for dysfunction: (1) a cross-sectional Web-based questionnaire and (2) prospective cohort analysis of preoperative musculoskeletal assessment combined with postoperative Shoulder Pain and Disability Index (SPADI) score. Data from the survey were summarized and analyzed using χ2 tests (P &lt; .05), while nonparametric measures were used to calculate temporal differences and associations between musculoskeletal risk factors and disability. Results: Commonly reported shoulder problems after treatment were stiffness (63.5%), restricted range of motion (61.9%), and changes in arm/hand sensation (61.9%). Axillary lymph node dissection and radiation therapy were associated with more shoulder problems than other treatment types. SPADI scores increased by an average of 8.1% from baseline to 3 months postsurgery. A clinically significant 18% increase between these time points was moderately associated with a history of shoulder problems and restricted humeral extension preoperatively (average = 37.7° vs 48.9°). Conclusions: Breast cancer survivors from Saskatchewan have a high prevalence of shoulder problems following treatment. Clinically significant impairments in shoulder function are associated with select treatment types and preoperative impairments. These results can be used to identify high-risk patients before cancer treatment and direct their rehabilitation.

Locoregional Management of Early-Stage Breast Cancer

Locoregional management of early-stage breast cancer has been trending toward less-extensive axillary resections, based on increasing evidence showing that patients with 1 or 2 positive sentinel nodes and/or micrometastases can safely be managed with sentinel node biopsy alone, thereby avoiding complete axillary lymph node dissection (cALND) in the significant majority of patients. Because of the 15% to 20% lymphedema risk associated with cALND, increasing efforts are being made to avoid the procedure when evidence suggests that more limited procedures are safe, as reflected by acceptable locoregional recurrence rates. Axillary radiotherapy (RT) has been shown to be an effective alternative to ALND for patients fitting criteria from the pivotal AMAROS trial: patients with T1/T2 disease and are clinically node-negative, who undergo either breast-conserving therapy or mastectomy. Considerations for RT begin with the question of nodal involvement, with treatment planned accordingly. With more neoadjuvant therapy being used, there are nuances in locoregional management that clinicians must now appreciate, both in terms of ALND and axillary RT.

Comparison between stromal vascular fraction and adipose derived stem cells in a mouse lymphedema model

Background: Lymphedema is one of the most common complications following breast cancer. Axillary lymph node dissection and radiotherapy are two well-known risk factors resulting in either removal or damage to the lymph nodes. As stem cells are known for their regenerative capabilities, they could theoretically repair/restore the damaged lymph vessels leading to a decrease in lymphedema.Methods: We evaluated the treatment of SVF and ASC on a mouse lymphedema model. Forty-five mice were allocated into three groups containing 15 mice each. The SVF group was injected with 100 μl containing 1 × 106 SVF, the ASC group with 100 μl ml containing 1 × 106 ASC and the NS with 100 μl ml of NS. Volumes of the mice were assessed weekly by μCT hindlimb volumetry for a total of 8 weeks. Lymph vessel morphometry was assessed by cross-sections of both hindlimbs stained for anti-LYVE1. Lymphatic function was assessed by lymphatic clearance.Results: The volume change between the groups was non-significant throughout all 8 weeks. The immunohistochemistry showed a statistically significant difference between the hindlimbs in ASC vs. NS group p = 0.032, 95% CI [–2121, −103].Conclusion: The volume of the hindlimbs showed that treatment with SVF or ASC yielded very similar results compared to the control group when assessed after 8 weeks. In week two the biggest difference between ASC and NS was seen but the difference diminished during the 8 weeks. The secondary outcomes showed that the lymph vessel lumen decreased when treated with ASC compared to the control group. Lymphoscintigraphy yielded non-significant results.

Conserving the lymphatics from the arm using fluorescence imaging in patients with breast cancer at high risk of postoperative lymphedema: a pilot study.

Postoperative lymphedema in breast cancer survivors is a serious complication that develops from axillary lymph node dissection (ALND), chemotherapy, and radiation therapy. Axillary reverse mapping (ARM) was recently introduced to reduce lymphedema. This pilot study aimed to investigate the feasibility of preserving the ARM node using fluorescence imaging for patients at high risk of lymphedema. We prospectively screened patients with breast cancer who had pathologic node-positive disease at diagnosis and were scheduled for neoadjuvant chemotherapy (NCT). The sentinel lymph node (SLN) was identified using blue dye and radioisotope, while the ARM node was traced using indocyanine green (ICG). In cases in which SLN was negative on the intraoperative frozen section examination, the ARM node and lymphatics were preserved. Of the 20 screened patients, six whose metastatic axillary lymph node (ALN) was converted to clinically node-negative disease after NCT were enrolled. No patients experienced recurrence at 24 months postoperative. Four patients who had a preserved ARM node did not develop lymphedema. One patient whose ARM node was not preserved due to SLN identification failure did not develop postoperative lymphedema. One patient who underwent ALND without ARM node conservation because of metastatic SLN on frozen section examination developed postoperative lymphedema. ARM is oncologically safe, decreases the incidence of postoperative lymphedema, and allows for the early detection of postoperative lymphedema in patients who underwent ALND. Ultimately, ARM may help improve the quality of life of patients with pathologic node-positive breast cancer.

P132: Neoadjuvant chemotherapy and its effects to the axilla - Can we safely downgrade axillary surgery to mirror the approach in the breast

Introduction: The use of neoadjuvant chemotherapy (NACT) to downgrade surgery in the breast from mastectomy to breast-conserving surgery is well established. In certain patients the use of adjuvant axillary radiotherapy can be safe and effective in place of axillary node clearance. What remains less clear are the alternative surgical options to the axilla following NACT. The aim of this study was to examine the effects of NACT in the axilla and whether downgrading axillary node clearance to axillary conserving surgery to mirror the approach in the breast may be a viable and safe practice.

Breast-conserving surgery without axillary lymph node surgery or radiotherapy is safe for HER2-positive and triple negative breast cancer patients over 70years of age.

The prognosis of elderly patients with hormone receptor-positive breast cancer is very good, and their survival is unaffected by performing breast-conserving surgery (BCS) without radiotherapy. Therefore, we aimed to verify that BCS without axillary lymph node dissection, sentinel lymph node biopsy, or radiotherapy (BCSNR) is safe for patients over 70years of age with luminal-type breast cancer, as well as for those with HER2-positive and triple negative breast cancer (TNBC). This study retrospectively included 450 patients > 70-year-old with breast cancer from 2010 to 2016. The patients were divided into two groups, one treated with BCSNR and the other treated with mastectomy and axillary lymph node dissection (MALND), with a median follow-up period of 5years. Disease-free survival (DFS), overall survival, local recurrence, distant metastasis, and ipsilateral breast tumor recurrence (IBTR) were compared between the two groups. The 5-year DFS for patients who underwent BCSNR and MALND was 90.1 and 91.3% (p = 0.903), respectively. In the BCSNR and MALND groups, respectively, the 5-year DFS for patients with luminal A type breast cancer was 99.2 and 100% (p = 0.167), that for patients with luminal B type breast cancer was 89.2 and 95.5% (p = 0.138), that for patients with HER2-positive breast cancer was 86.7 and 75.9% (p = 0.455), and that for TNBC patients was 71.7 and 89.7% (p = 0.195). IBTR significantly differed between the BCSNR and MALND groups for patients with TNBC (18.9% vs 0.0%, p = 0.040) and luminal B type patients (5.6% vs 0.0%, p = 0.043). BCSNR is not only suitable for elderly patients with luminal-type breast cancer but also for those with HER2-positive breast cancer and TNBC.

126TiP Tailored axillary surgery with or without axillary lymph node dissection followed by radiotherapy in patients with clinically node-positive breast cancer (SAKK 23/16 / IBCSG 57-18 / ABCSG-53 / GBG 101 - TAXIS): A multicenter randomized phase III trial

Complete lymph node removal through conventional axillary lymph node dissection (ALND) has been standard treatment for breast cancer patients for almost a century. However, ALND came under increasing scrutiny due to its association with significant patient morbidity. Several studies have since provided evidence to suggest omission of ALND, often in favor of axillary radiation, in selected clinically node-negative sentinel lymph node (SLN)-positive patients. Clinically node-positive patients, by contrast, continue to undergo ALND in many cases.

Analysis of safety of postoperative accelerated hypofractionated radiotherapy for patients with stage I-IIIA breast cancer

Aim: to conduct a comparative analysis of the safety of postoperative accelerated hypofractionated radiotherapy for patients with stage I-IIIA breast cancer. Material and Methods. From 2013 to 201, 316 patients with stage I-IIIA breast cancer were treated at A.F. Tsyb Medical Radiological Research Center. Postoperative accelerated hypofractionated radiotherapy at a single daily dose of 2.7 Gy to a total dose of 40.5 Gy was given to 223 patients. The control group patients received the conventional radiation therapy at 2 Gy per fraction to a total dose of 50 Gy (n=93). The quality of life of patients was evaluated using the questionnaire EQ-5D consisting of descriptive part and a visual analogue scale (EQ VAS). Results. The frequency of edema of the upper limb did not depend on the fractionation regimen. This complication occurred more often in cases with axillary radiotherapy ( р &lt;0.01) and in cases with radical mastectomy. No difference in the quality of life between the patient groups was found. Conclusion. Postoperative accelerated hypofractionated radiotherapy at 2.7 Gy per fraction to a total dose of 40.5 Gy is safe and can be used after both organ-sparing surgery and radical mastectomy. This radiotherapy regimen is more preferable than the conventional one due to the reduced treatment time. Axillary radiotherapy signifcantly increases the risk of lymphedema of the upper limb.

Risk factors for breast cancer-related lymphedema: correlation with docetaxel administration.

Upper-limb lymphedema is a well-known complication of breast cancer and its treatment. This retrospective cohort study aims to determine what risk factors affect breast cancer-related lymphedema in patients with breast cancer. This retrospective study comprised patients diagnosed with breast cancer and who underwent surgery at Wakayama Medical University Hospital between January 1, 2012 and December 31, 2018. Assessed factors using univariate and multivariate analyses were patient-related factors (age, gender, and BMI), breast cancer-related factors (tumor size, nodal status, histology, tumor location, and intrinsic subtype), and treatment-related factors (type of surgery, application, timing and regimen of chemotherapy, and application of radiotherapy). This study included 1041 patients. BMI did not affect the onset of breast cancer-related lymphedema. There were only six sentinel lymph node biopsy cases in the breast cancer-related lymphedema group (6.6%). In cases of axillary lymph node dissection, adjuvant chemotherapy was marginally associated with increased risk of breast cancer-related lymphedema compared to no chemotherapy (HR 2.566; 95% CI 0.955-6.892; p = 0.0616). Among anti-cancer agents, docetaxel (HR 3.790; 95% CI 1.413-10.167; p = 0.0081) and anti-HER2 therapy (HR 2.507; 95% CI 1.083-5.803; p = 0.0318) were associated with increased risk of lymphedema according to multivariate analysis. Neo-adjuvant chemotherapy did not affect the onset of breast cancer-related lymphedema. Radiotherapy (HR 2.525; 95% CI 1.364-4.676; p = 0.0032) was an important risk factor for breast cancer-related lymphedema. Axillary lymph node dissection, radiotherapy and adjuvant chemotherapy, especially docetaxel, were risk factors for breast cancer-related lymphedema, but BMI and neo-adjuvant chemotherapy were not.

Breast cancer-related lymphedema: focus on surgical treatment

Breast cancer-related lymphedema (BCRL) can affect breast cancer patients, especially after axillary surgery and radiation treatment, for life. First line treatment is conservative and involves physical therapy and compression. It requires absolute, life-long compliance with treatment by the patient and, in some cases, it is ineffective. In recent years, surgery has emerged as a possible alternative or even, complementary therapy for BCRL. The most commonly reported techniques are reconstructive or debulking procedures. Reconstructive procedures are aimed at restoring the lymphatic pathways and can be effective early in the disease process, when increased arm volumes are mostly due to the accumulation of protein-rich fluid in the interstitial space. In more advanced stages, where fibrotic and hypertrophic adipose tissues are dominant, debulking techniques such as liposuction can be recommended. A standard of care for the treatment of BCRL has not been established. Currently, different techniques can be combined to optimize clinical outcomes, and the surgical approach must be individualized for each patient, based on sound clinical and imaging assessment. BCRL surgical treatment remains a challenging topic that requires further study before it can be standardized.

Dosimetric comparison of incidental axillary irradiation between three-dimensional conformal and volumetric modulated arc techniques for breast cancer.

Radiotherapy techniques for breast cancer have evolved with efforts to reduce treatment-related side effects. In the present study, we conducted dosimetric analysis of incidental axillary irradiation between volumetric modulated arc therapy (VMAT) and three-dimensional conformal radiotherapy (3D-CRT). A total of 20 patients with early stage left breast cancer who underwent breast-conserving surgery followed by postoperative radiotherapy were analyzed. For VMAT plans, dose-volume constraints were not imposed on the axilla, as with 3D-CRT. We compared the dosimetric parameters of the planning target volumes, organs at risk and axillary level I-III of the two plans. VMAT showed better target coverage and a normal organ-sparing effect compared with 3D-CRT. The incidental axillary irradiation of VMAT was lower; the mean dose and the V40Gy were significantly reduced at all axillary levels, with the exception of no difference in the maximum dose to axillary level I. In conclusion, VMAT decreased incidental axillary irradiation, even in the absence of a dose-volume constraint on the axilla, and can, therefore, decrease the risk of radiotherapy-related lymphedema. However, caution is also required because it is unclear whether this incidental axillary irradiation is beneficial for reducing recurrence on the axilla.