Radiation Oncology/Toxicity/Lymphedema

Lymphedema Breast Cancer National Cancer Center Goyang, Korea; 2013 (2004-2009) PMID 23541809 -- "A model to estimate the risk of breast cancer-related lymphedema: combinations of treatment-related factors of the number of dissected axillary nodes, adjuvant chemotherapy, and radiation therapy." (Kim M, Int J Radiat Oncol Biol Phys. 2013 Jul 1;86(3):498-503. doi: 10.1016/j.ijrobp.2013.02.018. Epub 2013 Mar 28.) Retrospective. 772 patients, breast cancer, surgery, ALND. Adjuvant chemotherapy in 88%. Adjuvant radiation therapy 88%; SCV RT 35%. Median F/U 5.1 Outcome: 5-year lymphedema risk 17%. Within 2 years in 76%, within 3 years in 91%. Multivariate analysis showed number of lymph nodes, adjuvant chemo, and supraclavicular RT as risk factors Model: If 1 risk factor, 5-year lymphedema 3%; 2 risk factors 19%, 3 risk factors 38% Conclusion: A model developed for predicting lymphedema risk Fox Chase; 2008 PMID 19028274 -- "Does axillary boost increase lymphedema compared with supraclavicular radiation alone after breast conservation?" (Hayes SB, Int J Radiat Oncol Biol Phys. 2008 Dec 1;72(5):1449-55.) Retrospective. 2579 women, T1-2N0-3 breast cancer, BCT. RT breast only (B) 84%, breast + SCV 9% and breast + SCV + PAB 7%. Median F/U 6.7 years Outcome: Lymphedema 18%. After B 16%, B+SCV 23%, B+SCV+PAB 31%. Predictors for lymphedema: regional nodal irradiation, obesity, systemic therapy, and number LNs dissected. In N1 patients, PAB addition to SCV no difference; in N2 patients, 4.5x increase in lymphedema Conclusion: Decision to boost axilla must be weighed against increased risk of lymphedema Harvard; 2003 (1982-1995) PMID 12654429 -- "Risk of lymphedema after regional nodal irradiation with breast conservation therapy." (Coen JJ, Int J Radiat Oncol Biol Phys. 2003 Apr 1;55(5):1209-15.) Retrospective. 727 Stage I-II BCA patients treated with BCT. Lymphedema defined >2 cm difference in forearm circumference. Breast RT alone 68%, Breast + lymphatics RT 32%. Most Level I-II axillary dissection. Median F/U 6 years 10-year outcome: 4% (tangents alone 2% vs. axillary 9%, SS) Predictors for lymphedema: only axillary irradiation Conclusion: Risk lower than generally recognized NSABP B-04, PMID 18029105 — "The Incidence of Arm Edema in Women With Breast Cancer Randomized on the National Surgical Adjuvant Breast and Bowel Project Study B-04 to Radical Mastectomy Versus Total Mastectomy and Radiotherapy Versus Total Mastectomy Alone." (Deutsch M et al. Int J Radiat Oncol Biol Phys. 2008 Mar 15;70(4):1020-1024.) For more information see page at Axilla Halsted radical mastectomy (RM) vs. total mastectomy + RT (TM+RT) vs. TM alone. Recorded ipsilateral and contralateral arm circumference every 3 months (avg of >= 6 sets of measurements per pt). Increase of >=2cm in arm circumference was seen in 58.1% (RM), 38.2% (TM+RT) vs 49.1% (TM). Severe edema (>=4cm) in 21.5%, 11.4%, and 13.1%. 25% with edema at one time had no edema at the time of final measurement. Increased BMI associated with edema. High incidence of edema with these surgical techniques. Management Royal Marsden PMID 15542159 -- "Double-blind placebo-controlled randomised trial of vitamin E and pentoxifylline in patients with chronic arm lymphoedema and fibrosis after surgery and radiotherapy for breast cancer" (Gothard L, Radiother Oncol. 2004 Nov;73(2):133-9. doi: 10.1016/j.radonc.2004.09.013.) Randomized phase II. 68 patients, >20% arm volume at median 15 years after RT. 1) dl-alpha tocopheryl acetate (Vitamin E) 500 mg twice daily + pentoxifylline 400 mg twice daily x 6 months vs 2) placebo x 6 months. Primary endopoint volume of ipsilateral imb Outcome: 1 year arm volume: Tx 2.5% vs placebo 1.2% (NS). No difference in tissue fibrosis, photographic appearance, or patient QoL Conclusion: No benefit in this setting