Determining the Organ at Risk for Lymphedema After Regional Nodal Irradiation in Breast Cancer

Gross, Jeffrey P.; Lynch, Connor; Flores, Anne Marie; Jordan, Sumanas W.; Helenowski, Irene; Gopalakrishnan, Mahesh; Cutright, Dan; Donnelly, Eric D.; Strauss, Jonathan B.

doi:10.1016/j.ijrobp.2019.06.2509

Cited by 40 publications

(24 citation statements)

References 37 publications

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“…[16][17][18] Although it makes intuitive sense that irradiation of more lymphatic basins after axillary surgery will increase the risk of BCRL, prospective data on the risk of BCRL by surgical and radiation treatment are limited. [18][19][20] Previous cadaveric and indocyanine green (ICG) studies identified the axillary lymphatic pathways of the arm but also a "lateral pathway" that bypasses the axilla. 21 These lymphatic vessels run along the cephalic vein in the outer aspect of the upper arm and pass between the pectoralis major and deltoid muscle, pierce the coracoclavicular fascia, cross the axillary artery, and end in the axillary vein just below the clavicle.…”

Section: Introductionmentioning

confidence: 99%

The Risk of Subclinical Breast Cancer-Related Lymphedema by the Extent of Axillary Surgery and Regional Node Irradiation: A Randomized Controlled Trial

Boyages

Vicini

Shah

et al. 2021

International Journal of Radiation Oncology*Biology*Physics

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Purpose: To compare the risk of subclinical breast cancererelated lymphedema (sBCRL) using bioimpedance spectroscopy (BIS) or tape measure (TM) by the extent of axillary surgery and regional nodal irradiation (RNI). Methods and Materials: Patients were randomized to surveillance with TM or BIS. A BIS !6.5 L-Dex units or TM volume change !5 and <10% above presurgical baselines "triggered" sBCRL. The incidence of sBCRL by sentinel node biopsy or axillary lymph node dissection (ALND) with or without RNI was examined for 484 patients. Radiation was categorized as "limited RNI" (axilla level I/II only) or "extensive RNI" (axilla level III or supraclavicular fossa with or without level I/II). Results: At a median follow-up of 20.5 months, 109 of 498 patients (21.9%) triggered sBCRL (BIS 13.5% vs TM 25.6%; P <.001). In patients not receiving RNI, BIS triggered 12.9% of patients undergoing SNB and 25.0% undergoing ALND (P Z .18). Extensive RNI significantly increased triggering with BIS versus no RNI after sentinel node biopsy (SNB; 33.3% vs 12.9%; P Z .03) but not ALND (30.8% vs 25.0%; P Z .69). Triggering by TM was greater than 25% for most subgroups and was inferior to BIS in discriminating the risk of sBCRL by utilization of RNI or axillary surgery. Conclusions: The lower triggering rates with BIS and its better discrimination of the risk of sBCRL by receipt and type of RNI compared with TM support its use for posttreatment surveillance to detect sBCRL and to initiate early intervention. The

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Section: Introductionmentioning

confidence: 99%

The Risk of Subclinical Breast Cancer-Related Lymphedema by the Extent of Axillary Surgery and Regional Node Irradiation: A Randomized Controlled Trial

Boyages

Vicini

Shah

et al. 2021

International Journal of Radiation Oncology*Biology*Physics

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“…This can then be mapped to be included, or spared, from the radiation field, with one study finding that the majority (72%) of ARM nodes were located outside of the tangential whole breast radiotherapy fields 31 . With this approach the anatomical location could be excluded from the radiation field, where oncologically safe to do so, to reduce the risk of upper extremity lymphedema 32,33 . Alternatively, targeted radiation therapy to the ARM SLN(s) could be an oncologically acceptable alternative treatment to its surgical excision that may reduce the risk of upper extremity lymphedema.…”

Section: Discussionmentioning

confidence: 99%

Anatomy and physiology of the sentinel lymph nodes of the upper extremity: Implications for axillary reverse mapping in breast cancer

Coroneos

Woodward

Wong

et al. 2020

Journal of Surgical Oncology

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Background This study characterizes the physiological drainage of the normal upper extremity using single‐photon emission computed tomography/computed tomography (SPECT/CT) lymphoscintigraphy axillary reverse lymphatic mapping (ARM). Methods A consecutive series of patients assessed with SPECT/CT lymphoscintigraphy ARM of the upper extremity were included. Anatomical localization of the axillary sentinel lymph nodes (SLN) was completed in normal axillae in relation to consistent anatomic landmarks. Retrospective case note analysis was performed to collect patient demographic data. Results A total of 169 patients underwent SPECT/CT lymphoscintigraphy, and imaging of 182 normal axillae was obtained. All patients (100%) had an axillary SLN identified: 19% had a single contrast‐enhanced SLN in the axilla and the remainder had multiple. The SLN(s) of the upper extremity was located in the upper outer quadrant (UOQ) of the axilla in 97% of cases (177 axillae). When the SLN(s) was found in the UOQ of the axilla, second‐tier lymph nodes were found predominantly in the upper inner quadrant (50% of cases). Conclusions The upper extremity SLN(s) is located in a constant region of the axilla. This study provides the most complete investigation to date and results can be directly applied clinically to ARM techniques and adjuvant radiation planning.

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“…As described by Gross et al, radiation field design can result in increasing radiation to the volume of axillary tissues, thereby increasing the incidence of lymphedema [18], whereas other previous studies focused on radiation field arrangement. Besides, a recent study has identified that dose delivered to the axillary-lateral thoracic vessel juncture (ALTJ, the area superior to axillary level I) can be associated with lymphedema risk [25]. As a consequence, radiation field design can be a more relevant risk factor for development of lymphedema than radiation field arrangement.…”

Section: Impact Of Posterior Axillary Boost Field On Lymphedemamentioning

confidence: 99%

A historical literature review on the role of posterior axillary boost field in the axillary lymph node coverage and development of lymphedema following regional nodal irradiation in breast cancer

Ardekani

Ghaffari

Mardi

et al. 2021

Rep Pract Oncol Radiother.

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To elucidate whether (1) a posterior axillary boost (PAB) field is an optimal method to target axillary lymph nodes (LNs); and (2) the addition of a PAB increases the incidence of lymphedema, a systematic review was undertaken. A literature search was performed in the PubMed database. A total of 16 studies were evaluated. There were no randomized studies. Seven articles have investigated dosimetric aspects of a PAB. The remaining 9 articles have determined the effect of a PAB field on the risk of lymphedema. Only 2 of 9 articles have prospectively reported the impact of a PAB on the risk of lymphedema development. There are conflicting reports on the necessity of a PAB. The PAB field provides a good coverage of level I/II axillary LNs because these nodes are usually at a greater depth.The main concern regarding a PAB is that it produces a hot spot in the anterior region of the axilla. Planning studies optimized a traditional PAB field. Prospective studies and the vast majority of retrospective studies have reported the use of a PAB field does not result in increasing the risk of lymphedema development over supraclavicular-only field. The controversies in the incidence of lymphedema suggest that field design may be more important than field arrangement. A key factor regarding the use of a PAB is the depth of axillary LNs. The PAB field should not be used unless there is an absolute indication for its application. Clinicians should weigh lymphedema risk in individual patients against the limited benefit of a PAB, in particular after axillary dissection. The testing of the inclusion of upper arm lymphatics in the regional LN irradiation target volume, and universal methodology measuring lymphedema are all areas for possible future studies.

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Determining the Organ at Risk for Lymphedema After Regional Nodal Irradiation in Breast Cancer

Cited by 40 publications

References 37 publications

The Risk of Subclinical Breast Cancer-Related Lymphedema by the Extent of Axillary Surgery and Regional Node Irradiation: A Randomized Controlled Trial

The Risk of Subclinical Breast Cancer-Related Lymphedema by the Extent of Axillary Surgery and Regional Node Irradiation: A Randomized Controlled Trial

Anatomy and physiology of the sentinel lymph nodes of the upper extremity: Implications for axillary reverse mapping in breast cancer

A historical literature review on the role of posterior axillary boost field in the axillary lymph node coverage and development of lymphedema following regional nodal irradiation in breast cancer

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