Shoulder girdle impairment in breast cancer survivors: the role of range of motion as predictive factor for dose distribution and clinical outcome

Abstract

Background:Pain and functional impairment of the ipsilateral shoulder girdle in patients who underwent surgery and radiotherapy for breast cancer (BC) is a late complication reported in the literature. We analyze a correlation with dosimetric parameters and propose an algorithm for sparing strategies.Methods:A total of 111 patients treated for BC were included in this observational analysis during follow-up protocol visits. Exclusion criteria were the presence of moderate or severe arthrosis history and/or rheumatologic diseases. All the patients had complete physical and multidimensional examinations during joint (physiatrist and radiotherapy oncology) follow-up visits. A scapula–humeral articulation (SHA) standardized contouring was performed retrospectively on Eclipse® treatment plans. A possible correlation between patients’ characteristics, radiotherapy, and dosimetry analysis and functional impairment was investigated at statistical analysis. Results of analysis were summarized into a proposal of algorithm for sparing SHA.Results:A total of 111 patients were selected during follow-up visits. Mean age of patients was 60 years (range 41–85 years). A total of 103 patients (93%) underwent conservative surgery, with 110 patients (99%) undergoing axilla surgery as well. Fifty-two patients (46.8%) presented a reduction of range of motion (ROM) abduction on the treated side at the observational analysis. Mean ROM abduction reduction was 13°06’ (range 0°–100°). Disability of the Arm, Shoulder and Hand questionnaire (DASH) score results were excellent in 79 patients (71.2%), discrete in 15 patients (13.5%), good in 15 patients (13.5%), and sufficient in 2 patients (1.8%). Median EQD2Dmaxat SHA was 18 Gy (range 0.22–51.9 Gy) and median EQD2mean dose at SHA was 2 Gy (range 0.04–24.32 Gy). Univariate analysis showed a linear correlation between DASH score and ROM of abduction of treated side (ρ=−0.7), ROM of abduction and ROM of flexion in ipsilateral arm (ρ=0.8), or ROM of abduction and ROM of flexion in contralateral arm (ρ=0.8). A statistically significant difference in ROM abduction between the 2 arms was found at χ2test ( P<0.05 at χ2confidence interval = 95%). Cox linear regression analysis showed ROM abduction on treated arm as a predictive factor of DASH score ( P<0.0001). Age ( P<0.05), DASH score ( P=0.006), and ROM abduction on treated arm ( P=0.005) were found as independent predictive factors of mean dose at multivariate analysis. A mean dose higher than 7 Gy and ROM abduction reduction more than 30° were related to DASH score level reduction.Conclusions:This hypothesis-generating study introduces an algorithm to be validated for management of sparing SHA and improving quality of survivorship. ROM evaluation after surgery, early physiotherapy, standard contouring, and planning adaptation represent possible indications to preserve shoulder impairment. Further prospective studies are needed to discriminate impairment of surgery and radiotherapy in order to personalized therapeutic plan programs.

Exercise Protocol With Limited Shoulder Range of Motion for 15 or 30 Days After Conservative Surgery for Breast Cancer With Oncoplastic Technique

“…31 In our study, despite lower DASH scores on PO30 compared with the preoperative evaluation in the Limited ROM Group, the change was minimal. The same was noted by Marazzi et al, 32 who conducted an observational study with cross-sectional assessment in patients after conservative oncomammary surgery and radiotherapy, and found a mean DASH questionnaire score of 13.6 after treatment.…”

Cognitions and physical impairments in relation to upper limb function in women with pain and myofascial dysfunctions in the late stage after breast cancer surgery: an exploratory cross-sectional study

“…Altered movement of the shoulder complex is indeed already described in women following breast cancer surgery with a reported decrease in active range of motion in up to 84% of breast cancer survivors [4,[21][22][23]. In particular humerothoracic abduction and scapulothoracic lateral rotation motion can be affected [12,[24][25][26]. The presence and impact of these impairments each individually have already been described before [10].…”

Scapular Dyskinesia After Modified Radical Mastectomy Surgery and Breast Conserving Surgery.

“…It is thought that more SD may develop especially in the long-term results of surgery where mPM is preserved. mPM in breast cancer surgeries is very important in determining postoperative physiotherapy and exercise approaches (Marazzi, et al 2019). This study showed that SD should be considered in the early period of mastectomy.…”

“…The presence of one or more of these findings leads to a negative impact of shoulder girdle structures and consequently deteriorates both upper extremity functionality and quality of life (Ribeiro, Camargo, Alburquerque-Sendín, Ferrari, Arrais, and Salvini, 2019;Marazzi, Masiello, Marchesano, Boldrini, Luzi, Ferrara, et al 2019).…”