Influence of Adjuvant Irradiation on the Development ...

Acta Oncologica 27 (1988) F a x . 6 a

FROM THE SURGICAL DEPARTMENT K AND DEPARTMENT OF ONCOLOGY AND RADIOTHERAPY, ODENSE UNIVERSITY HOSPITAL, DK-5000 ODENSE C, DENMARK.

Acta Oncol Downloaded from informahealthcare.com by 31.47.37.45 on 05/20/14 For personal use only.

INFLUENCE O F ADJUVANT IRRADIATION ON THE DEVELOPMENT OF LATE ARM LYMPHEDEMA AND IMPAIRED SHOULDER MOBILITY AFTER MASTECTOMY FOR CARCINOMA OF THE BREAST N . Rrrrov, N. V. HOLM, N . QVISTand M . BLICHERT-TOFT

Abstract

Material and Methods

The influence of postoperative radiation therapy on development of late arm lymphedema and shoulder joint disability following mastectomy was evaluated from a series of 57 women with operable carcinoma of the breast. The patients were divided into three groups. Common for all three groups was mastectomy and partial axillary dissection. In addition one group received postoperative irradiation plus systemic therapy and another group systemic therapy alone. The incidence of late arm lymphedemdimpaired shoulder mobility was 1 1 %/4% in the group of patients undergoing surgery alone, 46%/38% in the group of patients receiving adjuvant irradiation and 6%/12% in the group of patients receiving adjuvant systemic therapy. It is concluded that adjuvant irradiation to the axilla in patients with metastatic lymph nodes highly increases the risk of late physical sequelae following modified radical mastectomy. Adjuvant systemic therapy can be administered to high risk patients without increasing the risk of late arm lymphedema and shoulder disability.

The series consisted of 57 consecutive women with primarily operable unilateral carcinoma of the breast. During the period 1st October 1982 to 31st December 1983 all probands underwent mastectomy and partial axillary node dissection and fulfilled the following inclusion criteria; 1) invasive carcinoma, 2) age 69 years or less at the time of diagnosis, 3) no history of shoulder disease or impaired shoulder joint mobility, and 4) no clinical signs of local, regional or general spread of the disease at the time of evaluation. The patients were divided into 2 risk groups on the basis of the histopathologic examination of the mastectomy specimen (Figure). Group I . This group was a low-risk group consisting of 27 women with a median age of 54 (33-68) years. Criteria for admission to this group were 1) tumour of 5 cm or less in diameter, 2) no extension of growth to skin or deep fascia of the breast, and 3) no metastatic axillary lymph nodes. Group ZI. This group was a high-risk group consisting of 30 women. Criteria for admission to this group were 1) tumour more than 5 cm in diameter, and/or 2 ) extension of growth to skin or deep fascia of the breast, and/or 3) metastatic axillary lymph nodes. The median age in group I1 was 58 (4048) years. Treatment. Group I was treated by modified radical mastectomy alone. The axillary dissection was slightly modified according to Cady (3) (Figure).

Key words: Breast cancer, mastectomy, postoperative irradiation, arm lymphedema, shoulder mobility.

The aims of management of the axilla in patients with breast carcinoma are to obtain adequate diagnostic information and to ensure regional control of tumour in the axilla. However, some morbidity is associated with the treatment, especially arm lymphedema and impaired shoulder mobility (4, 5 , 9). The aim of the present study was to evaluate the influence of adjuvant irradiation on the development of late arm lymphedema and shoulder joint disability. A comparison was made between 3 treatment groups of patients with breast carcinoma. Common for all 3 groups was modified radical mastectomy. In addition, one group received irradiation plus systemic therapy, and another group adjuvant systemic therapy alone.

Presented at the DBCG meeting, Copenhagen, January 22-23, 1988.

667


668

N.

RYnOV,

N . V. HOLM, N . QVISl AND M . BLICHERT-TOFT

In group 11, the patients had a modified radical mastectomy similar to that of group I and were randomly assigned to receive adjuvant irradiation plus systemic therapy (subgroup IIA, 13 patients) or systemic therapy alone (subgroup IIB, 17 patients) (Figure). The target volume of radiation therapy included regional lymph nodes in the axilla, supra- and infraclavicular region and parasternal nodes as well as the chest wall including the scar. Irradiation technique was identical in all patients. One anterior photon field (8 MV) was used against the supraclavicularl infraclavicular and axillary region. A 5 mm wax bolus covered the surgical scar with a margin of 3 cm in the axilla. The chest wall was irradiated with 2 anterior shaped electron fields to the scar (6-8 MeV) and parasternal(10-14 MeV) regions. The electron energy was chosen to give the minimal target dose at the pleural surface. All patients received a median absorbed target dose of 50 Gy (maximal absorbed dose=% Gy) in 25 fractions for 5 weeks in the axillary, suprdinfraclavicular and parasternal fields and a maximum absorbed dose of 50 Gy in 25 fractions for 5 weeks in the scar region. The equipment used was either a linear accelerator, Philips 75/20 o r a microtron, MM 14 using a SSD=100 cm. The systemic therapy was given as C M F (cyclophosphamide, methotrexate and 5-fluorouracil) o r tamoxifen alone, o r as a combination, stratified according to menopausal status. Postoperative physiotherapy program. All patients followed the same postoperative routine training program described earlier (9). On discharge from hospital the patients were given a home exercise program and urged to continue with the training. Follow-up. The circumference of each arm was measured 10 cm above the medial humeral epicondyle, with the elbow flexed to 90" and the shoulder in the anatomical position. Lymphedema was defined as a difference of 2.5 cm or more between the circumferences of the 2 arms. At the same time the active shoulder joint mobility was measured, forward-upward (0-1 800) and outward-upward (0-180'). Movements less than 170" were defined as impaired shoulder mobility. The median length of follow-up time was in group I 42 (32-48) months, subgroup IIA 31 (12-48) months and subgroup IIB 46 (41-53) months. Early physical sequelae of mastectomy. Seroma developed in 1 I patients in group I, 3 in subgroup IIA and 9 in subgroup IIB. All were managed by needle puncture and aspiration of wound fluid from 1 to 5 times. In one patient a hematoma developed (group I). No flap necrosis o r wound infection occurred in the series. Statistics. Test of significance for the development of lymphedema and impaired shoulder mobility: Fisher's test. Level of significance: 0.05. Test of significance regarding the number of axillary lymph nodes removed: Kruskal-Wallis' test. Level of significance: 0.05. All median values are followed by range. Relative risks and frequencies expressed in percentages are followed by 95 % confidence intervals.

m Eligible patients nz57

1

i

Evilluatinri 01 late a r m Igmphedetna and shoulder mobility

I

Figure. Stratification and treatment regimens in patients with breast carcinoma.

Results

Axillary lymph nodes. In group I the median value of axillary lymph nodes removed was 7 (4-18), in subgroup IIA 8 (3-17) and in subgroup IIB 9 (4-14). There was no significant difference in the number of lymph nodes removed between the 3 groups ( p ~ - ~ > 0 . 0 5 ) . Late a r m lymphedema. In group I, 3 patients ( 1 1 %) developed moderate lymphedema of the arm with a difference in arm circumference from 2.5 to 3.0 cm. In subgroup IIA 6 patients (46%) had moderate lymphedema at follow-up (2.5 to 4.0 cm) and in subgroup IIB only one patient (6%) had arm swelling (2.5 cm), (Table I). The difference in the number of patients with lymphedema between group I and subgroup IIA was significant (pF0.05).

PHYSICAL SEQUELAE AFTER MASTECTOMY A N D ADJUVANT IRRADIATION

669

Table 1 Late arm lymphedema in mastectomized patients with carcinoma of the hreaJi stratifed according to differeni adjuvani treatment regimens. (In parentheses percentage and 95 % confidence interuals)

Group I No. of patients

Group 11 Subgroup 11A No. of patients

Subgroup IIB No. of patients

Lymphedema No lymphedema

3 ( I 1 %, 2-29) 24 (89%, 71-98)

6 (46 %, 19-75) 7 (54%, 25-81)

1 (6%, 0-29) 16 (94%, 71-100)

Total

27

13

17

Table 2


Late impaired shoulder mobility in mastectomired patients with carcinomo uf the breast siratified according to different adjuvant treatment regimens. (In parentheses percentage and 95 % confidence intervals)

Group I No. of patients

Group 11 Subgroup HA N o . of patients

Subgroup 11B No. of patients

5 (38%, 14-68)

2 (12%, 2-36)

Impaired shoulder mobility Normal shoulder mobility

26 (96%, 81-100)

8 (62%, 32-86)

15 (88%, 6 4 9 9 )

Total

27

13

17

1 (4%, 0-19)

Shoulder joint mobility. Impaired ipsilateral shoulder joint mobility was found in one patient (4%) in group I , 5 patients (38%) in subgroup IIA and in 2 patients (12%) in subgroup IIB (Table 2). The difference between group I and subgroup IIA was significant (pF