Supraclavicular radiotherapy must be limited laterally by the coracoid to avoid significant adjuvant breast nodal radiotherapy lymphoedema risk

Abstract

This cross-sectional study aimed to investigate the effect of supraclavicular fossa (SCF) radiotherapy volumes as well as patient characteristics and nodal pathology on the development of lymphoedema. Ninety-one women who had received SCF nodal radiotherapy after axillary dissection were evaluated. Lymphoedema was defined by two measurements: limb volume difference 200 mL, or circumference difference 10 cm proximal or distal to the olecranon>2 cm. On univariate analysis, the addition of axillary to SCF radiotherapy, increasing width of the SCF field, increasing age, presence of extracapsular extension of nodal involvement and use of hormone treatment was associated with lymphoedema by either one or both definitions. For both definitions of lymphoedema, on multivariate analysis, increasing nodal radiotherapy volume remained significant (P=0.02 to 0.007), as did increased age (P=0.05 to 0.001). We conclude that conventionally fractionated SCF radiotherapy limited laterally by the coracoid process has a lymphoedema risk similar to that expected from axillary dissection alone and a lower risk than wider SCF fields with or without an axillary boost.

Impact of Ipsilateral Blood Draws, Injections, Blood Pressure Measurements, and Air Travel on the Risk of Lymphedema for Patients Treated for Breast Cancer

“…High BMI, RLNR, and ALND are consistently cited in the literature as risk factors for arm swelling and lymphedema, and our data further support these claims. 6,8,10,11,[13][14][15][16]19,20,24,49,50 The increased risk for developing lymphedema after infection including cellulitis is also well documented in the literature, 2,6,22,51 and our results support these findings. Interestingly in our cohort, episodes of cellulitis were not associated with a risk event that occurred before the cellulitis.…”

The changing role of axillary treatment in breast cancer: Who will remain at risk for developing arm morbidity in the future?

“…In the study of Warren et al, it seems that periclavicular nodes were irradiated with a much smaller anteroposterior field, with sometimes an additional medially-localized posteroanterior field to treat axillary level 3. This corresponds with a study of Graham et al, who found that there was no increased risk of lymphedema if the lateral border of the supraclavicular field did not extend laterally from the coracoid process [22]. BCRL due to radiation therapy is thought to develop by increasing fibrosis over the years, resulting in progressive obstruction and infiltration of lymphatic structures.…”

Mapping Patterns of Nodal Metastases in Esophageal Carcinoma: Rethinking the Clinical Target Volume for Supraclavicular Nodal Irradiation

“…A prospective study by Warren showed that SCV irradiation was a significant independent risk factor for lymphedema in 1,476 patients, with 21% and 3% of patients developing lymphedema with and without SCV irradiation, respectively (23). Graham et al also showed that irradiation lateral to the coracoid process was a significant risk factor for lymphedema (P=0.002) (24). The MA.20 trial, in which the SCV field included the head of clavicle medially and the coracoid process laterally and the level I-II axilla irradiated in about 32% of patients, showed that the regional nodal irradiation group had higher rates of lymphedema (8.4% vs. 4.5%; P=0.001) and grade 2 acute pneumonitis (1.2% vs. 0.2%; P=0.01) (25).…”