Treatment of radiation-induced brachial plexopathy with omentoplasty

Abstract

Radiation-induced brachial plexus neuropathy (RIBPN) is a rare and delayed non-traumatic injury to the brachial plexus, which occurs following radiation therapy to the chest wall, neck, and/or axilla in previously treated patients with cancer. The incidence of RIBPN is more common in patients treated for carcinoma of the breast and Hodgkin lymphoma. With the improvement in radiation techniques, the incidence of injury to the brachial plexus following radiotherapy has dramatically reduced. The currently reported incidence is 1.2% in women irradiated for breast cancer. The progression of symptoms is gradual in about two-thirds of cases; the patients may initially present with paresthesia followed by pain, and later progress to motor weakness in the affected limb. We present the case of a 68-year-old female patient with breast cancer submitted to surgery, chemotherapy, and radiotherapy in the year 2000. Eighteen years later, she developed symptoms and signs compatible with RIBPN and was successfully submitted to omentoplasty for pain control. Omentoplasty is an alternative treatment for RIBPN refractory to conservative treatment, which seems to be effective in improving neuropathic pain. However, postoperative worsening of the motor strength is a real possibility, and all candidates for this type of surgery must be informed about the risk of this complication.

Brachial plexopathy after breast cancer: A persistent late effect of radiotherapy

“…In fact, the U.S. death rate from breast cancer declined by 40% between 1989 and 2017, 36 thus supporting increased longevity from the disease with a greater opportunity for developing very late effects of treatment. Recently published case reports support the finding that very late effects of radiation therapy (after 15–20 years) continue to result in RIBP in survivors of breast cancer, 18,37–39 as well as in a patient with nasopharyngeal cancer 5 . As Bajrovic et al 40 noted in their study of RIBP after supraclavicular lymph node radiotherapy: “a follow‐up period of 5 years … is too short a time a time interval for recording the majority of lesions occurring in total.”…”

Outcome of Nerve Grafting for Radiation-Induced Brachial Plexopathy

“…Microvascular omental flap had been reported to treat RIBP to improve neuropathic pain. 12,13 We used pedicled muscular flap to improve the soft conditions around the brachial plexus. The pedicled muscular flap was used in 6 cases in this study.…”

“…5,10 Microvascular omental flaps, pulsed radiofrequency ablation, and hyperbaric oxygen therapy had been reported to treat RIBP with painful palsies. [11][12][13][14] There were few reports of treatment, which could improve the movement function of the patients suffered from RIBP. In the management of RIBP, it is a challenge to attain useful motor function.…”

Neurologic Complications in Adult Cancer Survivorship

“…Treatments to address pain include oral neuropathic pain medications (tricyclic antidepressants, selective serotonin-norepinephrine inhibitors, gabapentin), steroids, and pulsed radiofrequency ablation. 47,48 A study of hyperbaric oxygen for 34 patients with radiation-induced brachial plexopathy found no benefit to motor function, but 2 patients had improvement in temperature sensation. 49 A 1994 study demonstrated recovery of function in two patients with radiation plexopathy after anticoagulation for 3 to 6 months, but there have no further studies of this treatment.…”

“…Nerve conduction studies demonstrate both direct axonal injury and demyelination. 44 The pathophysiology of delayed radiation-induced nerve injury is favored to be perineural fibrosis with the resulting obstruction of small arterioles which results in ischemia to the capillary networks supplying the nerves 45,47 and the production of neo-vascularization, which is thought to be irreversible.…”