# Radiation Oncology/Toxicity/Lymphedema

* Front Page: Radiation Oncology | RTOG Trials | Randomized Trials
Lymphedema

## Breast Cancer

* National Cancer Center Goyang, Korea; 2013 (2004-2009) PMID 23541809 -- "A model to estimate the risk of breast cancer-related lymphedema: combinations of treatment-related factors of the number of dissected axillary nodes, adjuvant chemotherapy, and radiation therapy." (Kim M, Int J Radiat Oncol Biol Phys. 2013 Jul 1;86(3):498-503. doi: 10.1016/j.ijrobp.2013.02.018. Epub 2013 Mar 28.)
** Retrospective. 772 patients, breast cancer, surgery, ALND. Adjuvant chemotherapy in 88%. Adjuvant radiation therapy 88%; SCV RT 35%. Median F/U 5.1
** Outcome: 5-year lymphedema risk 17%. Within 2 years in 76%, within 3 years in 91%. Multivariate analysis showed number of lymph nodes, adjuvant chemo, and supraclavicular RT as risk factors
** Model: If 1 risk factor, 5-year lymphedema 3%; 2 risk factors 19%, 3 risk factors 38%
** Conclusion: A model developed for predicting lymphedema risk
* Fox Chase; 2008 PMID 19028274 -- "Does axillary boost increase lymphedema compared with supraclavicular radiation alone after breast conservation?" (Hayes SB, Int J Radiat Oncol Biol Phys. 2008 Dec 1;72(5):1449-55.)
** Retrospective. 2579 women, T1-2N0-3 breast cancer, BCT. RT breast only (B) 84%, breast + SCV 9% and breast + SCV + PAB 7%. Median F/U 6.7 years
** Outcome: Lymphedema 18%. After B 16%, B+SCV 23%, B+SCV+PAB 31%. Predictors for lymphedema: regional nodal irradiation, obesity, systemic therapy, and number LNs dissected. In N1 patients, PAB addition to SCV no difference; in N2 patients, 4.5x increase in lymphedema
** Conclusion: Decision to boost axilla must be weighed against increased risk of lymphedema
* Harvard; 2003 (1982-1995) PMID 12654429 -- "Risk of lymphedema after regional nodal irradiation with breast conservation therapy." (Coen JJ, Int J Radiat Oncol Biol Phys. 2003 Apr 1;55(5):1209-15.)
** Retrospective. 727 Stage I-II BCA patients treated with BCT. Lymphedema defined >2 cm difference in forearm circumference. Breast RT alone 68%, Breast + lymphatics RT 32%. Most Level I-II axillary dissection. Median F/U 6 years
** 10-year outcome: 4% (tangents alone 2% vs. axillary 9%, SS)
** Predictors for lymphedema: only axillary irradiation
** Conclusion: Risk lower than generally recognized
* NSABP B-04, PMID 18029105 — "The Incidence of Arm Edema in Women With Breast Cancer Randomized on the National Surgical Adjuvant Breast and Bowel Project Study B-04 to Radical Mastectomy Versus Total Mastectomy and Radiotherapy Versus Total Mastectomy Alone." (Deutsch M et al. Int J Radiat Oncol Biol Phys. 2008 Mar 15;70(4):1020-1024.)
    For more information see page at Axilla
** Halsted radical mastectomy (RM) vs. total mastectomy + RT (TM+RT) vs. TM alone. Recorded ipsilateral and contralateral arm circumference every 3 months (avg of >= 6 sets of measurements per pt).
** Increase of >=2cm in arm circumference was seen in 58.1% (RM), 38.2% (TM+RT) vs 49.1% (TM). Severe edema (>=4cm) in 21.5%, 11.4%, and 13.1%. 25% with edema at one time had no edema at the time of final measurement. Increased BMI associated with edema.
** High incidence of edema with these surgical techniques.

## Management

* Royal Marsden PMID 15542159 -- "Double-blind placebo-controlled randomised trial of vitamin E and pentoxifylline in patients with chronic arm lymphoedema and fibrosis after surgery and radiotherapy for breast cancer" (Gothard L, Radiother Oncol. 2004 Nov;73(2):133-9. doi: 10.1016/j.radonc.2004.09.013.)
** Randomized phase II. 68 patients, >20% arm volume at median 15 years after RT. 1) dl-alpha tocopheryl acetate (Vitamin E) 500 mg twice daily + pentoxifylline 400 mg twice daily x 6 months vs 2) placebo x 6 months. Primary endopoint volume of ipsilateral imb
** Outcome: 1 year arm volume: Tx 2.5% vs placebo 1.2% (NS). No difference in tissue fibrosis, photographic appearance, or patient QoL
** Conclusion: No benefit in this setting