Analysis of Radiation Dose to the Shoulder by Treatment Technique and Correlation With Patient Reported Outcomes in Patients Receiving Regional Nodal Irradiation

Jose G Bazan; Dominic DiCostanzo; Karen Hock; Sachin Jhawar; Karla Kuhn; Kylee Lindsey; Kayla Tedrick; Erin Healy; Sasha Beyer; Julia R White

doi:10.3389/fonc.2021.617926

Analysis of Radiation Dose to the Shoulder by Treatment Technique and Correlation With Patient Reported Outcomes in Patients Receiving Regional Nodal Irradiation

Front Oncol. 2021 Mar 11:11:617926. doi: 10.3389/fonc.2021.617926. eCollection 2021.

Authors

Affiliations

¹ Department of Radiation Oncology, The Ohio State University Comprehensive Cancer Center and Stefanie Spielman Comprehensive Breast Center - Arthur G. James Cancer Hospital and Solove Research Institute, The Ohio State University, Columbus, OH, United States.
² Department of Physical Therapy, The Ohio State University Comprehensive Cancer Center and Stefanie Spielman Comprehensive Breast Center - Arthur G. James Cancer Hospital and Solove Research Institute, The Ohio State University, Columbus, OH, United States.

Abstract

Background/purpose: Shoulder/arm morbidity is a late complication of breast cancer treatment with surgery and regional nodal irradiation (RNI). We set to analyze the impact of radiation technique [intensity modulated radiation therapy (IMRT) or 3D conformal radiation therapy (3DCRT)] on radiation dose to the shoulder with a hypothesis that IMRT use results in smaller volume of shoulder receiving radiation. We explored the relationship of treatment technique on long-term patient-reported outcomes using the quick disabilities of the arm, shoulder, and hand (q-DASH) questionnaire.

Materials/methods: We identified patients treated with adjuvant RNI (50 Gy/25 fractions) from 2013 to 2018. We retrospectively contoured the shoulder organ-at-risk (OAR) from 2 cm above the ipsilateral supraclavicular (SCL) planning target volume (PTV) to the inferior SCL PTV slice and calculated the absolute volume of shoulder OAR receiving 5-50 Gy (V5-V50). We identified patients that completed a q-DASH questionnaire ≥6 months from the end of RNI.

Results: We included 410 RNI patients: 54% stage III, 72% mastectomy, 35% treated with IMRT. IMRT resulted in significant reductions in the shoulder OAR volume receiving 20-50 Gy vs. 3DCRT. In total, 82 patients completed the q-DASH. The mean (SD) q-DASH=25.4 (19.1) and tended to be lower with IMRT vs. 3DCRT: 19.6 (16.4) vs. 27.8 (19.8), p=0.078.

Conclusion: We found that IMRT reduces radiation dose to the shoulder and is associated with a trend toward reduced q-DASH scores ≥6 months post-RNI in a subset of our cohort. These results support prospective evaluation of IMRT as a technique to reduce shoulder morbidity in breast cancer patients receiving RNI.

Keywords: 3DCRT; IMRT; PMRT; RNI; quick DASH; shoulder.