WHAT IS RADIATION INDUCED BRACHIAL PLEXOPATHY? (RIBP) 

Radiation-Induced Brachial Plexopathy (RIBP) is a progressive and painful paralysis of the arm and shoulder, brought on by radiation treatment for breast cancer and certain other cancers. With improvements in radiation technology, RIBP is rare these days, but can still occur when multiple overlapping radiation fields or high radiation doses are used. It most often involves lymphedema of the affected arm and, like lymphedema, RIBP can develop at any time following radiation treatment of the area. There is no cure, though interventions are possible to slow progression, optimize remaining arm and hand function, control related lymphedema, and relieve pain. An excellent article by Joachim Zuther, founder of the Academy of Lymphatic Studies and author of the "Textbook of Comprehensive Lymphedema Management", defines and discusses the causes of RIBP and its relation to lymphedema. 

 

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CONNECTING WITH OTHERS WHO HAVE RIBP

 

If you have RIBP it can be difficult to find others to communicate with who share this diagnosis. These resources may help:

 

The discussion boards at BreastCancer.org include a thread for women and men with RIBP. The site is public, so you can read posts without registering. If you'd like to join the discussion, registration is quick and free. Participants offer one another encouragement, coping tips, and information about any new directions in RIBP research and treatment, as well as a comfortable and understanding forum for airing the frustrations and grief of living with this condition. Advocacy for RIBP awareness among breast cancer patients, the medical community and the public is another goal of the group.

 

In the UK, an organization called R.A.G.E. (Radiotherapy Action Group Exposure) unites RIBP patients for mutual encouragement and to advocate for improved treatment and research. An annual £5 membership fee provides a quarterly newsletter and a voice in their annual meeting. For information, contact janice.millington@btinternet.com

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VOICES OF RIBP

This arm problem started with burning in my hand and has now progressed so that I can't button things or open jars or cans or do anything that requires fine motor skills. Also my fingers are numb along with the constant burning and I have arm pain that feels like a vice. Apparently, there is no treatment for radiation-induced brachial plexopathy so this is a new disability that I will have to deal with for the rest of my life.  Searching for the energy to meet this new challenge....  Erica

 

I had breast cancer just about 30 years ago, followed by radiation therapy just as all of you had. I did not have nodal involvement, so I did not have chemo or any other drugs. That's how I know the plexopathy came from the radiation alone. Within the first year my upper chest became disfigured and discolored, so that was the end of bathing suits, necklaces, or any neckline but a high one.  At 44, one is not quite ready for such an assault on body image. But, okay, I am supposed to be grateful to be alive.  About 5 years ago, my plexopathy problems began, but my radiation oncologist assured me that it 'couldn't' be the radiation.  It took a neurologist to properly diagnose it.

Adding insult to injury, a year ago I took a plane trip and my arm blew up like a leg of lamb.  No one, in all that time, ever warned me about lymphedema.  I had no idea I was at risk for it once I had passed that important first year. When you look up lymphedema, the first thing it says is, you are always at risk if you have had surgery or radiation, and you should never fly without compression on your arm.

So now I have two permanent, debilitating, and extremely unattractive conditions, neither of which might have happened if I had been forewarned.  I suppose I should still be grateful, but I really would have enjoyed being able to lift my two little granddaughters, 1 and 2, and put pony tails in their hair and make cookies for them. – barbaraellen

 

I have been dealing with the lymphedema for quite some time now but the brachial plexopathy just started in December of last year and has just about debilitated my right hand (I am right handed), and the numbness and nerve pain is driving me nuts!  The worst part is no one, and I mean no one, seems to be able to help me.  They just kind of shrug their shoulders.  I am on Lyrica and that helps some with the nerve jumping in my hand.  Like barbaraellen, I too have lymphedema, which compels everything!  I would be willing to go anywhere in the world if someone could help. That's the most frustrating part is finding someone to help with this and at least keep it from getting worse. Even knowing that I am not the only one helps, too. – Sharalyn

 

This is a monster to live with and has dramatically changed my quality of life.  I was treated for breast cancer ten years ago and have been dealing with lymphedema for seven.  I was never told or warned about this stuff in any way. – ronimom

The pain (burning) and numbness drive me to distraction.  I do not use Lyrica because I am an intermediate metabolizer of tamoxifen and don't want to risk that Lyrica would inhibit my tamoxifen benefit.  The hand symptoms have really made it difficult for me to work and sleep.  I have mild lymphedema in my affected hand that started about two to three months after the symptoms of the brachial plexopathy.  I haven't sought treatment for that yet as I have been overwhelmed with other cancer issues.  Hearing the comments about how they interact, I think I need to get myself to a lymphedema specialist as well. – Erica

 

Last year I went to Johns Hopkins, to the only guy whose secretary said that he treated adults for brachial plexopathy.  I specified that my brachial plexopathy came from radiation, not a trauma or accident, and they checked it out and said, come on.  So we fly from Chicago to Baltimore and see this doctor for maybe two minutes.  His assistant already filled him in on the up-teen pages I had to fill out first.  The doctor says, you have to make an appointment to get a neurogram in Philadelphia!  Nobody mentioned that that was the necessary next step, so we had to fly back home and then fly again to Philadelphia. They say there are only a few machines in the country that show the nerves this way, and it is a very new and sensitive test.  I thought we're going to walk into a space age lab.  It was a very crummy office in an even crummier neighborhood.  The machine looks exactly like an MRI machine and the exact same procedure takes place, noise and all.  Then they tell us these results have to be analyzed in California, it'll take weeks to get any kind of report.  Many, many weeks later, after endless phone calls and emails, my results were described very briefly like this:  the nerves are all matted together because of the radiation and there is nothing we can do surgically besides make it worse. – barbaraellen

Very anxious as it is getting cooler here nights and mornings and I have a huge intolerance to any temperature under 74 degrees. . .pain begins.  I call it the "rose thorn people come around to visit me".  Yes. . .thorny tingling. . .that's what it is. – Sharalyn

For anywhere from say, 24 or 25 years post-radiation, which was not cobalt, so don't let them kid you, I was symptom free.  I think.  The first clue was my handwriting, which was getting sloppy.  I figured it was arthritis or something, and my radiation oncologist was only too happy to agree.  I can map the progress via my grandchildren.  My daughter had me caring for my now 6 year old 3 days a week when he was a newborn.  I noticed no problem.  I could carry, change and feed him easily.  but I did notice that I was having trouble lifting his 2 year old cousin.  Again, I attributed it to natural causes, although I did start to question my doctors.  I was pooh-poohed away. I could open some jars and containers, but not others.  I started to avoid side zippers, but could still handle front ones.  I could use a knife on soft vegetables, but not hard ones.  I started to order fish in restaurants instead of steak because I was afraid of making a mess.  And still my radiation oncologist assured me it couldn't be the radiation.  Three years after my 6 year old was born, my first granddaughter was born, and.....I could not lift that 7 pound infant up in my arms.  My son put her in my arms as I sat down and held a bottle for her.  I had to ask him to take the bottle because my hand was trembling so, I was afraid I would drop it on her.  That was when I finally decided to see a neurologist. . .all of which leaves me nowhere, with two permanent, disabling, ugly conditions, one of which can be somewhat controlled, and the other that no one has any idea how to control.  This is tough company, honey, but it's company. – barbaraellen

With this lymphedema and/or brachial plexopathy, it's hard to stay positive but sometimes I need to sit down, take in deep breaths (alone of course) and think about the beauty and blessings that I do have. – Sharalyn

 

I have lymphedema and brachial plexopathy.  Right arm and hand, and I am a rightie. My chemo, stem cell transplant and radiation were 10 years ago. I have worn custom Class 1 lymphedema garments and a JoviPak at night for the past 8 years. A few years ago I noticed I was losing strength and feeling in my right hand, and I now have tingling, burning, limp hand with out-turning wrist, and sensation that my right hand is going to explode 24/7. Very difficult to tolerate day-to-day. I am being challenged by a bone spur-arthritis in my left thumb.  I am now wearing splints, hard and soft, on my thumb.  I cannot chop or cut anything on my plate.  My children and my friends cut things up for me. I have to ask for help more than I like. I had to retire early because of my disability. I live a full, purposeful life and I have lots of support. – ronimom

 

As much as I hate to say I can't do something, I am getting better at asking for help. – Lefty

There are many things I can no longer do, like signing my name or shaking hands, but the most upsetting one for me, the one problem I cannot solve, is getting my bra on. However, I have learned a few things that make life a little less complicated. I wear pants with no zippers, just pull-ups, Shoes with no laces. Socks I can handle, but panty-hose is just a memory. Cardigan style tops with buttons, no overheads. Clip-on earrings only, and overhead necklaces. Jackets with buttons, no zippers. Cooking is cut way, way back (which is not all bad) but be careful not to buy things you can't open with one hand. Eat out, order in. Use liquid soap with a washcloth, not bar. There are lots of tricks, some of which I am sure you know already, but the most important thing is not to beat yourself up over anything, - barbaraellen

 

For 18 months I worked out  2-3 times a week with a personal trainer, and it was really helpful. My trainer held my hand around weights and helped me exercise my whole arm and it began to make a difference in the size of my right arm almost immediately.  I also learned how to eat more protein and be less hungry and less apt to snack.  All this has kind of enhanced my metabolism, or something.  And I have lost 50 pounds since then, and can wear a size med-large sweater instead of the 1X I was buying to fit my arm and big waist.  The bad thing is I have difficulty working out in any gym by myself, because I need so much help adjusting the equipment, moving things out of my way, etc. – ronimom

 

This arm is starting to hang down like a club, which is not too good for the lymphedema.  I have to be careful lifting it now, because if I lift it too high or too suddenly my upper arm goes into a painful spasm.  That was last month's selection.  It's like belonging to surprise-of-the-month club. – barbaraellen

 

I am glad I'm alive, but what a way to have to live!!! – ronimom

 

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COPING TIPS

 

AROUND THE HOUSE:

 

Those soft, mesh-like rolls of non-skid shelf liner can be cut into convenient sizes to lay out on the counter or kitchen table, where they'll steady a plate or mixing bowl. Or use it to hold your toast steady while you spread it with butter and marmalade. It can also be used as a grip aid to open jar lids.  Available at YouCan TooCan.

 

 

Ronco Bagel Cutter

High-quality surgical stainless steel Bagel knife that slices evenly and quickly Full tang throughout the blade and handle on knife Dishwasher-safe bagel knife Keeps fingers safe Cuts Bagels into Quarters with the bagel slats Cuts Bagels so thinly Slices so thinly, you can make Bagel Chips! Cuts bagels, bialis, english muffins Removable crumb catch tray

 

 

 Larien Bagel Biter

This guillotine for the kitchen will strike fear into the heart of the most stalwart bagel. No more monkeying around with bread knives and spraying crumbs everywhere, this device is fun, safe and efficient.  Easy and safe to operate with one hand!

 

 

 Fasta Pasta Microwave Pasta Cooker

 

 

Fasta Pasta allows you to quickly cook pasta right in your microwave. Two holes on the lid help you measure pasta portions, and lines on the inside make adding the right amount of water effortless. The straining lid is convenient for removing water after pasta is done cooking, and you can even add sauce, butter, or cheese right in the cooker--no extra dishes needed!

Comment by ronimom:  It is light and easy to handle with one hand.  The directions say to drain the pasta with the lid on.  I could not hold on to the lid tight enough to drain it, and wound up with a sink full of pasta!  So now I pour the pasta  into a colander.

 

 

Chef'n Garlic Zoom

 

 

• Whimsical wheeled gadget chops garlic as it rolls
• Clear acrylic with stainless-steel blades
• Place garlic cloves inside, run back and forth on counter
• Easy to see when chopping is done; no garlic smell on hands
• Blade unit removes for cleaning; top-rack dishwasher-safe

Comment by ronimom:  Chops garlic in small quantities. Halve or quarter garlic first, depending on size.  The top is easy to open.  Then roll on wheels to chop it.  It took me a few tries, but it worked and I just rinsed it out in hot water and set it to drain. 

 

ULA Knives

 

 

For single-handed cutting of food whether it is due to RIBP or trouble while wrapped, we have been told about a fabulous one-handed cutting tool, making it easy to cut with one hand, whether in food preparation or cutting the food on your plate.

 

Knork Utensil

 

 

Here's another eating utensil that's a combination knife and fork in one. It's called a "knork," and it's actually kind of lovely:  http://www.knork.net  They sell them in sets of four or twenty, but you can order a "sample" one for $5.00.

 

 

 

Electric knives have a power handle with detachable blades that make it easy to cut anything from fresh bread to the toughest chunk of meat. They come in a wide variety of styles, both cordless and plug-in, so shop around and find the one that fits your hand comfortably.

 

 

"I am on my 2nd electric knife, and hold my right arm and hand behind my back when I use it." – ronimom

 

 

The Black and Decker "JW400 Lids off Open It All Jar Opener Can opener Combo" sits on the countertop and opens bottles, cans and jars with the touch of a button.

 

 

 

The portable Tranquility Zone Lighted Lapdesk is good for reading, writing or as a workspace.  Iis adjustable, and it has a comfortably cushioned base.

 

 

 

Amazon's Kindle Wireless Reading Device is pricey, but it eliminates the need for troublesome page-turning – excellent for reading in bed. Over 200,000 books are available for use with it from Amazon, including most best-sellers, each for around $10.00. Buy books directly from your Kindle and they're auto-delivered in less than one minute. It holds over 200 titles. Lightweight, thin, and manageable – just click to turn the page.  There are now many different types of Kindle's available.

There are now also many other e-readers available, including the Nook and the Sony E-Reader.

Prices on all of these, including Kindle, have come down considerably.

NOTE: Some colleges and universities are now starting to make their textbooks available on Kindle. If you're interested in taking a course or two, or even going back for a degree, ask at your local college or university about this option, and don't let the awkwardness and weight of the textbooks stand in your way.

 

For those who want to read a low-tech, old-fashioned, paper-paged book, turning the pages one-handed is easier with one of those equally old-fashioned rubber fingertips. If you're reading to children or grandchildren, let them wear the fingertip and turn the pages for you.

 

 

 

If you're a bridge player – or even an Uno player – simple card holders are available in a variety of lengths to make it easy to display and manage your cards.

 

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DRESSING:

 

 

Magnetic sew-on "buttons" are available for ease of dressing. These are small magnets with four holes at the edges so they can be sewn in place under a regular button. They're strong enough to keep your clothes securely fastened even through a big sneeze, and they're extremely easy to manage. Not cheap, but worth it for frustration-free dressing.

 

 

 

 

Velcro® Style Button Aids

These Button Aids press together to replace regular buttons, thereby enabling users to be more independent in self dressing. Fits most standard button holes. Machine washable. Comes in packages of 10. Latex free.

 

 

These button hooks with zipper pull are two aids in one — the Hook answers buttoning needs, and the Zipper pull attaches to hard-to-handle zipper tabs, making it easier to zip. Adds leverage to small zippers. Latex free.

 

 

Buckingham Bra-Angel

Specifically designed to assist those with mild to moderate upper limb restrictions or limited hand dexterity. The Bra-Angel holds one end of the brassiere securely while the other end is brought around the body and attached. It enables those who have the use of only one arm to be able to put on their bra independently. Adjusts to a wide variety of sizes. The telescopic action allows the Bra-Angel to be compacted and easy to carry. 16"L x 11/2"W.  Latex free.

 

 

Wearease offers a kit for converting shoes with ties to easy Velcro closures. No special tools are needed and conversion is quick and simple. Comes in black, brown, tan and white.

 

 

Curley laces (coilers) are available in a wild range of colors, or stick to the conservative basics of white, black and brown. Shoes slip on and off without tying.

 

 

 

Lock laces have a more athletic look, as they're used by runners and other sports-types who don't want their speed checked by tangled or unruly laces. Shoes slip on and off easily with no tying or adjusting.

 

The Handwriting for Heroes website offers links to YouTube videos that demonstrate one-handed skills.

Shoe tying:  http://www.youtube.com/watch?v=svyY1eNUvXw

Hair and jewelry management:  http://www.youtube.com/watch?v=vQWiN_fvd7E

 

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PERSONAL, HAIR AND NAIL CARE:

For ease and safety in climbing into and out of the bathtub with one hand, a double level rail that clamps to the edge of the tub offers assistance with pulling yourself up and steadying while standing.

Amazon.com: Medline Bathtub Bar, Locks to Side of Tub: Health & Personal Care

 

Countertop dispenser makes it easy to put correct amount of toothpaste on brush. Just align toothbrush with guide under nozzle and press long lever down with hand or arm. Accepts a 4.3 or 4.6 oz. stand-up pump style canister. White plastic. Latex free.

 

 

An adjustable-height hair dryer stand lets you style and dry your hair without having to handle the dryer.

 

 

 

Here is another:

 

 

 

 

A "hot brush" is a curling brush and hair dryer in one. Dry and style your hair easily with one hand.

 

 

"I use a brush that blow-dries and I sit down and rest my hand on my knee for support and it works!!  Oh...and a good hair cut once a month is the real key for me." – Sharalyn

"With only my left arm, ratting my hair was impossible. I took a potato chip clip (the kind that holds the bag closed), ran a string through the little holes and tacked it to my bedroom ceiling. It grabs a hunk of hair and holds it while you rat away! Vain, but I hated having flat hair." – epete

 

One-Handed Nail Care

Designed for people with weak grasp or use of only one hand.  Deluxe model has durable base with pivoting nail clipper.  Arched ramp accommodates different finger thicknesses.  Replaceable emery boards secured by thumb screws both horizontally and vertically.  Economy model has heavy-duty clipper and attached strip of filing paper.  Both models secure to table top with suction cups.
 

 

Etac Nail File Holder

Fits securely into the entire hand. Ideal for people with limited grasp. Comes with emery board. 41/4" (12cm) in length; weighs only 1.5 oz. (43g). Latex free.

 

 

Suction Emery Board

The Suction Emery Board consists of two grades of emery cloth covering a 4" (10cm) long board. Two suction cup feet keep the board stationary while filing nails.

 

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WRITTEN COMMUNICATION:

Limited strength and dexterity in your hand makes it difficult to handle pens and pencils, as well as silverware and craft items such as crochet hooks. Making them larger can result in a better grip and ease of use. 

 

Any pen or mechanical pencil (or eating utensil or craft tool with a similar shaft) can be made larger with a fitted grip made of Crayola Model Magic.  It's an easy-to-handle clay in a wide variety of colors that can be rolled onto the shaft of your pen, spoon, or tool and shaped to a personalized fit for your own hand. It dries when exposed to air, so will be hardened and ready to use within a day or two. If you buy it in the bag you should plan to use it all in one modeling session, as it will dry out without an air-tight container. If you have big plans for this stuff, it can be bought by the 2-pound bucket in both neon and natural colors and stored in the bucket for later use. Darker colors (black, for instance) might be a good choice, since they don't show the grime of constant handling.

 

A spongier material for this purpose is a roll of 2- or 3-inch wide self-adhesive bandage wrap, such as Coban.  Buy it at any drug store and wrap it tightly around the desired area until it's as thick as you'd like. A line of white glue along the edge will assure that it stays in place despite hard use.

 

 

FrogPad makes one-handed keypads for either left or right hands. They're small (5½" x 3 ½"), but they perform all the functions of a standard keyboard, with standard-sized keys for easy use. The arrangement of the keys is not standard, though, so patience is called for to relearn keyboarding with the new arrangement. Once you're back up to your former typing speed you'll find it's easy to use and easy on your hand as well – unlike one-handed pecking on a standard keyboard, there are no long stretches to reach any keys.

 

It's possible to learn to write using your non-dominant hand. It just calls for perseverance and a sense of humor – and maybe a few of those wide-lined writing tablets they use in the early elementary grades.

"Right now, I am starting to train my left hand to write...am starting with crayons and a detailed coloring book...don't laugh cause it's true." Sharalyn

"I learned to print with my left hand when my friend who is a speech therapist told me she teaches stroke victims to write with the unaffected hand. Her advice was to start with all caps. I have progressed to caps and small letters. My writing is large like a first grader's, but it is writing!! Small steps help. My signature is very poor penmanship, but it is mine!!!" - ronimom

 

Handwriting for Heros

 

Here's a new workbook developed by two experienced Occupational and Hand Therapists to help you learn to write with your non-dominant hand. Handwriting for Heroes: Learn to Write with Your Non-dominant Hand in Six Weeks is an encouraging but no-nonsense program for those who are serious about switching dominant sides. Daily and weekly practice assignments, tips for assuring success, and plenty of encouraging words are offered in a framework of adult interests and sensibilities – no more first-grade writing tablets and kid-level practice sentences! The workbook is well-organized, clear, and comprehensive. The authors even invite the user to visit their website  to ask questions or report on their progress. It should have been spiral bound for ease in laying it flat, but we tried bending the workbook's spine and that does keep it from becoming a frustration.

 

The advertising for a leading speech recognition system says, "Just about anything you do now by typing can be done faster using your voice. Create and edit documents or emails. Open and close applications. Control your mouse and entire desktop." In reality, it takes some time to "train" the voice activated system to understand your speech and type accordingly, but saves both time and frustration once the adjustment period is over.

 

"I use a speech recognition software for typing as I also can't type anymore with my right hand.  It is slow and frustrating but gets easier with time." – Erica

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TRANSPORTATION:

  

A spinner knob on your steering wheel allows you to steer with one hand. These knobs, popular hotrod accessories, are illegal in some states except when used by someone with a disability. The "standard spinner knob" is large and easy to grip.

 

Adaptations such as the Sure-Grip Palm Grip Spinner Knob can be used if the grip in your usable hand is compromised by arthritis or other injury. Installation of a spinner knob will require you to re-take your driver test using the adaptation. Be sure to keep a copy of your spinner knob permit in your glove compartment.

"In case some cop spots you and decides you look like a wild-child, out to do mischief with your one-handed driving, you can just whip out your 3 or 4 page document and let him examine it as long as he likes." – barbaraellen

 

Is there a way to ride a bike safely with one hand? We found a 2004 article about four engineering students who discovered a way to stabilize bikes for one-handed riding. Though their invention is not commercially available, we located a similar product called a "Hopey steering damper," a hydraulic device that provides "a more controlled, stable, less-busy ride." At around $230 it's not cheap, but it can be installed on the handlebars of most bikes and gives significant added stability when turning sharply or hitting bumps.

 

A less expensive alternative for stabilizing your bike's steering is an old technology of attaching a short, sturdy spring between the headset and the frame. This helps to bring the front wheel back into line quickly in case of bumps or sharp turns. Some bikes come with them, like the Gary Fisher Simple City 8 (above left) or the Electra Holiday Townie 3i (below right) .  You can rig your own bike with this kind of stabilizer with the help of your local bike shop. Whatever you select, keep in mind that one-handed riding is still risky. Plan your route to avoid difficult or dangerous terrain, and of course always wear a safety helmet.

 

 

 

There are other riding options as well. The three-wheel adult bike is stable by design and offers plenty of room in a back basket for lugging groceries or a picnic lunch.

 

 

 

 

 

A more companionable way to get around is on the back of a tandem, where you benefit from the exercise of pedaling with none of the headaches of steering and stopping.

 

 

If your favorite form of transportation is your own two feet, there are single-shoulder back packs and totes called cross-body sling bags. They come in several sizes and styles. Here's an example of a rugged pack with a large capacity for serious hikers.

 

 

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FOR COLD INTOLERANCE:

 

These half-finger gloves can be made on any 3.4 inch in gauge round knitting loom. The blue 24 peg Knifty-Knitter round knitting loom is perfect, many stitches can be made with one hand if you're able to steady the loom with your other arm, the designer uses an icing turntable propped on top of her chest with a cushion to stop it sliding off.  Or ask a "crafty" friend to knit you a pair. The designer, Helen Jacobs-Grant, is wheelchair bound and suffers from cold intolerance due to nerve damage. Her original pattern is available on her Blog and on Ravelry as a free download.

 

 

Grabber Mini Handwarmers can be bought in packs of three pair.

Each one warms in minutes and lasts up to seven hours. Activate it by exposing it to the air, then put it in your pocket, where you can re-warm your hand between chores. Or use them in your glove outdoors on wintry days. Available at sporting goods stores, because campers and hikers love them.

"I make a hand warming bag out of raw rice (or corn) in a sturdy sock which I tie or rubber band at the 'ankle'.  I microwave that for 60 to 90 seconds. it stays warm for up to 20 minutes." - apple

 

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LYMPHEDEMA CARE:

 

Neosporin's NEO TO GO! First Aid/Pain Relieving Antiseptic Spray is a non-aerosol antiseptic spray that fits in your purse or pocket, so you can keep it handy for unexpected nicks or scratches. Designed to be used easily with one hand.

 

 

 

 

Control of swelling can reduce lymphedema-related pain and discomfort and ease the weight of a dependent (unsupported) arm. Brachial plexopathy limits the natural arm movement that helps pump lymph fluid out of the arm and back into circulation. The static downward-hanging position of the arm also causes fluid to collect in the hand, causing more pumping problems. Manual Lymph Drainage, as part of a complete program of lymphedema self-care, can help clear lymph fluid from the arm, but it can also be difficult, tiring or just plain frustrating to do. In consultation with your doctor and your lymphedema therapist, you may consider the use of a gentle pneumatic device for home Manual Lymph Drainage, such as the Flexitouch System. Your therapist can arrange for a company representative to give you a free, private demonstration so you can judge it's potential for helping you with self-care. Newly designed garments for use with the system offer ease of use. The gentle action of the Flexitouch is tolerated well by patients with pain and sensitivity to touch. During the once or twice-daily treatment you are free to watch TV, listen to music, talk on the phone or simply relax. The company is helpful and experienced in pursuing insurance and Medicare coverage.

"I've been using Flexi-touch for nearly a year now in my home. It is relaxing, seems to help with my hand pain. My insurance paid full amount. Worth checking into." – epete

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Treatment Strategies

Even though there is currently no cure for RIBP, comprehensive care of this condition should continue to include strategies to control pain, support psycho-social adjustment to the progressive nature of this condition, slow progression through appropriate exercise, and adapt to changing arm and shoulder stabilization needs. Excellent lymphedema control is challenging but essential for pain reduction, lessening of shoulder damage from the added weight of a swollen arm, lowering infection risk, and reducing the impact of further fibrosis (hardening) of the tissues. Physical therapists and occupational therapists with specific training in lymphedema can address the whole range of RIBP needs, but may lack experience with this uncommon condition. The suggestions below are meant to guide you and your therapist toward workable interventions to ease all aspects of coping with RIBP.

• Pain control [coming soon]

 

• Anti-depressants and other medications [coming soon]

 

• Exercises (coming soon)           

 

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Arm And Shoulder Support

Here's a possible solution for supporting the shoulder despite advancing paralysis, especially if bending the elbow causes pain or cramping. The shoulder sling adds support for the shoulder joint so that it does not continue to droop, but does not constrict the lymph flow. It can be worn with compression garments to help control hand swelling, and the slight lift to the lower arm will also help control lymph congestion. 

These are some supports for the arm that are used with stroke patients. They have a humeral cuff, and possibly your therapist can change out the forearm support to thera-tubing so that the springiness of the tubing promotes some elbow flexion and extension. In this way some passive lymph drainage can occur when you're walking around.

This one is an example, it can be found at Sammons-Preston online and has an additional forearm cuff.  A local orthotics supplier should be able to order something like it.

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Shoulder sling adaptations

AliMed Hemi Shoulder Sling

• The shoulder saddle serves as a secure anchor point. and the scapula bears the arm weight.
• Distraction straps adjust up or down and can control rotation.
• The cuff is lined with cool, open-cell polyurethane. It can't slip.
• It offers full joint mobility
• An elastic panel accommodates muscle volume changes.
• A biceps-triceps belly band locks cuff in place.

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AliMed Hemi Shoulder Sling

This is more lightweight and versatile than conventional arm braces. Shoulder saddle and humeral cuff are connected by three highly adjustable distraction straps that allow for full joint mobility while supporting the shoulder.

Sizing: Measure arm circumference at widest point of bicep. Round up if between sizes.

• X-Small fits 9" circumference
• Small fits 11" circumference
• Medium fits 13" circumference
• Large fits 15" circumference

Patent #5,403,268

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GivMohr Sling

GivMohr Sling is an innovative new design based on the principles of neuro-developmental treatment. It promotes functional positioning of the arm while standing and walking and naturally reduces shoulder subluxation (partial dislocation that results in drooping).  It helps protect the arm from injury and is easy to apply and to custom fit.

Sizing: Measure distance between right and left acromion of scapula.

• Small, 13" - 14"
• Medium, 15" - 16"
• Large, 17"+
• X-Large

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Night garment options

The custom made garment here was designed by JoviPak. The arm loop supports the lower arm, so when you shift position in your sleep your arm shifts with you. If bending your elbow to this angle is a problem, the lower edge of the garment can be extended in order to place the support loop lower. This company will place a zipper in the forearm or upper arm area of the sleeve if your fitter requests it, to make donning easier. The separate glove, with zipper and Velcro closure, is also easy to put on and remove.

 

 

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Sleeping Positions for RIBP

Keeping your arm and hand elevated on pillows throughout the night can help reduce swelling from lymphedema. But it can also be a challenge. Here are some comfortable positions suggested by occupational therapist Naomi Aaronson MA OTR/L CHT.  Special thanks to Ann Marie Turo, OTR/L for her taking of these pictures.

For back sleepers, make a nest of two pillows for your head and shoulders and lay another across your abdomen to support your affected arm. The arm can be extended if flexing is difficult.

 

 

 

For arm support while sleeping on your side, "hug" a pillow between your arms, affected arm on top. To sleep with your arm extended, use a longer (king size) pillow or body pillow.

 

For hand and finger swelling this support position provides additional support.

 

 

"I had already been sleeping with an extra pillow to raise my arm up, and made a small pillow out of a sleeve from an old shirt to lay under my arm when sleeping on my side to keep hand from falling down across my belly. It works better than a full size pillow. I got the idea when I rolled up a fleece throw to that size and slept with it. Since it was smaller than a bed pillow, I didn't get as hot over night but it was stiff enough to support the weight of my arm.

 

"I just cut the sleeve off an old shirt straight out from the under arm seam where the sleeve is sewn onto the body of the shirt (didn't cut the round area at the top of the sleeve), turned it inside out and made a seam across the opening. I turned it right side out again, stuffed it rather firm with poly fiberfill through the cuff, and sewed the end of the cuff and the button placket shut. I put it under my arm when I am sleeping on my side to help hold my arm flat (keeps my wrist and hand from falling down across my belly). You could even make one out of a straight piece of fabric (approx 16-20 inches long by 8-10 inches wide), just long enough to reach from your elbow to the tips of your fingers."-- lvtwoqlt

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Supportive accessories

coming soon . . .

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Lymphedema Therapy and Control 

An article by Joachim Zuther, founder of the Academy of Lymphatic Studies and author of the "Textbook of Comprehensive Lymphedema Management", suggests important strategies for on-going intervention by a well-trained lymphedema therapist.

Lymphedema Garments coming soon

Kinesio taping

In seeking treatment options for aspects of RIBP care, our research turned up the possibility of using Kinesio taping for both reducing the swelling of lymphedema and supporting the shoulder of the dependent arm. Below is our email correspondence with an expert in Kinesio tape therapy, explaining some uses and concerns for the application of Kinesio tape in treating these aspects of RIBP.

StepUp-SpeakOut: "One intriguing piece of information that we've heard mentioned briefly is the possible role of Kinesio taping in stabilizing subluxation of the shoulder, a major problem as RIBP progresses. So far, though, we haven't been able to find any solid information about that. We wondered if you could steer us to information about we could share with patients and therapists? Or are we barking up the wrong tree?"

Ruth Coopee MOT, OTR/CHT, MLD/CDT, CMT: "No, you are correct in thinking and seeing that Elastic support and Taping could assist with this condition. I have used it with Brachial plexus injuries many times and subluxed shoulders for stabilization of the anterior capsule. In the past I had a patient with radiation injury post radical neck treatment and it did help with relief of the 'burning parasthesias' that radiated to the hand.

"The only concern is the strength/health of the skin of the individual where the tape will be placed. Each case would also need to be assessed for implementation. Provide anterior capsule stabilization?  Supporting the weight of the arm? Relax the antagonist (Latissimus Dorsi)? Many ways it can be used, and in addition the edema in the area will be reduced."

 

Pneumatic compression devises

To learn about using a pneumatic compression device (sometimes erroneously called a "lymphedema pump") we contacted Christina Badger, RN, BSN, a Product Specialist with Tactile Systems, the makers of Flexitouch. She in turn referred us to Leslie Benson, OTR/L, CLT-LANA, CRA, who is a Clinical Research Associate at the same company. Our email correspondence is below:

StepUp-SpeakOut: "We wonder if Tactile Systems has any information to share about the use of the Flexitouch with a flaccid arm, especially in a patient experiencing nerve pain. Special considerations? Donning hints? Tips for adjusting the fit? Any hope here?"

Christina Badger: "See the response below from Leslie Benson…In addition, I have worked with a couple of patients who had a flaccid arm. One that I remember actually lived alone, and we were able to teach her to don/doff very well. I think as far as pain issues are concerned, these women do excellent with the Flexitouch. I think the most important message is that Flexitouch will provide the in-home support and training that will be needed to help these special patients out. If I know that I have a patient with special concerns like this, I will almost always make it a point to train the patient myself rather than have one of my trainers do it, just to ensure that they get comfortable and we can have a solution for them."

Leslie Benson: "For the flaccid arm and nerve pain patient it would be vital to have supervised treatments with the Flexitouch. The reasoning is

1) patient tolerance is unknown;

2) therefore, perform skin inspections frequently during the treatment to assess changes and adverse events;

3) the patient lacks the necessary feedback loops for sensing and needs someone to complete assessment for risks during the treatment.

"Donning hints: prepare the arm in a cone, use gravity to assist with navigating the arm into the sleeve, or you may need to use a tabletop. Try different methods for what works best for the patient. I think once the therapist begins working with the patient, they will both discover optimal ways to don the garments together."

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RESEARCH AND EXPERIMENTAL TREATMENT OPTIONS

 INCIDENCE OF RADIATION-INDUCED BRACHIAL PLEXOPATHY IN BREAST CANCER TREATMENT

Note: It is currently impossible to say how many women treated for breast cancer will eventually develop RIBP. These studies do begin to raise that question, but they fall short of providing any answers.

March 2010

Lancet Oncol. 2010 Mar;11(3):231-40. Epub 2010 Feb 6.

Comparison of patient-reported breast, arm, and shoulder symptoms and body image after radiotherapy for early breast cancer: 5-year follow-up in the randomised Standardisation of Breast Radiotherapy (START) trials.

Hopwood P, Haviland JS, Sumo G, Mills J, Bliss JM, Yarnold JR; START Trial Management Group.

Collaborators (15)

Agrawal RK, Aird EG, Barrett JM, Barrett-Lee PJ, Brown J, Dewar JA, Dobbs HJ, Hoskin PJ, Lawton PA, Magee BJ, Morgan DA, Owen JR, Simmons S, Sydenham MA, Venables K.

Clinical Trials and Statistics Unit (ICR-CTSU), Section of Clinical Trials, The Institute of Cancer Research, Sutton, Surrey, UK. penny.hopwood@icr.ac.uk

Abstract

BACKGROUND: Few trials of adjuvant breast radiotherapy have incorporated patient-reported breast symptoms and related areas of quality of life. We assessed these measures in a quality-of-life study that was part of the randomised START (Standardisation of Breast Radiotherapy) trials.

METHODS: In START trial A, 2236 patients were randomly assigned to receive either 39 Gy or 41.6 Gy delivered in 13 fractions over 5 weeks or a global standard of 50 Gy in 25 fractions. In START trial B, 2215 women were randomly assigned to receive either 40 Gy in 15 fractions over 3 weeks or the same control regimen (50 Gy in 25 fractions) as in trial A. 2739 patients were eligible for the quality-of-life study of whom 2208 (81%) were accrued (1129 patients from trial A and 1079 from trial B). Participants completed the EORTC QLQ-C30 and BR23 questionnaires and protocol-specific radiotherapy items up to 5 years after radiotherapy. We compared results across regimens with generalised estimating equations and survival analyses. The START trials are registered, ISRCTN59368779.

FINDINGS: At 5 years, up to 40% women reported moderate or marked changes to the breast after radiotherapy, and arm and shoulder pain affected up to a third of patients. Breast symptoms and body image concerns reduced over time. Rates of radiotherapy adverse effects were lower for the 39 Gy regimen in trial A and the 40 Gy regimen in trial B, compared with the 50 Gy control regimen; rates of radiotherapy adverse effects were similar between the 41.6 Gy and 50 Gy regimens in trial A. Adverse change in skin appearance was significantly lower for patients who received 39 Gy compared with those who received 50 Gy (HR 0.63, 95% CI 0.47-0.84) and for those who received 40 Gy compared with those who received 50 Gy (0.76, 0.60-0.97); no significant difference was observed between patients who received 41.6 Gy and those who received 50 Gy in trial A (0.83, 0.63-1.08). Patient self-ratings of breast symptoms discriminated a 10% difference in randomised dose intensity. Up to a third of women reported moderate or marked pain in the arm and shoulder over 5 years whilst more than 10% experienced moderate or marked arm and hand swelling, with no significant difference in arm/shoulder subscale scores between the regimens in trial A or trial B; many baseline arm and shoulder symptoms were associated with prior surgery.

INTERPRETATION: A substantial proportion of women report moderate or marked breast, arm, and shoulder symptoms over 5 years of follow-up after radiotherapy, but with no detriment to body image. Nonetheless, most patients stand to gain from hypofractionated radiotherapy regimens with a potential for fewer adverse effects; this strengthens the evidence from the START trials for hypofractionated regimens for women requiring radiotherapy for early breast cancer.

FUNDING: Cancer Research UK, UK Medical Research Council, UK Department of Health.

Copyright 2010 Elsevier Ltd. All rights reserved.

PMID: 20138809 [PubMed - indexed for MEDLINE]

1992

Int J Radiat Oncol Biol Phys. 1992;23(5):915-23.

Long-term radiation complications following conservative surgery (CS) and radiation therapy (RT) in patients with early stage breast cancer.

Pierce SM, Recht A, Lingos TI, Abner A, Vicini F, Silver B, Herzog A, Harris JR.

Joint Center for Radiation Therapy, Boston, MA 02115.

Abstract

The frequency of brachial plexopathy, rib fracture, tissue necrosis, pericarditis, and second non-breast malignancies occurring in the treatment field among 1624 patients with early stage breast cancer treated with conservative surgery and radiation therapy at the Joint Center for Radiation Therapy between 1968 and 1985 is reported. The median follow-up time for survivors was 79 months (range 5-233 months). Brachial plexopathy was related to the use of a third field, the use of chemotherapy and the total dose to the axilla. Brachial plexopathy developed in 20 of 1117 women (1.8%) who received supraclavicular irradiation with or without axillary irradiation. The median time to its occurrence was 10.5 months (range 1.5-77 mo), and the majority (80%) of cases completely resolved. Among patients treated with a three-field technique, the incidence of brachial plexopathy was 1.3% (13/991) in patients treated with a dose to the axilla of less than or equal to 50 Gy, compared with 5.6% (7/126) in women treated with an axillary dose of greater than 50 Gy. The incidence of brachial plexopathy was 4.5% (15/330) among patients receiving chemotherapy, compared with 0.6% (5/787) when chemotherapy was not used (p less than 0.0001). Rib fracture was seen in 29 patients (1.8%), at a median time of 12 months following treatment (range 1-57). In all cases, the rib fracture healed without intervention. The incidence of rib fracture was 2.2% (28/1300) among patients treated on a 4 MV linear accelerator, compared with 0.4% (1/276) for patients treated on a 6 or 8 MV machine (p = 0.05). Of patients treated on a 4 MV machine, 0.4% (1/279) developed a rib fracture when a whole breast dose of 45 Gy or less was given, 1.4% (10/725) after receiving between 45 and 50 Gy, and 5.7% (17/296) following 50 Gy or higher. Tissue necrosis requiring surgical correction developed in three patients (0.18%) 22, 25, and 114 months after treatment. Presumed pericarditis (requiring hospitalization) was seen in 0.4% of women (3/831) who received radiation therapy to the left breast 2, 2, and 11 months after the start of treatment. Three women (0.18%) developed sarcomas in the treatments field at 72, 107, and 110 months, for a 10-year actuarial rate of 0.8%. Two of these sarcomas developed in areas of probable match-line overlap. One patient (0.06%) developed an in-field basal cell carcinoma at 42 months. In conclusion, the risk of significant complications following conservative surgery and radiation therapy for early stage breast cancer is low.(ABSTRACT TRUNCATED AT 400 WORDS

PMID: 1639653 [PubMed - indexed for MEDLINE]

 

CAUSES OF RADIATION INDUCED BRACHIAL PLEXOPATHY

Note: Many studies have looked at the factors that contribute to the development of RIBP. From information like this we can hope refinements to treatment techniques will reduce or eliminate this condition.

February 2010

Neurol Clin. 2010 Feb;28(1):217-34.

Neurotoxicity of radiation therapy.

Dropcho EJ.

Department of Neurology, Indiana University Medical Center, CL 292, Indianapolis, IN 46202, USA. edropcho@iupui.edu

Abstract

Direct or incidental exposure of the nervous system to therapeutic irradiation carries the risk of symptomatic neurologic injury. Central nervous system toxicity from radiation includes focal cerebral necrosis, neurocognitive deficits, and less commonly cerebrovascular disease, myelopathy, or the occurrence of a radiation-induced neoplasm. Brachial or lumbosacral plexopathy are the most common syndromes of radiation toxicity affecting the peripheral nervous system. This article focuses on the clinical features, diagnosis, and management options for patients with radiation neurotoxicity.

PMID: 19932383 [PubMed - indexed for MEDLINE]

2009

Acta Oncol. 2009;48(6):822-31.

Hypofractionation in radiotherapy. An investigation of injured Swedish women, treated for cancer of the breast.

Friberg S, Rudén BI.

Department of Oncology, Radiumhemmet, Karolinska University Hospital Solna, Stockholm, Sweden. Bengt-Inge.Ruden@Telia.com

Abstract

BACKGROUND: The Swedish Insurance Company for Patient Injuries asked the two authors of this report to identify the Swedish women with cancer of the breast who had been injured by radiotherapy with a hypofractionated schedule. The purpose was to provide a basis on which the Company could decide if indemnification could be given.

MATERIAL AND METHODS: We define hypo-fractionation as any fraction dose exceeding 2.0 gray (Gy) per day. We set the lower limit for the "late effect" at 53.0 Gy with 2 Gy/fraction. All departments of radiotherapy in Sweden were asked to identify women who had developed brachial plexus neuropathy (BPN). Their medical records were obtained. The clinical picture of their injuries was recorded, and the absorbed dose was calculated or reconstructed. All doses, no matter in what way they were expressed, were recalculated to "late effect", presented in EQD(2 Gy) (Equalized Total Dose in 2 Gy/fraction). The latency period from therapy to onset of symptoms was also noted.

RESULTS: A variety of treatment techniques was used, fractions ranging in size from 2.5 to 6.0 Gy. Absorbed doses up to a Biologically Equivalent Dose (BED) 146 EQD(2 Gy) in late effects were recorded (6 Gy x 13). More than 95% of the injured women had a combination of stiff shoulder, paralysis, pain, oedema and atrophy of the muscles to the arm and/or hand. Latency from end of radiotherapy to onset of symptoms could be as long as 30 years. Discussion. Hypofractionated radiotherapy has injured severely numerous patients. The lesions have become a medico-legal issue in some countries. The life of many of these women has been ruined: physically, mentally, socially and economically.

CONCLUSION: Hypofractionated radiotherapy can cause injuries if the target volume is not exact, or the total dose is not adjusted to a tolerable level as compared to conventional treatments employing 2 Gy/day fractions.

PMID: 19504371 [PubMed - indexed for MEDLINE]

 2007

Folia Neuropathol. 2007;45(1):26-30.

Radiation-induced brachial plexus neuropathy - aetiopathogenesis, risk factors, differential diagnostics, symptoms and treatment.

Gosk J, Rutowski R, Reichert P, Rabczyński J.

Department of Trauma and Hand Surgery, Medical University of Wrocław, R Traugutta 57/59, Wrocław, Poland. chiruraz@churaz.am.wroc.pl

Abstract

The success of radiation oncology has led to longer patient survival. This provides a greater opportunity for radiation injuries of the peripheral nerves to develop. Brachial plexus neuropathy in cancer patients may result from either tumour recurrence or as a consequence of radiation therapy. Distinguishing between radiation injury and cancer disease recurrence as a cause of brachial plexus dysfunction may be difficult. In this article the most important principles of the differential diagnostics have been presented. Furthermore the aetiopathogenesis of brachial plexus neuropathy after radiotherapy has been discussed as well as main risk factors, symptoms of plexopathy and methods of treatment. It ought to be emphasized that complications of radiation therapy sometimes occur many years after treatment and this may create difficulties in initial diagnostics.

PMID: 17357008 [PubMed - indexed for MEDLINE]

 2006

Acta Oncol. 2006;45(3):280-4.

Radiation-induced brachial plexopathy and hypofractionated regimens in adjuvant irradiation of patients with breast cancer--a review.

Gałecki J, Hicer-Grzenkowicz J, Grudzień-Kowalska M, Michalska T, Załucki W.

Department of Radiotherapy, Maria Skłodowska-Curie Memorial Cancer Center and Institute of Oncology, W. K. Roentgen 5, 02-781, Warsaw, Poland. jacekg@coi.waw.pl

Abstract

In order to increase the availability of adjuvant radiotherapy of breast cancer patients and make it more convenient and cheaper, in numerous cancer centres, the dose per fraction has been increased from 2 Gy to 2.25-2.75 Gy and the total dose has been decreased from 50 Gy to 40-45 Gy. The risk of developing any late complications after conventionally fractionated megavoltage radiotherapy is estimated to be below 1%. The aim of this review is to determine whether hypofractionated regimens increase the risk of damage to the brachial plexus. A review of the published literature shows that the use of doses per fraction in the range from 2.2 Gy to 4.58 Gy with the total doses between 43.5 Gy and 60 Gy causes a significant risk of brachial plexus injury which ranged from 1.7% up to 73%. The risk of radiation induced brachial plexopathy was smaller than 1% using regimens with doses per fraction between 2.2 and 2.5 Gy with the total doses between 34 and 40 Gy. Surgical manipulations in the axilla and chemotherapy have to be taken into account as additional factors which may increase the risk of brachial plexopathy.

PMID: 16644570 [PubMed - indexed for MEDLINE] 

June 2004

Radiother Oncol. 2004 Jun;71(3):297-301.

Is there a life-long risk of brachial plexopathy after radiotherapy of supraclavicular lymph nodes in breast cancer patients?

Bajrovic A, Rades D, Fehlauer F, Tribius S, Hoeller U, Rudat V, Jung H, Alberti W.

Department of Radiotherapy and Radiation Oncology, University Hospital Hamburg-Eppendorf, Martinistrasse 52, 20246 Hamburg, Germany.

Abstract

BACKGROUND AND PURPOSE: To contribute to the question whether the risk of radiation-related brachial plexopathy increases, remains constant or decreases with time after treatment.

PATIENTS AND METHODS: Between 12/80 and 9/93, 140 breast cancer patients received supraclavicular lymph node irradiation using a telecobalt unit. Total dose was 60 with 3Gy per fraction at a depth of 0.5 cm and 52 with 2.6Gy per fraction to the brachial plexus at a depth of 3 cm. Twenty-eight women received chemotherapy, 34 tamoxifen. Brachial plexopathy was graded using a modified LENT-SOMA score. Actuarial complication-free survival and overall survival were obtained from Kaplan-Meier analysis. The impact of chemotherapy or tamoxifen was tested using the chi2 test. The annual incidence of radiation-related brachial plexopathy was assessed by exponential regression as described by Jung et al. [Radiother Oncol 61 (2001) 233].

RESULTS: Actuarial overall survival was 67.1% after 5 years, 54.0% after 10 years, 49.9% after 15 years, and 44.0% after 20 years. In 19/140 patients, brachial plexopathy grade>/=1 occurred after a median interval of 88 (30-217) months. The percentage of patients being free from plexopathy was 96.1% after 5 years, 75.5% after 10 years, 72.1% after 15 years, and 46.0% after 19 years, respectively. A significant impact of type of surgery, chemotherapy or tamoxifen was not observed. The annual incidence of brachial plexopathy was 2.9% for grade>/=1 lesions and 0.8% for grade>/=3 lesions. The rates did not change significantly with time.

CONCLUSIONS: The risk of brachial plexopathy after supraclavicular lymph node irradiation in breast cancer patients remains constant for a considerable portion of the patient's life.

PMID: 15172145 [PubMed - indexed for MEDLINE]

February 2004

J Reconstr Microsurg. 2004 Feb;20(2):149-52.

Radiation-induced brachial plexopathy: review. Complication without a cure.

Schierle C, Winograd JM.  Harvard Medical School, Boston, MA 02114, USA.

Abstract

Radiation-induced brachial plexopathy, especially the chronic and progressive form, has become an increasingly rare entity in patients receiving radiation therapy to the chest wall and axilla. However, for the patients affected by this pathologic process, the chronic pain, decline in function, and absence of a satisfactory treatment are a continuing challenge to the reconstructive peripheral nerve surgeon. The authors have undertaken a review of the relevant literature addressing radiation-induced brachial plexopathy, and here present a summary of the current understanding of the pathophysiology, diagnosis, and treatment of this disorder.

PMID: 15011123 [PubMed - indexed for MEDLINE]

 April 2002

Int J Radiat Oncol Biol Phys. 2002 Apr 1;52(5):1207-19.

Dose response and latency for radiation-induced fibrosis, edema, and neuropathy in breast cancer patients.

Johansson S, Svensson H, Denekamp J.  Department of Radiation Sciences, Translational Research Group, Umeå University Hospital, Sweden. silvia.johansson@onkologi.umu.se

Abstract

PURPOSE: To study the incidence of various forms of late normal tissue injuries to determine the latency and dose-response relationships.

METHODS: We retrospectively analyzed the clinical records of 150 breast cancer patients treated with radiotherapy after mastectomy in the mid to late 1960s. None of the patients had received chemotherapy as a part of their primary treatment. Radiotherapy was delivered to the parasternal, axillary, and supraclavicular lymph node regions. Almost all the patients continued to be checked at regular 3-month to 1-year intervals at our Oncology Department. Detailed records were available for the entire 34 years of the follow-up period. The patients were divided into 3 groups. The prescribed dose was either 11 x 4 Gy (treated with 60Co photons) or 11 x 4 Gy or 14-15 x 3 Gy (treated with both 60Co photons and electrons). The dose recalculation at the brachial plexus where the axillary and supraclavicular beams overlapped was performed in the early 1970s and expressed in cumulative radiation effect (CRE) units. It varied widely among the individual patients. The received dose has now been converted to biologic effective dose(3) units, and from that into the equivalent dose in 2-Gy fractions to plot the dose-response relationships.

RESULTS: We present a comparison of the latency and frequency of fibrosis, edema, brachial plexus neuropathy, and paralysis in the three different subgroups and the total group. Dose-response relationships are shown at 5, 10, and 30 years after irradiation.

CONCLUSION: The use of large daily fractions, combined with hotspots from overlapping fields, was the cause of the complications. Clear dose-response curves were seen for late radiation injuries. The incidence seen at 5 years did not represent the full spectrum of injuries. Doses that seem safe at 5 years can lead to serious complications later.

PMID: 11955731 [PubMed - indexed for MEDLINE]

 February 2002

Clin Rehabil. 2002 Mar;16(2):160-5.

Radiation-induced brachial plexopathy in women treated for carcinoma of the breast.

Fathers E, Thrush D, Huson SM, Norman A.

Department of Neurology, Derriford Hospital, Plymouth, UK. Edward.Fathers@btinternet.com

Abstract

OBJECTIVES: To study the clinical presentation and natural history of radiation-induced brachial plexopathy in 33 women treated for carcinoma of the breast.

METHODS: All of the patients were referred to a single consultant neurologist. Details of surgical procedures, radiotherapy, symptoms at presentation and follow-up and neurological findings were recorded. Patients were reviewed at six or 12 monthly intervals for 2-19 years (median 9.5 years). Investigations included blood tests, chest X-ray, bone scan, neurophysiological studies, computerized tomography (CT) or magnetic resonance imaging (MRI) of the cervical spine and cerebrospinal fluid examination.

RESULTS: Symptoms began from six months to 20 years after radiotherapy (median time 1.5 years). Progressive weakness was universal and resulted in loss of any useful hand function in all but three patients. The time taken to loss of useful hand function ranged from six weeks to five years (median 1.25 years). Three patterns of upper limb weakness were identified, distal limb weakness only (13 patients), global limb weakness that was more marked distally (11 patients), and completely flaccid arm (10 patients). Seventeen patients required long-term morphine to palliate pain. A chemical sympathectomy benefited three patients.

CONCLUSIONS: Most patients developed symptoms within three years, but late presentations 8-20 years later were encountered. Symptoms were progressive in all patients, though the rate did vary. Pain was common and persisted indefinitely in all but one patient. Morphine was effective and should be used early and in adequate doses. Chemical sympathectomy provided sustained relief in three of six patients.

PMID: 11911514 [PubMed - indexed for MEDLINE]

  October 2000

Int J Radiat Oncol Biol Phys. 2000 Oct 1;48(3):745-50.

Timescale of evolution of late radiation injury after postoperative radiotherapy of breast cancer patients.

Johansson S, Svensson H, Denekamp J.

Translational Research Group, Department of Radiation Sciences, Umeå University, Umeå, Sweden. silvia.johansson@onkologi.umu.se

Abstract

PURPOSE: To evaluate the incidence and prevalence of various signs of late morbidity, their time of appearance and pattern of progression during an observation period up to 34 years in breast cancer patients treated with postoperative radiation therapy after radical mastectomy.

METHODS AND MATERIALS: A group of 71 breast cancer patients received in 1963-1965 aggressive postoperative telecobalt therapy to the parasternal, axillary, and supraclavicular lymph node regions after total mastectomy and axillary clearance. None of the patients received chemotherapy either prior to, or after the irradiation as part of their primary treatment. The prescribed dose to the three lymph node regions was 44 Gy in 11 fractions. Only two of the three fields were treated per day. This total dose was given in 16-17 fractions over 3-4 weeks. Because of the overlap of the supraclavicular and axillary fields, the dose received by the brachial plexus was not the dose that was prescribed. A retrospective dose calculation showed that the total dose to the brachial plexus was 57 Gy, delivered as a complex combination of 1.8 Gy, 3.4 Gy, and 5.2 Gy fractions. This cohort of patients has now been followed to 34 years and the late side effects of the treatment evaluated and scored.

RESULTS: This series is unique in the literature. There is no comparable report of a detailed long-term follow-up in a homogeneously treated group of patients with such a high survival, especially among the younger women, where it is almost 50% at 30 years. This is the reason that they were able to develop some of the very slowly evolving injuries. There was progression of many of the late effects in the period between 5 and 34 years. The more serious morbidities have increased progressively over the whole 34-year follow-up period. Ninety-two percent of the long-term survivors have paralysis of their arm. Other neurological findings included unilateral vocal cord paralysis among 5% of the patients, who developed the disease after a median time of 19 years. All of them were left-sided, indicating a mediastinal involvement of the recurrent nerve. Local recurrence or the appearance of a new primary tumor infiltrating or causing pressure on the recurrent nerve were vigorously investigated and excluded as possible causes of these symptoms.

CONCLUSION: The greatest risk for all cancer patients is the inadequate treatment of their disease, because this is inevitably lethal. The aggressiveness of the therapy and the acceptable risk of complications must therefore be balanced against the risk of recurrence. The neuropathy seems to be closely linked to the development of fibrosis around the nerve trunks. The use of large daily fractions, combined with hot spots from overlapping fields contributed to the severity of the complications.

PMID: 11020571 [PubMed - indexed for MEDLINE]

2000

Acta Oncol. 2000;39(3):373-82.

Brachial plexopathy after postoperative radiotherapy of breast cancer patients--a long-term follow-up.

Johansson S, Svensson H, Larsson LG, Denekamp J.

Department of Oncology and Radiation Physics, Umeå University, Sweden. Silvia.Johansson@onkologi.umu.se

Abstract

In 1963-1965 a group of 71 patients operated on for breast cancer with total mastectomy and axillary clearance were given aggressive postoperative telecobalt therapy to the axillary, supraclavicular and parasternal lymph node regions. The prescribed dose to these lymph node regions was 44 Gy in 11 fractions. Only two of the three fields were treated per day. Retrospective dose calculations showed that the total dose in the brachial plexus from the axillary and supraclavicular fields was c. 57 Gy in 16-17 fractions over 3-4 weeks. After a few years, symptoms and signs of brachial plexus injury appeared in many patients, which was reported in some early papers. The cohort has now been followed-up to 34 years. As expected, there was progression of both prevalence and severity of the late effects between 5 and 34 years and 11 of 12 patients who are still alive have paralysis of their arms. The neuropathy seems to be closely linked to fibrosis around the nerve trunks. The use of large daily fractions, in some cases combined with hot spots from overlapping fields, was certainly the cause of the complication.

PMID: 10987234 [PubMed - indexed for MEDLINE]

 Jan-Feb 1990

Arch Neurobiol (Madr). 1990 Jan-Feb;53(1):23-32.

[Post-radiation brachial plexus disease. Clinical and neurophysiological study]

[Article in Spanish]

Esteban A, Traba A.

Servicio de Neurofisiología Clínica, Hospital General Gregorio Marañón, Madrid.

Abstract

Nine patients who developed 11 brachial plexopathies after a radiation therapy for cancer have been studied. They clinically showed heterogeneity in the common criteria used to establish the differential diagnosis between post-radiation and tumoral brachial plexopathies (PRBP and TBP) and specially within the period free of symptoms from the end of radiation, and the presence and intensity of pain. Neurophysiological studies showed a diffused neurogenic lesion with muscular denervation associated to motor and sensory nerve conduction impairment on proximal segments of the arm. Somatosensory evoked potentials were frequently abnormal with absence of N9 potential in 6 out of 7 explored plexuses. The most characteristic findings were, however, the presence of fasciculation potentials and myokymic discharges in 73 per cent of cases, and the motor nerve conduction blocking with proximal -supraclavicular and cervical spine- stimulation in all of them. Both of these phenomena, when analyzed in the same neuromuscular territory, were highly correlated, supporting a probable causal relationship. The neurophysiological data may contribute to the proper differentiation between brachial plexopathies of radiation or tumoral origin. The also would permit to consider a similar physiopathological basis of PRBP with some other infrequent neuropathies where they have been described as relevant features.

PMID: 2168163 [PubMed - indexed for MEDLINE]

October 1994

Rev Neurol (Paris). 1994 Oct;150(10):664-77.

[Radiation-induced neuropathies. Experimental and clinical data]  [Article in French]

Pradat PF, Poisson M, Delattre JY. 

Service de Neurologie, Groupe Hospitalier Pitié-Salpêtrière, Paris.

Abstract

In contrast with the central nervous system, the peripheral nerves are usually considered radioresistant. However, experimental and clinical data show evidence of peripheral nerve injury after radiation therapy. The physiopathology remains unclear. Vascular alterations appear to play an important role. Direct damage to axon or Schwann cell and nervous compression in areas of radiation fibrosis could also be involved. Clinically, brachial plexopathy is a well-recognized complication but all the structures of the peripheral nervous system can be involved: cranial nerves, roots, plexus and nerve trunks. A syndrome of early and reversible plexopathy differs from the classical progressive form with pejorative outcome. Radiation-induced peripheral nerve tumors are infrequent.

PMID: 7792473 [PubMed - indexed for MEDLINE]

  April 1993

Int J Radiat Oncol Biol Phys. 1993 Apr 30;26(1):43-9.

Radiation-induced brachial plexopathy: neurological follow-up in 161 recurrence-free breast cancer patients.

Olsen NK, Pfeiffer P, Johannsen L, Schrøder H, Rose C.

Department of Neurology, Odense University Hospital, Denmark.

Abstract

PURPOSE: The purpose was to assess the incidence and clinical manifestations of radiation-induced brachial plexopathy in breast cancer patients, treated according to the Danish Breast Cancer Cooperative Group protocols.

METHODS AND MATERIALS: One hundred and sixty-one recurrence-free breast cancer patients were examined for radiation-induced brachial plexopathy after a median follow-up period of 50 months (13-99 months). After total mastectomy and axillary node sampling, high-risk patients were randomized to adjuvant therapy. One hundred twenty-eight patients were treated with postoperative radiotherapy with 50 Gy in 25 daily fractions over 5 weeks. In addition, 82 of these patients received cytotoxic therapy (cyclophosphamide, methotrexate, and 5-fluorouracil) and 46 received tamoxifen.

RESULTS: Five percent and 9% of the patients receiving radiotherapy had disabling and mild radiation-induced brachial plexopathy, respectively. Radiation-induced brachial plexopathy was more frequent in patients receiving cytotoxic therapy (p = 0.04) and in younger patients (p = 0.04). The clinical manifestations were paraesthesia (100%), hypaesthesia (74%), weakness (58%), decreased muscle stretch reflexes (47%), and pain (47%).

CONCLUSION: The brachial plexus is more vulnerable to large fraction size. Fractions of 2 Gy or less are advisable. Cytotoxic therapy adds to the damaging effect of radiotherapy. Peripheral nerves in younger patients seems more vulnerable. Radiation-induced brachial plexopathy occurs mainly as diffuse damage to the brachial plexus.

PMID: 8387067 [PubMed - indexed for MEDLINE]

  DIFFERENCIATING BRACHIAL PLEXOPATHY CAUSED BY TUMOR INFILTRATION (METASTASES) FROM BRACHIAL PLEXOPATHY CAUSED BY INJURY FROM RADIATION THERAPY

Note: Two possibilities exist for the development of Brachial Plexopathy following breast cancer treatment. Radiation-Induced Brachial Plexopathy results from injury to the brachial plexis nerve from radiation therapy. New tumor growth in the area of the nerve can also cause brachial plexopathy, and as these studies show, the treatment of those two condition may differ somewhat.

 January 1981

Neurology. 1981 Jan;31(1):45-50.

Brachial plexus lesions in patients with cancer: 100 cases.

Kori SH, Foley KM, Posner JB.

Abstract

In patients with cancer, brachial plexus signs are usually caused by tumor infiltration or injury from radiation therapy (RT). We analyzed 100 cases of brachial plexopathy to determine which clinical criteria helped differentiate tumor from radiation injury. Seventy-eight patients had tumor (34 with previous RT), and 22 had radiation injury. Severe pain occurred in 80% of tumor patients but in only 19% of patients with radiation injury. The lower trunk (C7-8, T1) was involved in 72% of the tumors, and 32% also had epidural tumors. Seventy-eight percent of the radiation injuries affected the upper plexus (C5-6). Horner syndrome was more common in tumor, and lymphedema in radiation injury. The time from RT to onset of plexus symptoms, and the dose of RT, also differed. For symptoms within 1 year of RT, doses exceeding 6000 R were associated with radiation damage, whereas lower doses were associated with infiltration. Therefore, painless upper trunk lesions with lymphedema suggest radiation injury, and painful lower trunk lesions with Horner syndrome imply tumor infiltration.

PMID: 6256684 [PubMed - indexed for MEDLINE]

April 1989

Neurology. 1989 Apr;39(4):502-6.

Distinction between neoplastic and radiation-induced brachial plexopathy, with emphasis on the role of EMG.

Harper CM Jr, Thomas JE, Cascino TL, Litchy WJ.

Department of Neurology, Mayo Clinic Foundation, Rochester, MN 55905.

Abstract

The results of clinical, radiologic, and electrophysiologic studies are retrospectively reviewed for 55 patients with neoplastic and 35 patients with radiation-induced brachial plexopathy. The presence or absence of pain as the presenting symptom, temporal profile of the illness, presence of a discrete mass on CT of the plexus, and presence of myokymic discharges on EMG contributed significantly to the prediction of the underlying cause of the brachial plexopathy. The distribution of weakness and the results of nerve conduction studies were of no help in distinguishing neoplastic from radiation-induced brachial plexopathy.

PMID: 2538777 [PubMed - indexed for MEDLINE]

June 1978

Cancer. 1978 Jun;41(6):2154-7.

Carcinomatous versus radiation-induced brachial plexus neuropathy in breast cancer.

Bagley FH, Walsh JW, Cady B, Salzman FA, Oberfield RA, Pazianos AG.

Abstract

A retrospective study was performed of 18 women in whom ipsilateral brachial plexus neuropathy developed after treatment for carcinoma of the breast. In the absence of metastatic tumor elsewhere, the only distinguishing feature between carcinomatous neuropathy and radiation-induced neuropathy was the symptom-free interval after mastectomy and radiation therapy. Women with an interval of less than a year have radiation-induced neuropathy. Brachial plexus exploration in difficult diagnostic situations will permit early treatment and avoid debilitating loss of function. Brachial plexus exploration for biopsy is safe and free of complications if performed carefully. Treatment of carcinomatous neuropathy is most likely to succeed if the tumor is hormonally sensitive, but radiotherapy may also be effective. Treatment of radiation-induced neuropathy remains largely ineffective.

PMID: 207407 [PubMed - indexed for MEDLINE]

 METASTATIC BRACHIAL PLEXOPATHY

 June 2009

Int J Clin Oncol. 2009 Jun;14(3):219-24. Epub 2009 Jul 11.

Effective treatment of the brachial plexus syndrome in breast cancer patients by early detection and control of loco-regional metastases with radiation or systemic therapy.

Kamenova B, Braverman AS, Schwartz M, Sohn C, Lange C, Efiom-Ekaha D, Rotman M, Yoon H.

Department of Medicine, Downstate Medical College, State University of New York, Brooklyn, New York 11203-2098, USA.

Abstract

BACKGROUND: In breast cancer (BC) patients the brachial plexus syndrome (BPS) has been reported to be due to loco-regional metastases or radiation plexopathy. Associated arm edema is considered more suggestive of the latter. Radiation therapy is the only effective treatment for BPS reported.

METHODS: The charts of all BC patients who presented to our clinic from 1982 to 2006 with homolateral arm pain and neurological deficits, without humerus, cervical spine, or brain metastases, were reviewed.

RESULTS: There were 28 patients fulfilling these criteria for BPS. Supraclavicular, axillary or chest wall metastases developed synchronously with the BPS in 26 patients; in 21 they were recurrences, found 6-94 months (median 34 months) after primary BC treatment, while in 5 others they were progressing inoperable primary tumors and nodes. Arm edema first occurred at the same time as loco-regional metastases in 19 patients. Treatment for the BPS was administered to 22 patients; it was directed at their locoregional metastases. The BPS was initially treated with radiation (8 patients) or chemo- or endocrine therapy (14 patients); 19 (86%) had partial or complete remission of pain and neurologic deficits, with an 8-month median duration.

CONCLUSION: The BPS in BC patients is due to loco-regional metastases and is often associated with arm edema. Chemo- or endocrine therapy induced the remission of pain and deficits as frequently as radiation therapy.

PMID: 19593613 [PubMed - indexed for MEDLINE]

 August 1995

Oncology (Williston Park). 1995 Aug;9(8):756-60; discussion 765.

Diagnosis and management of brachial plexus lesions in cancer patients.

Kori SH.

Neurology Department, University of South Florida, College of Medicine, Tampa, USA.

Abstract

Brachial plexus dysfunction is a well-known complication of cancer. Metastatic brachial plexus (RBP) are the most common causes. The distinction between MBP and RBP is very important but is not easy to make. This article presents in detail the distinguishing features of these types of brachial dysfunction. In regard to treatment, radiation, chemotherapy, narcotic analgesics, paravertebral nerve blocks, dorsal rhizotomy, dorsal root entry zone procedure, and high contralateral cordotomy are helpful in managing the symptoms of MBP. Transdermal electrical nerve stimulation, dorsal column stimulators, neurolysis, and neurolysis with omentoplasty have been tried in RBP. Good physical therapy, tricyclics, antiarrhythmics, anti-convulsants, nonsteroidal anti-inflammatory drugs and steroids are helpful in both conditions.

PMID: 7577375 [PubMed - indexed for MEDLINE]

1989

Hand Clin. 1989 Feb;5(1):23-32.

Postirradiation lesions of the brachial plexus. Results of surgical treatment.

LeQuang C.

Chirurgie Plastique et Microchirurgie, Clinique du Chateau de Vincennes, France.

Abstract

In a series of 103 cases of postirradiation lesions of the brachial plexus operated on between 1978 and 1986--of which 60 patients have been reviewed with a follow up from 2 to 9 years--the surgical results are analyzed according to an anatomic classification, a clinical classification, and the surgical procedures. We conclude that the radiation plexitis should be treated surgically and at the earliest possible time after the onset of paresthesias. Also, the surgical procedure which gives the best results is neurolysis with pedicled omentoplasty.

PMID: 2722964 [PubMed - indexed for MEDLINE]

September 1983

Ital J Orthop Traumatol. 1983 Sep;9(3):357-63.

Post irradiation lesions of the brachial plexus.

Cherubino P, Berzero GF.

Abstract

The authors discuss the clinical and therapeutic problems of post irradiation lesions of the brachial plexus resulting from radiotherapy in the treatment of breast cancer. Twelve such cases were referred to our clinic in the 2 year period ending June 1980. The results after 2 years are reported and the literature on the subject is reviewed. Surgical treatment aimed at mobilising the nerve roots (neurolysis) is recommended, but we would stress that the best treatment is prophylactic. With more strict control of the radiotherapeutic technique, particularly with regard to the total dosage administered, it should never happen.

PMID: 6662713 [PubMed - indexed for MEDLINE]

 May 1983

Neurochirurgia (Stuttg). 1983 May;26(3):86-8.

A multidisciplinary approach for the treatment of metastatic brachial plexus neuropathy from breast cancer: neurosurgical, plastic, and radiotherapeutic.

Tognetti F, Poppi M, Poppi V.

Abstract

A new approach for the treatment of metastatic brachial plexus neuropathy at the axillary level is described. This may be used in patients previously submitted to radical mastectomy followed by radiotherapy for breast cancer. The method consists of external neurolysis of the cords of the plexus, dissection and excision of the pathological axillary contents along with the overlying atrophic cutaneous and subcutaneous tissues, reconstruction of the axilla by the latissimus dorsi musculocutaneous flap, and finally early radiotherapy by high-dose radiation delivered to the entire area. The advantages of the procedure are briefly discussed.

PMID: 6308487 [PubMed - indexed for MEDLINE]

  

EXPERIMENTAL TREATMENT OPTIONS

 SURGERY

 NERVE TRANSFER SURGERY FOR ELBOW FUNCTION

 June 2009

Hand (N Y). 2009 Jun;4(2):123-8. Epub 2008 Oct 9.

Nerve transfer for elbow flexion in radiation-induced brachial plexopathy: a case report.

Tung TH, Liu DZ, Mackinnon SE.

Division of Plastic & Reconstructive Surgery, Washington University School of Medicine, 660 South Euclid Avenue, Campus Box 8238, St. Louis, MO 63110, USA. tungt@wustl.edu

Abstract

Radiation-induced brachial plexopathy is an uncommon but devastating late complication seen in patients receiving radiation therapy to the chest wall and axilla. Treatment options are unfortunately limited. We report a case of a 59-year-old woman treated with radiation therapy for breast cancer 12 years earlier, who presented with loss of elbow flexion and marked shoulder weakness. Electromyogram and intraoperative stimulation of the musculocutaneous nerve branches were consistent with a proximal motor nerve conduction block. Microsurgical transfer of median and ulnar nerve fascicles to the biceps and brachialis branches of the musculocutaneous nerve, respectively, were performed. The patient recovered MRC grade 4/5 elbow flexion after surgery. The characteristics of this disorder and surgical treatment options are reviewed.

PMID: 18843522 [PubMed]

 

NEUROLYSIS (MICROSURGERY TO FREE THE NERVE FROM ADHESIONS)

Please note: Those of us who have dealt with breast cancer may be familiar with the terms "TRAM flap" and "Lat flap" as breast reconstruction procedures. As used in the following studies, however, the terms refer to a similar procedure, but for the purpose of protectively covering the nerve rather than providing tissue for breast reconstruction.

Folia Neuropathol. 2007;45(1):31-5.

Brachial plexus injuries after radiotherapy - analysis of 6 cases.

Gosk J, Rutowski R, Urban M, Wiecek R, Rabczyński J.

Department of Trauma and Hand Surgery, Medical University of Wrocław, R Traugutta 57/59, Wrocław, Poland. chiruraz@churaz.am.wroc.pl

Abstract

Radiation-induced brachial plexus neuropathy is caused by compression of the nerve fibres by dense and inelastic fibrous connective tissue. In this study our own experience in treatment of lesions of the brachial plexus after radiotherapy is presented. The clinical material consisted of 6 patients aged from 40 to 64 years with injuries of the brachial plexus after radiotherapy. The analysis of the material comprised: basic disease, duration of radiotherapy, radiated fields, total dose of radiation, onset and character of symptoms, location and severity of injury. 5 women were qualified for surgical treatment. After neurolysis of the brachial plexus a significant improvement was obtained in 2 cases. In one patient remission of pain and sensory recovery was temporary. No improvement was observed in the remaining 2 patients. Lesions of the brachial plexus after radiotherapy are rare but difficult to prevent. The treatment depends on the grade of severity of injury. Surgical neurolysis is advised for grades 3 and 4 on the LENT-SOMA scale.

PMID: 17357009 [PubMed - indexed for MEDLINE]

January 2004

Zhonghua Zheng Xing Wai Ke Za Zhi. 2004 Jan;20(1):13-5.

[The complications of radiotherapy for breast cancer and the treatment for radiation ulcer]

[Article in Chinese]

Li YY, Liang M, Wang JL, Jiao LR, Huang J.

Department of Plastic Surgery, Guangzhou Red Cross Hospital, Jinan University Medical College, Guangzhou 510220, China.

Abstract

OBJECTIVE: To explore the effective treatment for chronic ulcer following radiotherapy for breast cancer and reveal the universality and severity of radiation-induced brachial plexus neuropathy.

METHODS: The TRAM flap, the local expanded flap or the delayed skin flap were applied to repair the ulcer wounds in 16 patients. Electromyogram examinations were used to evaluate the radiation lesions of the brachial plexus.

RESULTS: All the flaps survived successfully with satisfactory results except one, which sustained partial necrosis due to infection. Ten patients underwent regular electromyogram examinations, seven of them were found to have radiation-induced brachial plexus neuropathy.

CONCLUSIONS: Radiation ulcer following radiotherapy for breast cancer is often concomitant with brachial plexus neuropathy. These injuries presented a chronically progressive and irreversible course. Application of the flaps that have adequate blood supply can reconstruct the wounds effectively.

PMID: 15131854 [PubMed - indexed for MEDLINE]

  December 2002

Chin J Traumatol. 2002 Dec;5(6):329-32.

Diagnosis and operative treatment of radiation-induced brachial plexopathy.

Lu L, Gong X, Liu Z, Wang D, Zhang Z.  Department of Hand Surgery, First Hospital Affiliated to Jilin University, Changchun 130021, China. Lulaijin@public.cc.jl.cn

Abstract

OBJECTIVE: To explore the diagnosis and operative treatment of radiation-induced brachial plexopathy.

METHODS: Nine cases of radiation-induced brachial plexopathy were divided into two groups, 4 cases undergoing neurolysis of brachial plexus as Group A and 5 cases undergoing transfer of myocutaneous flaps after neurolysis as Group B. In Group B, 4 cases were treated with latissimus dorsi myocutaneous flaps (about 20 cm x 20 cm) and 1 case with pectoralis major myocutaneous flap (about 8 cm x 6 cm).

RESULTS: All the 9 cases of radiation-induced brachial plexopathy were followed up for a period of 2 to 5 years, with an average of 2.3 years. As far as pain relief and function recovery were concerned, the results of Group B were better than those of Group A.

CONCLUSIONS: Based on the results of Group B in the series, we suggest that the procedure of covering the wounds with transferred myocutaneous flaps after neurolysis of the brachial plexus should be performed to those advanced patients. The procedure may improve the blood supply of the fibrotic brachial plexus by reestablishing a good nerve bed.

PMID: 12443571 [PubMed - indexed for MEDLINE]

July 1990

J Neurol. 1990 Jul;237(4):247-50.

Natural history of radiation-induced brachial plexopathy compared with surgically treated patients.

Killer HE, Hess K.

Department of Neurology, Kantonspital Aarau, Switzerland.

Abstract

Twelve patients who developed radiation-induced brachial plexopathy (RIBP) after receiving radiation therapy for breast carcinoma (7 patients) or Hodgkin's lymphoma (5 patients) were followed for 12 or more years, with a mean follow-up time of 20 years. Tingling and numbness of the fingers as well as weakness of the hand or arm were the most prominent presenting symptoms of RIBP. Whereas pain in most patients evolved only later in the course, it became a predominant feature in only 2. In 8 of the 12 patients, the plexopathy was surgically treated, either by neurolysis only or by neurolysis plus omental grafting in order to stop progression or paresis and/or pain. In 8 patients, including 6 of the operated group, there was slow and steady progression of RIBP over time, with the final outcome being almost complete paralysis of the arm (2 patients) or severe sensorimotor paresis rendering the hand useless (6 patients). In only 4 patients, including 2 of the non-operated group, was there absence of progression and stabilization of the paresis with only slight functional loss of the affected arm in 3 patients and severe palsy in 1. None of the 12 patients had any clear long-lasting improvement of their sensorimotor impairment. It is concluded from this study that RIBP, irrespective of surgery (neurolysis and/or omentum transplant), left two-thirds of the patients with severe or total paresis of the arm. However, the almost complete relief of severe pain (6 of 8 patients), both immediately and in follow-up patients treated with neurolysis and/or omental transplant, indicates that surgical treatment has a beneficial effect on pain relief.

PMID: 2391547 [PubMed - indexed for MEDLINE]

 1988

Chirurgie. 1988;114(5):421-31.

[Microsurgical neurolysis of post-radiotherapy brachial plexitis. Results apropos of 20 cases. Experimental justification of the treatment]

[Article in French]

Merle M, Duprez K, Delandre D, Bour C, Dap F, Duprez A.

PMID: 3066602 [PubMed - indexed for MEDLINE

DRUGS: TRENTAL (PENTOXIFYLLINE) AND VITAMIN E (TOCOPHEROL)

Note: Because combinations of the Trental and vitamin E appear to reduce the effects of certain radiation side effects (such as radiation-induced fibrosis and trismus), it was hoped that these drugs might halt or reverse the effects of RIBP as well. Sadly, the studies below do not indicate any benefit for RIBP from this regimen.

September 2009

Eur J Cancer. 2009 Sep;45(14):2488-95. Epub 2009 Jun 17.

Pentoxifylline and vitamin E treatment for prevention of radiation-induced side-effects in women with breast cancer: a phase two, double-blind, placebo-controlled randomised clinical trial (Ptx-5).

Magnusson M, Höglund P, Johansson K, Jönsson C, Killander F, Malmström P, Weddig A, Kjellén E.

Department of Clinical Pharmacology, Lund University Hospital, Lund SE 221 85, Sweden.

Abstract

BACKGROUND: A previous study has shown that pentoxifylline in combination with vitamin E can reverse radiation-induced fibrosis. The aim of the present study is to investigate if the same drugs could prevent radiation-induced side-effects in women with breast cancer.

PATIENTS AND METHODS: A randomised, placebo-controlled, double-blind, parallel group trial was performed. Women with breast cancer were treated for 12 months with 400 mg pentoxifylline t.i.d. or placebo, in combination with 100 mg vitamin E t.i.d., starting 1-3 months after the completion of radiotherapy. The primary end-point was passive abduction of the shoulder, and the secondary end-point was difference in arm volumes. The trial is registered on the ISRCTN.org website, number ISRCTN39143623.

RESULTS: 83 patients were included in the study; 42 in the pentoxifylline+vitamin E group and 41 in the placebo+vitamin E group. Both treatments were generally well tolerated. Seven patients were withdrawn from the treatment due to disease progression; four in the pentoxifylline group and three in the placebo group. At inclusion, patients had impaired passive abduction of the shoulder. During treatment, both the groups improved significantly. Median improvement from baseline was 3.7 degrees (p=0.0035) on pentoxifylline and was 9.4 degrees (p=0.0041) in the placebo group, but no difference between the groups was detected (p=0.20). Arm volumes increased over time in the placebo group (1.04%), but not on pentoxifylline (0.50%), and differed significantly between the groups (p=0.0172).

CONCLUSIONS: The combination of pentoxifylline and vitamin E was safe and may be used for the prevention of some radiation-induced side-effects.

PMID: 19540105 [PubMed - indexed for MEDLINE]

  December 2005

J Clin Oncol. 2005 Dec 1;23(34):8570-9. Epub 2005 Oct 31.

Kinetics of response to long-term treatment combining pentoxifylline and tocopherol in patients with superficial radiation-induced fibrosis.

Delanian S, Porcher R, Rudant J, Lefaix JL.

Service d'Oncologie-Radiothérapie, Hôpital Saint-Louis, 1 Ave Claude Vellefaux, 75010 Paris, France. sylvie.delanian@sls.ap-hop-paris.fr

Abstract

PURPOSE: Significant regression of radiation (RT) -induced fibrosis (RIF) has been achieved after treatment combining pentoxifylline (PTX) and alpha-tocopherol (vitE). In this study, we focus on the maximum response, how long it takes to achieve response, and changes after treatment discontinuation.

PATIENTS AND METHODS: Measurable superficial RIF was assessed in patients treated by RT for breast cancer in a long-treatment (24 to 48 months) PTX-vitE (LPE) group of 37 patients (47 RIFs) and in a short-treatment (6 to 12 months) PTX-vitE (SPE) group of seven patients (eight RIFs). Between April 1995 and April 2000, women were treated with a daily combination of PTX (800 mg) and VitE (1,000 IU).

RESULTS: Combined PTX-vitE was continuously effective and resulted in exponential RIF surface area regression (-46% for LPE and -68% for SPE at 6 months, -58% for LPE and -69% for SPE at 12 months, -63% for LPE and -62% for SPE at 18 months, and -68% for LPE at 24 and 36 months). The mean estimated maximal treatment effect was 68% RIF surface area regression. The mean time to this effect was 24 months and was shorter (16 months) in more recent RIF (< 6 years since RT) than in older RIF (28 months; P = .0003). Symptom severity (Subjective Objective Medical Management and Analytic Evaluation score) was halved in both groups. After treatment discontinuation, mean RIF surface area at 1 year had increased by +40% in the SPE group (rebound) and +8.5% in the LPE group.

CONCLUSION: Under combined PTX-vitE treatment, RIF regression was exponential, with a two-thirds maximum response after a mean of 2 years. There was a risk of a rebound effect if treatment was too short. Long treatment (>/= 3 years) is recommended in patients with severe RIF.

PMID: 16260695 [PubMed - indexed for MEDLINE]

 

November 2004

Radiother Oncol. 2004 Nov;73(2):133-9.

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, Cornes P, Earl J, Hall E, MacLaren J, Mortimer P, Peacock J, Peckitt C, Woods M, Yarnold J.

Department of Radiotherapy, Royal Marsden Hospital, Sutton, Surrey, UK.

Abstract

BACKGROUND AND PURPOSE: Treatment-induced arm lymphoedema is a common and distressing complication of curative surgery and radiotherapy for early breast cancer. A number of studies testing alpha-tocopherol (vitamin E) and pentoxifylline suggest evidence of clinical regression of superficial radiation-induced fibrosis but there is only very limited evidence from randomised trials. Arm lymphoedema after lymphatic radiotherapy and surgery has been used in the present study as a clinical system for testing these drugs in a double-blind placebo-controlled randomised phase II trial.

PATIENTS AND METHODS: Sixty-eight eligible research volunteers with a minimum 20% increase in arm volume at a median 15.5 years (range 2-41) after axillary/supraclavicular radiotherapy (plus axillary surgery in 51/68 (75%) cases) were randomised to active drugs or placebo. All volunteers were given dl-alpha tocopheryl acetate 500 mg twice a day orally plus pentoxifylline 400 mg twice a day orally, or corresponding placebos, for 6 months. The primary endpoint was volume of the ipsilateral limb measured opto-electronically using a perometer and expressed as a percentage of the contralateral limb volume.

RESULTS: At 12 months post-randomisation, there was no significant difference between treatment and control groups in terms of arm volume. Absolute change in arm volume at 12 months was 2.5% (95% CI -0.40 to 5.3) in the treatment group compared to 1.2% (95% CI -2.8 to 5.1) in the placebo group. The difference in mean volume change between randomisation groups at 12 months was not statistically significant (P = 0.6), -1.3% (95% CI -6.1 to 3.5), nor was there a significant difference in response at 6 months (P = 0.7), where mean change in arm volume from baseline in the treatment and placebo groups was -2.3% (95% CI -7.9 to 3.4) and -1.1% (95% CI -3.9 to 1.7), respectively. There were no significant differences between randomised groups in terms of secondary endpoints, including tissue induration (fibrosis) in the irradiated breast or chest wall, pectoral fold or supraclavicular fossa, change in photographic breast/chest wall appearance or patient self-assessment of function and Quality of Life at either 6 or 12 months.

CONCLUSIONS: The study fails to demonstrate efficacy of dl-alpha tocopheryl acetate plus pentoxifylline in patients with arm lymphoedema following axillary surgery and lymphatic radiotherapy, nor does it suggest any benefits of these drugs in radiation-induced induration (fibrosis) in the breast, chest wall, pectoral fold, axilla or supraclavicular fossa.

PMID: 15542159 [PubMed - indexed for MEDLINE]

 July 2003

J Clin Oncol. 2003 Jul 1;21(13):2545-50.

Randomized, placebo-controlled trial of combined pentoxifylline and tocopherol for regression of superficial radiation-induced fibrosis.

Delanian S, Porcher R, Balla-Mekias S, Lefaix JL.

Service d'Oncologie-Radiothérapie, Hôpital Saint Louis 1, Paris, France. sylvie.delanian@sls.ap-hop-paris.fr

Abstract

PURPOSE: Radiation-induced fibrosis (RIF) is a rare morbid complication of radiotherapy, without an established method of management. RIF treatment with a combination of pentoxifylline (PTX) and alpha-tocopherol (vitamin E; Vit E) was recently prompted by the good results of a clinical trial and an animal study. The present double-blind, placebo-controlled, monocentric study was designed to assess the efficacy of this combination in treating RIF sequelae.

PATIENTS AND METHODS: Twenty-four eligible women with 29 RIF areas involving the skin and underlying tissues were enrolled from December 1998 to April 2000. These patients, previously irradiated for breast cancer, were randomly assigned to four balanced treatment groups: (A) 800 mg/d of PTX and 1,000 U/d of Vit E; (B) PTX plus placebo; (C) placebo plus Vit E; and (D) placebo-placebo. The main end point measure was the relative regression of measurable RIF surface after 6 months of treatment. Assessment was completed by depth (with ultrasonography) and associated symptom measures.

RESULTS: Twenty-two patients with 27 RIF areas were analyzed at 6 months. Mean RIF surface regression was significant with combined PTX/Vit E versus double placebo (60% +/- 10% v 43% +/- 17%; P =.038). The median slope for the speed of RIF surface area and volume regression was significantly higher for group A than groups B, C, and D. All treatments were well tolerated.

CONCLUSION: Six months' treatment of combined PTX/Vit E can significantly reduce superficial RIF. Synergism between PTX and Vit E is likely, as treatment with each drug alone is ineffective, but these results require confirmation in larger series.

PMID: 12829674 [PubMed - indexed for MEDLINE]

 October 1999

J Clin Oncol. 1999 Oct;17(10):3283-90.

Striking regression of chronic radiotherapy damage in a clinical trial of combined pentoxifylline and tocopherol.

Delanian S, Balla-Mekias S, Lefaix JL.

Service d'Oncologie-Radiothérapie, Hôpital Saint-Louis, Paris, France. delanian@chu-stlouis.fr

Abstract

PURPOSE: Radiation-induced fibrosis (RIF) remains the most morbid complication of radiotherapy because of the absence of spontaneous regression and the difficulty of patient management. RIF treatment with combined pentoxifylline (PTX) and tocopherol (Vit E) was prompted by recent advances in cellular and molecular biology that have improved researchers' understanding of radiation-induced late-injury mechanisms and by the excellent results from our previous human and animal studies.

PATIENTS AND METHODS: Forty-three patients (mean [+/- SD] age, 59 +/- 10 years) presenting with 50 symptomatic RIF areas involving the skin and underlying tissues were treated from April 1995 to September 1997. Patients had had radiotherapy for head and neck or breast cancer a mean period of 8.5 +/- 6.5 years previously. RIF developed in the first year after irradiation and gradually worsened, without spontaneous regression. The mean measurable surface area of RIF ([S]) at the time of this study ([S(0)]) was 42 +/- 34 cm(2). The initial Subjective Objective Medical management and Analytic (SOMA) injury evaluation score was 13.2 +/- 5.9 and included evidence of edema, plexitis, restricted movement, and local inflammatory signs. A combination of PTX (800 mg/d) and Vit E (1,000 IU/d) was administered orally for at least 6 months.

RESULTS: Treatment was well tolerated. All assessable injuries exhibited continuous clinical regression and functional improvement. Mean RIF surface area and SOMA scores improved significantly (P <.0001) at 3 months ([S(3)], -39%; [SOMA(3)], -22%), 6 months ([S(6)], -53%; [SOMA(6)], -35%), and 12 months ([S(12)], -66%; [SOMA(12)], -48%), and mean linear dimensions ([D]) diminished from the start of the study ([D(0)], 6.5 +/- 2.5 cm) to the end of treatment 12 months later ([D(12)], 4 +/- 2 cm). At the time of the treatment, we did not attempt to achieve the maximum effect, and the study was continued.

CONCLUSION: The PTX-Vit E combination reversed human chronic radiotherapy damage and, because no other treatment is presently available for RIF, should be considered as a therapeutic measure.

PMID: 10506631 [PubMed - indexed for MEDLINE]

HYPERBARIC TREATMENT

Note: Like the Trental and Vitamin E treatment, hopes were high that hyperbaric treatment might reverse the symptoms of RIBP, because other radiation induced conditions were improved by it. Unfortunately the research does not support that hope.

October 2010

Radiother Oncol. 2010 Oct;97(1):101-7. Epub 2010 May 31.

Randomised phase II trial of hyperbaric oxygen therapy in patients with chronic arm lymphoedema after radiotherapy for cancer.

Gothard L, Haviland J, Bryson P, Laden G, Glover M, Harrison S, Woods M, Cook G, Peckitt C, Pearson A, Somaiah N, Stanton A, Mortimer P, Yarnold J.

Department of Radiotherapy, The Royal Marsden NHS Foundation Trust, Sutton, UK.

Abstract

BACKGROUND: A non-randomised phase II study suggested a therapeutic effect of hyperbaric oxygen (HBO) therapy on arm lymphoedema following adjuvant radiotherapy for early breast cancer, justifying further investigation in a randomised trial.

METHODS: Fifty-eight patients with ≥ 15% increase in arm volume after supraclavicular ± axillary radiotherapy (axillary surgery in 52/58 patients) were randomised in a 2:1 ratio to HBO (n=38) or to best standard care (n=20). The HBO group breathed 100% oxygen at 2.4 atmospheres absolute for 100 min on 30 occasions over 6 weeks. Primary endpoint was ipsilateral limb volume expressed as a percentage of contralateral limb volume. Secondary endpoints included fractional removal rate of radioisotopic tracer from the arm, extracellular water content, patient self-assessments and UK SF-36 Health Survey Questionnaire.

FINDINGS: Of 53/58 (91.4%) patients with baseline assessments, 46 had 12-month assessments (86.8%). Median volume of ipsilateral limb (relative to contralateral) at baseline was 133.5% (IQR 126.0-152.3%) in the control group, and 135.5% (IQR 126.5-146.0%) in the treatment group. Twelve months after baseline the median (IQR) volume of the ipsilateral limb was 131.2% (IQR 122.7-151.5%) in the control group and 133.5% (IQR 122.3-144.9%) in the treatment group. Results for the secondary endpoints were similar between randomised groups.

INTERPRETATION: No evidence has been found of a beneficial effect of HBO in the treatment of arm lymphoedema following primary surgery and adjuvant radiotherapy for early breast cancer.

Copyright © 2010 Elsevier Ireland Ltd. All rights reserved.

PMID: 20605648 [PubMed - in process]

December 2005

Radiother Oncol. 2005 Dec;77(3):327. Epub 2005 Oct 10.

Double-blind randomised phase II study of hyperbaric oxygen in patients with radiation-induced brachial plexopathy.

Yarnold J.

PMID: 16216362 [PubMed - indexed for MEDLINE]

March 2004

Radiother Oncol. 2004 Mar;70(3):217-24.

Non-randomised phase II trial of hyperbaric oxygen therapy in patients with chronic arm lymphoedema and tissue fibrosis after radiotherapy for early breast cancer.

Gothard L, Stanton A, MacLaren J, Lawrence D, Hall E, Mortimer P, Parkin E, Pritchard J, Risdall J, Sawyer R, Woods M, Yarnold J.

Department of Radiotherapy, Royal Marsden NHS Trust, Sutton, Surrey SM2 5PT, UK.

Abstract

BACKGROUND: Radiation-induced arm lymphoedema is a common and distressing complication of curative treatment for early breast cancer. Hyperbaric oxygen (HBO(2)) therapy promotes healing in bone rendered ischaemic by radiotherapy, and may help some soft-tissue injuries too, but is untested in arm lymphoedema.

METHODS: Twenty-one eligible research volunteers with a minimum 30% increase in arm volume in the years after axillary/supraclavicular radiotherapy (axillary surgery in 18/21 cases) were treated with HBO(2). The volunteers breathed 100% oxygen at 2.4 ATA for 100 min in a multiplace hyperbaric chamber on 30 occasions over a period of 6 weeks. The volume of the ipsilateral limb, measured opto-electronically by a perometer and expressed as a percentage of contralateral limb volume, was selected as the primary endpoint. A secondary endpoint was local lymph drainage expressed as fractional removal rate of radioisotopic tracer, measured using lymphoscintigraphy.

RESULTS: Three out of 19 evaluable patients experienced >20% reduction in arm volume at 12 months. Six out of 13 evaluable patients experienced a >25% improvement in (99)Tc-nanocolloid clearance rate from the ipsilateral forearm measured by quantitative lymphoscintigraphy at 12 months. Overall, there was a statistically significant, but clinically modest, reduction in ipsilateral arm volume at 12 months follow-up compared with baseline (P = 0.005). The mean percentage reduction in arm volume from baseline at 12 months was 7.51. Moderate or marked lessening of induration in the irradiated breast, pectoral fold and/or supraclavicular fossa was recorded clinically in 8/15 evaluable patients. Twelve out of 19 evaluable patients volunteered that their arms felt softer, and six reported improvements in shoulder mobility at 12 months. No significant improvements were noted in patient self-assessments of quality of life.

CONCLUSION: Interpretation is limited by the absence of a control group. However, measurement of limb volume by perometry is reportedly reliable, and lymphoscintigraphy is assumed to be operator-independent. Taking all data into account, there is sufficient evidence to justify a double-blind randomised controlled trial of hyperbaric oxygen in this group of patients.

PMID: 15064005 [PubMed - indexed for MEDLINE]

 Spring 2002

Undersea Hyperb Med. 2002 Spring;29(1):4-30.

A systematic review of the literature reporting the application of hyperbaric oxygen prevention and treatment of delayed radiation injuries: an evidence based approach.

Feldmeier JJ, Hampson NB.

Radiation Oncology Department, Medical College of Ohio, Toledo, Ohio, USA.

Abstract

The treatment of delayed radiation injuries (soft tissue and bony radiation necrosis) is one of thirteen conditions approved by the Hyperbaric Oxygen Therapy Committee of the Undersea and Hyperbaric Medical Society as appropriate indications for hyperbaric oxygen (HBO2). This paper provides a systematic review of the literature reporting the results of HBO2 therapy in the treatment and/or prophylaxis of delayed radiation injury. Since the introduction of the concept of evidence based medicine, the medical community in general has set out to apply more critical and stringent standards in evaluating published support for therapeutic interventions. Evidence based medicine is designed to discover the best evidence available and apply it in daily practice for treatment of the individual patient. The preferred level of evidence is the randomized controlled trial, however, other evidence has merit as well. In this review, seventy-four publications are represented reporting results of applying HBO2 in the treatment or prevention of radiation injuries. These are appraised in an evidence-based fashion by applying three established systems of evaluation. All but seven of these publications report a positive result when HBO2 is delivered as treatment for or prevention of delayed radiation injury. These results are particularly impressive in the context of alternative interventions. Without HBO2, treatment often requires radical surgical intervention, which is likely to result in complications. Other alternatives including drug therapies are rarely reported, and for the most part have not been the subject of randomized controlled trials. Based on this review, HBO2 is recommended for delayed radiation injuries for soft tissue and bony injuries of most sites. Of note, an increasing body of evidence supports HBO2 for radiation-induced necrosis of the brain. For other radiation-induced neurological injuries, additional study is required before recommendations for routine hyperbaric therapy can be made.

PMID: 12507182 [PubMed - indexed for MEDLINE]

March 2001

Radiother Oncol. 2001 Mar;58(3):279-86.

Double-blind randomized phase II study of hyperbaric oxygen in patients with radiation-induced brachial plexopathy.

Pritchard J, Anand P, Broome J, Davis C, Gothard L, Hall E, Maher J, McKinna F, Millington J, Misra VP, Pitkin A, Yarnold JR.

Radiotherapy Action Group Exposure, 24 Edgeborough Way, Bromley, Kent BR1 2UA, UK.

Abstract

BACKGROUND: Radiation-induced brachial plexopathy (RIBP) is an untreatable complication of curative radiotherapy for early breast cancer, characterized by chronic neuropathic pain and limb paralysis. Hyperbaric oxygen (HBO2) therapy is known to promote healing of tissue rendered ischaemic by radiotherapy, but is untested in RIBP.

METHODS: Thirty four eligible research volunteers suffering from RIBP were randomized to HBO2 or control group. The HBO2 group breathed 100% oxygen for 100 min in a multiplace hyperbaric chamber on 30 occasions over a period of 6 weeks. The control group accompanied the HBO2 group and breathed a gas mixture equivalent to breathing 100% oxygen at surface pressure. All volunteers and investigators, except the operators of the hyperbaric chamber and the trial statistician, were blind to treatment assignments. The warm sensory threshold, which measures the function of small sensory fibres, was selected as the primary endpoint.

FINDINGS: Pre-treatment neurophysiological tests were grossly abnormal in the affected hand compared to the unaffected hand in both HBO2 and control groups, as expected, but no statistically significant differences were noted in either group at any time up to 12 months post-treatment. However, normalization of the warm sensory threshold in two of the HBO2 group was reliably recorded. Two cases with marked chronic arm lymphoedema reported major and persistent improvements in arm volume for at least 12 months after treatment with HBO2. I

INTERPRETATION: There is no reliable evidence to support the hypothesis that HBO2 therapy slows or reverses RIBP in a substantial proportion of affected individuals, although improvements in warm sensory threshold offer some suggestion of therapeutic effect. Improvement in long-standing arm lymphoedema was not anticipated, and justifies further investigation.

PMID: 11230889 [PubMed - indexed for MEDLINE]

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MORE ABOUT RIBP

Brachial plexus neuropathy is a relatively rare complication of modern radiotherapy, although, in the past, its incidence was much higher. It has been predominantly observed in women treated with high dose per fraction or with overlapping fields. The most remarkable data on this complication come from the Umea series, in which, over 30 years after hypofractionated radiotherapy with possible field overlapping, more than 90% of women developed complete paralysis of the arm.

The damage continued to progress up to 30 years after radiotherapy. The latency period for this complication ranges from 1.5 to 10 years (7 to 14 years for complete paralysis), and is similar for motor and sensory impairment. The late presentation of damage results from slow turnover of tissues, which attempt cell division many years after injury. Lost tissue is then replaced by fibrosis, leading to formation of dense, inelastic and constricting tissue. Brachial plexopathy is strongly correlated with late fibrosis and muscle atrophy within the shoulder region. The damage may encompass the whole plexus or only its lower part.

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What are the symptoms of RIBP?

Brachial plexus neuropathy is defined as motor or sensory symptoms or physical signs, with or without accompanying pain in a nerve-root distribution in the arm. Neurological manifestations may include paresthesia (abnormal physical sensation, such as itching or tingling)  in the fingers or hands, hypoesthesia (decreased touch sensitivity) , hypoalgesia (decreased pain sensitivity), disesthesia (distorted sense of touch), paresis (partial paralysis), hyporeflexia (weakened reflexes) and muscular atrophy (wasting). The limb weakness may be selectively distal (toward the hand), global with more marked distal deficits or a complete flaccid paralysis. Most women have abnormal neurophysiology findings: absent sensory nerve action potential, axonal changes, myokymia (muscle contractions, twitching) and prolonged F-waves. Magnetic resonance imaging studies show only soft-tissue fibrosis.

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What are the causes and risk factors for RIBP?

The incidence of RIBP depends on total dose, dose per fraction (low a/b value) patient age and concomitant use of chemotherapy. Frequently, the toxicity results from unplanned overdosage originating from field overlap caused by changing the woman’s position between treatment fields or from ‘matchline’ problems.

One of the suggested pathomechanisms of radiation-induced neuropathy is nerve entrapment by radiation-induced fibrosis, chronic oedema, or both.  Another postulated cause was direct damage to neurones or glial cells and ischaemic damage resulting from microvascular injury. There are probably two phases of radiation-induced neuropathy: the first includes more direct changes in electrophysiology and histochemis­try, whereas the second involves fibrotic changes around the nerves and injury of the adjacent vessels.

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How is RIBP diagnosed?

A proportion of women with breast cancer experience some degree of post-surgery shoulder stiffness, which may further be aggravated by the use of axillary radiotherapy. Symptoms usually include reduced flexion, external rotation and abduction, and pain at movement or at rest. In some women, this leads to reduced working ability.

Shoulder stiffness is usually caused by fibrosis of the major pectoralis muscle and damage to vasculature or to the joints. Movement range may also be decreased as a result of lymphoedema or neural damage. Symptoms usually appear after a median latency of 4 years. Increased risk of radiation-related impaired shoulder mobility is related to the use of large doses per fraction (low a/b value), older age, use of concomitant systemic treatment, co-existence of subcutaneous fibrosis and degree of movement impairment at the start of radiotherapy.

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How is RIBP treated?

Radiation induced brachial plexopathy is irreversible.

To diminish the consequences of shoulder and arm problems, women should be recommended physical exercise programmes. However, some women with oedema or neurological deficits may not be able to follow these programmes.

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REFERENCES

Complications of Breast-cancer Radiotherapy
 Clinical Oncology, Volume 18, Issue 3, April 2006, Pages 229-235,E. Senkus-Konefka, J. Jassem

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SOME SUGGESTIONS FOR FURTHER STUDY

One-Handed in a Two-Handed World (Second Edition) by Tommye-K. Mayer

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