Arm and shoulder morbidity following surgery and radiotherapy for breast cancer

Figures & data

Table I. Patient demographics and treatment-related characteristics for 183 included breast cancer patients.

Characteristics	N = 183
Age median (range) ≤ 50 years N (%) > 50 years N (%)	55 (30–75) 52 (28%) 131 (72%)
Follow-up time (months) Median (range)	42 (29–58)
Stage/treatment N (%)
Stage II Stage III Mastectomy Lumpectomy Radiotherapy dose (Gy) 50 Gy 50 + 10 Gy 50 + 16 Gy Received chemotherapy^1 Received tamoxifen	115 (62) 68 (37) 127 (69) 56 (31) 155 (85) 23 (12) 5 (3) 143 (78) 151 (82)

¹FEC (66%) = 5fluoro-uracil, epirubicin, cyclophosfamide and taxanes (11%).

Figure 1. A. Schematic display of the four-field arrangement used in CT-RT. The red field borders depict the anterior-posterior field (1), the pink color indicated the oblique filed (2), and the blue color illustrates the location of the tangential fields (3 and 4). B. Delineated shoulder joint on the planning CT-images.

Table II. Arm/shoulder morbidity with different endpoints and morbidity degrees. The number of patients with a specific degree of morbidity for an endpoint is shown.

Symptom, grade	Number of patients
Arm stiffness
1	100 (55%)
2	58 (32%)
3	18 (10%)
4	5 (3%)
5	2 (1%)
Arm pain
1	73 (40%)
2	69 (38%)
3	29 (16%)
4	10 (5%)
5	2 (1%)
Swollen arm
1	87 (48%)
2	61 (33%)
3	23 (13%)
4	7 (4%)
5	5 (3%)
Use of arm
1	53 (29%)
2	49 (27%)
3	46 (25%)
4	18 (10%)
5	17 (9%)
Numbness
1	68 (37%)
2	82 (45%)
3	26 (14%)
4	6 (3%)
5	1 (1%)
Shoulder flexion difference
< 25°	162 (89%)
≥ 25°	21 (11%)
Shoulder abduction difference
< 25°	143 (78%)
≥ 25°	40 (22%)
Fibrosis
0	100 (55%)
1	66 (36%)
2	5 (3%)
3	1 (1%)
4	11 (6%)
Lymphedema
No	155 (85%)
Yes	28 (15%)

Figure 2. Correlation between dose and the shoulder volume (%) receiving 15 Gy or more (V15) with Use of arm as endpoint assessed by KAPS scores between 1 and 5 (1 = no symptom and 5 = severe symptom). Median values are indicated as horizontal bars.

Table III. Spearman's correlation between clinical endpoints and arm/shoulder dose. Statistically significant correlations are indicated with a cross.

	Stiffness	Pain	Swelling	Use	Numbness	Flexion	Abduction	Fibrosis	BCRL	Mean dose	Max.dose	V15*
Stiffness	1.0
Pain	0.52^†	1.0
Swelling	0.33^†	0.46^†	1.0
Use	0.57^†	0.61^†	0.38^†	1.0
Numbness	0.37^†	0.44^†	0.22^†	0.36^†	1.0
Flexion	0.34^†	0.26^†	0.15^†	0.34^†	0.21^†	1.0
Abduction	0.38^†	0.31^†	0.21^†	0.43^†	0.22^†	0.66^†	1.0
Fibrosis	0.33^†	0.29^†	0.08	0.27^†	0.23^†	0.2^†	0.22^†	1.0
BCRL	0.13	0.13	0.46^†	0.14	− 0.12	0.17^†	0.2^†	0.05	1.0
Mean dose	0.10	0.08	0.09	0.15^†	0.1	− 0.01	− 0.02	0.04	− 0.09	1.0
Max. dose	0.03	0.08	0.05	0.03	0.06	0.01	− 0.02	0.05	− 0.11	0.79^†	1.0
V15	0.20^†	0.16^†	0.15^†	0.22^†	0.13	0.09	0.04	0.08	− 0.03	0.92^†	0.66^†	1.0

^†Significant (p < 0.05); BCRL, breast cancer-related lymphedema; * V₁₅, Arm/shoulder volume (%) receiving 15 Gy or more.

Figure 3. Spearman's correlation between clinical endpoints and the shoulder volume receiving more than the specified dose, with 95% confidence interval indicated by vertical error bars. Only endpoints showing any significant correlations with dose are depicted. (*: significant correlation).