A historical literature review on the role of posterior axillary boost field in the axillary lymph node coverage and development of lymphedema following regional nodal irradiation in breast cancer
Abstract
To elucidate whether (1) a posterior axillary boost (PAB) field is an optimal method to target axillary lymph nodes (LNs); and (2) the addition of a PAB increases the incidence of lymphedema, a systematic review was undertaken. A literature search was performed in the PubMed database. A total of 16 studies were evaluated. There were no randomized studies. Seven articles have investigated dosimetric aspects of a PAB. The remaining 9 articles have determined the effect of a PAB field on the risk of lymphedema. Only 2 of 9 articles have prospectively reported the impact of a PAB on the risk of lymphedema development. There are conflicting reports on the necessity of a PAB. The PAB field provides a good coverage of level I/II axillary LNs because these nodes are usually at a greater depth. The main concern regarding a PAB is that it produces a hot spot in the anterior region of the axilla. Planning studies optimized a traditional PAB field. Prospective studies and the vast majority of retrospective studies have reported the use of a PAB field does not result in increasing the risk of lymphedema development over supraclavicular-only field. The controversies in the incidence of lymphedema suggest that field design may be more important than field arrangement. A key factor regarding the use of a PAB is the depth of axillary LNs. The PAB field should not be used unless there is an absolute indication for its application. Clinicians should weigh lymphedema risk in individual patients against the limited benefit of a PAB, in particular after axillary dissection. The testing of the inclusion of upper arm lymphatics in the regional LN irradiation target volume, and universal methodology measuring lymphedema are all areas for possible future studies.
Keywords: posterior axillary boostbreast cancer radiotherapyaxillary lymph noderegional nodal irradiation
References
- Bentel GC, Marks LB, Hardenbergh PH, et al. Variability of the depth of supraclavicular and axillary lymph nodes in patients with breast cancer: is a posterior axillary boost field necessary? Int J Radiat Oncol Biol Phys. 2000; 47(3): 755–758.
- Hernandez V, Arenas M, Müller K, et al. An optimized posterior axillary boost technique in radiation therapy to supraclavicular and axillary lymph nodes: a comparative study. Med Dosim. 2013; 38(4): 413–417.
- Wang X, Yu TK, Salehpour M, et al. Breast cancer regional radiation fields for supraclavicular and axillary lymph node treatment: is a posterior axillary boost field technique optimal? Int J Radiat Oncol Biol Phys. 2009; 74(1): 86–91.
- Sethi RA, No HS, Jozsef G, et al. Comparison of three-dimensional versus intensity-modulated radiotherapy techniques to treat breast and axillary level III and supraclavicular nodes in a prone versus supine position. Radiother Oncol. 2012; 102(1): 74–81.
- Ahmed RL, Prizment A, Lazovich D, et al. Lymphedema and quality of life in breast cancer survivors: the Iowa Women's Health Study. J Clin Oncol. 2008; 26(35): 5689–5696.
- Jäger G, Döller W, Roth R. Quality-of-life and body image impairments in patients with lymphedema. Lymphology. 2006; 39(4): 193–200.
- Rajasekar D, Datta NR, Das KJ, et al. Partial transmission block for optimization of anterior supraclavicular-posterior axillary boost in the radiation therapy of carcinoma breast. Med Dosim. 1998; 23(2): 105–108.
- Goodman RL, Grann A, Saracco P, et al. The relationship between radiation fields and regional lymph nodes in carcinoma of the breast. Int J Radiat Oncol Biol Phys. 2001; 50(1): 99–105.
- Jephcott CR, Tyldesley S, Swift CL. Regional radiotherapy to axilla and supraclavicular fossa for adjuvant breast treatment: a comparison of four techniques. Int J Radiat Oncol Biol Phys. 2004; 60(1): 103–110.
- Chua B, Ung O, Boyages J. Competing considerations in regional nodal treatment for early breast cancer. Breast J. 2002; 8(1): 15–22.
- Coen JJ, Taghian AG, Kachnic LA, et al. Risk of lymphedema after regional nodal irradiation with breast conservation therapy. Int J Radiat Oncol Biol Phys. 2003; 55(5): 1209–1215.
- Hinrichs CS, Watroba NL, Rezaishiraz H, et al. Lymphedema secondary to postmastectomy radiation: incidence and risk factors. Ann Surg Oncol. 2004; 11(6): 573–580.
- Hayes SB, Freedman GM, Li T, et al. Does axillary boost increase lymphedema compared with supraclavicular radiation alone after breast conservation? Int J Radiat Oncol Biol Phys. 2008; 72(5): 1449–1455.
- Bar Ad V, Dutta PR, Solin LJ, et al. Time-course of arm lymphedema and potential risk factors for progression of lymphedema after breast conservation treatment for early stage breast cancer. Breast J. 2012; 18(3): 219–225.
- Shah C, Wilkinson JB, Baschnagel A, et al. Factors associated with the development of breast cancer-related lymphedema after whole-breast irradiation. Int J Radiat Oncol Biol Phys. 2012; 83(4): 1095–1100.
- Warren LEG, Miller CL, Horick N, et al. The impact of radiation therapy on the risk of lymphedema after treatment for breast cancer: a prospective cohort study. Int J Radiat Oncol Biol Phys. 2014; 88(3): 565–571.
- Chandra RA, Miller CL, Skolny MN, et al. Radiation therapy risk factors for development of lymphedema in patients treated with regional lymph node irradiation for breast cancer. Int J Radiat Oncol Biol Phys. 2015; 91(4): 760–764.
- Gross JP, Sachdev S, Helenowski IB, et al. Radiation Therapy Field Design and Lymphedema Risk After Regional Nodal Irradiation for Breast Cancer. Int J Radiat Oncol Biol Phys. 2018; 102(1): 71–78.
- Pierce LJ, Oberman HA, Strawderman MH, et al. Microscopic extracapsular extension in the axilla: is this an indication for axillary radiotherapy? Int J Radiat Oncol Biol Phys. 1995; 33(2): 253–259.
- Zhao Y, Moran K, Yewondwossen M, et al. Clinical applications of 3-dimensional printing in radiation therapy. Med Dosim. 2017; 42(2): 150–155.
- Shaitelman SF, Chiang YJ, Griffin KD, et al. Radiation therapy targets and the risk of breast cancer-related lymphedema: a systematic review and network meta-analysis. Breast Cancer Res Treat. 2017; 162(2): 201–215.
- Graham P, Jagavkar R, Browne L, et al. Supraclavicular radiotherapy must be limited laterally by the coracoid to avoid significant adjuvant breast nodal radiotherapy lymphoedema risk. Australas Radiol. 2006; 50(6): 578–582.
- Veronesi U, Paganelli G, Viale G, et al. A randomized comparison of sentinel-node biopsy with routine axillary dissection in breast cancer. N Engl J Med. 2003; 349(6): 546–553.
- Lucci A, McCall LM, Beitsch PD, et al. American College of Surgeons Oncology Group. Surgical complications associated with sentinel lymph node dissection (SLND) plus axillary lymph node dissection compared with SLND alone in the American College of Surgeons Oncology Group Trial Z0011. J Clin Oncol. 2007; 25(24): 3657–3663.
- Gross JP, Lynch CM, Flores AM, et al. Determining the Organ at Risk for Lymphedema After Regional Nodal Irradiation in Breast Cancer. Int J Radiat Oncol Biol Phys. 2019; 105(3): 649–658.