Uso de antitranspirante en pacientes en tratamiento de radioterapia por cáncer de mama / Use of antiperspirant in patients undergoing radiotherapy treatment for breast cancer / Uso de antitranspirante em pacientes submetidos a tratamento radioterápico para câncer de mama

Patients who are diagnosed with breast cancer face multiple challenges and fears: from the diagnosis, the acceptance of the diagnosis and the beginning of the treatments, as well as the side effects that they entail, the most worrying for the patients being the possible anatomical alterations due to surgery, alopecia due to chemotherapy treatment, and radiodermatitis due to radiant treatment. A systematic review was carried out in MedLine/Pubmed following the PRISMA 2020 criteria on the use of antiperspirant during radiant treatment in the axilla and its relationship or not with the increase in acute adverse effects. Based on the analysis of the results of this search and with emphasis on: dosimetric aspects, psychological impact, treatment acceptance, feeling of well-being and adherence. We justify its use.

As pacientes diagnosticadas com câncer de mama enfrentam múltiplos desafios e medos: desde o diagnóstico, a aceitação do diagnóstico e o início do tratamento, bem como os efeitos colaterais que estes acarretam, o mais preocupante para as pacientes são as possíveis alterações anatômicas devidas à cirurgia, alopecia devido ao tratamento quimioterápico e a radiodermatite devido ao tratamento radiante. Foi realizada uma revisão sistemática no MedLine/Pubmed seguindo os critérios do PRISMA 2020 sobre o uso de antitranspirante durante o tratamento radiante na axila e sua relação ou não com o aumento dos efeitos adversos agudos. Com base na análise dos resultados desta busca e com ênfase em: aspectos dosimétricos, impacto psicológico, aceitação do tratamento, sensação de bem-estar e aderência. Justificamos seu uso.

Las pacientes que son diagnosticadas con cáncer de mama se enfrentan a múltiples desafíos y temores: desde el diagnóstico, la aceptación del mismo y el inicio de los tratamientos, así como los efectos secundarios que ellos conllevan, siendo los más preocupantes para las pacientes las posibles alteraciones anatómicas por cirugía, la alopecia por el tratamiento quimioterápico, y la radiodermitis por el tratamiento radiante. Se realizó una revisión sistematizada en MedLine/Pubmed, Google Académico, EMBASE, SciELO y Epistemonikos, siguiendo los criterios PRISMA 2020 del uso de antitranspirante durante el tratamiento radiante en axila y su relación o no con el aumento de efectos adversos agudos. En función del análisis de los resultados de dicha búsqueda y con énfasis en: aspectos dosimétricos, impacto psicológico, la aceptación al tratamiento, el sentimiento de bienestar y la adherencia. Justificamos su uso.

Effect of hypofractionation on the incidental axilla dose during tangential field radiotherapy in breast cancer.

OBJECTIVE: Tangential field irradiation in breast cancer potentially treats residual tumor cells in the axilla after sentinel lymph node biopsy (SLNB). In recent years, hypofractionated radiotherapy has gained importance and currently represents the recommended standard in adjuvant breast cancer treatment for many patients. So far, the impact of hypofractionation on the effect of incidental lymph node irradiation has not be addressed. MATERIALS AND METHODS: Biological effective dose (BED) and tumor control probability (TCP) were estimated for four different hypofractionated radiation schemes (42.50 Gy in 16 fractions [Fx]; 40.05 Gy in 15 Fx; 27 Gy in 5 Fx; and 26 in 5 Fx) and compared to conventional fractionation (50 Gy in 25 Fx). For calculation of BED and TCP, a previously published radiobiological model with an α/ß ratio of 4 Gy was used. The theoretical BED and TCP for incidental irradiation between 0 and 100% of the prescribed dose were evaluated. Subsequently, we assessed BED and TCP in 431 axillary lymph node metastases. RESULTS: The extent of incidental lymph node irradiation and the fractionation scheme have a direct impact on BED and TCP. The estimated mean TCP in the axillary nodes ranged from 1.5 ± 6.4% to 57.5 ± 22.9%, depending on the patient's anatomy and the fractionation scheme. Hypofractionation led to a significant reduction of mean TCP of lymph node metastases for all schedules. CONCLUSION: Our data indicate that hypofractionation might affect the effectiveness of incidental radiotherapy in the axilla. This is particularly relevant for patients with positive sentinel lymph nodes who receive SLNB only.

[Comparative analysis of the correlation between axillary treatment and upper limb lymphedema].

In the surgical treatment of breast cancer, "de-escalating" is becoming more popular, especially in the treatment of axilla. Axillary sentinel lymph node biopsy has become a routine treatment for axillary-negative breast cancer patients because it can effectively reduce the occurrence of upper limb lymphedema, so that some patients with sentinel lymph node negative can be exempted from axillary lymph node dissection. However, in recent years, several international clinical studies, such as AMAROS trial, explored the use of radiotherapy instead of dissection when 1 to 2 sentinel lymph nodes were positive. The results showed that radiotherapy can reduce the incidence of upper limb edema by nearly 50% compared with dissection. How to interpret the results of such non-inferiority studies, and how to treat the impact of axillary dissection and axillary radiotherapy on the occurrence of lymphedema? Based on the review of literature in recent 10 years, the incidence and hazard ratio of edema related to the two axillary treatments were compared. The conclusion is the hazard ratios are close to each other, around 3 for both arms. The results of clinical studies such as radiotherapy instead of axillary dissection need to be carefully interpreted. At the same time, axillary dissection is still suitable for some patients at current stage, and the corresponding prevention of upper limb lymphedema still needs attention.

Impact of modern-day axillary treatment on patient reported arm morbidity and physical functioning in breast cancer patients.

PURPOSE: To reduce arm morbidity, routine axillary lymph node dissection (ALND) is often omitted or replaced by axillary radiotherapy (AxRT) in patients with limited nodal involvement. We evaluated patient-reported arm morbidity and physical functioning in breast cancer patients undergoing modern-day axillary treatment. METHODS: All patients within the UMBRELLA cohort undergoing local radiotherapy with sentinel lymph node biopsy (SLNB), ALND and/or AxRT were selected. Patient-reported arm morbidity and physical functioning were assessed with EORTC QLQ C30/BR23 questionnaires up to eighteen months after initiation of radiotherapy. Patient-reported outcomes were compared between patients with SLNB only, ALND only, AxRT (level I-II), AxRT (level I-IV) or AxRT plus ALND by means of mixed model analysis. RESULTS: In total, 949 patients were identified; 641 (68%) SLNB only, 57 (6%) ALND only, 94 (10%) AxRT level I-II, 72 (8%) AxRT level I-IV and 85 (9%) ALND + AxRT. SLNB only resulted in the least arm morbidity scores. ALND + AxRT resulted in most arm morbidity, with clinically relevant differences at 18 months. AxRT (level I-II or level I-IV) resulted in significantly less arm symptoms in the first 3 months compared to ALND. Arm symptom scores between those receiving AxRT on levels I-II and I-IV were similar. CONCLUSION: Of all axillary management strategies, ALND plus AxRT is associated with worst patient-reported outcomes. AxRT resulted in less arm morbidity compared to ALND. Selective radiotherapy treatment of the axilla, i.e. radiotherapy of levels I-II only instead of levels I-IV, did not lead to clinically relevant reduced arm morbidity.

Different radiation techniques to deliver therapeutic dose to the axilla in patients with sentinel lymph node-positive breast cancer: Doses, techniques challenges and clinical considerations.

PURPOSE: To evaluate the coverage of different levels of axillary lymph nodes and organs at risk according to the field design of AMAROS study (levels I-II-III-IV), breast tangents with supraclavicular and infraclavicular fields (levels II-III-IV) and high tangent fields to the breast after breast-conserving surgery. MATERIALS AND METHODS: We delineated the axillary lymph nodes levels I-IV in 34 patients treated with breast-conserving surgery and sentinel lymph nodes biopsy. Field design according to AMAROS study - levels I-IV in patients without axillary dissection - as well as irradiation of levels II-IV used in N+ patients after axillary dissection, and also high tangent fields was simulated. Mean dose levels and volumes covered by 95% or 80% isodoses were evaluated. Doses to ipsilateral lung, heart and brachial plexus were compared. Paired t test was used. RESULTS: AMAROS study and levels II-IV plans delivered therapeutic dose to high axilla (levels II-IV), but the high tangent fields showed inefficacy to cover these volumes, P<0.001). In terms of organs at risk, especially, ipsilateral lung, AMAROS study plan was found to significantly increase the volume receiving at least 10Gy (I-IV:46.8%, II-IV: 39%), but also the volume receiving at least 20Gy (I-IV: 39.3%, II-IV: 31.3%), and V30Gy (I-IV: 34.2% vs II-IV: 26.1%), as well as the mean dose (I-IV: 18.6Gy, II-IV: 15.2Gy, P<0.001). CONCLUSIONS: The omission of axillary dissection and the axilla irradiation need is associated with high dose irradiation of the lungs, and with higher toxicity. The indication of axillary dissection or irradiation of low axilla could be individualized in relation with individual comorbidities and factors of risk.

Laser treatment of primary axillary hyperhidrosis: a review of the literature.

Hyperhidrosis o`ccurs when the body produces sweat beyond what is essential to maintain thermal homeostasis. The condition tends to occur in areas marked by high-eccrine density such as the axillae, palms, and soles and less commonly in the craniofacial area. The current standard of care is topical aluminum chloride hexahydrate antiperspirant (10-20%), but other treatments such as anticholinergics, clonidine, propranolol, antiadrenergics, injections with attenuated botulinum toxin, microwave technology, and surgery have been therapeutically implicated as well. Yet, many of these treatments have limited efficacy, systemic side effects, and may be linked with significant surgical morbidity, creating need for the development of new and effective therapies for controlling excessive sweating. In this literature review, we examined the use of lasers, particularly the Neodynium:Yttrium-Aluminum-Garnet (Nd:YAG) and diode lasers, in treating hyperhidrosis. Due to its demonstrated effectiveness and limited side effect profile, our review suggests that Nd:YAG laser may be a promising treatment modality for hyperhidrosis. Nevertheless, additional large, randomized controlled trials are necessary to confirm the safety and efficacy of this treatment option.

Predicting loco-regional recurrence risk in T1, T2 breast cancer with 1-3 positive axillary nodes postmastectomy: Development of a predictive nomogram.

BACKGROUND: Role of postmastectomy radiotherapy (PMRT) in early breast cancer with 1-3 positive axillary nodes is still controversial. Hence, there is a need to identify subgroup of patients who have sufficiently high risk of disease recurrence to benefit from PMRT. AIM: The aim is to evaluate clinical outcomes of patients postmastectomy having pathological T1-T2 tumors with 1-3 positive axillary lymph nodes (LNs) treated with adjuvant systemic therapy and develop a predictive nomogram. MATERIALS AND METHODS: Data collected retrospectively from eligible patients from 2005 to 2011. Kaplan-Meier survival analysis was used for all time-to-event analysis. Various known clinical and pathological risk factors were correlated with outcome using uni- and multi-variable analysis in SPSS version 21. All comparisons were two-tailed and P < 0.05 were considered statistically significant. The nomogram to predict the risk of loco-regional control (LRC) was developed using least absolute shrinkage and selection operator shrinkage model in hdnom.io software. RESULTS: 38/242 (15.7%) patients had recurrent disease at loco-regional (10 patients), distant sites (22 patients) and simultaneous loco-regional and distant sites (6 patients) at a median follow-up 59.5 (range 4-133) months. Five years estimate of LRC, distant disease-free survival (DFS), DFS, cause-specific survival and overall survival was 87.8%, 85.4%, 84.2%, 93.1%, and 91.5%, respectively. Pathological tumor size, margin status, LN ratio as continuous variables and grade and triple negative breast cancer status as categorical variables were the risk factors included in the model for building nomogram. CONCLUSION: The nomogram developed based on institutional data can be a valuable tool in guiding adjuvant PMRT depending on the risk of 5 years loco-regional recurrence.

Avoiding antiperspirants during breast radiation therapy: Myth or sound advice?

Breast cancer patients are typically advised to avoid antiperspirants for fear of increasing radiation dermatitis in the axilla. We hypothesized that antiperspirants would have minimal effect on skin dose. We found no difference in surface dose±antiperspirants using 6MV photons at gantry angles of 0°/30°/60°/90° regardless of aluminum concentration.

Radiation therapy targets and the risk of breast cancer-related lymphedema: a systematic review and network meta-analysis.

PURPOSE: New indications have been found for regional nodal irradiation (RNI) in breast cancer treatment, yet the relationship of RNI and lymphedema risk is uncertain. We sought to determine the association of RNI and lymphedema. METHODS: We searched MEDLINE, EMBASE, and Scopus for articles in English on humans published from 1995 to 2015, using search terms breast neoplasm, treatment, and morbidity. Two investigators independently selected articles and extracted information, including manuscripts reporting incidence of lymphedema by radiation targets. Meta-analyses, review papers, case-control studies, matched-pair studies, repetitive datasets, and retrospective studies were excluded. A total of 2399 abstracts were identified and 323 corresponding articles reviewed. Twenty-one studies met inclusion criteria. Data were pooled using a random effects mixed model. Network meta-analyses were performed to determine the association of radiation targets alone and radiation targets plus extent of axillary surgery on incidence of lymphedema. RESULTS: The addition of RNI to breast/CW irradiation was associated with an increased incidence of lymphedema (OR 2.85; 95% CI 1.24-6.55). In patients treated with sentinel lymph node biopsy or axillary sampling, there was no association of lymphedema with the addition of RNI to breast/CW irradiation (OR 1.58; 95% CI 0.54-4.66; pooled incidence 5.7 and 4.1%, respectively). Among patients treated with axillary lymph node dissection (ALND), treatment with RNI in addition to breast/CW radiation was associated with a significantly higher risk of lymphedema (OR 2.74; 95% CI 1.38-5.44; pooled incidence 18.2 and 9.4%, respectively). CONCLUSIONS: RNI is associated with a significantly higher risk of lymphedema than irradiation of the breast/CW, particularly after ALND.

Trends in axillary treatment for breast cancer patients undergoing sentinel lymph node biopsy as determined by a questionnaire from the Japanese Breast Cancer Society.

BACKGROUND: Sentinel lymph node biopsy (SLNB) alone has been compared with SLNB followed by axillary lymph node dissection (ALND) in sentinel lymph node (SLN)-positive breast cancer patients in randomized phase III trials: the addition of ALND did not further improve the patient's outcome. However, there is still some controversy, regarding the clinical application of SLNB alone. To identify the optimal axillary treatment in the era of SLNB, the Japanese Breast Cancer Society conducted a group study of SLNB in 2014. METHODS: A questionnaire on axillary surgery and radiation therapy was sent to 432 Japanese institutes in December 2014, and 309 (72 %) completed the questionnaire. RESULTS: SLNB was performed at 98 % of the institutes, and 77 % offered irradiation for cancer treatment. Regarding breast-conserving surgery (BCS), SLNB alone was indicated at 41 % of the institutes in the cases of SLN with micrometastases. However, in the cases of SLN with macrometastases, ALND was performed at 64 %. The proportion of ALND seemed to be higher in total mastectomy than in BCS regardless of the SLN-positive status. In the cases of SLN with micrometastases, the radiation field was localized in the conserved breast at about half of the institutes. On the other hand, in the cases of SLN with macrometastases, it was extended to axillary and/or supraclavicular lesions beyond the conserved breast at about 70 % of the institutes. CONCLUSIONS: Japanese breast physicians were conservative with respect to the omission of ALND in SLN-positive breast cancer, especially in the cases of SLN with macrometastases.

Comprehensive Evaluation of Personal, Clinical, and Radiation Dosimetric Parameters for Acute Skin Reaction during Whole Breast Radiotherapy.

Skin reaction is major problem during whole breast radiotherapy. To identify factors related to skin reactions during whole breast radiotherapy, various personal, clinical, and radiation dosimetric parameters were evaluated. From January 2012 to December 2013, a total of 125 patients who underwent breast conserving surgery and adjuvant whole breast irradiation were retrospectively reviewed. All patients had both whole breast irradiation and boost to the tumour bed. Skin reaction was measured on the first day of boost therapy based on photography of the radiation field and medical records. For each area of axilla and inferior fold, the intensity score of erythema (score 1 to 5) and extent (score 0 to 1) were summed. The relationship of various parameters to skin reaction was evaluated using chi-square and linear regression tests. The V 100 (volume receiving 100% of prescribed radiation dose, p < 0.001, both axilla and inferior fold) and age (p = 0.039 for axilla and 0.026 for inferior fold) were significant parameters in multivariate analyses. The calculated axilla dose (p = 0.003) and breast separation (p = 0.036) were also risk factors for axilla and inferior fold, respectively. Young age and large V 100 are significant factors for acute skin reaction that can be simply and cost-effectively measured.

Dosimetric evaluation of incidental irradiation to the axilla during whole breast radiotherapy for patients with left-sided early breast cancer in the IMRT era.

The purpose of this study was to compare the dosimetric parameters for incidental irradiation to the axilla during whole breast radiotherapy (WBRT) with 3-dimensional conformal radiotherapy (3D-CRT) and intensity-modulated radiotherapy (IMRT). Twenty left breast cancer patients treated with WBRT after breast-conserving surgery (BCS) were enrolled in this study. Remnant breast tissue, 3 levels of the axilla, heart, and lung were delineated. We used 2 different radiotherapy methods: 3D-CRT with field-in-field technique and 7-field fixed-beam IMRT. The target coverage of IMRT was significantly better than that of 3D-CRT (Dmean: 49.72 ±â€Š0.64 Gy vs 50.24 ±â€Š0.66 Gy, P < 0.001; V45: 93.19 ±â€Š1.40% vs 98.59 ±â€Š0.30%, P < 0.001; V47.5: 86.43 ±â€Š2.72% vs 95.00 ±â€Š0.02%, P < 0.001, for 3D-CRT and IMRT, respectively). In the IMRT plan, a lower dose was delivered to a wider region of the heart and lung. Significantly lower axillary irradiation was shown throughout each level of axilla by IMRT compared to 3D-CRT (Dmean for level I: 42.58 ±â€Š5.31 Gy vs 14.49 ±â€Š6.91 Gy, P < 0.001; Dmean for level II: 26.25 ±â€Š10.43 Gy vs 3.41 ±â€Š3.11 Gy, P < 0.001; Dmean for level III: 6.26 ±â€Š4.69 Gy vs 1.16 ±â€Š0.51 Gy, P < 0.001; Dmean for total axilla: 33.9 ±â€Š6.89 Gy vs 9.96 ±â€Š5.21 Gy, P < 0.001, for 3D-CRT and IMRT, respectively). In conclusion, the incidental dose delivered to the axilla was significantly lower for IMRT compared to 3D-CRT. Therefore, IMRT, which only includes the breast parenchyma, should be cautiously used in patients with limited positive sentinel lymph nodes and who do not undergo complete axillary lymph node dissection.

Axillary radiotherapy in conservative surgery for early-stage breast cancer (stage I and II). / Radioterapia axilar en la cirugía conservadora del cáncer de mama en estadio temprano (estadio I y II).

INTRODUCTION: Several clinical studies analyze axillary treatment in women with early-stage breast cancer because of changes in the indication for axillary lymph node dissection. The aim of the study is to analyze the impact of axillary radiotherapy in disease-free and overall survival in women with early breast cancer treated with lumpectomy. METHODS: Retrospective study in women with initial stages of breast carcinoma treated by lumpectomy. A comparative analysis of high-risk women with axillary lymph node involvement who received axillary radiotherapy with the group of women with low risk without radiotherapy was performed. Logistic regression was used to determine factors influencing survival and lymphedema onset. RESULTS: A total of 541 women were included in the study: 384 patients (71%) without axillary lymph node involvement and 157 women (29%) with 1-3 axillary lymph node involvement. Patients with axillary radiotherapy had a higher number of metastatic lymph node compared to non-irradiated (1.6±0.7 vs. 1.4±0.6, P=.02). The group of women with axillary lymph node involvement and radiotherapy showed an overall and disease-free survival at 10 years similar to that obtained in patients without irradiation (89.7% and 77.2%, respectively). 3 lymph nodes involved multiplied by more than 7 times the risk of death (HR=7.20; 95% CI: 1.36 to 38.12). The multivariate analysis showed axillary lymph node dissection as the only variable associated with the development of lymphedema. CONCLUSION: The incidence of axillary relapse on stage I and II breast cancer is rare. In these patients axillary radiotherapy does not improve overall survival, but contributes to regional control in those patients with risk factors.

Axillary radiotherapy: an alternative treatment option for adjuvant axillary management of breast cancer.

Axillary lymph node dissection is standard management of axilla in invasive breast cancer. Radiotherapy also is important in local treatment. It is controversial as to whether axillary radiotherapy can displace axillary lymph node dissection. We performed a meta-analysis comparing axillary radiotherapy with axillary dissection. No significant difference was observed for disease free survival and overall survival between the radiation group and the dissection group. There was also no significant difference in either the axillary recurrence or the local recurrence between the two groups. But the axillary relapse rate in the radiation group was higher than in the surgery group at five-year follow-up while the local recurrence rate in the surgery group was higher than in the radiation group. A subgroup analysis showed that the difference in the axillary recurrence rate (RR = 0.20, P = 0.01) and local recurrence rate (RR = 4.7, P = 0.01) mainly appeared in the clinical node-positive subgroup. The edema rate in the surgery group was higher than in the radiation group (RR = 2.08, 95%: 1.71-2.54, P < 0.0001). We concluded that radiotherapy may be an alternative treatment option for adjuvant management of the axilla in selected sub-groups of patients.

Population based study on sentinel node biopsy before or after neoadjuvant chemotherapy in clinically node negative breast cancer patients: Identification rate and influence on axillary treatment.

The timing of the sentinel lymph node biopsy (SNB) is controversial in clinically node negative patients receiving neoadjuvant chemotherapy (NAC). We studied variation in the timing of axillary staging in breast cancer patients who received NAC and the subsequent axillary treatment in The Netherlands. Patients diagnosed with clinically node negative primary breast cancer between 1st January 2010 and 30th June 2013 who received NAC and SNB were selected from the Netherlands Cancer Registry. Data on patient and tumour characteristics, axillary staging and treatment were analysed. Two groups were defined: (1) patients with SNB before NAC (N=980) and (2) patients with SNB after NAC (N=203). Eighty-three percent of patients underwent SNB before NAC, with large regional variation (35-99%). The SN identification rate differed for SNBs conducted before and after NAC (98% versus 95%; p=0.032). A lower proportion of patients had a negative SNB when assessed before NAC compared to after (54% versus 67%; p=0.001). The proportion of patients receiving any axillary treatment was higher for those with SNB before NAC than after (45% versus 33%; p=0.006). In conclusion, variation exists in the timing of SNB in clinical practice in The Netherlands for clinically node negative breast cancer patients receiving NAC. The post-NAC SN procedure is, despite some lower SN identification rate, associated with a significantly less frequent axillary treatment and thus with less expected morbidity. The effect on recurrence rate is not yet clear. Patients in this registry will be followed prospectively for long-term outcome.

Consistency of breast and arm symptoms during the first two years after breast cancer surgery.

PURPOSE/OBJECTIVES: To examine the severity and development of breast and arm symptoms separately during the two years following breast cancer surgery, and to examine whether previously defined predictors of arm symptoms are associated with breast symptoms. DESIGN: Prospective cohort study with two-year follow-up. SETTING: Three institutions in the Stockholm, Sweden, region. SAMPLE: 645 women, aged 20-63 years, enrolled within 12 weeks of surgery for primary breast cancer. METHODS: Baseline register and questionnaire data with five follow-ups were submitted to descriptive, inferential, and logistic regression analysis. MAIN RESEARCH VARIABLES: Severity of breast and arm symptoms measured by the European Organisation for Research and Treatment of Cancer breast cancer-specific quality-of-life questionnaire. FINDINGS: Most participants had undergone breast-conserving surgery and sentinel lymph node dissection, and were scheduled for postoperative radiation therapy. Overall mean levels of breast and arm symptoms were low, but with large individual variations. At all six time points, the mean levels of breast symptoms were significantly higher than those of arm symptoms. Overall, the mean level of both types of symptoms decreased during follow-up. A body mass index (BMI) of 25 or greater and breast symptoms at eight months were associated with having breast symptoms at two years. Arm symptoms at baseline and at eight months, and radiation therapy and a BMI of 25 or greater were associated with having arm symptoms at two years. CONCLUSIONS: Breast symptoms show different patterns of change and are not associated with the same factors as arm symptoms. IMPLICATIONS FOR NURSING: For nurses monitoring women treated for breast cancer, the results of this study provide knowledge regarding the importance of early symptom identification and long-term symptoms after treatment.

Stick Together: A Nordic Walking Group Intervention for Breast Cancer Survivors.

Axillary lymph node dissection and axillary radiation as part of breast cancer treatment often result in arm and shoulder morbidity and limitations in daily functioning. Over and above the general benefits for cardiorespiratory fitness, Nordic Walking particularly targets at the muscles of the upper extremities and shoulder. This may increase shoulder range of motion and lead to a reduction in functional limitations. The aim of this study was to offer a Nordic Walking intervention to women after treatment for breast cancer and to investigate changes in subjective well-being and shoulder function. Three supervised Nordic Walking courses were organized (2009-2011). The intervention consisted of ten weekly 1-hour sessions focusing on upper body strength and condition. In total, 28 women participated in one of the cohorts. Results showed that after 10 weeks, patients' vitality had improved, whereas perceived shoulder symptom severity and limitations in daily activities had decreased. Goniometric data indicated that range of motion (forward flexion, abduction, and external rotation) of the affected shoulder improved significantly within 10 weeks of training. Group interviews at 6 months follow-up confirmed that patients had appreciated the physical and psychosocial benefits of the intervention. These benefits outweighed the practical disadvantages. Patient selection, assessment and training should take place under (para-)medical supervision and group instructors should have the knowledge and skills to work with a group of recent cancer survivors. Results from this explorative study suggest that Nordic Walking is a feasible and potentially valuable tool in the rehabilitation of patients with breast cancer.

Evaluation of axillary dose coverage following whole breast radiotherapy: variation with the breast volume and shape.

OBJECTIVE: To evaluate the axillary dose coverage in patients treated with tridimensional whole breast radiotherapy (3D-WBRT), according to the breast volume and shape in treatment position. BACKGROUND: Several studies have demonstrated an insufficient dose contribution to the axillary levels, using 3D-WBRT, remaining unclear whether the breast volume and shape can influence it. MATERIALS AND METHODS: We retrospectively delineated the axillary levels on planning CT-images of 100 patients, treated with 3D-WBRT along 2012 in our institution. To estimate the shape we established an anatomic CT-based interval, defined as the Thoracic Extent (TE). The breast volume matched its CTV. Mean dose levels and V95 (volume receiving at least 95% of the prescribed dose) were evaluated. RESULTS: Mean axillary level I (A1), II (A2) and III (A3) volume was 56.1 cc, 16.5 cc and 18.9 cc, respectively, and mean doses were 43.9 Gy, 38.6 Gy and 19.5 Gy. For breast volumes of <800 cc, 800-999 cc, 1000-1199 cc and >1200 cc, mean A1 V95 was 38%, 51%, 61.2% and 57.2% whereas median A2 V95 was 8.3%, 13.4%, 19.4% and 28% respectively. Regarding shape, where the breast relative position to the TE was categorized in intervals between 31% and 40%, 41% and 50%, 51% and 60%, and 61% and 70%, mean A1 V95 was 38.7%, 43.1%, 51.1% and 77.3% whereas mean A2 V95 was 6.1%, 11.2%, 17.1% and 37% respectively. CONCLUSIONS: We observed inadequate dose coverage to all axillary levels, even after applying a sub-analysis accounting for different breast volumes and shapes. Although higher doses were associated with the more voluminous and pendulous breasts, axillary coverage with 3D-WBRT seems to be inefficient, regardless of the breast morphology.