Nele Adriaenssens

Ultrasound elastography as an objective diagnostic measurement tool for lymphoedema of the treated breast in breast cancer patients following breast conserving surgery and radiotherapy

Background. Lymphoedema of the operated and irradiated breast is a common complication following early breast cancer treatment. There is no consensus on objective diagnostic criteria and standard measurement tools. This study investigates the use of ultrasound elastography as an objective quantitative measurement tool for the diagnosis of parenchymal breast oedema. Patients and methods. The elasticity ratio of the subcutis, measured with ultrasound elastography, was compared with high-frequency ultrasound parameters and subjective symptoms in twenty patients, bilaterally, prior to and following breast conserving surgery and breast irradiation. Results. Elasticity ratio of the subcutis of the operated breast following radiation therapy increased in 88.9% of patients, was significantly higher than prior to surgery, unlike the non operated breast and significantly higher than the non operated breast, unlike preoperative results. These results were significantly correlated with visibility of the echogenic line, measured with high-frequency ultrasound. Big preoperative bra cup size was a significant risk factor for the development of breast oedema. Conclusions. Ultrasound elastography is an objective quantitative measurement tool for the diagnosis of parenchymal breast oedema, in combination with other objective diagnostic criteria. Further research with longer follow-up and more patients is necessary to confirm our findings.

Pain following cancer treatment: Guidelines for the clinical classification of predominant neuropathic, nociceptive and central sensitization pain.

Abstract Background: In addition to fatigue, pain is the most frequent persistent symptom in cancer survivors. Clear guidelines for both the diagnosis and treatment of pain in cancer survivors are lacking. Classification of pain is important as it may facilitate more specific targeting of treatment. In this paper we present an overview of nociceptive, neuropathic and central sensitization pain following cancer treatment, as well as the rationale, criteria and process for stratifying pain classification. Material and methods: Recently, a clinical method for classifying any pain as either predominant central sensitization pain, neuropathic or nociceptive pain was developed, based on a large body of research evidence and international expert opinion. We, a team of 15 authors from 13 different centers, four countries and two continents have applied this classification algorithm to the cancer survivor population. Results: The classification of pain following cancer treatment entails two steps: (1) examining the presence of neuropathic pain; and (2) using an algorithm for differentiating predominant nociceptive and central sensitization pain. Step 1 builds on the established criteria for neuropathic pain diagnosis, while Step 2 applies a recently developed clinical method for classifying any pain as either predominant central sensitization pain, neuropathic or nociceptive pain to the cancer survivor population. Conclusion: The classification criteria allow identifying central sensitization pain following cancer treatment. The recognition of central sensitization pain in practice is an important development in the integration of pain neuroscience into the clinic, and one that is relevant for people undergoing and following cancer treatment.

Scapula alata in early breast cancer patients enrolled in a randomized clinical trial of post-surgery short-course image-guided radiotherapy

BackgroundScapula alata (SA) is a known complication of breast surgery associated with palsy of the serratus anterior, but it is seldom mentioned. We evaluated the risk factors associated with SA and the relationship of SA with ipsilateral shoulder/arm morbidity in a series of patients enrolled in a trial of post-surgery radiotherapy (RT).MethodsThe trial randomized women with completely resected stage I-II breast cancer to short-course image-guided RT, versus conventional RT. SA, arm volume and shoulder-arm mobility were measured prior to RT and at one to three months post-RT. Shoulder/arm morbidities were computed as a post-RT percentage change relative to pre-RT measurements.ResultsOf 119 evaluable patients, 13 (= 10.9%) had pre-RT SA. Age younger than 50 years old, a body mass index less than 25 kg/m2, and axillary lymph node dissection were significant risk factors, with odds ratios of 4.8 (P = 0.009), 6.1 (P = 0.016), and 6.1 (P = 0.005), respectively. Randomization group was not significant. At one to three months’ post-RT, mean arm volume increased by 4.1% (P = 0.036) and abduction decreased by 8.6% (P = 0.046) among SA patients, but not among non-SA patients. SA resolved in eight, persisted in five, and appeared in one patient.ConclusionThe relationship of SA with lower body mass index suggests that SA might have been underestimated in overweight patients. Despite apparent resolution of SA in most patients, pre-RT SA portended an increased risk of shoulder/arm morbidity. We argue that SA warrants further investigation. Incidentally, the observation of SA occurring after RT in one patient represents the second case of post-RT SA reported in the literature.

Early Contralateral Shoulder-Arm Morbidity in Breast Cancer Patients Enrolled in a Randomized Trial of Post-Surgery Radiation Therapy:

Introduction Shoulder/arm morbidity is a common complication of breast cancer surgery and radiotherapy (RT), but little is known about acute contralateral morbidity. Methods Patients were 118 women enrolled in a RT trial. Arm volume and shoulder mobility were assessed before and 1–3 months after RT. Correlations and linear regression were used to analyze changes affecting ipsilateral and contralateral arms, and changes affecting relative interlimb differences (RID). Results Changes affecting one limb correlated with changes affecting the other limb. Arm volume between the two limbs correlated (R = 0.57). Risk factors were weight increase and axillary dissection. Contralateral and ipsilateral loss of abduction strongly correlated (R = 0.78). Changes of combined RID exceeding 10% affected the ipsilateral limb in 25% of patients, and the contralateral limb in 18%. Aromatase inhibitor therapy was significantly associated with contralateral loss of abduction. Conclusions High incidence of early contralateral arm morbidity warrants further investigations.

Treatment of pain following cancer: applying neuro-immunology in rehabilitation practice

Abstract Aim: Pain is the second most frequent persistent symptom following cancer treatment. This article aims at explaining how the implementation of contemporary pain neuroscience can benefit rehabilitation for adults following cancer treatment within an evidence-based perspective. Materials and methods: Narrative review. Results: First, pain education is an effective but underused strategy for treating cancer related pain. Second, our neuro-immunological understanding of how stress can influence pain highlights the importance of integrating stress management into the rehabilitation approach for patients having cancer-related pain. The latter is supported by studies that have examined the effectiveness of various stress management programmes in this population. Third, poor sleep is common and linked to pain in patients following cancer treatment. Sleep deprivation results in a low-grade inflammatory response and consequent increased sensitivity to pain. Cognitive behavioural therapy for sleep difficulties, stress management and exercise therapy improves sleep in patients following cancer treatment. Finally, exercise therapy is effective for decreasing pain in patients following cancer treatment, and may even decrease pain-related side effects of hormone treatments commonly used in cancer survivors. Conclusions: Neuro-immunology has increased our understanding of pain and can benefit conservative pain treatment for adults following cancer treatment. Implications for Rehabilitation Pain education is effective for improving cancer pain; implementation of contemporary pain neuroscience into the educational programme seems warranted. Various types of stress management are effective for treating patients following cancer treatment. Poor sleep is common in patients following cancer treatment, and rehabilitation specialists can address this by providing exercise therapy, sleep hygiene, and/or cognitive behavioural therapy. Exercise therapy is effective for decreasing pain in patients following cancer treatment, including the treatment of pain as a common side effect of hormone treatments for breast cancer survivors.

The influence of multidisciplinary rehabilitation on physical well-being and quality of life of breast cancer survivors.

143 Background: Breast cancer treatment has adverse effects. The aim of this study was to examine the effects of a multidisciplinary oncologic rehabilitation program on health related quality of life (HRQoL), cancer related fatigue (CRF), muscle strength, physical fitness and anthropometrics in breast cancer survivors. METHODS This quasi-experimental study included 30 early breast cancer patients in the first year following treatment. Patients completed a 12-week exercise program for 4 hours a week combined with lifestyle guidance for 2 hours a week. The supervised training sessions consisted of aerobic exercises combined with muscular strengthening exercises. Measurements were carried out at baseline (T0), at the end of the intervention (T1) and at 12-weeks follow-up (T2). HRQoL (EORTC QLQ-C30 questionnaire) and CRF (FACIT-Fatigue questionnaire), were measured at T0, T1 and T2. Muscle strength (handgrip dynamometer) was measured at T0 and T1. Physical fitness and anthropometrics were assessed at T0 and T1 using spiro ergometrics, bioimpedance and waist- and hip circumference. RESULTS Significant positive changes in HRQoL were found, especially for physical functioning (p = 0.004) and dyspnea (p = 0,003) at T1, but HRQoL decreased at T2. Weight, BMI, waist - and hip circumference and fat free mass decreased significantly (respectively p = 0,030; p = 0,047; p = 0,020; p = 0,041 and p = 0,003). Body impedance increased significantly over time (p = 0,034). There was a significant improvement in CRF at T1 (p = 0.03), that was no longer significant at T2. No significant improvements were found in muscle strength at the affected side (p = 0.16) and the non-affected side (p = 0.95). Physical fitness increased significantly for VO2max at the maximal progressive cycle test (p = 0.005). CONCLUSIONS This study reports significant improvements in HRQoL, anthropometric characteristics, CRF and physical fitness after a 12-week rehabilitation program. The declines between T1 and T2 may be explained by discontinuation of physical activity. Further research should use randomized clinical trials to examine the effectiveness of rehabilitation programs with different contents, duration and initiation.

Hypofractionated radiation therapy for early breast cancer and regional nodal irradiation—the jury is still out

A recent study on the shoulder-arm morbidity of the breast cancer UK START trials in axillary node positive women argues that hypofractionated lymph node radiation therapy is safe, as the long-term complications rates such as arm edema and shoulder stiffness remained low at 10-year follow-up (1). Can the authors’ conclusions apply to all patients with breast cancer who require lymph nodes irradiation after lumpectomy or mastectomy? Is hypofractionation really safe?

Chronic pain in breast cancer survivors: nociceptive, neuropathic or central sensitization pain?

The differentiation between acute and chronic pain can be insufficient for appropriate pain management. The aim of this study was to evaluate the prevalence of the predominant pain type (nociceptive, neuropathic, or central sensitization [CS] pain) in breast cancer survivors (BCS) with chronic pain. The secondary aims were to examine (1) differences in health‐related quality of life (HRQoL) between the different pain groups; and (2) the associations between patient‐, disease‐, and treatment‐related factors and the different pain types.

Health-related quality of life in breast cancer patients prior to and 3 years following adjuvant radiotherapy: Comparison between conventional and short-course, image-guided radiotherapy.

247 Background: Breast cancer is nowadays the most common cause of cancer death in the female population. A very commonly used treatment is radiotherapy (RT). Due to improvements of medical imaging and RT, a combination can be used resulting in image guided radiotherapy (TT). The aim of the present study is to investigate the difference in health related quality of life (HRQoL) of breast cancer patients before and 3 years after post-operative conventional radiotherapy (CRT) and TT. METHODS 120 participating patients were randomly allocated to either CRT or TT. The CRT group received 50Gy/25 fractions over a 5 week period (2Gy/fraction) and an additional boost of 16Gy in 8 fractions over 2 weeks. The TT group received 42 Gy in 15 fractions over 3 weeks (2.8 Gy/fraction) and simultaneously an integrated boost of 0,6Gy/fraction. HRQoL was evaluated using the European Organisation for Research and Treatment of Cancer (EORTC) QLQ-C30 and -BR23 (breast cancer module). Questionnaires were filled in before treatment (T0), right after finishing RT (T1) and at 3 months (T2), 1 year (T3), 2 years (T4) and 3 years (T5) follow up. RESULTS At T1 no statistically significant differences between the two treatment arms were found except global health status for which TT group scored worse than CRT. At T5, less severe constipation, diarrhoea, breast symptoms, upset by hair loss and more severe insomnia was found in TT compared to CRT, but the differences did not reach significance. Functional scales were comparable in treatment arms. CONCLUSIONS Between the two treatment arms, no statistically significant differences were found at T5 but clinically meaningful differences in symptom scales favoured TT. Our study confirms the preliminary results of Versmessen et al. (BMC Cancer, 2012) in particular that a shorter more intensive fractionation schedule, using TT did not impair HRQoL in breast cancer patients. CLINICAL TRIAL INFORMATION NCT00459628.

The effect of material modeling on finite element analysis of human breast biomechanics

Purpose Finite element analysis has been used extensively in the study of biomechanical modeling of the breast. However, issues regarding the complexity of material models and the influences of geometric boundary conditions on the accuracy of a breast Finite Element (FE) model are still under debate. This work demonstrates the importance of material modeling in FE models of the breast. Methods A simple hemispherical geometry is used to model the shape of a human breast. Different material models are being investigated to accurately model changes in terms of displacement, stress, and reaction forces distribution. Results The results obtained using nonlinear material models are compared with those obtained employing their linear approximation. Results have shown that differences, in terms of displacement, ranging between 20% and more than 80%, may occur and that large differences are present in terms of maximum principal stresses when the displacement is correctly approximated. Conclusions This study clearly shows that, in a FE model, simulating large deformations material modeling strongly influences the accuracy of the solution.