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

World Journal of Surgical Oncology

Vincent Vinh-Hung³  Stephanie Pauwels²  Jan Lamote¹  Guy Storme⁴  Harijati Versmessen⁴  Mia Voordeckers⁴  Geertje Miedema⁴  Marian Vanhoeij¹  Hilde Van Parijs⁴  Pierre Lievens²  Mark De Ridder⁴  Nele Adriaenssens² 

[1] Breast Clinic, Oncologic Surgery, Universitair Ziekenhuis Brussel, Laarbeeklaan 101, 1090, Brussels, Belgium;Physical Therapy Department, Vrije Universiteit Brussel, Laarbeeklaan 103, 1090, Brussels, Belgium;Radiation Oncology, Geneva University Hospitals, Rue Gabrielle-Perret-Gentil 4, 1211, Geneva 14, Switzerland;Department of Radiotherapy, Oncology Centre, Universitair Ziekenhuis Brussel, Laarbeeklaan 101, 1090, Brussels, Belgium

关键词: Lymphedema;    Shoulder/arm morbidity;    Multiple outcomes;    Long thoracic nerve;    Scapular winging;    Winged scapula;    Complications;    Radiation treatment;    Surgery;    Breast cancer;   

Others  :  827768
DOI  :  10.1186/1477-7819-10-86

 received in 2011-12-15, accepted in 2012-05-16,  发布年份 2012

【 摘 要 】

Background

Scapula 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).

Methods

The 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.

Results

Of 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.

Conclusion

The 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.

【 授权许可】

   
2012 Adriaenssens et al.; licensee BioMed Central Ltd.

【 图 表 】

Figure 1.

Figure 2.

Figure 3.

Figure 4.

【 参考文献 】

• [1]Vanderstraeten J: Scapula alata. Rev Med Gen 2010, 269:32-33.
• [2]Martin RM, Fish DE: Scapular winging: anatomical review, diagnosis, and treatments. Curr Rev Musculoskelet Med 2008, 1:1-11.
• [3]Kauppila LI, Vastamaki M: Iatrogenic serratus anterior paralysis. Long-term outcome in 26 patients. Chest 1996, 109:31-34.
• [4]Paim CR, de Paula Lima ED, Fu MR, de Paula LA, Cassali GD: Post lymphadenectomy complications and quality of life among breast cancer patients in Brazil. Cancer Nurs 2008, 31:302-309.
• [5]Velpeau AALM: Traite d’anatomie chirurgicale ou anatomie des regions, consideree dans ses rapports avec la chirurgie. Paris, France: Crevot; 1825.
• [6]Lotze MT, Duncan MA, Gerber LH, Woltering EA, Rosenberg SA: Early versus delayed shoulder motion following axillary dissection: a randomized prospective study. Ann Surg 1981, 193:288-295.
• [7]Roses DF, Brooks AD, Harris MN, Shapiro RL, Mitnick J: Complications of level I and II axillary dissection in the treatment of carcinoma of the breast. Ann Surg 1999, 230:194-201.
• [8]Saied GM, Kamel RM, Dessouki NR: The effect of mastectomy and radiotherapy for breast carcinoma on soft tissues of the shoulder and its joint mobility among Egyptian patients. Tanzan Health Res Bull 2007, 9:121-125.
• [9]de Oliveira JF, Bezerra T, Ribeiro ACP, Dias RA, Abrahao F, Silva JG, Bergmann A: Incidence and risk factors of winged scapula after axillary lymph node dissection in breast cancer surgery. Appl Cancer Res 2009, 29:69-73.
• [10]de Sousa Mastrella A, Freitas-Junior R, Paulinelli RR, Soares LR: Escápula alada pós-linfadenectomia no tratamento do câncer de mama. Rev Bras Cancerologia 2009, 55:397-404.
• [11]Efron B: Forcing a sequential experiment to be balanced. Biometrika 1971, 58:403-417.
• [12]Karges JR, Mark BE, Stikeleather SJ, Worrell TW: Concurrent validity of upper-extremity volume estimates: comparison of calculated volume derived from girth measurements and water displacement volume. Phys Ther 2003, 83:134-145.
• [13]Nijs J, Roussel N, Vermeulen K, Souvereyns G: Scapular positioning in patients with shoulder pain: a study examining the reliability and clinical importance of 3 clinical tests. Arch Phys Med Rehabil 2005, 86:1349-1355.
• [14]Kibler WB: Role of the scapula in the overhead throwing motion. Contemp Orthop 1991, 22:525-532.
• [15]Kibler WB: The role of the scapula in athletic shoulder function. Am J Sports Med 1998, 26:325-337.
• [16]Mottram SL: Dynamic stability of the scapula. Man Ther 1997, 2:123-131.
• [17]de Groot JH: The scapulo-humeral rhythm: effects of 2-D roentgen projection. Clin Biomech (Bristol, Avon) 1999, 14:63-68.
• [18]National Cancer Institute: Common Terminology Criteria for Adverse Events (CTCAE). Version 4.0. NIH Publication No. 09-5410. 2010. Revised June 2010
• [19]Adriaenssens N, Vinh-Hung V, Miedema G, Versmessen H, Lamote J, Vanhoeij M, Lievens P, Van Parijs H, Storme G, Voordeckers M: Early contralateral shoulder-arm morbidity in breast cancer patients enrolled in a randomized trial of post-surgery radiation therapy. Breast Cancer 2012. in press
• [20]Riddle DL, Rothstein JM, Lamb RL: Goniometric reliability in a clinical setting. Shoulder measurements. Phys Ther 1987, 67:668-673.
• [21]Barnes CJ, Van Steyn SJ, Fischer RA: The effects of age, sex, and shoulder dominance on range of motion of the shoulder. J Shoulder Elbow Surg 2001, 10:242-246.
• [22]Conte AL, Marques AP, Casarotto RA, Amado-Joao SM: Handedness influences passive shoulder range of motion in nonathlete adult women. J Manipulative Physiol Ther 2009, 32:149-153.
• [23]Roy JS, MacDermid JC, Boyd KU, Faber KJ, Drosdowech D, Athwal GS: Rotational strength, range of motion, and function in people with unaffected shoulders from various stages of life. Sports Med Arthrosc Rehabil Ther Technol 2009, 1:4. BioMed Central Full Text
• [24]Mullaney MJ, McHugh MP, Johnson CP, Tyler TF: Reliability of shoulder range of motion comparing a goniometer to a digital level. Physiother Theory Pract 2010, 26:327-333.
• [25]Van Hoof T, Vangestel C, Shacklock M, Kerckaert I, D’Herde K: Asymmetry of the ULNT1 elbow extension range-of-motion in a healthy population: Consequences for clinical practice and research. Phys Ther Sport 2012. in press
• [26]Agresti A: Categorical data analysis. 2nd edition. Hoboken NJ: Wiley; 2002.
• [27]Armitage P, Berry G, Matthews JNS: Statistical Methods in Medical Research. Malden, MA: Blackwell Science; 2002. Reprinted 2007. ISBN Fourth
• [28]Brown MB: A method for combining non-independent, one-sided tests of significance. Biometrics 1975, 31:987-992.
• [29]R Development Core Team: R: A language and environment for statistical computing. R Foundation for Statistical Computing: Vienna, Austria; http://www.R-project.org/ webcite
• [30]van Buuren S: Multiple imputation of discrete and continuous data by fully conditional specification. Stat Methods Med Res 2007, 16:219-242.
• [31]Venables WN, Ripley BD: Modern Applied Statistics with S. 4th edition. New York: Springer-Verlag; 2002.
• [32]Meininger AK, Figuerres BF, Goldberg BA: Scapular winging: an update. J Am Acad Orthop Surg 2011, 19:453-462.
• [33]Auchincloss H: Significance of location and number of axillary metastases in carcinoma of the breast: a justification for a conservative operation. Ann Surg 1963, 158:37-46.
• [34]Petrek JA, Blackwood MM: Axillary dissection: current practice and technique. Curr Probl Surg 1995, 32:257-323.
• [35]Martin JK: Axillary dissection. Oper Tech Gen Surg 2000, 2:152-160.
• [36]Mostafa A, Mokbel K, Engledow A, Leris AC, Choy C, Wells C, Carpenter R: Is dissection of the internerve tissue during axillary lymphadenectomy for breast cancer necessary? Eur J Surg Oncol 2000, 26:153-154.
• [37]Overpeck DO, Ghormley RK: Paralysis of the serratus magnus muscle, caused by lesions of the long thoracic nerve. JAMA 1940, 114:1994-1996.
• [38]Ilfeld FW, Holder HG: Winged scapula: case occurring in soldier from knapsack. JAMA 1942, 120:448-449.
• [39]Duncan MA, Lotze MT, Gerber LH, Rosenberg SA: Incidence, recovery, and management of serratus anterior muscle palsy after axillary node dissection. Phys Ther 1983, 63:1243-1247.
• [40]Pugliese GN, Green RF, Antonacci A: Radiation-induced long thoracic nerve palsy. Cancer 1987, 60:1247-1248.
• [41]Post M: Pectoralis major transfer for winging of the scapula. J Shoulder Elbow Surg 1995, 4:1-9.
• [42]Watson CJ, Schenkman M: Physical therapy management of isolated serratus anterior muscle paralysis. Phys Ther 1995, 75:194-202.
• [43]Kibler WB, Uhl TL, Maddux JW, Brooks PV, Zeller B, McMullen J: Qualitative clinical evaluation of scapular dysfunction: a reliability study. J Shoulder Elbow Surg 2002, 11:550-556.
• [44]Wiater JM, Flatow EL: Long thoracic nerve injury. Clin Orthop Relat Res 1999, 368:17-27.
• [45]Dumontier C, Soubeyran M, Lascar T, Laulan J: Compression du nerf thoracicus longus (Nerf de Charles-Bell). Chir Main 2004, 23:S63-S76.
• [46]Sherman SC, O’Connor M: An unusual cause of shoulder pain: Winged scapula. J Emerg Med 2005, 28:329-331.
• [47]Lee SG, Kim JH, Lee SY, Choi IS, Moon ES: Winged scapula caused by rhomboideus and trapezius muscles rupture associated with repetitive minor trauma: a case report. J Korean Med Sci 2006, 21:581-584.
• [48]Vinson EN: Clinical images: scapular winging. Arthritis Rheum 2006, 54:4027.
• [49]Daubinet G, Graveleau N, Rousseau D: L’epaule du sportif. The athletes shoulder. Rev Rhum 2007, 74:581-586.
• [50]Nath RK, Melcher SE: Rapid recovery of serratus anterior muscle function after microneurolysis of long thoracic nerve injury. J Brachial Plex Peripher Nerve Inj 2007, 2:4. BioMed Central Full Text
• [51]Noel E: Les syndromes canalaires de l’epaule. Nerve entrapment of the shoulder. Rev Rhum 2007, 74:339-343.
• [52]Galano GJ, Bigliani LU, Ahmad CS, Levine WN: Surgical treatment of winged scapula. Clin Orthop Relat Res 2008, 466:652-660.
• [53]Aksoy IA, Schrader SL, Ali MS, Borovansky JA, Ross MA: Spinal accessory neuropathy associated with deep tissue massage: a case report. Arch Phys Med Rehabil 2009, 90:1969-1972.
• [54]Cerqueira WA, Barbosa LA, Bergmann A: Proposta de conduta fisioterapêutica para o atendimento ambulatorial nas pacientes com escápula alada após linfadenectomia axilar. Rev Bras Cancerologia 2009, 55:115-120.
• [55]McClure P, Tate AR, Kareha S, Irwin D, Zlupko E: A clinical method for identifying scapular dyskinesis, part 1: reliability. J Athl Train 2009, 44:160-164.
• [56]Sivan M, Hassan A: Images in emergency medicine. Winged scapula as the presenting symptom of Guillain-Barre syndrome. Emerg Med J 2009, 26:790.
• [57]Blum A, Lecocq S, Louis M, Wassel J, Moisei A, Teixeira P: The nerves around the shoulder. Eur J Radiol 2011. [epub ahead of print]
• [58]Pereira TB, Bergmann A, Ribeiro AC, Da Silva JG, Dias R, Ribeiro MJ, Thuler LC: Myoeletric activity pattern of scapular muscles after axillary lymphadenectomy in breast cancer. Rev Bras Ginecol Obstet 2009, 31:224-229.
• [59]Ribeiro A, Bergmann A, Bezerra T, Silva M, Silva J, Ribeiro M, Dias R: Incidência de escápula alada no pós-operatório de linfadenectomia axilar [abstract]. Rev Bras Cancerologia 2007, 53:491.
• [60]Vastamaki M, Kauppila LI: Etiologic factors in isolated paralysis of the serratus anterior muscle: a report of 197 cases. J Shoulder Elbow Surg 1993, 2:240-243.
• [61]May S, Chance-Larsen K, Littlewood C, Lomas D, Saad M: Reliability of physical examination tests used in the assessment of patients with shoulder problems: a systematic review. Physiotherapy 2010, 96:179-190.
• [62]Nijs J, Roussel N, Struyf F, Mottram S, Meeusen R: Clinical assessment of scapular positioning in patients with shoulder pain: state of the art. J Manipulative Physiol Ther 2007, 30:69-75.
• [63]Struyf F, Nijs J, De CK, Giunta M, Mottram S, Meeusen R: Clinical assessment of scapular positioning in musicians: an intertester reliability study. J Athl Train 2009, 44:519-526.
• [64]Struyf F, Nijs J, Horsten S, Mottram S, Truijen S, Meeusen R: Scapular positioning and motor control in children and adults: a laboratory study using clinical measures. Man Ther 2011, 16:155-160.