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Association between shoulder joint radiation dose and arm morbidity in the randomized breast cancer trial SENOMAC

Alkner, Sara LU ; Appelgren, Matilda ; Szulkin, Robert ; Wieslander, Elinore LU ; Rogowski, Viktor LU ; Gustafsson, Christian Jamtheim LU ; Nissen, Henrik Dahl ; Sackey, Helena ; Lundstedt, Dan and Andersson, Yvette , et al. (2026) In Radiotherapy and Oncology 218.
Abstract

Background: Postoperative lymph node irradiation can affect shoulder morbidity in breast cancer patients, yet widely accepted dose-volume constraints for the shoulder joint are lacking. The SENOMAC trial randomized patients with breast cancer and 1–2 sentinel lymph node (SLN) macrometastases to axillary lymph node dissection (ALND) or SLN biopsy only. We aimed to analyze the association between the radiation dose to the shoulder joint and patient-reported arm morbidity one and three years after surgery using SENOMAC data. Methods: Radiotherapy plans from 868 Swedish SENOMAC patients randomized 2015–2019 were collected. The humeral head was auto-segmented, and a 1 cm margin added to represent the shoulder joint. Arm morbidity was... (More)

Background: Postoperative lymph node irradiation can affect shoulder morbidity in breast cancer patients, yet widely accepted dose-volume constraints for the shoulder joint are lacking. The SENOMAC trial randomized patients with breast cancer and 1–2 sentinel lymph node (SLN) macrometastases to axillary lymph node dissection (ALND) or SLN biopsy only. We aimed to analyze the association between the radiation dose to the shoulder joint and patient-reported arm morbidity one and three years after surgery using SENOMAC data. Methods: Radiotherapy plans from 868 Swedish SENOMAC patients randomized 2015–2019 were collected. The humeral head was auto-segmented, and a 1 cm margin added to represent the shoulder joint. Arm morbidity was assessed using the Lymph-ICF questionnaire, focusing on questions regarding physical arm function and shoulder-related mobility tasks. Results: The radiation dose was evaluable for 386 patients receiving ALND and 421 receiving SLN biopsy. The dose distribution to the shoulder joint was similar in both study groups. In the SLN group, a higher near-maximum dose (D0.5cc) was associated with significantly worse arm morbidity scores three years after surgery, particularly among patients treated with breast-conserving surgery. No association was found in the ALND group. No dose thresholds for development of arm/shoulder related side effects could be identified. Conclusion: Our results indicate a possible association between maximum radiation dose to the shoulder joint and subsequent side effects. Extended follow-up within SENOMAC will provide further insights into the incidence of arm morbidity in relation to radiotherapy dose over time.

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organization
publishing date
type
Contribution to journal
publication status
published
subject
keywords
Breast cancer, Dose–volume constraints, Nodal radiotherapy, Patient-reported arm morbidity, SENOMAC trial, Shoulder joint
in
Radiotherapy and Oncology
volume
218
article number
111454
publisher
Elsevier
external identifiers
  • pmid:41730479
  • scopus:105030663548
ISSN
0167-8140
DOI
10.1016/j.radonc.2026.111454
language
English
LU publication?
yes
additional info
Publisher Copyright: © 2026 The Author(s)
id
970775f0-857f-49a8-b045-070ebf175252
date added to LUP
2026-04-21 16:26:12
date last changed
2026-05-19 18:12:57
@article{970775f0-857f-49a8-b045-070ebf175252,
  abstract     = {{<p>Background: Postoperative lymph node irradiation can affect shoulder morbidity in breast cancer patients, yet widely accepted dose-volume constraints for the shoulder joint are lacking. The SENOMAC trial randomized patients with breast cancer and 1–2 sentinel lymph node (SLN) macrometastases to axillary lymph node dissection (ALND) or SLN biopsy only. We aimed to analyze the association between the radiation dose to the shoulder joint and patient-reported arm morbidity one and three years after surgery using SENOMAC data. Methods: Radiotherapy plans from 868 Swedish SENOMAC patients randomized 2015–2019 were collected. The humeral head was auto-segmented, and a 1 cm margin added to represent the shoulder joint. Arm morbidity was assessed using the Lymph-ICF questionnaire, focusing on questions regarding physical arm function and shoulder-related mobility tasks. Results: The radiation dose was evaluable for 386 patients receiving ALND and 421 receiving SLN biopsy. The dose distribution to the shoulder joint was similar in both study groups. In the SLN group, a higher near-maximum dose (D<sub>0.5cc</sub>) was associated with significantly worse arm morbidity scores three years after surgery, particularly among patients treated with breast-conserving surgery. No association was found in the ALND group. No dose thresholds for development of arm/shoulder related side effects could be identified. Conclusion: Our results indicate a possible association between maximum radiation dose to the shoulder joint and subsequent side effects. Extended follow-up within SENOMAC will provide further insights into the incidence of arm morbidity in relation to radiotherapy dose over time.</p>}},
  author       = {{Alkner, Sara and Appelgren, Matilda and Szulkin, Robert and Wieslander, Elinore and Rogowski, Viktor and Gustafsson, Christian Jamtheim and Nissen, Henrik Dahl and Sackey, Helena and Lundstedt, Dan and Andersson, Yvette and Bergkvist, Leif and Frisell, Jan and Olofsson Bagge, Roger and Sund, Malin and Rydén, Lisa and Offersen, Birgitte Vrou and de Boniface, Jana}},
  issn         = {{0167-8140}},
  keywords     = {{Breast cancer; Dose–volume constraints; Nodal radiotherapy; Patient-reported arm morbidity; SENOMAC trial; Shoulder joint}},
  language     = {{eng}},
  publisher    = {{Elsevier}},
  series       = {{Radiotherapy and Oncology}},
  title        = {{Association between shoulder joint radiation dose and arm morbidity in the randomized breast cancer trial SENOMAC}},
  url          = {{http://dx.doi.org/10.1016/j.radonc.2026.111454}},
  doi          = {{10.1016/j.radonc.2026.111454}},
  volume       = {{218}},
  year         = {{2026}},
}