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Joachim Zuther, Lymphedema Specialist. Read more
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Radiation-Induced Brachial Plexopathy

 

Today I would like to address the important and often neglected issue of radiation induced brachial plexopathy (RIBP), and how it relates to lymphedema. This first part covers the causes and symptoms of this condition, the next blog entry will discuss the treatment of RIBP with special considerations to the presence of lymphedema.

Radiation-Induced Brachial Plexopathy is caused by radiation damage to the brachial plexus, a network bundle of nerves located near the neck and shoulder. The nerves forming the brachial plexus originate at the spinal cord in the neck and are responsible for the sensory and muscular innervation of the entire upper extremity. 

The beneficial effects of radiation therapy in breast cancer and other malignant diseases are well known and documented. However, this life-saving therapy has potentially adverse effects on a number of body systems, which are exposed to the rays during treatment – such as skin, nerves and inner organs.

In breast cancer, radiation treatment is administered to the axillary area, chest, or neck. Radiation damage to this network of nerves can result

Brachial Plexus

in sensory and/or motor damage, with or without accompanying pain in the brachial plexus distribution in the arm. Symptoms may include paresthesia (tingling, pricking, numbness), dysesthesia (abnormal sense of touch, such as burning, itching, feeling of an electric current, “pins and needles”, pain), decreased sensitivity, partial loss of movement (muscle weakness and difficulty performing simple tasks such as opening jars, or containers, holding objects), complete paralysis of the arm, muscular atrophy, impaired mobility and partial dislocation of the shoulder joint.

The exact mechanism of RIBP is not yet completely understood; research indicates that damage to the brachial plexus results from a combination of direct nerve cell damage from ionizing radiation and more progressive damage by the development of scar tissue (radiation fibrosis) in and around the nerves, combined with damage to adjacent vessels that supply these nerves with oxygen and nutrients. Radiation of nerve tissue also causes the nerve cells to shrink, resulting in a decrease in elasticity of nerve fibers, which further aggravates the situation. The extent of damage is associated with the radiation dose and technique, and the concurrent use of chemotherapy.

The progressive damage to vessels and the development of scar tissue continues to evolve significantly in some, and gradually in other patients [3] after the initial radiation therapy, which explains why some patients develop RIBP symptoms many years after radiation treatment. Most patients develop symptoms within the first three years; however, the average interval between the last dose of radiation and the onset of RIBP symptoms reported in the literature varies widely (range between six months and 20 years [1, 2] ). The prevalence of RIBP is reported to be between 1.8% and 4.9% [1]; RIBP is more common after radiation in combination with chemotherapy, and nerve tissue of younger patients seems to be more vulnerable [4].

The Relationship between RIBP and Lymphedema

Individuals who had surgery and radiation for breast cancer and do not present with post-mastectomy/lumpectomy lymphedema are considered to be in a latency stage, and are always at risk to develop lymphedema. Any additional stress to the lymphatic system, such as trauma, loss of mobility or pain may cause the onset of lymphedema in the upper extremity.

The presence of RIBP, especially in cases with partial or complete loss of mobility is one of these triggering factors. The return of lymphatic fluid from the upper extremity partially depends on the pumping action the muscles exert to the outside of the lymph vessels. Immobility of these muscles due to pain, partial or complete paralysis has a detrimental effect to the return of lymphatic fluid and causes lymph to stagnate in the extremity. Combined with the adverse effects of gravity, this may trigger the onset of lymphedema.

Those individuals who already have lymphedema and develop RIBP may experience an increase in swelling due to pain and partial or complete loss of motor function.

Stay tuned for the next blog entry covering the treatment of RIBP with special considerations to the presence of lymphedema.

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53 comments to Radiation-Induced Brachial Plexopathy

  • Joe, many thanks for this very readable and informative article. As you mention, it’s so often neglected — as are the patients who deal with it, unfortunately. Much brainstorming and research is needed on this subject in order to address these needs adequately, and I thank you so much for kicking off the discussion!
    Bonnie

  • janice

    I want to know if it happened the same symptoms to the lower extrimity part of the body?

    • Joachim Zuther

      Dear Janice:
      The brachial plexus is located on the neck and shoulder area. Brachial plexopathy only occurs in the upper extremity.
      Nerve damage caused by radiation on those nerves responsible for the innervation of the lower extremities is rare, but possible.

  • Durell Darr

    Thank you Joe for continuing to educate and serve those afflicted with lymphedema. It is much needed and greatly appreciated. The more we learn as therapists, the better we too can serve!

  • Debra

    My daughter had radiation on a malignant tumor in her knee and since then has terrible back pains. No one seems to be able to tell her what the problem is, and she is beginning to feel that she is imagining it. Could there be something like what you are talking about in the lower extremetries? If so, what could be done?

    • Joachim Zuther

      Dear Debra:
      While it is possible that there is a relationship between the radiated area and the back pain, it is unlikely. Physical therapy and other exercise modalities, such as Yoga should be investigated to alleviate the symptoms.

    • Charles

      Dear Debra,

      A common back pain is Back Strain, which can be a very severe pain. There are number of causes for the back strain (attempting to relieve body weight from injuried knee and changing walking style might be a cause in this case), and symptomes are similar (do a web search and comparison to see if the pain matches).

  • JJH

    I am very interested in the treatment of this. I have been dealing with a painful upper shoulder area for years. It’s a tightness that starts to get more painful as the day elapses. Have tried massage and chiropractic work which helps for a short period. I have been thinking that my lymphedema could perhaps be an underlying cause, but wasn’t sure. I am going to bring this to my MLD therapists attention…I just haven’t wanted to take away from MLD time and that perhaps it seemed off base to even mention.
    Thank you for this!

  • Susan Sherrill

    Joachim: Do you know how doctors and therapists are currently treating this problem? I know a cancer patient who was prescribed a drug for pain for this problem. She is having numbness in her hand and pain in her lymphedema arm.

  • Matt Turse

    Thank you for addressing this issue. I am a 41 year old male and I had radiation to the brachial plexus area and developed lymphedema along with major nerve damage.
    I have also had surgery in the same area, complicating things even more.Ironically, the only help that I recieve is thru breast cancer sights.Looking forward to the therapy section.
    Thanks,
    Matt T
    Orlando

  • Robyn

    This explains a lot! I appreciate it. I always wondered where this condition might have originated. I was fine until I had radiation-I have every symptom.

  • Joe, another wonderful post–you are providing such a wonderful service to patients and providers–a place to find evidence based information that can assist us all. I work in radiation oncology, and attend survivorship CME and this topic is rarely if ever addressed. Thank you again.

  • Barbara Ellen

    Thank you so much for tying LE to RIBP. There can never be enough information about these two conditions as they exist together. I eagerly await the next blog entry about RIBP, particularly about any exercise that might help with the creeping paralysis.

  • Liz

    Joe,
    I worked with many women who are breast cancer survivors and it was noticeable in my practice the amount of ladies who come back with these type of symptoms. After these ladies undergo radiation you could see a change in the tissue around the axilla area and the pectoreal region. Unfortunately, many ladies return with lymphedema as well making these symptoms worse.

    Like your blog Thank you

  • Carmela Groce

    I am curious about your response to Janice. I had radiation therapy due to non-hodgkinson lymphoma 24 years ago and I guess I am one of the “possible” cases. Funny and quite a relief after all these years to find a name for it. All of those symptoms apply to me in my left leg. I am still in the process of finding someone “in my insurance plan” who can help with the problem. I have to say that massage therapy has helped to alleviate the awful pain that I used to suffer from years ago.

  • Denise

    Re: radiation to tumor at knee and back pain.

    As a PT we often see problems in the back as a result of injury to the leg. A good PT should be able to help with this problem.

  • Sue Csejka

    Hi Joe: Another area of concern and not often addressed is neoplastic brachial plexopathy and possible lymphedema. I was diagnosed with stage 4 metastatic breast cancer in 2005 (6 years out from initial diagnosis and treatment) with a non-specific “tumor” radiating through nerves of the brachial plexus. I had noticed swelling of right arm and hand during the summer with decreasing strength and feeling. Involvement became significant enough for me to seek help from my radiation oncologist (and friend) who immediately found upon examination a suspicious swollen lymph node above my collar bone. Subsequent surgery, radiation, manual lymph drainage, massage, massive wrapping for over 6 months to get things under control and a year of Herceptin treatment. Initially, I thought I would lose all function of my right hand forever (and I am right-handed) but with the aid of my lymphedema therapist and time, I can use that hand and arm to do most chores. I do wear a compression 1 sleeve everyday and would feel almost naked without it…even here in the Texas Hill Country where temps can get into triple digits. There is significant atrophy but the alternatives could have been much worse. There’s not alot written about THIS complication because I understand that it doesn’t occur all that often but it is out there… Thanks for your very vital and informative column…folks need to know that there is help out there!!

  • Dorie Bawks

    I have not officially been diagnosed with RIBP. That is, the EMG came up negative. But a very thorough neuro-physical examination by a RIBP Specialist at UoM (Michigan), Dr. Linda Yang, is convinced I do have it. She told me what to look for: A continuing flattening of the web between my thumb and forefinger. I am having an MRI of the Brachial Plexus tomorrow evening. I am hoping it is more definitive than an EMG. So little known about this, but I believe it is far too possible that a lot of people who get diagnosed with lymphedema after breast cancer, associate the pain of RIBP to the swelling of lymphedema instead. I do not know how long it will take until I have medical evidence of my actual experience. But I have searched the web (I actually think I found the end of it!) and everything I have learned points to RIBP. I have mild lymphedema. Trust me, it doesn’t explain this kind of pain!! Nor does it explain the loss of motor control and continuing atrophy. Far too many disorders leave a patient writhing in pain until years later some test finally finds what they have been trying to get some doctor to believe all along. I wish we had more compassion, and less cookie cutter medicine. No one has to test me to tell me I have a cold. They listen to my symptoms! Thank you so much for taking this on. I can’t wait to read the next entry!

  • amber

    Hi there,
    I was wondering what everyone’s thoughts were on the Flexitouch garmets…any help would be GREATLY appreciated!
    Thanks!

  • teresa

    dear mr. Joaquin, do you see patients? i would like to be see an evaluated by you, please let me know, thank you.

  • Karen

    Hi Joe: We have an interesting case in our clinic. A 48 y/o male, s/p Rt. lower back malignant melanoma, brain surgery, lymph nodes removed from Rt.axillary area, Multifocal Myxopapillary Ependymoma, multiple spinal surgeries and abdominal procedures due to spinal tumors, left knee surgery, with subsequent paralyzed lower extremity, abdominal lymphedema and lower extremity lymphedema. He’s been receiving CDT for about 3 weeks and his LE lymphedema has significantly decreased; however, his abdominal lymphedema hasn’t decreased at all, his abodmen feels softer though. We have tried abdominal garments and short-stretch bandages, but nothing seems to help. We appreciate your input and thank you for your support.

    • Joachim Zuther

      Dear Karen, normally I would suggest concentrating on abdominal and deep abdominal techniques. However, this would be contraindicated in light of the spinal and abdominal procedures this pt received. I’d suggest to continue with abdominal compression and make sure the pt knows how to diaphragmatically breath.

  • Adria

    My husband had squamous cell neck cancer treated with modified dissection and 41 rad treatments (6000 rads?) 22 years ago. He had progressive weakness of Rt shoulder and arm starting ten years ago. Now he can barely use it and has spasms and atrophy. He still has fine motor use of the fingers if he lifts his Rt arm up with his left. EMG and multi MRI’s = RIBP. His brother wants him to try accupuncture. Have you heard of any success with this? Also, he was just prescribe Baclofen, but is hesitant to try it because the MD said it had many side effects. He is really grieving the loss of his limb and mobility. If you have advice, I would be forever greatful. (He did the PT/OT thing at length, but is discouraged, thinking that his arm will eventually die anyway!) Is it always continually progressive? If accupunture would help, we would do it.

  • David Thomas

    My son has just had radiotherapy to his left chest, including brachial plexus/T1 nerve root (at around 40Gy). He finished 2 weeks ago. He is now complaining of pain to his left upper arm, shoulder blade, back of neck, upper hemithorax, wrist, ear. Is it possible that this is caused by the radiation to the brachial plexus?

    Many thanks.

  • Thanks for this, Joe. I’m a PT and a breast cancer survivor, and I’m always looking for good info to explain this to my patients and friends.

  • Gina Babauta

    Dear Mr. Zuther,
    In 1982, at the age of 17- I was diagnosed with Hodgkins Disease(stage 2b)& was treated with 6600 rads of radiation. In 1989, I was diagnosed with being a Type 1 diabetic due to the pancreas being radiated during treatment. In 2002, I was diagnosed with Pulmonary Fibrosis due to radiation. In 2005, I went in for a Lung Transplant Evaluation, during the process& a CT scan, they found a mass in my breast. It turned out to be “radiation induced breast cancer”. I had a lumpectomy and it was decided that would be it for treatment for me due to my lung situation and the meds that would have been used cause pulmonary embolisms. I, also was not a candidate for lung transplant due to “extensive chest mantle damage due to overradiation” & the breast cancer. For the last two years the area that had the original Hodgkins disease, (right side, neck and upper chest area) I have a tearing and burning sensation. It’s quite uncomfortable and a bit painful. My doctors don’t have an answer to why or have a type of remedy. They do say it’s likely due to the damage of the tissue to radiation & I need to learn to live with it. I, also have lymphedema on the right side(the breast cancer was on the left but the original tumors were found on my clavicle and in my chest on the right side) I, also have weakness and numbness in my hands and arms, hourly. I am constantly dropping things, I can not hold onto anything, put on makeup, dry my hair, cut vegetables, fruit, etc. Is there anything I can do to help regain mobility? It is becoming harder to function. Is there anyone you can recommend in the San Diego area or Southern California who is knowledgeable in the long term side effects of radiation? Thank you very much for your time.

    • Joachim Zuther

      Dear Ms. Babauta:
      You would certainly benefit from physical therapy to regain some of the mobility you have lost as a result of radiation treatment. I would suggest to contact the National Lymphedema Network (http://lymphnet.org/) in San Francisco at 800-541-3259 in order to locate a therapist in your area. You may also try the link on this page to locate a PT/Lymphedema Therapist close to you – http://www.lymphedemablog.com/find-a-therapist/

  • Karen

    My husband was diagnosed with tongue cancer in 2007. He had surgury on the back of the tongue and radiation (everyday for 7 weeks) and chemo (once a week for 7 weeks) Cisplatin. Treatment was Jan. 2008 – March 2008. In February 2009 he started noticing his hand could not write as well and his foot started acting funny. He just keeps getting worse. Now he is paralyzed on his right side, vocal chords are open to 6mm, he can not walk or get out of bed. This just keeps getting worse and worse. I think he has Lou Gerhig Disease and is misdiagnosed with Radiation nerve damage. What are your thoughts on this. The VA tried to do EMG/ Nerve Conduct test but it was to painful to endure so did not get a reading. They have done no other tests.

  • Karen

    Cont’d:

    He say’s it feels like 1000 lbs. are pushing his head down. Now he has the last 4 months pain inside chest on right side just under arm.

  • Jennifer

    I had a modified radical mastectomy of my left breast (with 9 nodes taken) on April 5, 2011. Chemo (adriamycin, cytoxin and taxol) began on May 5 every other week for 8 treatments (4 ac and 4 t) which ended on 8/12. Radiation (28 treatments) began on September 14 and ended November 1 and included the breast area, node area under the arm and in the neck. Even my back got red (in the area directly behind my left breast.) About 3 weeks into radiation I began to experience numbness, tingling and some pain in my left arm…but also in my right arm (though to a lesser extent). Both arms feel like there is a tournaquet tied around my shoulders cutting off the circulation. The numbness and tingling is much worse at night but also gets bad when I am driving. There seems to be some disagreement about whether this is RIBP or chemo induced peripheral neuropathy. I did have some numbness in my fingers and toes during and a little after taxol but that seemed to have disapated by the time I started radiation. I am desperate to stop this or — better — reverse it. It seems to be getting worse. Have you ever heard of RIBP affecting the non-radiated side? Help!

  • Joanna

    Hi,

    I had lumpectomy, 2 lympth nodes removed, chemo, 20 sessions of radiotherapy. No problems intitally (first 2/3 months after rads finished) but since then have had shoulder pain/reduced mobility/decreasing strength problems.

    No problems with mobility following lumpectomy. Previously very strong. Still have the same level of lower body strength (despite recent hysterectomy).

    Have had a nuclear bone scan (no bone mets). I have had arthritis in my hips but the shoulder pain/problems are much more extreme and severe.

    I’ve had 6 months of UK NHS physio, which has made absolutely NO difference.

    1) Is this likely to be RIBP?
    2) Is there any treatment available? I have heard of other breast cancer patients having some sort of heat treatment which proved very successful.

    Thanks,

    Joanna

  • cathe tappan

    i have had 15 radiation treatments and for two nights have had horrible pain in back of thighs , medium pain in upper arms..both right and left sides…last night was so bad i was up most of the night with pain..slept 2 hrs. …woke up with numbness all the way down left leg into foot….i had breast lumpectomy on left side with cancer in one sentinel node with 12 more removed and no cancer…lump was about one half inch,,,i do not want to finish radiation which is 20 more treatments…what is your opinion? plus what do i do for pain ? thanks for listening…cathe tappan

  • Sonya Perduta

    I have a T9 ASIA A complete spinal cord injury for over 37 years? I am totally independent in taking care of myself and currently work full time. I push a manual wheelchair. I recently had bilateral mastectomies for left breast cancer. Right one prophylactically. Following surgery i had clear margins and sentinel nodes were clear. I am now being encouraged to pursue radiation treatment. However, I am concerned over.potential side effects which may decrease the function in my left arm and from the burns which will prevent function esp pushing wheelchair, transfers and doing typical activities of daily living. I am red headed with fair skin. I would prefer to maintain quality over quantity of life and am thinking no radiation due to lympedema and brachial plexopathy potentials. I noticed yesterday, almost 10 weeks post op, that I have mild edema of left arm. I anticipate more following radiation. Are there any studies on women with disabilities and breast cancer treatment? Can you offer your expertise please as I need to make decision soon?

    • Joachim Zuther

      While I am unable to give specific advise on this issue (it is ultimately a decision you and your treating physician have to make), I can tell you that negative side effects with modern radiation treatments are not common any longer

  • Daire

    Hi Joachim
    I have a client who has had a mastectomy and full node clearance . She has had reconstruction in 2005. This year due to problems with the implant she has had to have it changed. She has developed mild secondary oedema which is being controlled with MLD and compression. My question is …Why would she suffer pain after her MLD treatment which can last up to 7 days ? . After reading your article on RIBP I’m just wondering is it because of the position I have to put her arm in while treating her and its nerve pain due to stretching her arm ?
    There is no discomfort while I’m treating her. It only comes after treatment.
    I have many clients who do not present with this problem. Any suggestions greatly appreciated. Thank you …Daire

    • Joachim Zuther

      Dear Daire: While it is possible that RIBP is resposible, this is certainly an issue that should be cleared up by the referring physician.

  • Peggy

    Thank you so much for this information and forum. I am halfway into radiation treatment (180 cGy x 28 treatments=5040 cGy)for cancer of right breast. Tumor was 2.8 cm, one sentinal node of 4 removed was involved with extracapsular extension. I elected not to have axillary node dissection and am not undergoing chemotherapy. Radiation is to axillary and supraclavicular areas, right side,5 days a week for 5.5 weeks (slow to reduce the risk of lymphedema, I’m told).

    Within a few days of beginning radiation (evenings), I began experiencing dull nerve pain in upper right arm over night and early the following morning, and by the second week felt heat and nerve sensations to both my shoulder and supraclavicular areas immediately after radiation (as leaving the building)followed by persistent nerve pain in outer upper arm just below the shoulder. This pain did not subside and I began taking Ibuprofen (max. dose) to get some relief.

    My Dr. felt it is likely temporary internal swelling due to my body reacting differently to the invasion of radiation and that it will pass once treatment is complete. She prescribed a very low dose of steroid (4 mg)taken daily during radiation and it has relieved most of the pain, though it has not subsided completely. Does this indicate that it is just a temporary reaction or could RIBP be indicated so soon? If so, does this seem likely or unlikely?

    Thank you so much. Given that I’m in radiation now, your prompt response is greatly appreciated.

    • Joachim Zuther

      Dear Peggy:
      Radiation-induced brachial plexopathy can be divided into 2 categories:
      1. relatively rare instances occurring during or shortly after completion of radiotherapy and
      2. the more common “delayed progressive” cases.
      Please also see http://www.medlink.com/medlinkcontent.asp

      While it is possible that you experience the onset of RIBP symptoms, it is more likely that the symptoms are caused by temporary internal swelling as your physician suggested..

  • Anonymous

    I only discover your web recently as my symptoms getting worse after RIBP diagnosis. I desperately need some solution. I had my right radical mastectomy nearly 40 years ago when I was pregnant. I was given a maxium dose of Cobalt readiation for 3 weeks and deep X-ray for 4 days!
    But RIBP symptoms seems started or getting worse about 20 years ago. Now my right arm and hand(I am right handed)are totally lost function. This happened without ‘warning’ whithin a few months I noticed the spasm, spasticity, twitching, numbness and the muscle weakness to a stage of no use at all. My shoulder was very boney and has skin covered the bone only, but within a few months it looks a bit rounded and fuller. Would this be lymphedema?
    What I need most now is a devise to give me some function to my hand! Is there any to help?
    Thank you very much.

  • Joachim Zuther

    Dear Sue – if you did not do so already, I would advise you to read the following article: http://www.lymphedemablog.com/2011/03/01/treatment-of-ribp-in-the-presence-of-lymphedema/

  • Anonymous

    Thank you Jo. But please hide my name and Email address from the page. Thank you.

  • Janet Logan

    Dear Jo,
    Do you have any thoughts on the use of Tens EMS machines to reduce atrophy of the arm muscles?
    I have late effects RIBP which over the lat 15 years has reduced the functionality of my right arm enormously and continues even now. I discovered this year that my right-side diaphragm is sort of stuck in the nearly “up” position because of Phrenic Nerve involvement.
    However, the lymphodema problem is a worry and I’m casting about for ways to slow down the atrophy, hence my Tens EMS enquiry.
    I’d be grateful for any insight you might have.
    Kind regards.

    • Joachim Zuther

      Janet – these machines are very helpful to treat muscle atrphy and other conditions. With care and knowledge it can certainly be applied in lymphedematous areas as well. TENS machines do not cause increased arterial blood flow underb=neath the electrodes, so there is no worry that swelling could be worsened.

  • AmySamples

    I have recently been diagnosed with radiation induced brachial plexopathy @ age 36 with issues beginning 8 years after radiation treatment. I spent nearly a year growing weaker & experiencing more & more constant pain as I visited doctor after doctor just to be told they were perplexed. Now that I’ve been diagnosed, I am waiting for a treatment plan other than medications. I have had a consult for the Hyperbaric Oxygen treatment. I understand this is a rare condition. I could really use & would much appreciate advice on this impairment as I must live with it & in order to understand this issue. I hope to know my options for treatment & how to a manage it for my lifetime. Thanks so much & I am looking forward to hearing from you.

  • claire

    I have optical meningioma on my optic nerve I have had 7 weeks of targeted radiation every day 12 months ago now and I keep getting a strange rash that starts in and around my eyes and spreads rapidly if I don’t put steroid cream on.
    please help what can I do to help this, is it from radiation or the toxins that they put me on for pain relief, they gave , me way to many pain killers because I know the tumour is there, so my brain was saying ouch. its not painful just uncomfortable I have been off the tablets for 6 months now. acupuncture helped for a while, helped me made peace with it. I need advice Dr Zuther

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