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Current Cancer Therapy Reviews


ISSN (Print): 1573-3947
ISSN (Online): 1875-6301

Systematic Review Article

Brachial Plexopathy as a Complication of Radiotherapy: A Systematic Review

Author(s): Dheyauldeen Shabeeb, Ahmed E. Musa , Mansoor Keshavarz, Ehsan Mihandoust, Gholamreza Hassanzadeh , Mohammad R. Hadian, Alireza Shirazi and Masoud Najafi *

Volume 16, Issue 2, 2020

Page: [110 - 120] Pages: 11

DOI: 10.2174/1573394715666190724102937


Background: Radiotherapy is a commonly used cancer treatment modality. However, radiation-induced complications are major drawbacks, especially at high doses. Radiation-induced brachial plexopathy (RIBP) is mostly observed in breast and lung cancer patients some months to years after radiotherapy. RIBP symptoms have negative effects on patients’ quality of life. The aim of this study was to review RIBP according to the preferred reporting items for systematic reviews and meta-analyses (PRISMA) guidelines.

Methods: Online databases (PubMed, Scopus, Web of Science and Embase) were searched to retrieve relevant studies on brachial plexopathy as a complication of radiotherapy.

Results: Initial search results yielded a total of 657 articles. After careful screening of their titles and abstracts, according to the inclusion and exclusion criteria, 31 articles were finally included in this study. Findings from these 31 papers showed that a total of 9192 cancer patients had undergone radiotherapy for different regions including chest, axillary area, thoracic outlet, neck and breast. 26.4% of these patients had RIPB (associated with symptoms such as paresthesia, pain, weakness, and/or motor dysfunction, organ pathology/dysfunction etc.) with different follow up times, where 8.2% of patients had RIPB after a mean time of 1.2 years, 15.8% after 2.6 years, 51% after 5 years, 14% after 7.8 years, and 11% after 10.5 years.

Conclusion: From our findings, we can conclude that the issue of radiation-induced brachial plexus complication in human is of great concern. Common symptoms associated with this complication include paresthesia, numbness, pain and weakness. We recommend the use of individual dose planning and computer-assisted image segmentation techniques that support rapid and reliable contouring of the brachial plexus. Also, the radiation dose to the brachial plexus should be limited as much as possible to reduce the risk of brachial plexopathy.

Keywords: Radiotherapy, peripheral neuropathy, brachial plexopathy, irradiation, organ-conserving therapy, hormone therapy.

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Milano MT, Constine LS, Okunieff P. Normal tissue tolerance dose metrics for radiation therapy of major organs. Semin Radiat Oncol 2007; 17(2): 131-40.
[PMID: 17395043]
Hall EJ, Giaccia AJ. Radiobiology for the Radiologist. 7th ed. Lippincottt Williams & Wilkins, Pennsylvania, USA 2006.
Ilnytskyy Y, Koturbash I, Kovalchuk O. Radiation-induced bystander effects in vivo are epigenetically regulated in a tissue-specific manner. Environ Mol Mutagen 2009; 50(2): 105-13.
[] [PMID: 19107897]
Cross NE, Glantz MJ. Neurologic complications of radiation therapy. Neurol Clin 2003; 21(1): 249-77.
[] [PMID: 12690652]
Dropcho EJ. Neurotoxicity of radiation therapy. Neurol Clin 2010; 28(1): 217-34.
[] [PMID: 19932383]
Pimperl LC. Radiation as a nervous system toxin. Neurol Clin 2005; 23(2): 571-97.
[] [PMID: 15757798]
Danesh-Meyer HV. Radiation-induced optic neuropathy. J Clin Neurosci 2008; 15(2): 95-100.
[] [PMID: 18068989]
Kline LB, Kim JY, Ceballos R. Radiation optic neuropathy. Ophthalmology 1985; 92(8): 1118-26.
[] [PMID: 4047605]
Brown GC, Shields JA, Sanborn G, Augsburger JJ, Savino PJ, Schatz NJ. Radiation optic neuropathy. Ophthalmology 1982; 89(12): 1489-93.
[] [PMID: 7162793]
Parsons JT, Bova FJ, Fitzgerald CR, Mendenhall WM, Million RR. Radiation optic neuropathy after megavoltage external-beam irradiation: analysis of time-dose factors. Int J Radiat Oncol Biol Phys 1994; 30(4): 755-63.
Parsons JT, Bova FJ, Fitzgerald CR, Mendenhall WM, Million RR. Radiation retinopathy after external-beam irradiation: analysis of time-dose factors. Int J Radiat Oncol Biol Phys 1994; 30(4): 765-73.
Ross HS, Rosenberg S, Friedman AH. Delayed radiation necrosis of the optic nerve. Am J Ophthalmol 1973; 76(5): 683-6.
[] [PMID: 4355948]
Finger PT. Radiation therapy for choroidal melanoma. Surv Ophthalmol 1997; 42(3): 215-32.
[] [PMID: 9406368]
Finger PT. Radiation therapy for orbital tumors: concepts, current use, and ophthalmic radiation side effects. Surv Ophthalmol 2009; 54(5): 545-68.
[] [PMID: 19682622]
Chen AM, Hall WH, Li J. Beckett L, Farwell DG, Lau DH, et al.. Brachial plexus-associated neuropathy after high-dose radiation therapy for head-and-neck cancer. Int J Radiat Oncol Biol Phys 2012; 84(1): 165-9.
Pettigrew LC, Glass JP, Maor M, Zornoza J. Diagnosis and treatment of lumbosacral plexopathies in patients with cancer. Arch Neurol 1984; 41(12): 1282-5.
[] [PMID: 6093750]
Dahele M, Davey P, Reingold S, Shun Wong C. Radiation-induced lumbo-sacral plexopathy (RILSP): an important enigma. Clin Oncol (R Coll Radiol) 2006; 18(5): 427-8.
[] [PMID: 16817337]
Mendes DG, Nawalkar RR, Eldar S. Post-irradiation femoral neuropathy. A case report. J Bone Joint Surg Am 1991; 73(1): 137-40.
[] [PMID: 1985985]
Zeman W. Cytochemistry of delayed radionecrosis of the murine spinal cord Indiana Univ, Indianapolis School of Medicine 1963.Available at:
Ferrante MA. Brachial plexopathies: classification, causes, and consequences. Muscle Nerve 2004; 30(5): 547-68.
[] [PMID: 15452843]
Jaeckle KA, Ed. 2004.
Fathers E, Thrush D, Huson SM, Norman A. Radiation-induced brachial plexopathy in women treated for carcinoma of the breast. Clin Rehabil 2002; 16(2): 160-5.
[] [PMID: 11911514]
Bajrovic A, Rades D, Fehlauer F, et al. Is there a life-long risk of brachial plexopathy after radiotherapy of supraclavicular lymph nodes in breast cancer patients? Radiother Oncol 2004; 71(3): 297-301.
[] [PMID: 15172145]
Hall EJ, Giaccia AJ. Radiobiology for the Radiologist. Philadelphia: Lippincott Williams & Wilkins 2006.
Zhang B, Su Y, Ai G, Wang Y, Wang T, Wang F. Involvement of peroxiredoxin I in protecting cells from radiation-induced death. J Radiat Res (Tokyo) 2005; 46(3): 305-12.
[] [PMID: 16210786]
Mansour HH, Hafez HF, Fahmy NM, Hanafi N. Protective effect of N-acetylcysteine against radiation induced DNA damage and hepatic toxicity in rats. Biochem Pharmacol 2008; 75(3): 773-80.
[] [PMID: 18028880]
Phan C, Mindrum M, Silverman C, Paris K, Spanos W. Matched-control retrospective study of the acute and late complications in patients with collagen vascular diseases treated with radiation therapy. Cancer J 2003; 9(6): 461-6.
[] [PMID: 14740974]
Dumitru D, Zwarts M. Brachial plexopathies and proximal mononeuropathies Electrodiagnostic medicine. 2nd ed. 2002; pp. 623-4.
Gillette E, Mahler P, Powers B, Gillette S, Vujaskovic Z. Late radiation injury to muscle and peripheral nerves. Int J Radiat Oncol Biol Phys 1995; 31(5): 1309-18.
Vasić L. Radiation-induced peripheral neuropathies: Etiopathogenesis, risk factors, differential diagnostics, symptoms and treatment. Arch Oncol 2007; 15(3-4): 81-4.
Azinovic I, Calvo FA, Puebla F, Aristu J, Martínez-Monge R. Long-term normal tissue effects of intraoperative electron radiation therapy (IOERT): late sequelae, tumor recurrence, and second malignancies. Int J Radiat Oncol Biol Phys 2001; 49(2): 597-604.
Wilbourn A. Brachial plexus disorders Peripheral neuropathy 1993; 2: 911-50.
Liberati A, Altman DG, Tetzlaff J, et al. The PRISMA statement for reporting systematic reviews and meta-analyses of studies that evaluate health care interventions: explanation and elaboration. PLoS Med 2009; 6(7): e1000100
[] [PMID: 19621070]
Fowble BL, Solin LJ, Schultz DJ, Goodman RL. Ten year results of conservative surgery and irradiation for stage I and II breast cancer. Int J Radiat Oncol Biol Phys 1991; 21(2): 269-77.
Olsen NK, Pfeiffer P, Mondrup K, Rose C. Radiation-induced brachial plexus neuropathy in breast cancer patients. Acta Oncol 1990; 29(7): 885-90.
[] [PMID: 2261203]
Powell S, Cooke J, Parsons C. Radiation-induced brachial plexus injury: follow-up of two different fractionation schedules. Radiother Oncol 1990; 18(3): 213-20.
[] [PMID: 2217869]
Sood SS, McClinton C, Badkul R, Aguilera N, Wang F, Chen AM. Brachial plexopathy after stereotactic body radiation therapy for apical lung cancer: Dosimetric analysis and preliminary clinical outcomes. Adv Radiat Oncol 2017; 3(1): 81-6.
[] [PMID: 29556585]
Fairchild A, Weir L, Mates D, Olivotto I. Loco-regional radiation for high risk breast cancer-results of short fractionation. Breast Cancer Res Treat 2000; 64(1): 35.
Johansson S, Svensson H, Denekamp J. Timescale of evolution of late radiation injury after postoperative radiotherapy of breast cancer patients. Int J Radiat Oncol Biol Phys 2000; 48(3): 745-50.
Ragaz J, Jackson SM, Le N, et al. Adjuvant radiotherapy and chemotherapy in node-positive premenopausal women with breast cancer. N Engl J Med 1997; 337(14): 956-62.
[] [PMID: 9309100]
Olsen NK, Pfeiffer P, Johannsen L, Schrøder H, Rose C. Radiation-induced brachial plexopathy: neurological follow-up in 161 recurrence-free breast cancer patients. Int J Radiat Oncol Biol Phys 1993; 26(1): 43-9.
Stoll BA, Andrews JT. Radiation-induced peripheral neuropathy. BMJ 1966; 1(5491): 834-7.
[] [PMID: 20790877]
Delouche G, Bachelot F, Premont M, Kurtz J. Conservation treatment of early breast cancer: Long term results and complications. Int J Radiat Oncol Biol Phys 1987; 13(1): 29-34.
Livsey JE, Magee B, Stewart AL, Swindell R. Axillary recurrence following conservative surgery and radiotherapy in early breast cancer. Clin Oncol (R Coll Radiol) 2000; 12(5): 309-14.
[PMID: 11315717]
Pierce SM, Recht A, Lingos TI, et al. Brachial plexus lesions in patients with cancer: 100 cases. Neurology 1992; 31(1): 45.
Kori SH, Foley KM, Posner JB. Brachial plexus lesions in patients with cancer: 100 cases. Neurology 1981; 31(1): 45-50.
[] [PMID: 6256684]
Thomas JE, Colby MY Jr. Radiation-induced or metastatic brachial plexopathy? A diagnostic dilemma. JAMA 1972; 222(11): 1392-5.
[] [PMID: 4344104]
Wouter van Es H, Engelen AM, Witkamp TD, Ramos LM, Feldberg MA. Radiation-induced brachial plexopathy: MR imaging. Skeletal Radiol 1997; 26(5): 284-8.
[] [PMID: 9194228]
Barr LC, Kissin MW. Radiation-induced brachial plexus neuropathy following breast conservation and radical radiotherapy. Br J Surg 1987; 74(9): 855-6.
[] [PMID: 2822202]
Mondrup K, Olsen NK, Pfeiffer P, Rose C. Clinical and electrodiagnostic findings in breast cancer patients with radiation-induced brachial plexus neuropathy. Acta Neurol Scand 1990; 81(2): 153-8.
[] [PMID: 2327236]
Basso-Ricci S, della Costa C, Viganotti G, Ventafridda V, Zanolla R. Report on 42 cases of postirradiation lesions of the brachial plexus and their treatment. Tumori 1980; 66(1): 117-22.
[] [PMID: 7376261]
Wu S-G, Huang S-J, Zhou J, et al. Dosimetric analysis of the brachial plexus among patients with breast cancer treated with post-mastectomy radiotherapy to the ipsilateral supraclavicular area: report of 3 cases of radiation-induced brachial plexus neuropathy. Radiat Oncol 2014; 9(1): 292.
[] [PMID: 25499205]
Cooke J, Powell S, Parsons C. The diagnosis by computed tomography of brachial plexus lesions following radiotherapy for carcinoma of the breast. Clin Radiol 1988; 39(6): 602-6.
[] [PMID: 3243051]
Esteban A, Traba A. Fasciculation-myokymic activity and prolonged nerve conduction block. A physiopathological relationship in radiation-induced brachial plexopathy. Electroencephalogr Clin Neurophysiol/Evoked Potent Sec 1993; 89(6): 382-91.
Cai Z, Li Y, Hu Z, et al. Radiation-induced brachial plexopathy in patients with nasopharyngeal carcinoma: a retrospective study. Oncotarget 2016; 7(14): 18887-95.
[] [PMID: 26934119]
Gu B, Yang Z, Huang S, et al. Radiation-induced brachial plexus injury after radiotherapy for nasopharyngeal carcinoma. Jpn J Clin Oncol 2014; 44(8): 736-42.
[] [PMID: 24842865]
Amini A, Welsh J, Yang J, McBurney M, Williamson R, Karhade M, et al. Dose constraints to prevent radiation-induced brachial plexopathy in patients treated for lung cancer. Int J Radiat Oncol Biol Phys 2011; 81(2): S110.
Westling P, Svensson H, Hele P. Cervical plexus lesions following post-operative radiation therapy of mammary carcinoma. Acta Radiol Ther Phys Biol 1972; 11(3): 209-16.
[] [PMID: 4626383]
Rawlings G, Arriagada R, Fontaine F, Bouhnik H, Mouriesse H, Sarrazin D. Radiation-induced brachial plexopathy. Bull Cancer 1983; 70(2): 77-83.
[PMID: 6871488]
Chen A, Lau D, Mathai M, Hall W, Farwell G, Luu Q, et al. Prospective clinical-dosimetric evaluation of normal tissue tolerance of the brachial plexus among patients treated by intensity modulated radiotherapy for head and neck cancer. Int J Radiat Oncol Biol Phys 2010; 78(3): S152.
Forquer JA, Fakiris AJ, Timmerman RD, et al. Brachial plexopathy from stereotactic body radiotherapy in early-stage NSCLC: dose-limiting toxicity in apical tumor sites. Radiother Oncol 2009; 93(3): 408-13.
[] [PMID: 19454366]
Gałecki J, Hicer-Grzenkowicz J, Grudzień-Kowalska M, Michalska T, Załucki W. Radiation-induced brachial plexopathy and hypofractionated regimens in adjuvant irradiation of patients with breast cancer--a review. Acta Oncol 2006; 45(3): 280-4.
[] [PMID: 16644570]
Ko K, Sung DH, Kang MJ, et al. Clinical, electrophysiological findings in adult patients with non-traumatic plexopathies. Ann Rehabil Med 2011; 35(6): 807-15.
[] [PMID: 22506209]
Johansson S, Svensson H, Larsson L-G, Denekamp J. Brachial plexopathy after postoperative radiotherapy of breast cancer patients--a long-term follow-up. Acta Oncol 2000; 39(3): 373-82.
[] [PMID: 10987234]
van der Kogel AJ. Dose-volume effects in the spinal cord. Radiother Oncol 1993; 29(2): 105-9.
[] [PMID: 8310135]
Jephcott CR, Tyldesley S, Swift C-L. Regional radiotherapy to axilla and supraclavicular fossa for adjuvant breast treatment: a comparison of four techniques. Int J Radiat Oncol Biol Phys 2004; 60(1): 103.
Hoeller U, Bonacker M, Bajrovic A, Alberti W, Adam G. Radiation-induced plexopathy and fibrosis. Is magnetic resonance imaging the adequate diagnostic tool? Strahlenther Onkol 2004; 180(10): 650-4.
[] [PMID: 15480514]
Ahmad A, Barrington S, Maisey M, Rubens RD. Use of positron emission tomography in evaluation of brachial plexopathy in breast cancer patients. Br J Cancer 1999; 79(3-4): 478-82.
[] [PMID: 10027316]
Shabeeb D, Najafi M, Hasanzadeh G, Hadian MR, Musa AE, Shirazi A. Electrophysiological measurements of diabetic peripheral neuropathy: A systematic review. Diabetes Metab Syndr 2018; 12(4): 591-600.
[] [PMID: 29610062]
Thames HD, Withers HR, Peters LJ, Fletcher GH. Changes in early and late radiation responses with altered dose fractionation: implications for dose-survival relationships. Strahlentherapie 1982; 153(7): 467-9.
Kogelnik HD. [Influence of dose-time relationship on the pathogenesis of peripheral neuropathy (author’s transl)]. Strahlentherapie 1977; 153(7): 467-9.
[PMID: 197662]
Brennan MJ. Breast cancer recurrence in a patient with a previous history of radiation injury of the brachial plexus: a case report. Arch Phys Med Rehabil 1995; 76(10): 974-6.
[] [PMID: 7487441]
Wadd NJ, Lucraft HH. Brachial plexus neuropathy following mantle radiotherapy. Clin Oncol (R Coll Radiol) 1998; 10(6): 399-400.
[] [PMID: 9890543]
Nich C, Bonnin P, Laredo JD, Sedel L. [An uncommon form of delayed radio-induced brachial plexopathy]. Chir Main 2005; 24(1): 48-51.
[] [PMID: 15754713]
Churn M, Clough V, Slater A. Early onset of bilateral brachial plexopathy during mantle radiotherapy for Hodgkin’s disease. Clin Oncol (R Coll Radiol) 2000; 12(5): 289-91.
[PMID: 11315711]
Gerard JM, Franck N, Moussa Z, Hildebrand J. Acute ischemic brachial plexus neuropathy following radiation therapy. Neurology 1989; 39(3): 450-1.
[] [PMID: 2927663]
Malow BA, Dawson DM. Neuralgic amyotrophy in association with radiation therapy for Hodgkin’s disease. Neurology 1991; 41(3): 440-1.
[] [PMID: 2006016]
Lin YS, Jen YM, Lin JC. Radiation-related cranial nerve palsy in patients with nasopharyngeal carcinoma. Cancer 2002; 95(2): 404-9.
[] [PMID: 12124841]
Kumar AJ, Leeds NE, Fuller GN, et al. Malignant gliomas: MR imaging spectrum of radiation therapy- and chemotherapy-induced necrosis of the brain after treatment. Radiology 2000; 217(2): 377-84.
[] [PMID: 11058631]
DeVita VT. Cancer Principles & Practice of Oncology Breast Cancer. 10th ed. Wolters Kluwer; Netherlands, 2005.

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