ABSTRACT
The frequency of shoulder dystocia in different reports has varied, ranging 0.2-3% of all vaginal deliveries. Once a shoulder dystocia occurs, even if all actions are appropriately taken, there is an increased frequency of complications, including third- or fourth-degree perineal lacerations, postpartum hemorrhage, and neonatal brachial plexus palsies. Health care providers have a poor ability to predict shoulder dystocia for most patients and there remains no commonly accepted model to accurately predict this obstetric emergency. Consequently, optimal management of shoulder dystocia requires appropriate management at the time it occurs. Multiple investigators have attempted to enhance care of shoulder dystocia by utilizing protocols and simulation training.
Subject(s)
Birth Injuries/diagnosis , Brachial Plexus Neuropathies/diagnosis , Delivery, Obstetric/adverse effects , Delivery, Obstetric/methods , Dystocia/diagnosis , Shoulder , Birth Injuries/etiology , Birth Injuries/mortality , Birth Injuries/therapy , Brachial Plexus/injuries , Brachial Plexus Neuropathies/etiology , Brachial Plexus Neuropathies/mortality , Brachial Plexus Neuropathies/therapy , Clavicle/embryology , Clavicle/injuries , Dystocia/mortality , Dystocia/therapy , Female , Fractures, Bone/diagnosis , Fractures, Bone/embryology , Humans , Humeral Fractures/diagnosis , Humeral Fractures/embryology , North America/epidemiology , Patient Positioning , Perineum/injuries , Postpartum Hemorrhage/etiology , Postpartum Hemorrhage/mortality , Postpartum Hemorrhage/therapy , Practice Guidelines as Topic , Predictive Value of Tests , Pregnancy , Tocolytic AgentsABSTRACT
PURPOSE: Data are limited on the clinical significance of brachial plexopathy in patients with apical non-small cell lung cancers (NSCLC) treated with definitive radiation therapy. We report the rates of radiation-induced brachial plexopathy (RIBP) and tumor-related brachial plexopathy (TRBP) and associated dosimetric parameters in apical NSCLC patients. METHODS AND MATERIALS: Charts of NSCLC patients with primary upper lobe or superiorly located nodal disease who received ≥50 Gy of definitive conventionally fractionated radiation or chemoradiation were retrospectively reviewed for evidence of brachial plexopathy and categorized as RIBP, TRBP, or trauma-related. Dosimetric data were gathered on ipsilateral brachial plexuses (IBP) contoured according to Radiation Therapy Oncology Group atlas guidelines. RESULTS: Eighty patients were identified with a median follow-up and survival time of 17.2 and 17.7 months, respectively. The median prescribed dose was 66.6 Gy (range, 50.4-84.0), and 71% of patients received concurrent chemotherapy. RIBP occurred in 5 patients with an estimated 3-year rate of 12% when accounting for competing risk of death. Seven patients developed TRBP (estimated 3-year rate of 13%), comprising 24% of patients who developed locoregional failures. Grade 3 brachial plexopathy was more common in patients who experienced TRBP than RIBP (57% vs 20%). No patient who received ≤78 Gy to the IBP developed RIBP. On multivariable competing risk analysis, IBP V76 receiving ≥1 cc, and primary tumor failure had the highest hazard ratios for developing RIBP and TRBP, respectively. CONCLUSIONS: RIBP is a relatively uncommon complication in patients with apical NSCLC tumors receiving definitive doses of radiation, while patients who develop primary tumor failures are at high risk for developing morbid TRBP. These findings suggest that the importance of primary tumor control with adequate doses of radiation outweigh the risk of RIBP in this population of patients.
