[Postmastectomy lymphedema and carpal tunnel syndrome. Surgical considerations and advice for patients]

A Systematic Review of Peripheral Neuropathies in Breast Cancer-Related Lymphedema

Controversy exists regarding the influence of breast cancer-related lymphedema (BCRL) in the development of peripheral neuropathies. Our aim was to evaluate the association of secondary lymphedema with peripheral neuropathies in patients with breast cancer. We performed a systematic review by querying PubMed, EMBASE, Ovid Medline and Epub Ahead of Print, In-Process & Other Non-Indexed Citations, and Cochrane Central Register of Controlled Trials databases. The keywords "lymphedema" AND ("neuropathy" OR "carpal tunnel syndrome" OR "cubital tunnel syndrome" OR "neuropathic pain") and synonyms in titles and abstracts were used to perform the search. Seventeen articles met the inclusion criteria. Discrepancies were found in studies that analyzed whether a cause-effect association exists between carpal tunnel syndrome (CTS) and secondary lymphedema. No evidence indicated that lymphedema predisposes to developing peripheral neuropathies such as CTS or brachial plexopathy. No studies found an association between patients with breast cancer at risk of or with lymphedema and the development or worsening of CTS. Carpal tunnel release can be safely performed in patients with BCRL. Neuropathic pain worsens with lymphedema, and treatment seems to improve the pain. Our study did not find enough evidence to conclude that BCRL is associated with the development of peripheral neuropathies. Carpal tunnel release is a safe procedure that can be performed in patients with BCRL and does not influence the development or worsening of lymphedema. Neuropathic pain seems to worsen after development of lymphedema, and treatment has been found to improve neuropathic pain.

Carpal Tunnel Syndrome Management in Breast Cancer Survivors at Risk for Lymphedema: A Markov Model

BACKGROUND

Breast cancer survivors that have undergone axillary lymph node dissection have an increased risk of developing same-side upper extremity lymphedema. Patients with carpal tunnel syndrome in the ipsilateral limb may not receive appropriate surgical therapy (carpal tunnel release) because of concerns that it may trigger or worsen lymphedema.

METHODS

A state transition cohort model was used to evaluate the treatment options for breast cancer survivors at risk of upper extremity lymphedema presenting with carpal tunnel syndrome. The model reflected three treatment strategies: (1) early surgical intervention, (2) delayed surgical intervention, or (3) nonsurgical management. Both life-years and quality-adjusted life-years were modeled over a 30-year time horizon.

RESULTS

Over a 30-year time horizon, the preferred strategy was delayed surgery, which resulted in 21.41 quality-adjusted life-years. Early surgery and nonsurgical management yielded 20.42 and 21.06 quality-adjusted life-years, respectively. The model was robust and was not sensitive to variation in any of the parameters within the clinically plausible ranges.

CONCLUSIONS

Based on this decision analytic model, the optimal choice for breast cancer survivors with mild carpal tunnel syndrome who are at risk for lymphedema would be delaying surgery until severe symptoms develop. This strategy balances the potential increased risk of lymphedema following carpal tunnel release with the decreased long-term risk of severe carpal tunnel syndrome. The model comprehensively assesses a controversial area in the breast cancer and hand surgery literature to inform decision-making for patients and clinicians.

Association Between Precautionary Behaviors and Breast Cancer-Related Lymphedema in Patients Undergoing Bilateral Surgery

Purpose This study examined the lifestyle and clinical risk factors for lymphedema in a cohort of patients who underwent bilateral breast cancer surgery. Patients and Methods Between 2013 and 2016, 327 patients who underwent bilateral breast cancer surgery were prospectively screened for arm lymphedema as quantified by the weight-adjusted volume change (WAC) formula. Arm perometry and subjective data were collected preoperatively and at regular intervals postoperatively. At the time of each measurement, patients completed a risk assessment survey that reported the number of blood draws, injections, blood pressure readings, trauma to the at-risk arm, and number of flights since the previous measurement. Generalized estimating equations were applied to ascertain the association among arm volume changes, clinical factors, and risk exposures. Results The cohort comprised 327 patients and 654 at-risk arms, with a median postoperative follow-up that ranged from 6.1 to 68.2 months. Of the 654 arms, 83 developed lymphedema, defined as a WAC ≥ 10% relative to baseline. On multivariable analysis, none of the lifestyle risk factors examined through the risk assessment survey were significantly associated with increased WAC. Multivariable analysis demonstrated that having a body mass index ≥ 25 kg/m2 at the time of breast cancer diagnosis ( P = .0404), having undergone axillary lymph node dissection ( P = .0464), and receipt of adjuvant chemotherapy ( P = .0161) were significantly associated with increased arm volume. Conclusion Blood pressure readings, blood draws, injections, and number or duration of flights were not significantly associated with increases in arm volume in this cohort. These findings may help to guide patient education about lymphedema risk reduction strategies for those who undergo bilateral breast cancer surgery.

Elective hand surgery after axillary lymph node dissection for cancer

After axillary lymph node dissection (ALND), patients are cautioned against ipsilateral interventional procedures to avoid the theoretical increased risk of postoperative complications, particularly lymphedema. The authors' goal was to evaluate the complications of elective hand surgery after ALND. The authors reviewed patients presenting to their hand clinic from 1998 to 2011, selecting those with a diagnosis of breast cancer or melanoma and a history of previous ALND; the authors excluded those treated nonoperatively and those treated with elective surgery in the contralateral hand. Average age of the 22 patients meeting the criteria (20 with a history of breast cancer, 6 with preexisting lymphedema) was 53.9 years (range, 26.7 to 73.6 years) at the time of ALND and 63.1 years (range, 31.7 to 83.5 years) at the time of hand surgery. Average interval between surgeries was 9.2 years (range, 8 days to 37.3 years). Follow-up averaged 9.2 months (range, 8 days to 41.7 months). Fifteen patients were surveyed for long-term postoperative results (average surgery-to-survey interval, 4.3 years [range, 1 to 11.9 years]). Fifteen patients had uneventful postoperative recoveries, 4 had peri-incisional erythema requiring oral antibiotics, 1 had incisional pain and scarring, 1 had chronic wound-healing issues, and 1 had a dehiscence requiring a return to the operating room. In the 15 patients who completed the follow-up survey, there was no disease exacerbation in the 3 patients with preexisting lymphedema, and there were no new cases of lymphedema. Routine minor hand surgery did not result in lymphedema and did not increase existing lymphedema in these patients with previous ipsilateral ALND, but almost one-third of them had short-term complications in the postoperative recovery period.

Carpal tunnel syndrome caused by supernumerous lumbrical muscle in hemihyperplasia of the upper extremity

INTRODUCTION

Hemihyperplasia of the upper extremity is a rare pathology that occurs in 1/86,000 births. Carpal tunnel syndrome may be associated with this disease.

CLINICAL PRESENTATION

We describe the case of a 74-year-old male who has hemihyperplasia of both upper extremities since birth. At the age of 73, he started experiencing continuous, progressive and high intensity pain that occurred more frequently at night and was localized in the right hand. It was associated with paresthesia and hypoesthesia predominantly of the thumb, index finger and middle finger. Clinical examination and electrodiagnosis led to diagnosis of carpal tunnel syndrome.

RESULTS

The patient underwent surgical carpal tunnel release to treat the disease. The enlarged nerve was compressed by a supernumerous lumbrical muscle, which was resected intraoperatively. After six months of follow-up the patient has normal sensitivity and grip strength in the right hand.

CONCLUSION

Hemihyperplasia should be clearly distinguished from other complex pathologies that may also entail CTS. Since significant variation in the anatomy of the hemihyperplasic extremities is the rule rather than the exception, a conventional open approach should be taken to localize and treat the compression.

Hand surgery after axillary lymph node clearance for breast cancer: contra-indication to surgery?

INTRODUCTION

Breast cancer patients who have had prior axillary lymph node clearance (ALNC) can present with ipsilateral hand conditions that could easily be treated with surgical intervention. These patients are often advised to avoid interventional procedures due to risks of complications such as lymphoedema, infection and cellulitis.

SUBJECTS AND METHODS

Between April and June 2009, we conducted an online survey of hand surgeons, breast surgeons and breast-care nurses to obtain their views on hand surgery after ipsilateral axillary lymph node clearance.

RESULTS

The majority of hand surgeons (58%) felt there was no contra-indication to surgery in a breast cancer patient with prior ipsilateral ALNC compared to just 30% of breast surgeons and 10% of breast-care nurses. The majority of breast surgeons and breast-care nurses (70% and 89%, respectively) felt that hand surgery was a relative contra-indication compared to just 41% of hand surgeons. Postoperative lymphoedema was the commonest cited reason for avoiding surgery. The majority of hand surgeons (79%) and nearly two-thirds of breast surgeons (57%) would use a tourniquet during surgery if it was normal practice.

CONCLUSIONS

A review of the published literature does not support the notion that these patients experience increased complications; therefore, we recommend the advice given to breast cancer patients regarding ipsilateral surgery be re-evaluated.

Postoperative infections: prevention and management

Postoperative infections continue to be a challenging problem. The incidence of bacterial antibiotic resistance such as methicillin-resistant Staphylococcus aureus is rising. There are numerous intrinsic patient factors that should be optimized before surgery to minimize the risk of surgical site infections. When postoperative infections develop, treatment must be individualized. This article outlines the principles that can help guide treatment.

[Carpal tunnel syndrome in diabetes mellitus]

The carpal tunnel syndrome (CTS) occurs frequently in patients with diabetes mellitus. The prevalence of CTS is higher in diabetic patients with peripheral polyneuropathy compared to patients with diabetes, who do not have diabetes-related late complications (30% vs. 14%). Moreover, CTS seems to be a risk factor for later manifestation of diabetes mellitus, as patients with newly diagnosed diabetes showed CTS manifestation 1.4-fold more often than the age-matched reference population. This paper describes the diagnostics, differential diagnostics and particularities in the therapy of patients with both CTS and diabetes. In case of oral or local application of corticoids, the persistent elevation of blood glucose levels has to be taken into account with potential need for intensification of diabetes therapy. In case of progression of the CTS, surgery is indicated.