Hand Surgery after Breast Cancer

As a breast cancer survivor, are you living with hand or upper extremity impairments due to outdated medical assumptions?

After axillary lymph node dissection for the treatment of malignancies, patients have been cautioned to avoid procedures on the ipsilateral upper extremity to avoid risks of infections, wound healing complications, and lymphedema.

Despite changes in breast cancer treatment, recommendations and precautions regarding lymphedema and procedures in the ipsilateral arm have been ingrained in patients as well as physicians. Patients might chose to live with a painful but treatable condition, or physicians themselves might discourage patients from having an elective surgery, even in the absence of lymphedema. Thus patients often forego surgeries for hand and upper extremity conditions, though there is little data in the literature and no consensus in the recommendations for these patients. Learn more about twenty years of research that can put your mind at ease, and lead you to the relief you seek.

Lymphedema occurs when the lymphatic system fails to drain the lymph volume, thereby causing fluid to accumulate in tissues. Breast cancer treatment can affect the lymph system at the axillary lymph node level or the tissue level. Axillary lymph node dissection, mastectomy, and irradiation can interrupt the lymphatic system by node removal or scarring. The incidence of lymphedema following breast cancer treatment has been reported to range from 6% to 70%. The highest incidence has been shown to be with radical mastectomy, axillary dissection, and irradiation.

Example of Study Results

The following is the summary of one study found in the list below. Since they are prepared for the medical community, they are not written for the average lay person. For those interested in getting a more thorough idea of the research results on this topic over the last twenty or so years, this is time well spent.

Hand Surgery After Axillary Lymph Node Dissection for Cancer
Rushyuan Jay Lee, MD; Dawn M. Laporte, MD; E. Gene Deune, MD, MBA
Orthopaedics, Johns Hopkins Hospital, Baltimore, MD

Introduction: After axillary lymph node dissection for the treat of malignancies, patients are cautioned to avoid procedures on the ipsilateral upper extremity to avoid the risks of infections, wound healing complications, and lymphedema. Thus patients often forego surgeries for hand ailments, though there is little data in the literature and no consensus in the recommendations for these patients. The purpose of this study is to evaluate if patients who have had axillary lymph node dissection have an increased incidence of postoperative complications.

Methods: A review of all patients presenting to our hand clinic for two senior surgeons over a 13-year period was performed (1998-2011). Patients with the diagnosis of breast cancer or melanoma or a history of prior axillary lymph node dissection were selected. Operative and clinic notes were reviewed. Patients who were treated without surgical intervention and those who had elective hand surgery in the contralateral upper extremity were excluded.

Results: 147 patients were identified. 52 patients were treated surgically for various hand conditions. Of this group, 20 patients (19 females with breast cancer, 1 male with melanoma) had axillary lymph node dissection on the ipsilateral extremity. Procedures included 7 carpal tunnel releases, 6 trigger finger releases, 4 soft tissue lesion excisions, and 1 each of Dupuytren’s release, CMC arthroplasty, scar revision, flexor tendon repair, and foreign object removal. 2 patients had concomitant procedures. The average age at the time of lymph node dissection was 55.1 years (37.5-73.6); age at the time of hand surgery was 64.5 years (41.6-83.5). The interval between the two surgeries was 8.2 years (7 days-37.3 years). 4 of these patients had pre-existing lymphedema. Post-operatively there was no exacerbation of existing lymphedema and no new cases of lymphedema. 4 patients (25%) had periincisional erythema, requiring oral antibiotics for presumed superficial infection. 2 patients had issues with incisional pain and scarring, each resolved after corticosteroid treatment. No patients required a return to the operating room.

Conclusion: With breast cancer alone diagnosed at a rate of more than 200,000 per year in the United States, there are likely many such patients with a history of lymph node dissection. We have shown, in our limited number of patients, that routine minor hand surgery does not result in lymphedema and did not increase existing lymphedema in patients who had a previous ipsilateral axillary lymph node dissection. This study suggests surgery may be pursued safely.

References

  1. Ganel A, Engel J, Sela M, Brooks M. Nerve entrapments associated with post-mastectomy lymphedema. Cancer. 1979;44:2254-9. [PubMed]
  2. Breast Cancer Care UK. Reducing the risk of lymphoedema. How can I reduce my risk of developing lymphoedema. 2006:2. [Booklet]
  3. Bozentka DJ, Beredjiklian PK, Chan PSH, Schmidt S, Buzby GP, Bora F. Hand related disorders following axillary dissection for breast cancer. Uni Pennsylvania Orthop J. 2001; 14:35-7.
  4. Dawson WJ, Elenz DR, Winchester DP, Feldman JL. Elective hand surgery in the breast cancer patient with prior ipsilateral axillary dissection. Ann Surg Oncol. 1995;2:132-7. [PubMed]
  5. Hershko DD, Stahl S. Safety of elective hand surgery following axillary lymph node dissection for breast cancer. Breast 1. 2007;13:287-90. [PubMed]
  6. Gharbaoui IS, Netscher DT, Thornby J, Kessler F. Safety of upper extremity surgery after treatment for ipsilateral breast cancer: Results of an American Society For Surgery of the Hand
    membership survey and literature review. J Am Soc Surg Hand. 2005;5:232-8.
  7. Donachy JE, Christian EL. Physical therapy intervention following surgical treatment of carpal tunnel syndrome in an individual with a history of postmastectomy lymphedema. Phys
    Ther. 2002;82:1009-16. [PubMed]
  8. Larson D, Weinstein M, Goldberg I, Silver B, Recht A, Cady B, et al. Edema of the arm as a function of the extent of axillary surgery in patients with stage I-II carcinoma of the breast
    treated with primary radiotherapy. Int J Radiat Oncol Biol Phys. 1986;12:1575-82. [PubMed]
  9. Assmuss H, Staub F. Postmastectomy lymphoedema and carpal tunnel syndrome. Surgical advice and considerations for patients. Handchir Mikrochir Plast Chir. 2004;36:237-40. [PubMed]
  10. Tzarnas CD. Carpal tunnel release without a tourniquet. J Hand Surg Am. 1993;18:1041-3. [PubMed]
  11. Braithwaite BD, Robinson GJ, Burge PD. Haemostasis during carpal tunnel release under local anaesthesia: a controlled comparison of a tourniquet and adrenaline infiltration. J Hand
    Surg Br. 1993;18:184-6. [PubMed]
  12. Sonrnez A, Yarnan M, Ersoy B, Numanodluj A. Digital blocks with and without adrenala randomised-controlled study of capillary blood parameters. Hand Surg Eur. 2008;33 :515-8. [PubMed]