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Wu EJ, Lai CH, Muraoka K, Segovia N, Kleimeyer JP, Yao J. Prospective Analysis of Simulated Pneumatic Tourniquet Use and Oedema Following Axillary Lymph Node Dissection. J Hand Surg Asian Pac Vol 2024; 29:29-35. [PMID: 38299248 DOI: 10.1142/s242483552450005x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/02/2024]
Abstract
Background: Tourniquet use during upper extremity surgery in patients with a history of axillary lymph node dissection (ALND) remains controversial due to the perceived but unproven risk of lymphoedema. We prospectively evaluated upper extremity swelling in patients with a history of unilateral ALND using a standardised tourniquet model. Methods: A tourniquet was applied to the upper arm bilaterally, with the unaffected side serving as an internal control. Each arm was subsequently held in an elevated position to reduce swelling. Hand volume was measured using an aqueous volumeter. Results: The patients' ALND arms experienced slightly greater increases in volume following tourniquet application compared to their healthy control arms. However, this amount of oedema was temporary and reversible, as both arms experienced spontaneous resolution of swelling with no significant difference in residual hand volume at the conclusion of the study. Conclusions: Tourniquet use may be safe in patients with a history of ALND. Further investigation is needed to verify this in a surgical setting. Level of Evidence: Level II (Therapeutic).
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Affiliation(s)
- Edward J Wu
- Department of Orthopaedic Surgery, Stanford University School of Medicine, Redwood City, CA, USA
- Department of Orthopedic Surgery, University of Minnesota Medical School, Minneapolis, MN, USA
| | - Cara H Lai
- Department of Orthopaedic Surgery, Stanford University School of Medicine, Redwood City, CA, USA
| | - Kunihide Muraoka
- Department of Orthopaedic Surgery, Stanford University School of Medicine, Redwood City, CA, USA
| | - Nicole Segovia
- Department of Orthopaedic Surgery, Stanford University School of Medicine, Redwood City, CA, USA
| | - John P Kleimeyer
- Department of Orthopaedic Surgery, Stanford University School of Medicine, Redwood City, CA, USA
| | - Jeffrey Yao
- Department of Orthopaedic Surgery, Stanford University School of Medicine, Redwood City, CA, USA
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Fitzgerald MJ, Galina J, Kolodka E, Henig A, Hasan S, Maltser S, Lane LB, Nellans KW. The Risk of Lymphedema After Breast Cancer Surgery Should Not Restrict Necessary Hand Surgery Interventions. Hand (N Y) 2023:15589447231155583. [PMID: 37545375 DOI: 10.1177/15589447231155583] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 08/08/2023]
Abstract
BACKGROUND The purpose of this study was to evaluate the incidence of lymphedema onset or exacerbation in patients undergoing upper extremity interventions, both nonoperative and operative, after breast cancer surgery. METHODS The study inclusion criteria were the following: (1) prior history of breast cancer surgery or lymphedema from the cancer; (2) upper extremity intervention, ipsilateral to the breast cancer side; and (3) follow-up of at least 1 month. Patients were evaluated for demographic information, type of breast cancer procedure and hand intervention, number of lymph nodes dissected, preexisting lymphedema, exacerbation of lymphedema, and new-onset lymphedema. RESULTS A total of 161 patients undergoing 385 hand interventions (300 injections, 85 surgeries) were reviewed. Median follow-up was 31 months (range: 1-110). Nineteen patients had preexisting lymphedema ipsilateral to the hand procedure and none experienced an exacerbation of their lymphedema. Three patients developed new-onset lymphedema ipsilateral to their hand intervention at an average follow-up of 30 months (range: 4-67). One patient had a single injection and developed lymphedema over 5 years later. One had 2 injections in the same hand on the same date and developed lymphedema 3 months later. The third patient had 2 injections in the right hand, 1 injection and 1 surgery in the left hand, and developed either lymphedema or swelling due to rheumatoid arthritis in the right hand 1 year after the injections. CONCLUSIONS Patients who have undergone breast cancer surgery can safely undergo upper extremity intervention with low risk of lymphedema exacerbation or onset.
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Affiliation(s)
- Michael J Fitzgerald
- Donald and Barbara Zucker School of Medicine at Hofstra/Northwell Health, New Hyde Park, NY, USA
| | - Jesse Galina
- Donald and Barbara Zucker School of Medicine at Hofstra/Northwell Health, New Hyde Park, NY, USA
| | - Emily Kolodka
- Donald and Barbara Zucker School of Medicine at Hofstra/Northwell Health, New Hyde Park, NY, USA
| | - Ariel Henig
- Donald and Barbara Zucker School of Medicine at Hofstra/Northwell Health, New Hyde Park, NY, USA
| | - Sayyida Hasan
- Donald and Barbara Zucker School of Medicine at Hofstra/Northwell Health, New Hyde Park, NY, USA
| | - Susan Maltser
- Donald and Barbara Zucker School of Medicine at Hofstra/Northwell Health, New Hyde Park, NY, USA
| | - Lewis B Lane
- Donald and Barbara Zucker School of Medicine at Hofstra/Northwell Health, New Hyde Park, NY, USA
| | - Kate W Nellans
- Donald and Barbara Zucker School of Medicine at Hofstra/Northwell Health, New Hyde Park, NY, USA
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Is Smoking Associated with Carpal Tunnel Syndrome? A Meta-Analysis. Healthcare (Basel) 2022; 10:healthcare10101988. [PMID: 36292435 PMCID: PMC9601480 DOI: 10.3390/healthcare10101988] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/31/2022] [Revised: 10/06/2022] [Accepted: 10/08/2022] [Indexed: 11/04/2022] Open
Abstract
To date, the role of smoking in carpal tunnel syndrome (CTS) is unclear. The aim of this systematic review and meta-analysis was to assess the association between smoking and CTS. The literature searches were conducted in PubMed, Embase, and Scopus, from inception until October 2021. Three reviewers screened the titles, abstracts, and full-text articles and evaluated the methodological quality of the included studies. A random-effects meta-analysis was used, and heterogeneity across studies was examined using I2 statistic. A total of 31 (13 cross-sectional, 10 case-control, and 8 cohort) studies were qualified for meta-analysis. In a meta-analysis of cohort studies, the risk of CTS did not differ between current and never smokers (pooled hazard ratio (HR) 1.09, 95% CI 0.84–1.43), current and past/never smokers (HR 1.07, 95% CI 0.94–1.23), and past and never smokers (HR 1.12, 95% CI 0.83–1.49). Furthermore, a meta-analysis of case control studies found no difference in the risk of CTS between current and never smokers (pooled odds ratio (OR) 0.92, 95% CI 0.56–1.53), current and past/never smokers (OR 1.10, 95% CI 0.51–2.36), and past and never smokers (OR 0.91, 95% CI 0.59–1.39). However, a meta-analysis of cross-sectional studies showed the associations of ever (OR 1.36, 95% CI 1.08–1.72) and current smoking (OR 1.52, 95% CI 1.11–2.09) with CTS. However, the association between ever smoking and CTS disappeared after limiting the meta-analysis to higher quality studies or after adjusting for publication bias. The association between current smoking and CTS also attenuated after limiting the meta-analysis to studies that confirmed CTS by a nerve conduction study or studies with low attrition bias. This meta-analysis does not support an association between smoking and CTS. The association between smoking and CTS observed in cross-sectional studies could be due to biases and/or confounding factors.
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Ricci V, Ricci C, Gervasoni F, Giulio C, Farì G, Andreoli A, Özçakar L. From physical to ultrasound examination in lymphedema: a novel dynamic approach. J Ultrasound 2022; 25:757-763. [PMID: 35000129 PMCID: PMC9402863 DOI: 10.1007/s40477-021-00633-4] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/11/2021] [Accepted: 10/11/2021] [Indexed: 11/25/2022] Open
Abstract
In daily practice, medical history and physical examination are commonly coupled with anthropometric measurements for the diagnosis and management of patients with lymphatic diseases. Herein, considering the current progress of ultrasound imaging in accurately assessing the superficial soft tissues of the human body; it is noteworthy that ultrasound examination has the potential to augment the diagnostic process. In this sense/report, briefly revisiting the most common clinical maneuvers described in the pertinent literature, the authors try to match them with possible (static and dynamic) sonographic assessment techniques to exemplify/propose an 'ultrasound-guided' physical examination for different tissues in the evaluation of lymphedema.
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Affiliation(s)
- Vincenzo Ricci
- Physical and Rehabilitation Medicine Unit, Luigi Sacco University Hospital, ASST Fatebenefratelli-Sacco, Milan, Italy.
| | - Costantino Ricci
- Pathology Unit, Maggiore Hospital, Bologna, Italy
- Department of Experimental, Diagnostic and Specialty Medicine (DIMES), University of Bologna, Bologna, Italy
| | - Fabrizio Gervasoni
- Physical and Rehabilitation Medicine Unit, Luigi Sacco University Hospital, ASST Fatebenefratelli-Sacco, Milan, Italy
| | - Cocco Giulio
- Unit of Ultrasound in Internal Medicine, Department of Medicine and Science of Aging, G. d'Annunzio University, Chieti, Italy
| | - Giacomo Farì
- Section of Physical Medicine and Rehabilitation, Department of Basic Medical Sciences, Neuroscience and Sensory Organs, University of Bari, Bari, Italy
| | - Arnaldo Andreoli
- Physical and Rehabilitation Medicine Unit, Luigi Sacco University Hospital, ASST Fatebenefratelli-Sacco, Milan, Italy
| | - Levent Özçakar
- Department of Physical and Rehabilitation Medicine, Hacettepe University Medical School, Ankara, Turkey
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Forte AJ, Huayllani MT, Boczar D, Manrique OJ, Lu X, McLaughlin SA, Kung TA. A Systematic Review of Peripheral Neuropathies in Breast Cancer-Related Lymphedema. Hand (N Y) 2022; 17:668-675. [PMID: 33073616 PMCID: PMC9274882 DOI: 10.1177/1558944720963944] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
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.
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Affiliation(s)
- Antonio J. Forte
- Mayo Clinic, Jacksonville, FL, USA,Antonio J. Forte, Division of Plastic Surgery, Mayo Clinic, 4500 San Pablo Road, Jacksonville, FL 32224, USA.
| | | | | | | | - Xiaona Lu
- Yale School of Medicine, New Haven, CT, USA
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Kim SB, Moon KC. Surgical treatment of carpal tunnel syndrome in advanced-stage upper extremity lymphedema: A case report. Medicine (Baltimore) 2021; 100:e25872. [PMID: 34011053 PMCID: PMC8137099 DOI: 10.1097/md.0000000000025872] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/05/2021] [Accepted: 04/21/2021] [Indexed: 01/05/2023] Open
Abstract
RATIONALE Despite significant advances in microsurgical techniques, simultaneous release of transverse carpal ligament (TCL) and lymphovenous anastomosis (LVA) surgeries may be effective for treatment of carpal tunnel syndrome (CTS) and advanced-stage lymphedema. This case report describes the successful treatment of lymphedema with LVA in a patient with CTS and advanced-stage lymphedema. PATIENT CONCERNS A 60-year-old female patient was referred to our lymphedema clinic with a 12-year history of chronic, acquired, right upper extremity lymphedema and CTS following right mastectomy and axillary lymph node dissection and adjuvant chemoradiotherapy for treating breast cancer. DIAGNOSIS According to the indocyanine green lymphography, magnetic resonance lymphangiography, and electromyography, the patient was diagnosed with CTS and advanced-stage lymphedema (International Society of Lymphology late stage 2). INTERVENTION Release of the TCL was performed first, followed by LVA at the wrist, forearm, and antecubital area. The right arm was compressed and elevated immediately postoperatively and postoperative compression bandage therapy with 35 to 40 mm Hg pressure was instituted following surgery. OUTCOMES After 2 simultaneous surgeries, the patient had significant circumference and volume reduction of the right hand. The CTS and lymphedema symptoms have decreased following synchronous TCL release and LVA surgeries. LESSONS Simultaneous LVA and release of the TCL may be effective and safe in patients with advanced lymphedema and CTS.
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Baran E, Özçakar L, Özgül S, Aksoy S, Akbayrak T. Upper limb sensory evaluations and ultrasonographic skin measurements in breast cancer-related lymphedema receiving complex decongestive physiotherapy. Support Care Cancer 2021; 29:6545-6553. [PMID: 33913006 PMCID: PMC8081563 DOI: 10.1007/s00520-021-06235-4] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/14/2021] [Accepted: 04/19/2021] [Indexed: 11/25/2022]
Abstract
Purpose The aims of this study were to investigate if/how the presence of lymphedema affects the sensation of the upper limb and to assess whether complex decongestive physiotherapy (CDP) has a favorable impact on sensory testing. Methods A total of 27 patients with unilateral stage 2 breast cancer–related lymphedema (BCRL) were included in the study. Bilateral circumferential measurements were taken with a tape measure at different levels. Based on these measurements, limb volumes were determined by summing segment volumes derived from the truncated cone formula. Circumferential measurements and ultrasonographic evaluations (epidermis, dermis, and subcutaneous fat thicknesses) were performed at 10 cm distal to the elbow crease. The Semmes–Weinstein monofilament (SWM), static and moving two-point discrimination, pressure pain threshold (PPT), and tactile localization tests were also applied at the same site. After an initial evaluation, all patients underwent CDP phase 1 program. All the evaluations were repeated at the end of the treatment period. Results Before CDP, affected sides had significantly higher values than the unaffected sides in terms of SWM (p < 0.001), static (p = 0.002) and moving (p = 0.011) two-point discrimination, PPT (p = 0.001), and tactile localization (p < 0.001) values. After CDP, SWM (p = 0.002), static (p = 0.009) and moving (p = 0.024) two-point discrimination, PPT (p = 0.014), and tactile localization (p < 0.001) values decreased significantly on the affected sides. Conclusion BCRL seems to reduce light touch, static and moving two-point discrimination, PPT, and tactile localization sensations, whereas CDP seems to improve these sensory perceptions in women with BCRL. Ultrasonographic measurements also appear to be promising for prompt and convenient follow-up in the management of BCRL. Trial registration Clinical Trial Registration Number: NCT04296929 (date of registration: March 5, 2020)
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Affiliation(s)
- Emine Baran
- Faculty of Physical Therapy and Rehabilitation, Hacettepe University, 06100, Samanpazari, Ankara, Turkey.
| | - Levent Özçakar
- Faculty of Medicine, Department of Physical and Rehabilitation Medicine, Hacettepe University, Ankara, Turkey
| | - Serap Özgül
- Faculty of Physical Therapy and Rehabilitation, Hacettepe University, 06100, Samanpazari, Ankara, Turkey
| | - Sercan Aksoy
- Faculty of Medicine, Department of Medical Oncology, Hacettepe University, Ankara, Turkey
| | - Türkan Akbayrak
- Faculty of Physical Therapy and Rehabilitation, Hacettepe University, 06100, Samanpazari, Ankara, Turkey
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Timmins HC, Li T, Huynh W, Kiernan MC, Baron-Hay S, Boyle F, Goldstein D, Park SB. Electrophysiological and phenotypic profiles of taxane-induced neuropathy. Clin Neurophysiol 2020; 131:1979-1985. [PMID: 32291143 DOI: 10.1016/j.clinph.2020.02.028] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/23/2019] [Revised: 02/04/2020] [Accepted: 02/20/2020] [Indexed: 12/22/2022]
Abstract
OBJECTIVE To comprehensively describe patient-reported, functional and neurophysiological outcomes to elucidate the phenotypic profile of taxane-induced neuropathy. METHODS Taxane-treated patients (n = 47) completed cross-sectional bilateral clinical and sensory assessments and nerve conduction studies. Patients reported symptom severity via Functional Assessment of Cancer Therapy/Gynecologic Oncology Group-Neurotoxicity (FACT/GOG-Ntx13) questionnaire. RESULTS Symptoms of neuropathy were reported by 81% of patients. On clinical examination, 62% had 2 or more abnormalities, with 20% indicating significant symptomatic and objective neuropathy. Nerve conduction studies were consistent with a sensory predominant axonal neuropathy. However, features more typical of entrapment neuropathy were also present in > 50%, which were not associated with overall severity of chemotherapy-induced peripheral neuropathy (CIPN) or clinical risk factors. CONCLUSIONS There is considerable variation in CIPN phenotypes associated with taxane-treatment. Understanding their clinical associations may assist in identification of patients at risk of severe neurotoxicity. This would enable treatment modification decisions but also limit early cessation of effective anti-cancer treatment in patients with less severe neurological sequelae. SIGNIFICANCE Understanding the CIPN phenotype may inform treatment decisions which could impact clinical and survival outcomes.
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Affiliation(s)
- Hannah C Timmins
- Brain and Mind Centre, Faculty of Medicine and Health, University of Sydney, Australia
| | - Tiffany Li
- Brain and Mind Centre, Faculty of Medicine and Health, University of Sydney, Australia
| | - William Huynh
- Brain and Mind Centre, Faculty of Medicine and Health, University of Sydney, Australia; Prince of Wales Clinical School, UNSW, Australia
| | - Matthew C Kiernan
- Brain and Mind Centre, Faculty of Medicine and Health, University of Sydney, Australia
| | - Sally Baron-Hay
- Department of Oncology, Royal North Shore Hospital, Australia
| | - Frances Boyle
- Patricia Ritchie Centre for Cancer Care and Research, Mater Hospital, Australia
| | | | - Susanna B Park
- Brain and Mind Centre, Faculty of Medicine and Health, University of Sydney, Australia.
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An Evaluation of Safety and Patient Outcomes for Hand Surgery following Prior Breast Cancer Treatment: Establishing New Recommendations in Lymphedema. Plast Reconstr Surg 2020; 145:459-467. [DOI: 10.1097/prs.0000000000006438] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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10
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Marešová D, Kotková K, Kozler P, Pokorný J. Forelimb Movement Disorder in Rat Experimental Model. Physiol Res 2019; 68:1037-1042. [PMID: 31647297 DOI: 10.33549/physiolres.934172] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
Abstract
Study of motor activity is an important part of the experimental models of neural disorders of rats. It is used to study effects of the CNS impairment, however studies on the peripheral nervous system lesions are much less frequent. The aim of the study was to extend the spectrum of experimental models of anterior limb movement disorders in rats by blockade of the right anterior limb brachial plexus with the local anesthetic Marcaine (Ma), or with aqua for injection administered into the same location (Aq) (with control intact group C). Two other groups with anterior limb movement disorders underwent induction of cellular brain edema by water intoxication (MaWI and AqWI). Results showed a lower spontaneous motor activity of animals in all experimental groups versus controls, and lower spontaneous motor activity of animals in the MaWI group compared to other experimental groups in all categories. There was no difference in spontaneous activity between the groups Ma, Aq and AqWI. Our study indicates that alterations of spontaneous motor activity may result from the impaired forelimb motor activity induced by the anesthetic effect of Marcaine, by the volumetric effect of water, as a result of induced brain edema, or due to combination of these individual effects.
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Affiliation(s)
- D Marešová
- Institute of Physiology, First Faculty of Medicine, Charles University in Prague, Prague, Czech Republic.
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11
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Ayhan FF, Aykut M, Genç H, Mansız Kaplan B, Soran A. Is Complex Decongestive Physical Therapy Safe for Median Nerve at the Level of Carpal Tunnel in Breast Cancer Related Lymphedema? Lymphat Res Biol 2018; 17:78-86. [PMID: 30358471 DOI: 10.1089/lrb.2018.0011] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
BACKGROUND Multilayer bandaging used in complex decongestive therapy (CDT) may increase tissue pressure resulting in nerve entrapments. The aim of this study was to discover if median nerve damage is a consequence of CDT in patients with breast cancer-related lymphedema (BCRL). METHODS AND RESULTS Eighty-two arms of 41 patients with BCRL were included. Mean age was 56.05 (8.16) years and all stages of lymphedema were equally included. Fifteen sessions of CDT was applied to all patients. The calculated volume of extremities, the quality of life (cancer adaptation of Ferrans-Powell), neuropathic pain (NP; Douleur Neuropathique 4), and disability (quick disabilities of arm, shoulder, and hand [Q-DASH]) tests were recorded before and after therapy. Skin and subcutaneous tissue thicknesses of volar and dorsal sides and median nerve cross-sectional area (CSA) at the level of carpal tunnel were measured using ultrasonography (US), before and after therapy. Carpal tunnel syndrome (CTS; 41.37%) and polyneuropathy (10.34%) were common findings confirmed by electromyography. Neuropathic pain profile was also found in 34.14% of patients. The arm volume of affected side, quality of life, and skin and subcutaneous tissue thicknesses were improved after therapy (p < 0.05). However, median nerve CSA, the NP, and Q-DASH scores were not changed after therapy. CONCLUSIONS Although lymphedema is a painless condition, NP and CTS should not be ignored in patients with BCRL. US is an alternative, precise, and high technological method for evaluating treatment response. CDT is an effective and safe treatment according to volumetric calculations, US measurements of tissue thicknesses, and median nerve size.
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Affiliation(s)
- F Figen Ayhan
- 1 Division of Oncologic Rehabilitation and Lymphedema, Department of Physical Medicine and Rehabilitation, Ankara Training and Research Hospital, Health Sciences University, Ankara, Turkey.,2 Department of Physical Therapy and Rehabilitation, High School of Health, Uşak University, Uşak, Turkey
| | - Melek Aykut
- 1 Division of Oncologic Rehabilitation and Lymphedema, Department of Physical Medicine and Rehabilitation, Ankara Training and Research Hospital, Health Sciences University, Ankara, Turkey
| | - Hakan Genç
- 1 Division of Oncologic Rehabilitation and Lymphedema, Department of Physical Medicine and Rehabilitation, Ankara Training and Research Hospital, Health Sciences University, Ankara, Turkey
| | - Başak Mansız Kaplan
- 1 Division of Oncologic Rehabilitation and Lymphedema, Department of Physical Medicine and Rehabilitation, Ankara Training and Research Hospital, Health Sciences University, Ankara, Turkey
| | - Atilla Soran
- 3 Department of Surgery, Magee Women Hospital, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
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12
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Radial Nerve Injury Caused by Compression Garment for Lymphedema: A Case Report. PM R 2018; 11:436-439. [PMID: 30300765 DOI: 10.1016/j.pmrj.2018.09.039] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/23/2018] [Accepted: 09/26/2018] [Indexed: 11/24/2022]
Abstract
Lymphedema is a condition characterized by localized fluid retention and tissue swelling caused by a compromised lymphatic system. To minimize fluid buildup and stimulate the flow of fluid through the lymphatic system, compression garments are usually applied to patients with lymphedema. There are few studies to report complications of compression garments to treat breast cancer-related lymphedema. To our knowledge, this is the first report of radial nerve compression neuropathy associated with wearing a compression garment to treat lymphedema. Level of Evidence: V.
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13
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Ciudad P, Manrique OJ, Date S, Agko M, Chang WL, Chen HC. Simultaneous vascularized lymph node transfer and carpal tunnel release for treatment of advanced stage of breast cancer-related lymphedema with carpal tunnel syndrome. Microsurgery 2017; 37:745-746. [PMID: 28688165 DOI: 10.1002/micr.30196] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/05/2016] [Revised: 03/22/2017] [Accepted: 06/09/2017] [Indexed: 11/08/2022]
Affiliation(s)
- Pedro Ciudad
- Department of Plastic and Reconstructive Surgery; China Medical University Hospital; Taichung Taiwan
- Department of Biological Science and Technology; China Medical University; Taichung Taiwan
| | - Oscar J Manrique
- Department of Plastic and Reconstructive Surgery; China Medical University Hospital; Taichung Taiwan
| | - Shivprasad Date
- Department of Plastic and Reconstructive Surgery; China Medical University Hospital; Taichung Taiwan
| | - Mouchammed Agko
- Department of Plastic and Reconstructive Surgery; China Medical University Hospital; Taichung Taiwan
| | - Wei-Ling Chang
- Department of Plastic and Reconstructive Surgery; China Medical University Hospital; Taichung Taiwan
| | - Hung-Chi Chen
- Department of Plastic and Reconstructive Surgery; China Medical University Hospital; Taichung Taiwan
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Abstract
Edema of the arm with associated recurrent bouts of cellulitis, occurring immediately or as late as twenty years after treatment of breast cancer, has been a very common and major complication since the initiation of surgical treat ment of breast cancer. We now know the cause and have developed methods to prevent and treat the complication.
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Affiliation(s)
- Philip G. Gallagher
- Tufts Medical School, Instructor in Surgery, Harvard Medical School, Cambridge, Massachusetts
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15
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Stubblefield MD, Kim A, Riedel ER, Ibanez K. Carpal tunnel syndrome in breast cancer survivors with upper extremity lymphedema. Muscle Nerve 2015; 51:864-9. [DOI: 10.1002/mus.24506] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/17/2014] [Revised: 10/21/2014] [Accepted: 10/27/2014] [Indexed: 11/12/2022]
Affiliation(s)
- Michael D. Stubblefield
- Department of Neurology, Rehabilitation Medicine Service, Memorial Sloan Kettering Cancer Center; Sillerman Center for Rehabilitation; 515 Madison Avenue, 5th Floor New York New York 10022 USA
| | - Arum Kim
- Department of Rehabilitation Medicine, New York Presbyterian Hospital; University Hospital of Columbia and Cornell; New York New York USA
| | - Elyn R. Riedel
- Department of Epidemiology and Biostatistics; Memorial Sloan Kettering Cancer Center; New York New York USA
| | - Katarzyna Ibanez
- Department of Neurology, Rehabilitation Medicine Service, Memorial Sloan Kettering Cancer Center; Sillerman Center for Rehabilitation; 515 Madison Avenue, 5th Floor New York New York 10022 USA
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Lee RJ, LaPorte DM, Brooks JT, Schubert CD, Deune EG. Elective hand surgery after axillary lymph node dissection for cancer. Orthopedics 2015; 38:e367-73. [PMID: 25970362 DOI: 10.3928/01477447-20150504-52] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/03/2014] [Accepted: 07/28/2014] [Indexed: 02/03/2023]
Abstract
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.
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Upper Body Pain and Functional Disorders in Patients With Breast Cancer. PM R 2013; 6:170-83. [DOI: 10.1016/j.pmrj.2013.08.605] [Citation(s) in RCA: 108] [Impact Index Per Article: 9.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/26/2013] [Revised: 08/06/2013] [Accepted: 08/08/2013] [Indexed: 11/22/2022]
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Upper extremity surgery after lymph node dissection. J Hand Surg Am 2011; 36:1684-6. [PMID: 21741775 DOI: 10.1016/j.jhsa.2011.06.003] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/30/2011] [Accepted: 06/05/2011] [Indexed: 02/02/2023]
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Kara M, Özçakar L, Malas FÜ, Kara G, Altundağ K. Median, Ulnar, and Radial Nerve Entrapments in a Patient with Breast Cancer after Treatment for Lymphedema. Am Surg 2011. [DOI: 10.1177/000313481107700239] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Affiliation(s)
- Murat Kara
- Hacettepe University Medical School Ankara, Turkey
| | | | | | - Gamze Kara
- Hacettepe University Medical School Ankara, Turkey
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Fulford D, Dalal S, Winstanley J, Hayton MJ. Hand surgery after axillary lymph node clearance for breast cancer: contra-indication to surgery? Ann R Coll Surg Engl 2010; 92:573-6. [PMID: 20587171 DOI: 10.1308/003588410x12699663904475] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
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.
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Affiliation(s)
- Dean Fulford
- Department of Orthopaedics, Royal Bolton Hospital, Farnworth, UK.
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Effective treatment of the brachial plexus syndrome in breast cancer patients by early detection and control of loco-regional metastases with radiation or systemic therapy. Int J Clin Oncol 2009; 14:219-24. [DOI: 10.1007/s10147-008-0838-3] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/19/2008] [Accepted: 09/12/2008] [Indexed: 10/20/2022]
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Nishihori T, Choi J, DiGiovanna MP, Thomson JG, Kohler PC, McGurn J, Chung GG. Carpal tunnel syndrome associated with the use of aromatase inhibitors in breast cancer. Clin Breast Cancer 2008; 8:362-5. [PMID: 18757265 DOI: 10.3816/cbc.2008.n.043] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
Aromatase inhibitors (AI) inhibit peripheral conversion of androgens to estradiol and are commonly used as hormonal therapy for postmenopausal women with hormone receptor-positive breast cancer in the metastatic and adjuvant settings. Joint-related symptoms, however, are seen in a significant proportion of patients. Carpal tunnel syndrome (CTS) is a common nerve entrapment disorder affecting the median nerve. We describe 6 patients with newly diagnosed CTS after initiation of adjuvant AI therapy. Aromatase inhibitors were discontinued in several patients secondary to this toxicity with some switching to tamoxifen and most subsequently experiencing relief of their symptoms. Potential pathophysiologic roles of hormonal manipulation with AIs and other risk factors that might contribute to CTS are discussed. Aromatase inhibitors might accentuate the occurrence of CTS and potentially other nerve entrapment syndromes, and a more systematic approach should be used to better understand the clinical significance and incidence of these symptoms.
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Affiliation(s)
- Taiga Nishihori
- Department of Internal Medicine, Medical Oncology, Yale University School of Medicine, Yale Comprehensive Cancer Center, New Haven, CT, USA
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Hershko DD, Stahl S. Safety of Elective Hand Surgery Following Axillary Lymph Node Dissection for Breast Cancer. Breast J 2007; 13:287-90. [PMID: 17461904 DOI: 10.1111/j.1524-4741.2007.00423.x] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2022]
Abstract
The development of lymphedema is the most feared complication shared by breast cancer survivors undergoing hand surgery after prior axillary lymph node dissection (ALND). Traditionally, these patients are advised to avoid any interventional procedures in the ipsilateral upper extremity. However, the appropriateness of some of these precautions was recently challenged by some surgeons claiming that elective hand operations can be safely performed in these patients. The purpose of this study was to evaluate our experience and determine the safety of elective hand operations in breast cancer survivors. The medical records of patients operated for different hand conditions after prior breast surgery and ALND at our institution between 1983 and 2002 were reviewed. The techniques and preventive measures performed, use of antibiotics, and upper extremity complications associated with the operations were analyzed. Overall, we operated on 27 patients after prior ALND performed for breast cancer. Follow-up was available for 25 patients. Four patients had pre-existing lymphedema. The surgical technique used was similar to that performed in patients without prior ALND and antibiotic prophylaxis was not given. Delayed wound healing was observed in one patient and finger joint stiffness in another. Two patients with pre-existing lymphedema developed temporary worsening of their condition. None of the patients developed new lymphedema. The results of the present study support the few previous studies, suggesting that hand surgery can be safely performed in patients with prior ALND. Based on these findings, the appropriateness of the rigorous precautions and prohibitions regarding the care and use of the ipsilateral upper extremity may need to be reconsidered.
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Affiliation(s)
- Dan D Hershko
- Department of Surgery A, Breast Health Institute, Rambam Health Care Campus, Haifa, Israel.
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Vignes S, Arrault M, Ebelin M. Effet délétère d’un acte chirurgical sur le volume d’un lymphœdème du membre supérieur après cancer du sein. ACTA ACUST UNITED AC 2006; 31:202-5. [PMID: 17088788 DOI: 10.1016/s0398-0499(06)76544-1] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
OBJECTIVES Secondary upper lymphedema occurs in 15 to 20% of patients after breast cancer treatment. Surgery may be required on lymphedematous limb. The aim of our study was to analyze the effects of surgery on lymphedema volume. METHODS Nine women with upper limb lymphedema after breast cancer treatment were recruited. Mean age at time of breast cancer was 45.6 +/- 8 years. Breast cancer was localized at right side and was treated with mammectomy (n=4), radiotherapy (n=8), chemotherapy (n=4) and antiestrogen (n=5). Mean duration of lymphedema before upper limb surgery was 10 years. Six patients reported one or more previous cellulitis. Surgery was indicated for carpal tunnel syndrome (n=6), forearm (n=2) or humeral (n=1) fracture. Lymphedema volume, calculated by the difference of volume between the lymphedematous and the contralateral arm, was compared before and after surgery. RESULTS Six patients had carpal tunnel release by transecting the transverse carpal ligament under local anesthesia with short total time tourniquet. Humeral and forearm fractures were treated with osteosynthesis. Before surgery, lymphedema volume of upper limb was 747 +/- 315 ml. Lymphedema management included low stretch bandages, elastic sleeve, manual lymph drainage. After 8 months follow up, lymphedema volume was significantly higher, 858 +/- 293 ml (p=0.012). Mean absolute variation of lymphedema volume was 111 ml (CI 95%: 32 to 109 ml), i.e. 15% of pre surgery lymphedema volume. CONCLUSION Surgery of carpal tunnel syndrome or osteosynthesis for fractures may lead to increased lymphedema volume in patients previously treated for breast cancer despite compressive therapy.
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Affiliation(s)
- S Vignes
- Unité de Lymphologie, Hôpital Cognacq-Jay, 15 rue Eugène Millon, 75015 Paris.
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Gottrup H, Andersen J, Arendt-Nielsen L, Jensen TS. Psychophysical examination in patients with post-mastectomy pain. Pain 2000; 87:275-284. [PMID: 10963907 DOI: 10.1016/s0304-3959(00)00291-8] [Citation(s) in RCA: 139] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
Chronic pain, lymphoedema, post-irradiation neuropathy and other symptoms are reported in as many as 75% of women following breast cancer treatment. This study examined pain and sensory abnormalities in women following breast cancer surgery. Sensory tests were carried out on operated and contralateral sides in 15 women with spontaneous pain and sensory abnormalities and 11 pain-free women. Testing included the VAS score of spontaneous pain, detection and pain threshold to thermal and mechanical stimuli, temporal summation to repetitive heat and pinprick stimuli, and assessment of skin blood flow during repetitive brush and pinprick stimulation. Sensory threshold to pinprick and thermal stimuli was significantly higher on the operated side in both groups while pressure pain threshold was significantly lower in pain patients on the operated side compared to the contralateral side. No side to side difference was seen in pressure pain threshold in the pain-free group. Evoked pain intensity to repetitive stimuli at 0.2 and 2.0 Hz was significantly higher on the operated side in pain patients compared to the control area while no such difference was seen in pain-free patients. Cutaneous blood flow measured by laser Doppler (flux) was significantly higher when the skin was tapped at 2.0 Hz on the operated side compared to contralaterally in pain patients, while no side to side difference was seen in pain-free patients. Pinprick-evoked pain was correlated to spontaneous pain but not to flux. Spontaneous pain was not correlated to flux. Sensitization seems to be a feature in breast cancer-operated women with pain, but not in pain-free women.
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Affiliation(s)
- Hanne Gottrup
- Department of Neurology, Aarhus University Hospital, Aarhus, Denmark Danish Pain Research Center, Aarhus University, Aarhus, Denmark Department of Oncology, Aarhus University Hospital, Aarhus, Denmark Center for Sensory-Motor Interaction, Aalborg University, Aalborg, Denmark
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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. [PMID: 7728566 DOI: 10.1007/bf02303628] [Citation(s) in RCA: 28] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/26/2023]
Abstract
BACKGROUND We wished to determine if complications after elective hand surgery were greater in women with previous mastectomy and axillary dissection than in those without. METHODS We surveyed records of all women undergoing carpal tunnel release by the senior author (W.J.D.) from 1983 to 1993. The postaxillary dissection group (group A) was made up of 15 women; seven had some postdissection lymphedema. Group B was made up of 302 other patients who had not undergone breast surgery or axillary dissection. Anesthetic and surgical techniques were identical for both groups, with i.v. regional anesthesia used most commonly. RESULTS No patient in the axillary dissection group developed any postoperative infection or had any worsening of preexisting lymphedema or onset of new arm swelling after ipsilateral carpal tunnel release. The nonaxillary dissection group had a postoperative infection rate of 3.6%; all infections were superficial and resolved with conservative therapy. In addition, 31 women experienced other complications, including 13 with hand/finger stiffness and four with reflex dystrophy. Fifteen required formal hand therapy. CONCLUSIONS Women with prior ipsilateral axillary dissection can safely undergo elective upper extremity surgery, provided strict sterile technique and appropriate anesthetic and surgical precautions are observed. Patients having undergone previous axillary dissection should not be prohibited from future limb manipulations, including venepunctures, blood pressure measurements, or elective surgery.
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Affiliation(s)
- W J Dawson
- Department of Clinical Orthopaedic Surgery, Northwestern University Medical School, Evanston, IL, USA
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Thyagarajan D, Cascino T, Harms G. Magnetic resonance imaging in brachial plexopathy of cancer. Neurology 1995; 45:421-7. [PMID: 7898688 DOI: 10.1212/wnl.45.3.421] [Citation(s) in RCA: 74] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/27/2023] Open
Abstract
We retrospectively reviewed the clinical records of all patients with cancer and brachial plexopathy who had an MRI of the brachial plexus between 1984 and 1993 (71 patients). The MRIs were reevaluated in a blinded fashion. The presence of a mass adjacent to the brachial plexus on MRI was highly predictive of tumor infiltration as determined by clinicopathologic criteria and was the most useful feature in distinguishing radiation plexopathy from tumor infiltration. Increased T2 signal in or near the brachial plexus was commonly seen in both groups and was not useful in this distinction. MRI was very sensitive for brachial plexus abnormalities in this condition, and limited comparison with CT suggested that MRI is superior to CT as an imaging modality. CT performed sufficiently well, however, to suggest that a prospective comparison study of the cost effectiveness and clinical utility of the two imaging modalities in this clinical setting is warranted.
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Affiliation(s)
- D Thyagarajan
- Department of Neurology, Mayo Clinic, Rochester, MN 55905
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Abstract
The causes of ipsilateral arm pain were analyzed in a consecutive series of 38 patients with breast cancer. A lesion of the brachial plexus was diagnosed in 17 patients, of whom 8 had tumor involvement, 5 had radiation fibrosis, 1 had lymphedema entrapment, and 3 had a probable transient neuritis of the plexus. In four patients, a cervical radiculopathy was found; two of these patients had a Horner's syndrome. A carpal tunnel syndrome was seen in four patients and could possibly be attributed to lymphedema in two patients. In five patients, a pericapsulitis of the shoulder joint was seen. Seven of eight patients with a postsurgical pain had a neuropathic pain related to damage of the intercostobrachial nerve induced by a postaxillary dissection. These diagnoses probably indicate the most common causes of ipsilateral arm pain in breast cancer. A postaxillary dissection pain seems the most frequent type of postsurgical pain in breast cancer.
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Larson D, Weinstein M, Goldberg I, Silver B, Recht A, Cady B, Silen W, Harris JR. 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. [PMID: 3759582 DOI: 10.1016/0360-3016(86)90280-4] [Citation(s) in RCA: 282] [Impact Index Per Article: 7.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/07/2023]
Abstract
Edema of the arm can be a significant complication following treatment of breast cancer. To determine the risk of arm edema and factors associated with this risk in patients treated with primary radiotherapy, we reviewed the records of 475 women with early breast cancer treated between 1968 and 1980. During this period, the use of axillary surgery prior to radiation gradually increased, and all patients received full axillary irradiation until late in the series. Based on the surgeon's report, the extent of axillary surgery was classified as either a sampling, a lower dissection, or a full dissection. Edema of the arm was scored on clinical grounds and ranged from mild hand swelling to an increased arm circumference of 8 cm. At 6 years, the actuarial risk of developing arm edema was 8% for the entire study population. This risk was 13% for 240 patients who had axillary surgery and 4% for 235 patients not undergoing axillary surgery (p = 0.006). For patients undergoing axillary surgery, the risk of arm edema was 37% with full dissection compared to 5% with sampling (p = 0.0003), and 8% with lower dissection (p = 0.03). The risk of arm edema at 6 years was 28% if more than ten nodes were removed, and 9% if one to ten nodes were removed (p = 0.03). However, the extent of axillary dissection was stronger predictor of subsequent edema than was the number of nodes obtained. The role of axillary irradiation could not be evaluated since 91% of patients received axillary irradiation. The use of chemotherapy, the site or size of the primary tumor, clinical nodal status, patient age and weight, type of suture, the use of a drain, and subsequent local or distant failure did not appear to be significant risk factors. We conclude that the combination of full dissection and full axillary irradiation results in an unacceptably high risk of arm edema.
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