Abstract

An Evaluation of Safety and Patient Outcomes for Hand Surgery following Prior Breast Cancer Treatment: Establishing New Recommendations in Lymphedema

Madeline Paton, M.S. Alexandra Kovar, M.D. Matthew L. Iorio, M.D. Plast. Reconstr. Surg. 145: 459, 2020

Background: Injuries to the upper extremity lymphatic system from cancer may require measures to prevent secondary lymphedema. Guidelines were established relating to the use of tourniquet and elective hand and upper extremity surgery. However, reports in the setting of hand surgery have indicated that prior guidelines may not be protective to the patient.

Methods: The study systematically reviewed the current literature evaluating elective hand surgery in breast cancer patients. The authors evaluated the risk of complications, including new or worsening lymphedema and infection.

Results: One hundred ninety-eight abstracts were identified, and a bibliographic review was performed. Nine studies pertained to our subject, and four were included for final review. All studies included patients with prior breast cancer treatment involving breast surgery and axillary lymph node dissection. Pneumatic tourniquets were used during nearly all operations. Patients without presurgery ipsilateral lymphedema had a 2.7 percent incidence of developing new lymphedema and a 0.7 percent rate of postoperative infection. Patients with presurgery lymphedema had a 11.1 percent incidence of worsening lymphedema and a 16.7 percent rate of infection. However, all cases of new or exacerbated lymphedema resolved within 3 months. Tourniquet use was not found to increase rates of lymphedema.

Conclusions: Based on the available evidence, there is no increased risk of complications for elective hand surgery in patients with prior breast cancer treatment. Breast cancer patients with preexisting ipsilateral lymphedema carry slightly increased risk of postoperative infection and worsening lymphedema. It is the authors’ opinion and recommendation that elective hand surgery with a tourniquet is not a contradiction in patients who have received previous breast cancer treatments.

Main findings

• Complications following elective hand surgery in breast cancer patients with no history of ipsilateral lymphedema are similar to those in non– breast cancer patients.
• Breast cancer patients with preexisting ipsilateral lymphedema do carry an increased risk of postoperative infection and transient worsening lymphedema.
• However, tourniquet use was not found to be associated with an increased rate of complications or lymphedema exacerbation in either patient group. As such, hand surgeons should view patients with either preexisting lymphedema or a history of breast surgery as acceptable candidates for surgical intervention.
• Patients should be counseled regarding the relative risk of complications, with potentially limited side effects, including transient lymphedema exacerbation.