A comparative study of respiratory effects of erector spinae plane block versus paravertebral plane block for women undergoing modified radical mastectomy.

BACKGROUND: Inadequate acute postoperative pain control after modified radical mastectomy (MRM) can compromise pulmonary function. This work aimed to assess the postoperative pulmonary effects of a single-shot thoracic paravertebral block (TPVB) and erector spinae plane block (ESPB) in female patients undergoing MRM. METHODS: This prospective, randomized comparative trial was conducted on 40 female American Society of Anesthesiologists (ASA) II-III, aged 18 to 50 years undergoing MRM under general anesthesia (GA). Patients were divided into two equal groups (20 in each group): Group I received ESPB and Group II received TPVB. Each group received a single shot with 20 ml volume of 0.5% bupivacaine. RESULTS: Respiratory function tests showed a comparable decrease in forced vital capacity (FVC) and forced expiratory volume (FEV1) from the baseline in the two groups. Group I had a lower FEV1/FVC ratio than Group II after 6 h. Both groups were comparable regarding duration for the first postoperative analgesic request (P value = 0.088), comparable postoperative analgesic consumption (P value = 0.855), and stable hemodynamics with no reported side effects. CONCLUSION: Both ultrasound guided ESPB and TPVB appeared to be effective in preserving pulmonary function during the first 24 h after MRM. This is thought to be due to their pain-relieving effects, as evidenced by decreased postoperative analgesic consumption and prolonged time to postoperative analgesic request in both groups. GOV ID: NCT03614091 registration date on 13/7/2018.

Investigation of the analgesic effects of rhomboid intercostal and pectoral nerve blocks in breast surgery.

PURPOSE: The objective of this study was to examine the hypothesis that the opioid consumption of patients who receive a rhomboid intercostal block (RIB) or a pectoral nerve (PECS) block after unilateral modified radical mastectomy (MRM) surgery is less than that of patients who receive local anesthetic infiltration. METHODS: Eighty-one female patients aged 18-70 years who underwent unilateral MRM surgery with general anesthesia were randomly allocated to three groups. The first group received an RIB with 30 ml of 0.25% bupivacaine on completion of the surgery, and the second received a PECS block with the same volume and concentration of local anesthetic. In the third (control) group, local infiltration was applied to the wound site with 30 ml of 0.25% bupivacaine at the end of the surgery. The patients' total tramadol consumption, quality of recovery (QoR), postoperative pain scores, and sleep quality were evaluated in the first 24 h postoperatively. RESULTS: Both the RIB (58.3 ± 22.8 mg) and PECS (68.3 ± 21.2 mg) groups had significantly lower tramadol consumption compared to the control group (92.5 ± 25.6 mg) (p < 0.001 and p = 0.002, respectively). Higher QoR scores were observed in the RIB and PECS groups than the control group at 6 h post-surgery. The lowest pain values were observed in the RIB group. The sleep quality of the patients in the RIB and PECS groups was better than that of the control group (p < 0.001). CONCLUSION: Compared to local anesthetic infiltration, the RIB and PECS blocks applied as part of multimodal analgesia in MRM surgery reduced opioid consumption in the first 24 h and improved the quality of recovery in the early period.

Analgesia and stress attenuation of ultrasound-guided modified pectoral nerve block type-II with different volumes of 0.3% ropivacaine in patients undergoing modified radical mastectomy for breast cancer: A prospective parallel randomized double-blind controlled clinical trial.

WHAT IS KNOWN AND OBJECTIVE: A previous randomized clinical trial concluded that an optimal concentration of 0.3% ropivacaine could provide satisfactory analgesia for breast cancer patients undergoing modified radical mastectomy. We wondered if a smaller volume (30 ml vs. 40 ml) of 0.3% ropivacaine could still provide adequate analgesia in an ultrasound-guided PECS II block in modified radical mastectomy. METHODS: We performed a prospective parallel randomized double-blind controlled clinical trial. Eligible patients were assigned to either the P30 or P40 group (30 or 40 ml of 0.3% ropivacaine, respectively). The skin area of hypoesthesia, anaesthetic plane determined with ultrasound, pain visual analogue scale (VAS), anaesthetic dosages, and complications were recorded. Serum levels of interleukin-1ß and interleukin-6 were measured postoperatively. RESULTS AND DISCUSSION: A total of 40 patients completed the trials, with 20 patients in each group. Although the skin area of hypoesthesia and the anaesthetic planes were significantly larger in the P40 group compared with the P30 group (p < 0.05), the VAS, analgesic and opioid doses, serum cytokine levels, anaesthetic toxicity, and complications had no significant differences between the two groups. WHAT IS NEW AND CONCLUSION: Compared with 40 ml, 30 ml of 0.3% ropivacaine could provide adequate analgesia and reduce surgical stress in patients undergoing modified radical mastectomy for breast cancer.

Retrolaminar block: analgesic efficacy and safety evaluation.

PURPOSE: Retrolaminar block (RLB) is a thoracic truncal block that can produce analgesia for the thoracic and abdominal wall. However, the characteristics of RLB are not well known. The aim of this study was to determine analgesic efficacy by measuring postoperative consume of patient-controlled analgesia (PCA), additional nonsteroidal antiinflammatory drug (NSAID) rescue, and opioid rescue. Our secondary analysis included assessment of the chronological change in arterial levobupivacaine concentrations after the block. METHODS: This prospective, randomized, double-blinded study included 30 patients scheduled for modified radical mastectomy under general anesthesia. The patients were randomized to receive either a landmark-guided RLB or paravertebral block (PVB) catheter placement on T4. Continuous infusion with 4 ml/h of 0.25 % levobupivacaine was started for 72 h, after initial injection of 20 ml 0.375 % levobupivacaine before surgery. Postoperative pain was compared using the amount of block PCA (3 ml 0.25 % levobupivacaine with 30-min lockout), NSAID, and opioid rescue. Arterial blood was sampled for 120 min after the initial injection. RESULTS: The frequency of postoperative block PCA use was significantly high after RLB in 24 h [p = 0.01; 6 (3-12) vs. 2.5 (0.3-3) times, respectively]. There was no PCA use after 24 h in either group. There was no postoperative opioid rescue use throughout the study. After RLB and PVB, there was no significant difference in T max (p = 0.14; 15 ± 8 vs. 15 ± 8 min, respectively) and C max (p = 0.2; 0.9 ± 0.2 vs. 0.9 ± 0.3 µg/ml, respectively), and all the concentrations were below the threshold of local anesthetic systemic toxicity. CONCLUSION: Continuous RLB was not inferior to PVB except for the first 24 h, and was satisfactory after mastectomy. RLB showed safe, low peak arterial levobupivacaine concentrations.

Efficacy of dexmedetomidine as an adjuvant in paravertebral block in breast cancer surgery.

PURPOSE: This study evaluated the analgesic efficacy of dexmedetomidine in combination with bupivacaine for single-shot paravertebral block (PVB) in patients undergoing major breast cancer surgery. METHODS: This prospective, randomized double blind study was conducted in 45 ASA I/II/III females, aged ≥18 years, undergoing modified radical mastectomy or breast conservation surgery with axillary lymph node dissection. Patients in group PB (paravertebral-bupivacaine) received PVB with 0.5 % bupivacaine 0.3 ml/kg with 1 ml normal saline; group PBD (paravertebral-bupivacaine-dexmedetomidine) received PVB with 0.5 % bupivacaine 0.3 ml/kg and dexmedetomidine 1 µg/kg in a volume of 1 ml; and group C (control) patients were given a sham block (a subcutaneous injection with 2 ml normal saline) before receiving general anesthesia (GA). All patients received analgesia by fentanyl intraoperatively and morphine patient-controlled analgesia postoperatively. RESULTS: The control group patients required more intraoperative fentanyl than the other two groups. Patients receiving dexmedetomidine had lower morphine consumption (p < 0.001), pain scores and incidence of postoperative nausea/vomiting (p = 0.011); longer time to first analgesic request; earlier time to mobilize; and better satisfaction scores. Heart rate and blood pressure values during the intraoperative period were also lower at many time points in this group. However, the incidence of hypotension and bradycardia were statistically similar in all groups. CONCLUSIONS: PVB using dexmedetomidine 1 µg/kg added to 0.5 % bupivacaine in patients undergoing major breast cancer surgery under GA provides analgesia of longer duration with decreased postoperative opioid consumption and lower incidence of nausea/vomiting compared to PVB with bupivacaine alone or no PVB.

Randomized Phase II Study of Talc Versus Iodopovidone for the Prevention of Seroma Formation Following Modified Radical Mastectomy.

BACKGROUND: The most common complication following modified radical mastectomy is seroma formation. Numerous approaches have been attempted to prevent this complication, ranging from the use of chemical substances to mechanical means, and none of these have proven to be consistently reliable. AIM: The aim of this study was to evaluate the safety and efficacy of talc in preventing postoperative seromas compared with iodine and standard care. METHODS: Patients with breast cancer undergoing modified radical mastectomy were randomly assigned to one of three study groups: control, subcutaneous talc, or iodine application. The primary endpoint was frequency of seroma formation. Secondary outcomes included wound complications (surgical site infection, flap necrosis, and wound dehiscence), analgesic use, postoperative pain, total drain outputs, and drainage duration. RESULTS: Of the 86 patients randomized in the study, 80 were analyzed. After interim analysis, the iodine intervention was discontinued because of increased adverse outcomes (drainage duration and total amount of fluid drained). Talc failed to demonstrate that its application in subcutaneous breast tissue prevents seroma formation (19.4% for talc group vs. 23.3% for control group; p = 0.70). However, patients who developed seroma in the talc group had fewer aspirations per patient seroma and less volume drained when compared with the control group (88.2 ± 73 vs. 158.3 ± 90.5; p = 0.17). CONCLUSIONS: Subcutaneous talc application was safe in the short term, but there was not sufficient evidence to support its use for seroma prevention following modified radical mastectomy in patients with breast cancer.

New trends in breast cancer surgery: a therapeutic approach increasingly efficacy and respectful of the patient.

The surgical management of breast cancer has undergone continuous and profound changes over the last 40 years. The evolution from aggressive and mutilating treatment to conservative approach has been long, but constant, despite the controversies that appeared every time a new procedure came to light. Today, the aesthetic satisfaction of breast cancer patients coupled with the oncological safety is the goal of the modern breast surgeon. Breast-conserving surgery with adjuvant radiotherapy is considered the gold standard approach for patients with early stage breast cancer and the recent introduction of "oncoplastic techniques" has furtherly increased the use of breast-conserving procedures. Mastectomy remains a valid surgical alternative in selected cases and is usually associated with immediate reconstructive procedures. New surgical procedures called "conservative mastectomies" are emerging as techniques that combine oncological safety and cosmesis by entirely removing the breast parenchyma sparing the breast skin and nipple-areola complex. Staging of the axilla has also gradually evolved toward less aggressive approaches with the adoption of sentinel node biopsy and new therapeutic strategies are emerging in patients with a pathological positivity in sentinel lymph node biopsy. The present work will highlight the new surgical treatment options increasingly efficacy and respectful of breast cancer patients.

Single-shot lamina technique of paravertebral block as an adjunct to general anesthesia for modified radical mastectomy.

Thoracic paravertebral block can be employed as an alternative or an adjunct to general anesthesia (GA) for breast cancer surgery. There is no report of this new lamina technique for catheter placement in our environment. In low-resource settings, potent opioids are lacking and the extended postoperative analgesia it provides makes this regional block an invaluable addition to an anesthetist's armamentarium. We describe this single-shot, but titratable technique used as an adjunct to GA for modified radical mastectomy with axillary dissection for breast cancer. The total intraoperative opioid analgesic 50 mg pethidine was received at induction. The patient's vital signs remained stable throughout surgery that lasted 115 min. Pain score charted every 10 min in the postanesthesia care unit using the verbal rating scale was 0. The time to the first request for rescue analgesic was 18 h after surgery for which paracetamol 1 g was adequate.

Axillopexy.

The present paper is a presentation of our technique of axillopexy, used after the excision of the axillary lymph nodes in 29 cases of breast cancer patients. We have used this technique after Madden modified radical mastectomy or after quadrantectomy for tumors in the external quadrants of the mammary gland. We have studied and compared with a 30 case control group, the duration of the lymphorrhagia the moment of removing the drains, the presence absence of other local complications. We have also measured the time until the beginning of the oncological postoperative therapy. Every one of the aspects we have studied was improved in the axillopexy group.

Breast-conserving surgery versus modified radical mastectomy in T1-2N3M0 stage breast cancer: a propensity score matching analysis.

PURPOSE: Breast-conserving surgery (BCS) plus radiotherapy and mastectomy exhibit highly comparable prognoses for early-stage breast cancer; however, the safety of BCS for T1-2N3M0 breast cancer remains unclear. This study compared long-term survival for BCS versus (vs.) modified radical mastectomy (MRM) among patients with T1-2N3M0 breast cancer. METHODS: Data of patients with T1-2N3M0 breast cancer were extracted from the Surveillance, Epidemiology, and End Results database. Eligible patients were divided into 2 groups, BCS and MRM; Pearson's chi-squared test was used to estimate differences in clinicopathological features. Propensity score matching (PSM) was used to balance baseline characteristics. Univariate and multivariate analyses were performed to investigate the effects of surgical methods and other factors on breast cancer-specific survival (BCSS) and overall survival (OS). RESULTS: In total, 2124 patients were included; after PSM, 596 patients were allocated to each group. BCS exhibited the same 5-year BCSS (77.9% vs. 77.7%; P = 0.814) and OS (76.1% vs. 74.6%; P = 0.862) as MRM in the matched cohorts. Multivariate survival analysis revealed that BCS had the same BCSS and OS as MRM (hazard ratios [HR] 0.899 [95% confidence intervals (CI) 0.697-1.160], P = 0.413 and HR 0.858 [95% CI 0.675-1.089], P = 0.208, respectively); this was also seen in most subgroups. BCS demonstrated better BCSS (HR 0.558 [95% CI 0.335-0.929]; P = 0.025) and OS (HR 0.605 [95% CI 0.377-0.972]; P = 0.038) than MRM in those with the triple-negative subtype. CONCLUSIONS: BCS has the same long-term survival as MRM in T1-2N3M0 breast cancer and may be a better choice for triple-negative breast cancer.

Ultrasound-Guided Serratus Posterior Superior Intercostal Plane Block in Modified Radical Mastectomy Surgeries: A Case Series.

Effective pain management is crucial for modified radical mastectomy (MRM) surgeries. The Serratus Posterior Superior Intercostal Plane Block (SPSIPB), introduced in 2023, shows promise for postoperative analgesia. This study was designed to demonstrate the analgesic efficacy of the SPSIPB in MRM surgeries. SPSIPB was administered to 7 patients who underwent MRM for postoperative analgesia. NRS scores of patients were ≤4 and total tramadol consumption was 0 mg in 3 of 7 patients. In conclusion, SPSIPB appears to be an effective, safe, and easily applicable option for analgesia.

Superficial Dosimetry Study of the Frequency of Bolus Using in Volumetric Modulated Arc Therapy after Modified Radical Mastectomy.

OBJECTIVE: To investigate the effect of various frequencies of bolus use on the superficial dose of volumetric modulated arc therapy after modified radical mastectomy for breast cancer. METHODS: Based on the computed tomography images of a female anthropomorphic breast phantom, a 0.5 cm silicone-based 3D-printed bolus was created. Nine points evenly distributed on the breast skin were selected for assessing the skin dose, and a volume of subcutaneous lymphatic drainage of the breast (noted as ROI2-3) was delineated for assessing the chest wall dose. The treatment plans with and without bolus (plan_wb and plan_nb) were separately designed using the prescription of 50 Gy in 25 fractions following the standard dose constraints of the adjacent organ at risk. To characterize the accuracy of treatment planning system (TPS) dose calculations, the doses of the nine points were measured five times by thermoluminescence dosimeters (TLDs) and then were compared with the TPS calculated dose. RESULTS: Compared with Plan_nb (144.46 ± 10.32 cGy), the breast skin dose for plan_wb (208.75 ± 4.55 cGy) was significantly increased (t = -18.56, P < 0.001). The deviation of skin dose was smaller for Plan_wb, and the uniformity was significantly improved. The calculated value of TPS was in good agreement with the measured value of TLD, and the maximum deviation was within 5%. Skin and ROI2-3 doses were significantly increased with increasing frequencies of bolus applications. The mean dose of the breast skin and ROI2-3 for 15 and 23 times bolus applications were 45.33 Gy, 50.88 Gy and 50.36 Gy, 52.39 Gy, respectively. CONCLUSION: 3D printing bolus can improve the radiation dose and the accuracy of the planned dose. Setting Plan_wb to 15 times for T1-3N+ breast cancer patients and 23 times for T4N+ breast cancer patients can meet the clinical need. Quantitative analysis of the bolus application frequency for different tumor stages can provide a reference for clinical practice.

Hydromorphone combined with ropivacaine for erector spinae plane block in patients undergoing modified radical mastectomy: A prospective randomized controlled trial.

BACKGROUND: Combining hydromorphone with ropivacaine in ultrasound-guided erector spinae plane blocks enhances postoperative analgesia and reduces interleukin-6 expression in breast surgery patients. METHODS: In this study, breast cancer patients undergoing modified radical mastectomy were randomized into 3 groups for anesthesia (30 patients in each group): standard general (group C), Erector Spinae Plane Block (ESPB) with ropivacaine (group R), and ESPB with ropivacaine plus hydromorphone (group HR). Diagnosis: Breast cancer patients. Postsurgery, pain levels, IL-6, anesthetic doses, additional analgesia needs, and recovery milestones were compared to evaluate the efficacy of the ESPB enhancements. RESULTS: The 3 groups were not significantly different in baseline characteristics, operation time, number of cases with postoperative nausea, and serum IL-6 concentrations at T1 (the time of being returned to the ward after surgery). At T2 (at 6:00 in the next morning after surgery), the serum IL-6 concentration in group HR was significantly lower than that in groups R and C (P < .05); the intraoperative doses of remifentanil, sufentanil, and propofol were significantly lower in groups HR and R than those in group C (P < .05); Groups HR and R had significantly lower visual analog scale scores at T3 (4 hours postoperatively), T4 (12 hours postoperatively), and T5 (24 hours postoperatively) than those in group C (P < .05); the proportions of patients receiving postoperative remedial analgesia were significantly lower in groups HR and R than in group C (P < .05); groups HR and R had significantly lower proportions of patients with postoperative nausea than group C (P < .05); the time to the first anal exhaust and the time to the first ambulation after surgery were significantly shorter in groups HR and R than those in group C (P < .05). CONCLUSION: Hydromorphone combined with ropivacaine for ESPB achieved a greater postoperative analgesic effect for patients receiving MRM under general anesthesia. The combined analgesia caused fewer adverse reactions and inhibited the expression level of the inflammatory factor IL-6 more effectively, thereby facilitating postoperative recovery. ESPB using hydromorphone with ropivacaine improved pain control post-MRM, reduced adverse effects, and more effectively suppressed IL-6, enhancing recovery.

Simultaneous beating heart coronary artery bypass surgery and modified radical mastectomy.

Concomitant surgeries for unrelated diseases can be performed to minimize the risks associated with surgery and general anesthesia. In treating a male patient with breast cancer and severe coronary artery disease, we used the beating heart technique for a coronary artery bypass graft to avoid the negative effects of on-pump bypass on the possible acceleration of tumor growth. In this report, we present a unique case of concomitant off-pump coronary artery bypass graft surgery and modified radical mastectomy in a 56-year-old man.

Postoperative analgesia after modified radical mastectomy: the efficacy of interscalene brachial plexus block.

PURPOSE: In the present study, we evaluated the effects of interscalene brachial plexus block on postoperative pain relief and morphine consumption after modified radical mastectomy (MRM). METHODS: Sixty ASA I-III patients scheduled for elective unilateral MRM under general anesthesia were included. They were randomly allocated into two groups: group 1 (n = 30), single-injection ipsilateral interscalene brachial plexus block; group 2 (n = 30), control group. Postoperative analgesia was provided with IV PCA morphine during 24 h postoperatively. Pain intensity was assessed with the visual analogue scale (VAS). Morphine consumption, side effects of opioid, antiemetic requirement, and complications associated with interscalene block were recorded. RESULTS: VAS scores were significantly lower in group 1, except in the first postoperative 24 h (p < 0.007). The patients without block consumed more morphine [group 1, 5 (0-40) mg; group 2, 22 (6-48) mg; p = 0.001]. Rescue morphine requirements were also higher in the postoperative first hour in group 2 (p = 0.001). Nausea and antiemetic requirements were significantly higher in group 2 (p = 0.03 and 0.018). Urinary retention was observed in 1 patient in group 2 and signs of Horner's syndrome in 2 patients in group 1. CONCLUSIONS: The optimal method has not been defined yet for acute pain palliation after MRM. Our study demonstrated that the use of interscalene block in patients undergoing MRM improved pain scores and reduced morphine consumption during the first 24 h postoperatively. The block can be a good alternative to other invasive regional block techniques used for postoperative pain management after MRM.

[The multifocal breast cancer].

Survival data of patients with multifocal breast cancer in dependence on surgical resection volume were analyzed. Two types of surgery were performed: the modified radical mastectomy by Madden and radical resection of the mammary gland. It was stated, that organ-preserving operation in combination with complex adjuvant therapy of the multifocal breast cancer stage I-II did not lead to the decrease of the overall and recurrence-free 5 and 10-year survival rate.

Combined Thoracic Paravertebral Block-Interscalene Block as a Primary Anesthetic for Modified Radical Mastectomy: A Case Report.

Background: Regional anesthesia as a primary anesthetic can offer merits over general anesthesia for patients having multiple comorbidities who are at a high risk of perioperative morbidity and mortality. Thoracic paravertebral block (TPVB) and interscalene block (ISB) have been used widely to improve the quality of postoperative analgesia after breast surgery. Objective: There are limited data on the feasibility of combining TPVB-ISB as a sole anesthetic technique for extensive breast surgery with axillary lymph nodes dissection. Case presentation: In this report, the author presented a successful use of a combined TPVB and ISB as a sole anesthetic with conscious sedation in a 52-year-old patient with multiple comorbidities, including heart failure with reduced ejection fraction, who underwent modified radical mastectomy with left axillary lymph nodes dissection. Conclusion: Combining TPVB-ISB can be used as a sole anesthetic for extensive breast surgery in patients with a high risk for general anesthesia.

Survival benefit of post-mastectomy radiotherapy in breast carcinoma patients with T1-2 tumor and 1-3 axillary lymph node(s) metastasis.

OBJECTIVE: To investigate the role of post-mastectomy radiotherapy in breast carcinoma patients with a tumor size of 5 cm or smaller (T1-2) and 1-3 axillary lymph node(s) metastasis (N1). METHODS: We retrospectively reviewed the file records of 575 patients receiving radiotherapy (452 patients) and not receiving radiotherapy (123 patients). RESULTS: In the whole series, locoregional recurrence-free survival was significantly better in patients receiving radiotherapy compared with patients not receiving radiotherapy (P<0.001); in the multivariate Cox analysis, radiotherapy had an independent prognostic value (P<0.001). In patients with a tumor size of 2 cm or less (T1), locoregional recurrence-free survival was significantly better in patients receiving radiotherapy compared with those not receiving radiotherapy (P=0.016). In the patient subgroup with a T1 tumor and a lymph node ratio (the ratio of the number of metastatic lymph nodes to the number of removed lymph nodes) of 0.25 or less, there was no significant difference between the patients receiving and not receiving radiotherapy in terms of locoregional recurrence-free survival (P=0.071). In patients with a tumor size of 2.1-5 cm (T2), locoregional recurrence-free survival was significantly better for patients who received radiotherapy compared with those who did not (P=0.001). In patients with a T2 tumor and a lymph node ratio of ≤0.08, there was no significant difference in locoregional recurrence-free survival between the patients receiving and not receiving radiotherapy (P=0.645). CONCLUSIONS: Post-mastectomy radiotherapy is beneficial in reducing the locoregional recurrence risk in T1N1 breast carcinoma patients with a lymph node ratio of >0.25 and in T2N1 breast carcinoma patients with a lymph node ratio of >0.08. In patients with a lymph node ratio equal to or less than these ratios, post-mastectomy radiotherapy could be omitted to avoid radiotherapy-related risks.