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Background and Aims: Opioid-sparing analgesia for acute postoperative pain after breast cancer surgery is crucial due to opioid-related side effects. The utilisation of erector spinae plane block and low-dose intravenous ketamine-dexmedetomidine are widely recognised as non-opioid analgesic methodologies. The objective of this study was to conduct a randomised trial to examine the analgesic efficacy of both approaches while minimising the use of opioids. Methods: Seventy-two female patients scheduled for unilateral modified radical mastectomy were recruited. They were allocated randomly to Group ESPB, which received ipsilateral ultrasound-guided erector spinae plane block by 20 mL bupivacaine 0.5% at the level of T5 after induction of general anaesthesia, and Group Ket-Dex, which received intravenous (IV) bolus 0.25 mg/kg of ketamine and 0.5 µg/kg of dexmedetomidine, followed by an IV infusion of 0.25 mg/kg of ketamine and 0.3 µg/kg of dexmedetomidine per hour. Total postoperative morphine consumption (24 h) was the primary outcome. The secondary outcomes were pain scores over 24 hours during rest, duration of analgesia, isoflurane consumption, time to awakening, postoperative nausea and vomiting (PONV), and postoperative serum cortisol level. Results: The postoperative morphine consumption over 24-hour in Group ESPB was 3.26 mg (0-6.74) versus 2.35 mg (2.08-4.88) in Group Ket-Dex (P = 0.046). Group Ket-Dex had lower pain scores at rest, longer analgesia duration, longer awakening time, and lower postoperative serum cortisol levels. Conclusion: Intravenous low-dose ketamine-dexmedetomidine infusion intraoperatively with inhalational-based general anaesthesia provides superior opioid-sparing analgesia to that of ESPB in patients undergoing unilateral non-reconstructive modified radical mastectomy, with less postoperative opioid consumption and stress response. [ABSTRACT FROM AUTHOR]

Introduction: Breast cancer (BC) and its treatment can impair patient quality of life (QoL), and those undergoing more aggressive treatments may be more severely impacted. Objective: Assess the level of perception of the QoL of patients treated for BC at the Hospital de Clínicas and the Departmental Hospital of Soriano. Materials and Methods: A questionnaire for cancer patients(EORTC, QLQ-C30) and one specific for BC (EORTC QLQ-BR23) were used. Results: A total of 158 patients who had completed chemotherapy treatment at least one year prior to the evaluation were enrolled. The average age was 61 years old. QLQ-C30 Questionnaire: The global QoL score (GQOL) was high: 70.9. Patients undergoing breast-conservation surgery(BCS) had better scores in physical and emotional functioning (p < 0.005) and presented less frequently with: pain, constipation, and financial difficulties (p < 0.005). Those undergoing sentinel lymph node biopsy (SLNB) had higher scores for GQOL and for physical, role, and social functioning scales (p < 0.001) and had less fatigue, pain, insomnia, and financial difficulties (p < 0.005). Questionnaire QLQ-BR23: Sexual functioning and sexual enjoyment scales were relatively low. Patients undergoing BCS had better scores on the functional scales: body image and future outlook; and fewer breast symptoms (p < 0.005). Those undergoing SLNB also had better scores on the functional scales for body image and future outlook future and presented less frequently with symptoms (p < 0.005). Conclusion: Uruguayan BC patients experience high values on the GQOL scale; those undergoing BCS and SLNB had better scores on most functional and problem/symptom scales. Patients undergoing BCS had better scores in physical and emotional functioning and presented less frequently with pain, constipation, and financial difficulties. With respect to the type of axillary surgery received, patients who underwent SLNB had higher scores on the GQOL scale and on the physical, role, and social functional scales. The implementation of intervention strategies aimed at improving the quality of life, and the physical and emotional care of patients is recommended. [ABSTRACT FROM AUTHOR]

This article explores the connection between regional analgesia and cancer outcomes. While surgery is the primary treatment for non-metastatic solid tumors, it may contribute to cancer recurrence. Researchers have been investigating whether regional analgesia can reduce the body's response to surgery and improve cancer outcomes. However, multiple studies and a meta-analysis have found no evidence of regional analgesia benefiting cancer outcomes. Nonetheless, regional analgesia does offer advantages such as reducing opioid-related side effects and enhancing patient satisfaction. The article emphasizes the need for further research to fully comprehend the impact of regional analgesia on cancer outcomes. [Extracted from the article]

Background: Treatment of lymph node basins is prognostic and therapeutic for axillary lymph nodes (ALN) as well as internal mammary lymph nodes (IMLNs) in breast cancer. IMLNs can be the first echelon node for the inner/central quadrants of the breast. We evaluated the yield of IMLN dissection (IMLND) mainly in patients with inner and central tumors. Methods: IMLND was performed in 199 patients between 2000 and 2018, 127 of whom had tumors in the inner/ central quadrants. Clinico-pathological data were retrieved from Electronic Medical Records (EMR). Results: The median age was 50 (range: 24-81). Primary surgery was performed in 82 (41.2%), while 117 (58.8%) were operated post-chemotherapy. Overall, 124/199 (62.3%) had nodes identified in the specimen, more often in primary (61/82, 74.4%) than post-chemotherapy settings (63/117, 53.8%) (P = 0.003). A median of 1 (average: 1.24, range: 0--7) lymph nodes was dissected, and 1 (average: 1.5, range: 1-4) was involved. IMLN was positive in 46/199 (23.1%) patients, not significantly different in primary (21/82, 25.6%) versus post-chemotherapy (25/117, 21.4%) settings (P = 0.545). IMLN was involved in 44.8% of patients with ≥4 involved ALN and 8.2% with uninvolved ALN (P < 0.001). In the absence of ALN involvement and <2cm pT size, 9% of patients had positive IMLN in inner/central quadrant tumors. In univariate analysis, ALN positivity (P < 0.001), pT size (P = 0.023), and grade (P = 0.041) in primary and ALN involvement (P = 0.011) in post-chemotherapy patients were associated with IMLN involvement. On logistic regression, tumor size (OR: 13.914, P = 0.017) and ALN involvement (OR: 11.400, P = 0.005) in primary surgery and ALN involvement (OR: 7.294, P = 0.003) in post-chemotherapy patients correlated with IMLN involvement. Conclusions: In inner/central quadrant tumors, IMLN is more likely involved with high ALN burden and tumor size >2 cm, whereas those with ≤2cm inner/central quadrant tumors and negative ALN have <10% probability of IMLN involvement. [ABSTRACT FROM AUTHOR]

Background and Aims: Cancer chemotherapeutic agents cause alteration in the response to neuromuscular blocking drugs, which can have serious perioperative implications. Magnesium, commonly found to be deficient in these patients, plays an indispensable role in neuromuscular transmission. This study aimed to understand the effect of neoadjuvant chemotherapy on the neuromuscular blocking properties of cisatracurium. Material and Methods: One hundred female patients scheduled for breast cancer surgery were divided into two groups (n = 50 each). Group B received neoadjuvant chemotherapy with taxane, adriamycin, and cyclophosphamide, and Group A did not receive neoadjuvant chemotherapy. Neuromuscular block following cisatracurium 0.15 mg/kg was measured using peripheral nerve stimulator at the ulnar nerve. Onset time, duration of intense block, clinical duration of action, time to TOF4 after the last dose of cisatracurium, along with preoperative serum magnesium concentration were measured. Correlation and multiple regression were run to analyze the relationship between history of neoadjuvant chemotherapy, preoperative magnesium, and the abovementioned time points. Mediation analysis was done to ascertain if magnesium was mediating the observed effects. Results: Onset time was prolonged by nearly 18% in Group B compared to Group A (P = 0.001). The duration of intense block was 35.27 ± 8.9 min in Group B and 42.07 ± 10.99 min in Group A (P < 0.001). The clinical duration of action of cisatracurium was significantly shorter in Group B (46.06 ± 8.68 min) compared to Group A (55.87 ± 11.04 min, P < 0.001). The time to TOF4 was 32.86 ± 5.66 min in Group B and 36.57 ± 8.49 min in Group A (P < 0.05). Preoperative serum magnesium levels were significantly lower in Group B (P < 0.001). Conclusion: Patients who had received neoadjuvant chemotherapy had a delayed onset, shorter duration of action, and faster recovery for cisatracurium. Although preoperative magnesium levels were lower in Group B, it was found to be an independent predictor rather than a mediator of these effects. [ABSTRACT FROM AUTHOR]

Background Breast cancer is the most common cancer in women and the second-leading cause of cancer-related fatalities globally. Breast-conserving surgery (BCS) is the primary surgical treatment for early-stage breast cancer, with oncoplastic BCS techniques expanding its possibilities. BCS offers a higher quality of life compared to mastectomy. However, it has two absolute contraindications: the inability to produce negative margins without deforming the breast and inflammatory breast cancer. Oncoplastic displacement and replacement BCS allow resections of up to 50% of breast volume without creating deformity. Positive surgical margins often require a second procedure, which can increase pain, complications, and medical expenses. Patient and methods This retrospective cohort study analyzed 310 patients with primary invasive breast cancer or DCIS who underwent conventional or oncoplastic breast cancer surgery. Most patients underwent lateral and therapeutic reduction mammoplasties. Other techniques included LD flap, TDAP flap, mini-LD muscle flap, ICAP flap, grisotti flap, LICAP flap, and modified round block technique. Oncoplastic techniques were tailored based on breast cup size, tumor size, tumor location, and patient preference. Wide local excision of the tumor with free margins was confirmed through intraoperative frozen sections. Result The mean weight of the specimen was 55.89 gm in the conventional group and 101.55 gm in the oncoplastic group. The mean operative time was 65.9 min in the conventional group, while the oncoplastic group had 72.58 min Complications included seroma, hematoma, wound infection, wound dehiscence, lymphedema, and partial nipple necrosis. The aesthetic outcome was excellent, with 132 patients satisfied with their results in the oncoplastic group compared to 90 in the conventional group. Conclusion Oncoplastic breast surgeries are safe, feasible and became the standard of care in breast cancer. Oncoplastic breast surgeries are of choice in cases of multifocal cancer. People who performed oncoplastic breast surgeries had wider free margins, much more aesthetic outcome, better psychological status, less redo surgery, less late deformities, more time consuming, more wound complications improved with frequent dressing, and did not causea delay in the adjuvant therapy, more requirement for contralateral symmetrizing surgery. [ABSTRACT FROM AUTHOR]

Sublingual (SL) buprenorphine is approved for managing acute postoperative pain, characterized by easy administration, good pain relief and good patient compliance. We hypothesized that SL buprenorphine would be a better perioperative analgesic compared to intravenous (IV) opioids like tramadol in patients undergoing mastectomy surgery for breast cancer. After institutional ethics committee approval, we randomized 60 patients with breast cancer into 2 groups. In buprenorphine group, patients received 200 μg of SL buprenorphine thrice daily and in tramadol group patients received 100 mg of IV tramadol thrice daily. The analgesic efficacy of SL buprenorphine was comparable to that of IV tramadol. Visual Analogue Scale scores had no significant difference between the two groups at various time frames (0, 1, 3, 6, 12, 18 and 24 hours) at rest and movement except at 0 and 3 hours during movement when the score was lower in the tramadol group than the buprenorphine group. Four patients in the buprenorphine group received rescue analgesic (IV morphine 3 mg). Analgesic efficacy of SL buprenorphine appears comparable to IV tramadol for managing postoperative pain after mastectomy. SL buprenorphine can be administered sublingually, which is an advantage. [ABSTRACT FROM AUTHOR]

Background Breast cancer is the most prevalent cancer and the second leading cause of death among women is breast cancer. The likelihood of survival rises with early breast cancer diagnosis, which lowers death rates. For the treatment of breast cancer, axillary lymph nodes (ALNs) must be correctly staged and managed. The main goals of ALNs staging are to gather prognostic data and information that might influence management decisions. Objective To evaluate the accuracy of the preoperative ultrasound in detection of malignant ALNs in breast cancer patients. Methods The records of breast cancer patients at the breast surgery unit of Kasr Alainy Hospital, between 2017 and 2020, were reviewed. Patients with an axillary ultrasound report who underwent a sentinel lymph node biopsy (SLNB) or axillary lymph node dissection (ALND) were enrolled in the present study. Demographic and clinicopathologic characteristics including age, family history, body mass index (BMI), primary tumor size, histological and biological grade, Lymphovascular invasion (LVI), extracapsular invasion (ECE), were evaluated. Results Out of the 348 Breast Cancer patients who were managed in our department, the age range was 28–89 years (median age 52 years). The histopathology results of the tumor were 96% with invasive duct carcinoma (IDC) 2.3% invasive lobular carcinoma (ILC) and 1.7% were mixed ductal/lobular. Cortical thickness greater than 3 mm had a significant difference for positive nodal status, effacement of hilum had a sensitivity 56.2% in detecting positive lymph nodes (LNs), round LNs shape had a sensitivity of 82.3% in detecting true positive LNs. Pathological LNs by ultrasound had a sensitivity of 93% and specificity of 77% in detecting true positive LNS, BMI was not significant in ultrasound detection of pathological LNs. Conclusion The data shows that axillary ultrasound by its assessment has revealed to be useful in detection of malignant LNs with a sensitivity of 93.1% and specificity 77% in detecting true malignant LNs. [ABSTRACT FROM AUTHOR]

Background: Erector spinae plane (ESP) block provides postoperative analgesia in breast surgeries but has limited duration of action that restricts its efficacy to early postoperative period. This study aims to evaluate the analgesic efficacy and opioid sparing effect of ultrasound (US)‑guided continuous erector spinae plane (CESP) block in perioperative period in breast cancer surgery. Methods: Fifty ASA I/II patients aged more than 18 years, scheduled for elective breast cancer surgery were randomized to either Group B (Block group) or Group C (Control group). Patients in group B received US‑guided CESP block, whereas patients in group C did not receive the block prior to general anesthesia. The primary outcome of this study was to measure total tramadol consumption in 24 h postsurgery. Intraoperative fentanyl consumption, pain scores, postoperative nausea/vomiting, and patient satisfaction score at discharge were also recorded. Results: Total tramadol consumption was 94.6% lower in the block group as compared to the control group (5.4 ± 18.7 mg in CESP block group as compared to 99.7 ± 49.6 mg in control group). Intraoperative fentanyl requirement and pain scores were significantly lower in CESP group. Postoperative incidence of nausea/vomiting was similar, but satisfaction score was significantly better in block group. Conclusion: US‑guided CESP block provides effective and prolonged peri operative analgesia and opioid sparing in breast cancer surgeries. [ABSTRACT FROM AUTHOR]

Background and Aims: Paravertebral block has been found to be a recommended method of analgesia for breast surgeries. We aimed to assess the efficacy of paravertebral block compared to morphine by means of the visual analogue scale (VAS), pain-related biomarkers, and reactive oxygen species (ROS) in adult patients undergoing breast cancer surgeries under general anesthesia. Methodology: Forty patients undergoing breast surgery with or without lymph outcome were randomly divided into two groups. Group M received general anesthesia with intraoperative injection morphine (0.1 mg/kg) and group P received general anesthesia with paravertebral block with 0.25% bupivacaine (0.3 ml/kg). The primary objective was to compare the postoperative pain using VAS at baseline, 2 hours, 24 hours, and 48 hours. Secondary objectives were to compare the levels of pain-related biomarkers and ROS in both the groups at baseline, 24 hours, and 48 hours and to study the correlation between the VAS and level of pain-related biomarkers and ROS. Results: There was no significant difference in the postoperative VAS scores in both the groups (P = 0.252, 0.548, 0.488 at baseline, 24 hours, and 48 hours, respectively) and no significant difference in the mean biomarkers in both the groups. The mean VAS negatively correlated with biomarker levels at 24 hours and 48 hours, but the change in VAS after 24 hours and 48 hours did not significantly correlate with the change in the biomarkers. Conclusion: Paravertebral block is equally efficacious to intraoperative morphine for breast surgeries for postoperative analgesia. The biomarker levels were not significantly different when patients received paravertebral block or morphine. [ABSTRACT FROM AUTHOR]

Aims: Intra‑operative radiotherapy (IORT) is a new alternative way to give radiation therapy. During surgery to remove breast cancer, radiation is given as a single dose directly to the area where the tumor used to be. The aim of the study was to compare the results of IORT as partial breast irradiation and external whole breast irradiation (EBRT) for early breast cancer in elderly patients after breast‑conserving surgery. The results were retrospectively analyzed from a single institution. We report 7‑year results for local control. Settings and Design: Cross‑sectional study. Methods and Material: Between November 2012 and December 2019, 21 Gy partial breast irradiation was applied intra‑operatively to 40 selected patients. Two of these patients were excluded from the study, and 38 patients were evaluated. Also, 38 patients who had EBRT and had similar properties to that of IORT patients were selected to compare the treatment results in terms of local control. Statistical Analysis Used: SPSS version 21 was used for statistical analysis. Patient groups undergoing IORT and EBRT were analyzed with the Kolmogorov–Smirnov test. The groups were examined in terms of demographic features using t‑test, and P < 0.05 was considered as statistically significant. Local recurrence rates were calculated by Kaplan–Meier analysis. Results: The median follow‑up time was 58 months (range 20–95 months). The local control was 100% in both groups, and no local recurrences were observed. Conclusion: IORT seems to be a safe and effective alternative to EBRT for early breast cancer in elderly patients. [ABSTRACT FROM AUTHOR]

Background and Aims: Despite many analgesic modalities available, postoperative pain management after breast cancer surgery remains a challenge, which translates into poor quality of recovery, if untreated. Intravenous lignocaine with its anti-inflammatory, antihyperalgesic, and analgesic properties could provide a good option for these patients. The aim of this study was to evaluate the effect of intravenous lignocaine on postoperative pain relief and quality of recovery in patients undergoing surgery for breast cancer. Methods: In this prospective double-blind placebo-controlled randomised study, sixty-six patients undergoing breast cancer surgery were assigned 1:1 to placebo or intravenous lignocaine (Group L). Group L received an intravenous 1.5 mg/kg of lignocaine bolus at induction, followed by an intravenous infusion of 1 mg/kg/h for 24 hours intravenously, while the control group was given equal volume of normal saline. Pain scores, opioid utilisation, and quality of recovery (QoR-15) at 24 hours and on the day of suture removal were compared. Results: Statistically significant reduction was observed in both static (P = 0.01, 6 hours) and dynamic postoperative pain (P = 0.030, 24 hours), with consequential delay in the need for the first dose of opioid (P = 0.014) as well as decreased 24-hour postoperative opioid consumption (P < 0.001) and decreased post-operative nausea and vomiting (PONV) (P < 0.05) in the lignocaine group. Global QoR-15 was significantly better at 24 -hours in group L on postoperative day 1 (P < 0.001), albeit there was no significant difference at suture removal. No lignocaine related side effects were observed. Conclusion: Intravenous lignocaine can be safely used as an alternative perioperative non-opioid analgesic for early postoperative pain and recovery. [ABSTRACT FROM AUTHOR]

Introduction: Breast cancer is the most widely recognized malignant growth in ladies in India and accounts for 14% of all tumors in women. Modified radical mastectomy (MRM) is a surgery done for breast cancer. It leads to about 30% chances of postoperative nausea and vomiting (PONV) and 40% pain in the immediate postoperative period. Objectives: Changes in blood pressure after intubation, waiting time for postoperative pain medication, and possibility of adverse effects. Methodology: After the approval of ethical committee, the study was conducted in the procedure and possible complications associated with the procedure were explained to patients. Written informed consent was obtained from each patient. Result and Conclusion: We conclude that opioid-free anesthesia is "more effective in reducing the incidence of postoperative nausea and vomiting, produces stable hemodynamics, and reduces incidence of side effects when compared with opioid-based general anesthesia in patients undergoing breast cancer surgeries." [ABSTRACT FROM AUTHOR]

The article presents a case study of a 74 year old woman with a left breast lump. It is reported that fine-needle aspiration cytology revealed discohesive plasmacytoid cells, leading to a diagnosis of carcinoma, Yokohama grade five. It highlights the diagnostic challenge of plasmacytoid cells in breast FNAC (Fine Needle Aspiration Cytology) and emphasizes the rarity of SPC ( Solid Papillary Carcinoma) presenting this way.

Background and Aims: Breast surgery is associated with moderate-to-severe postoperative pain, nausea, and vomiting. For this, neuraxial anesthesia might be a better alternative to general anesthesia (GA), providing superior analgesia, with higher patient satisfaction and lesser incidence of nausea vomiting. This randomized-controlled open-label trial was done to compare segmental spinal and GA for breast cancer surgery. Material and Methods: The present study enrolled 56 female patients scheduled to undergo breast cancer surgery. They were randomly divided into two groups, group G (received standard GA) and group TS (received segmental thoracic spinal anesthesia with 0.5% isobaric levobupi vacaine at T5–T6 inter spaces). The primary objective of this study was patient satisfaction with the anesthetic technique, while secondary objectives were hemodynamic changes, perioperative complications, time of first rescue analgesic, total opioid consumption in first 24 h, and surgeon satisfaction score. Data were expressed as mean (SD) or number (%) as indicated and were compared using Chi-square, Fisher's exact, or Student's ttest as appropriate. Results: Patient in group TS had significantly higher satisfaction score median 5 (IQR 1) compared to patients in group G median 4 (IQR 3.5) (P = 0.0001). Nausea and vomiting were significantly higher in group G compared to group TS (P = 0.01). Mean time to rescue analgesia was 33.21 ± 7.48 min in group G as compared to 338.57 ± 40.70 in group TS and opioid consumption was also significantly lower in group TS (70.00 ± 27.38) as compared to group G (366.07 ± 59.40). There was no significant difference in hemodynamic parameters (except significantly lower heart rate at 15 min in group TS (P = 0.001) and surgeon satisfaction score between groups. Quality of postoperative analgesia was better in group TS. Conclusion: Segmental thoracic spinal anesthesia technique provides better satisfaction with superior postoperative analgesia and fewer complications in patients undergoing breast cancer surgery compared to GA. [ABSTRACT FROM AUTHOR]

Background The treatment of breast cancer evaluation nowadays relies on the cure rate figures and quality of life. Aim and objectives The aim of this study was to evaluate efficacy, complications, patient satisfaction, and esthetic outcomes of immediate lipomodeling used for correction of deformities resulting from breast-conserving surgery for patients with breast cancer and to evaluate lipomodeling and the incidence of local recurrence in its experimental level. Patients and methods This study was carried out on 50 female patients with malignant breast lesions admitted to the Surgical Department of Medical Research Institute and underwent breast-conserving surgery over a 1-year period. Results According to surgeon and patient assessment, most cases were good [20 (40%)] followed by excellent [18 (36%)] regarding surgeon assessment. Degree of satisfaction was four in 23 (46%) cases and five in 16 (32%) cases. Regarding esthetic results by the breast cancer conservation treatment core (BCCT.core) program, good results were higher, as seen in 23 (46%) patients, followed by fair results, with 18 (36%) patients. Conclusion Lipomodeling is a unique technique that enables autologous breast reconstruction and improves breast reconstructive surgery results by decreasing scar tissue, increasing breast softness, and creating a natural skin texture. It is possible to execute lipomodeling as a day-case procedure after breast cancer surgery, and the technique is safe. Without sacrificing oncological results, it seems to have adequate effectiveness in correcting abnormalities. [ABSTRACT FROM AUTHOR]

Background and Aims: Thoracic epidural analgesia (TEA) is an effective analgesic technique for breast surgery, although it has many associated complications. Ultrasound (US)-guided erector spinae plane (ESP) block requires less technical expertise, is safe and may be an alternative to TEA. We aimed to compare the efficacy of TEA with US-guided continuous ESP block for post-operative analgesia in patients undergoing modified radical mastectomy (MRM) surgeries. Methods: Sixty-six female patients of age group 18-65 years, and American Society of Anesthesiologists (ASA) physical status I and II, undergoing MRM surgeries were recruited. Patients received TEA in Group Ep and US-guided ESP block in Group Er, before induction of general anaesthesia. Both the groups received 0.2% ropivacaine 15 mL, followed by 5 mL.h-1 infusion for 24 h. The primary outcome was the duration of analgesia. Secondary outcomes were total doses of rescue analgesics in 24 hours and visual analogue scale (VAS) scores at 0 h, 1 h, 2 h, 4 h, 8 h, 12 h, and 24 h. Results: The mean duration of analgesia was 21.72 ± 4.73 hours in Ep group and 20.60 ± 5.77 hours in Er group (P = 0.39). The total dose of rescue analgesics in the postoperative period was comparable between both the groups. There was no significant difference in VAS scores between the groups over 24 h. Conclusion: US-guided ESP block can be used as safe and easy to perform alternative analgesic technique over thoracic epidural analgesia for peri-operative pain management in breast cancer surgeries. [ABSTRACT FROM AUTHOR]

Introduction: The standard treatment for advanced breast cancer is surgery consisting of breast-conserving surgery or modified radical mastectomy (MRM) postneoadjuvant chemotherapy followed by adjuvant radiation treatment (RT). Conventionally-fractionated whole breast irradiation has been the standard RT regimen, but recently shorter courses of hypofractionated whole breast or chest wall irradiation have been advocated for patient convenience and reduction in health-care costs and resources. Radiation is delivered through the same technique, but tumors receive a higher dose of radiation per treatment session with hypofractionation. Aim: The aim of the study was to compare different fractionation schedules of radiotherapy in postoperative cancer breast with respect to locoregional control and toxicities. Materials and Methods: One hundred and eighty-eight patients of cancer breast, who received RT between January 2017 and December 2019 were assessed. Since hypofractionation is well documented and established and being practiced in prestigious institutes, we treated the patients as per their choice to receive 10.15 or 25 fractions. 72 patients (Group A) were treated with conventional fractionation to a dose of 50 Gy/25 fractions/5 weeks. Second group of 62 patients (Group B) were given 40.5 Gy/15 fractions/3 weeks and third group of 54 patients (Group C) were treated with 34 Gy/10 fractions/2 weeks. All patients were T3 or more and underwent MRM after neoadjuvant chemotherapy. They were in the age group of 30-65 years. All of them received adjuvant chemotherapy and hormone therapy in case of estrogen/and progesterone receptor positivity and anti-Her2neu target therapy in case of Her2neu positivity. They were assessed for locoregional control and acute and chronic toxicities. Results: Grade 3 and 4 skin toxicity was similar in all three groups. At 6 months postcompletion of RT, two patients in Group A, 3 in Group B, and 5 in Group C lost to follow-up. In rest of the subjects, there was no locoregional failure. At 1 year, 1 patient from Group A, 2 from Group B, and 1 from Group C developed locoregional recurrence. There were no major chronic toxicities. Arm edema and Telangiectasia were similar in three groups. No rib fracture or major cardiotoxicity and pulmonary toxicity was seen. Conclusion: Hypofractionated RT is a part of the typical treatment regimen for breast cancer nowadays. The major advantage is of convenience to the patients as it is completed the full course of RT in fewer sessions. With both conventional and hypofractionated radiation, the patient receives radiation 5 days a week. In the conventional regimen, though the schedule lasts for 5 weeks, whereas hypofractionation therapy is completed in 2 to 3 weeks. Local control wise both conventional and hypofractionated regimen is similar in locoregional control and toxicity. Therefore, hypofractionated RT should be practiced in cancer breast as it is economical, convenient, and toxicity wise and result wise similar to conventional radiotherapy. [ABSTRACT FROM AUTHOR]

Background and Aims: Breast cancer surgeries are associated with both nociceptive and neuropathic pain, requiring strong analgesics. We aimed to evaluate the postoperative morphine-sparing effect of pre-emptive oral premedication with tramadol versus pregabalin in patients undergoing breast-conserving cancer surgeries (BCCS). Methods: This prospective, randomised, placebo-controlled trial was carried out at tertiary care centre on 90 patients undergoing BCCS randomised into three groups of 30 each. Group C received placebo, Group T received tramadol 100 mg and Group P received pregabalin 75 mg as oral premedication, 1 hour before surgery. General anaesthesia was administered. Postoperatively morphine 1 mg.h-1 through intravenous PCA was started at a visual analogue scale score ≥4. Total morphine consumption in 24 hours was calculated and its sparing effect was evaluated as the primary outcome. Results: The median with interquartile range (IQR) of total postoperative morphine consumed in 24 hours, was found to be 22 mg (IQR 0-25.77), 15 mg (IQR 0-16) and 17.50 mg (IQR 0-19.25) in groups C, T, P respectively, (P = 0.000, 0.003, 0.060). The median duration of analgesia in group C was 5.40 hours (IQR 3.30-11.40), 11.6 hours (IQR 9.30-24.0) in group T and 8.60 hours (IQR 6.97-16.27) in group P (P value C/T = 0.000, C/P = 0.007, T/P = 0.002). The postoperative side effects were comparable. Conclusion: Oral tramadol 100 mg and oral pregabalin 75 mg as premedication reduced the 24 hours postoperative morphine requirement as compared to placebo in BCCS. However, tramadol 100 mg provided superior analgesia for longer duration than pregabalin 75 mg and was associated with more side effects. [ABSTRACT FROM AUTHOR]

In early stages of breast cancer, breast conservation therapy (BCT) with lumpectomy and adjuvant irradiation is preferred. Accelerated partial breast irradiation (APBI) is considered as an alternative to whole breast irradiation. The reasons are it requires less number of irradiation fractions, shorter treatment time, and decreased size of irradiation. The procedure includes insertion of several brachycatheters, which is associated with significant pain in the postoperative period. We report case series of 8 patients of APBI where perioperative pain management was done using ultrasound (USG)-guided serratus anterior plane (SAP) block with catheter insertion. The catheter was placed between the serratus anterior muscle and external intercostal muscle. The drug used was 0.4 mL.kg−1 of 0.375% Ropivacaine with a maximum value of 30 mL. On the day of the procedure, all patients were given two boluses of ropivacaine 20 mL each at an interval of 6 h. From the next day onward, they received ropivacaine boluses on demand basis when Numerical Rating Scale (NRS) was >4. There were no complications during the procedure. None of the patients required extra fentanyl boluses intraoperatively. One patient did not have an SAP catheter inserted during primary insertion, as she failed to give consent for block. On repositioning of catheters, she experienced severe pain with a NRS of 8/10. After obtaining proper consent, SAP catheter was inserted and she had NRS of 1/10 postoperatively. 2/8 patients received rescue analgesics in the form of diclofenac. 7/8 SAP catheters were removed on day 5. Only one SAP catheter was removed accidentally on day 3. It was concluded that USG-guided SAP catheters are a novel, safe, and effective regional anesthesia technique for perioperative pain management in breast cancer surgeries undergoing APBI. [ABSTRACT FROM AUTHOR]

Background Thoracic epidural (TE) analgesia was considered as the gold standard for intraoperative and postoperative analgesia in breast surgeries. However, it is not routinely used because of its associated hemodynamic effects. Erector spinae plane (ESP) block is recognized as a promising perioperative analgesic intervention in breast surgeries. Aim To compare between ESP block and TE analgesia in unilateral breast cancer surgeries without axillary clearance performed under general anesthesia. Patients and methods Forty female patients scheduled for unilateral cancer breast surgeries without axillary clearance under general anesthesia were enrolled in this study. After induction of general anesthesia, patients were divided into two groups: TE group received single-shot 10-ml 0.25% bupivacaine in the TE space, while ESP group received single-shot 20-ml 0.25% bupivacaine ultrasound-guided ESP block. The primary outcome was to assess the analgesic effects through recording intraoperative fentanyl consumption and postoperative narcotic consumption (morphine in the post-anesthesia-care unit and pethidine in the surgical ward), visual analog scale (VAS) score for pain assessment in the first postoperative 24 h. The secondary outcomes were to compare hemodynamic changes and any complications related to the technique or drugs used, and patient satisfaction. Results No statistical differences were found between the two groups regarding their demographic data. As regards narcotic consumption, intraoperative fentanyl consumption was significantly higher in ESP group (P<0.001), postoperative morphine consumption in post-anesthesia-care unit was not statistically different between the groups (P=0.67), while pethidine consumption in the surgical ward was higher in TE group (P<0.001). Concerning pain assessment, VAS scores in ESP group were statistically lower when compared with TE group starting from 2 to 12 h postoperatively, and higher in patients' satisfaction about analgesia in the first 24 h postoperatively (i.e. 95% satisfied in ESP vs. 55% in TE) (P=0.01). As regards hemodynamic effects, TE group showed lower mean arterial blood-pressure recordings with a significant difference between the ESP group at 10 min, 30 min, and 1 h after the intervention (P=0.034, P<0.001, and P=0.006, respectively), TE group showed a significant difference with lower heart-rate recordings in comparison with ESP group, at 30 min after the block (P=0.002). Conclusion The current study revealed that ESP block showed lower postoperative pethidine consumption and lower VAS scores from 2 to 12 h. Postoperatively, while TE block showed lower intraoperative fentanyl consumption. ESP block showed better hemodynamic stability and higher patients' satisfaction to analgesia. We propose that ESP block should be included in the armamentarium of regional analgesic techniques for breast surgeries. [ABSTRACT FROM AUTHOR]

Background During the coronavirus disease 2019 pandemic, the surgical practice has been severely affected, and many nonemergency surgeries were postponed and rescheduled. This is considered to be harmful for cancer patients awaiting their definitive surgical treatment. To date, there is a shortage of large evidence-based studies providing clear guidelines for resuming routine management of these specific types of patients. Patients and methods A clinical multi-institutional prospective study was carried out on 1446 adult cancer patients operated with the intention of achieving a cure in the centers participating in this study in the past year under the unusual circumstances imposed by this widespread pandemic, aiming to share our experience in resuming surgical management of these special types of patients, with a focus on the short-term outcomes. Results The patients were allocated into two groups: the control group included 1178 patients and the task group included 252 patients. Due to the recent SARS-COV-2 infection, the most common type of surgery performed was breast cancer surgery (32.6, 30.2%) in both groups. The 30-day postoperative morbidity and mortality were comparable in both groups, but slightly higher in the task group (25.4, 3.2%). Patients more than 60 years, patients with two or more comorbidities, patients with American Society of Anesthesiologists score 3, and patients undergoing major surgery were more susceptible to developing postoperative complications. Conclusion Surgery for cancer patients can be safely resumed during the coronavirus disease 2019 pandemic, with caution in selected patients. [ABSTRACT FROM AUTHOR]

Background Being the symbol of femininity and motherhood, the breast is very precious to every female and its absence due to mastectomy due to cancer has a very negative impact on physical and psychological life for females. Breast-conserving and breast-reconstructive surgeries are the solution for these problems, while free autologous fat grafting is one of these options, and this study is designed to evaluate its efficiency. Patients and methods During the period from June 2016 to November 2020, a prospective study was performed over 45 patients who have undergone immediate dermal fat grafting aiming for breast reconstruction during conservative surgery for breast cancer. The follow-up period ranged from 4 to 40 months. Results The excised specimen volume size (tumor + safety margin) was 120 cm3 ranging from 95 to 145 cm3 and its weight was 55 g, ranging from 35 to 110 g. Although the graft volume was 140 cm3 with a range of 120–170 cm3 and its weight was 65 g ranging from 45 to 130 g. Last, the maximum surgical margin was 33 mm with a range of 27–42 mm. The results showed that for objective cosmetic satisfaction, the authors got excellent results in 15.55% of patients, while 62.23% were good, and 22.22% got a fair result with no poor ones. The subjective patient satisfaction was excellent in 48.88% of patients, 40% were good, and 11.12% got a fair result with no poor ones. The total actual number of patients who faced complications was 17.8%, which were all resolved and managed quickly with conservative methods. Conclusions Immediate dermal fat grafting in breast reconstruction during conservative surgery for breast cancer is a reliable, simple, safe, efficient, and rapid method for breast reconstruction with a very big advantage from being an autologous tissue with a relatively low rate of complications. [ABSTRACT FROM AUTHOR]

Background and Aims: Regional anaesthesia has been used to reduce acute post-operative pain as well as opioid-related side effects in breast cancer surgery. Erector spinae plane (ESP) block is a relatively new fascial plane block being tried in various surgical procedures. Our study is a double-blind randomised trial, designed to prove the efficacy of this block in breast surgeries. Methods: Seventy female patients scheduled for unilateral breast surgery were enroled in this prospective, randomised, double-blind study. Patients were randomised to group A and group B. All patients received general anaesthesia while group B received additional ultrasound-guided erector spinae block given at thoracic level—T5 with 20ml of 0.25% bupivacaine. Time to first rescue analgesia was the primary outcome. Secondary outcomes were total intraoperative opioid consumption, pain scores over 24 h, post-operative nausea and vomiting and patient satisfaction score at discharge. The Shapiro–Wilk test was used to check the normality of each variable. A comparison was done using Mann–Whitney test and the level of significance was set at 0.05. Results: The median time to first rescue analgesia in group A versus group B was 1 h (1–12h) versus 8 h (1–26h), respectively, with a P value of 0.044. Group B patients had lower pain scores post-operatively and better satisfaction scores at discharge. There was no statistically significant difference in intraoperative fentanyl consumption. Conclusion: Ultrasound-guided ESP block with general anaesthesia offers superior post-operative analgesia compared to general anaesthesia alone in patients undergoing unilateral nonreconstructive breast cancer surgeries. [ABSTRACT FROM AUTHOR]

Opioid-based anesthesia is associated with unwanted adverse effects such as postoperative nausea and vomiting, respiratory depression, itching, and urinary retention. Opioid-free anesthesia is a combination of multimodal analgesia that aims to avoid perioperative opioids altogether. Various methods, such as regional blocks, and drugs, such as lignocaine, dexmedetomidine, and ketamine, can be used to evade the use of opioids. Here, in a series of five cases undergoing breast cancer surgery, we attempt to use a combination of analgesic techniques that result in complete avoidance of opioids during the intraoperative period. [ABSTRACT FROM AUTHOR]

Background: Surgery for breast cancer and adjuvant radiotherapy are frequently associated with impairment of arm/shoulder function and development of lymphedema. However, most of the studies in Indian breast cancer survivors (BCSs) have focused on the development of lymphedema even though restriction of shoulder movement and pain are even more prevalent and adversely affect the quality of life (QOL). Hence, this study was conducted with the objectives to (1) study the prevalence of arm/shoulder problems (ASPs) including restricted shoulder mobility (ROM), lymphedema and arm/shoulder pain (2) assessment of the QOL in BCSs (3) to study the impact of ASPs on QOL.Methods: This descriptive study was conducted on BCSs at an academic center in Delhi These patients underwent a mastectomy and axillary lymph node dissection with adjuvant therapies and were within 6 months to 5 years of follow-up. Assessment of ASPs was done using Kwan's arm problem scale (KAPS), and survivors with scores of more than 21.5 were considered to have significant ASPs. Assessment of shoulder movements was done by using a goniometer, lymphedema by measuring arm circumference at multiple points and arm/shoulder pain by using a numerical pain rating scale (NPRS). QOL was assessed using short form (SF-36) questionnaire.Results: A total of 212 BCSs were studied with a mean duration of follow-up of 2.7 years (range = 6 months - 60 months). The prevalence of ASPs was 49% on KAPS. Prevalence of ROM, lymphedema, and arm/shoulder pain was found to be 51%, 27%, and 12% respectively. Patients with ASPs had poorer QOL scores on SF-36, significantly affecting both physical and mental component summary score. Among ASPs, worst scores were reported for limb swelling.Conclusion: There is a high prevalence of ASPs in BCSs. Survivorship care plans should appropriately address these issues. [ABSTRACT FROM AUTHOR]

Introduction: The ultrasound (US)-guided erector spinae plane (ESP) block is a new regional anesthetic technique that offers significant advantages over paravertebral block as it is easy and safe to perform. We aim to compare the efficacy of US-guided paravertebral block with ESP block for postoperative analgesia in modified radical mastectomy (MRM). Methods: Eighty female patients of age group 18–70 years, belonging to physical status American Society of Anesthesiologists (ASA) I and II, undergoing MRM were included in the study. In Group P, patients received paravertebral block and in Group E, patients received ESP block before induction of general anesthesia. Both the groups received 0.5% 20 mL ropivacaine. The time to first rescue analgesia and total doses of rescue analgesics were recorded in the postoperative period. Numeric Rating Scale (NRS) scores at 0 min, 30 min, 1 h, 2 h, 6 h, 12 h, and 24 h were noted, and patient satisfaction was evaluated at 24 h. Unpaired t-test or the Mann–Whitney U test was used to compare quantitative variables while Chisquare test or Fisher’s exact test was used to compare qualitative variables. Results: The time for the first analgesic request was 232.5 min (140-1200) in ESP group as compared to paravertebral group in which the duration was 205 min (135-1190) (P value = 0.29). The total dose of rescue analgesics and NRS scores in postoperative period were comparable. However, the time to perform ESP block was significantly shorter than that of paravertebral block. Conclusion: ESP block can be used as a safe and easy to perform alternative analgesic technique over paravertebral block in breast cancer surgeries. [ABSTRACT FROM AUTHOR]

Fecal microbiome transplantation from CPSP patients to mice led to development of hyperalgesia in these mice.[[6]] The gut microbiome composition has been attributed to development of opioid tolerance. Han I et al i . studied gut microbiota of mice after sevoflurane exposure and found that microbiome composition was reduced on day-1, 3, 7, and 14 after sevoflurane anaesthesia compared to the control group. Sir, The human body is inhabited by a multitude of bacteria, viruses, fungi, phages constituting the microbiota, and their gene pool called the microbiome which is essential for human well-being.[[1]] The role of gut microbiome in peri-operative medicine is recently being explored. [Extracted from the article]

Background and Aims: Pectoral block (PECS)-based anesthesia without opioids decreases analgesic requirement, pain scores and post-operative nausea vomiting (PONV) compared to conventional opioid-based general anesthesia in patients undergoing modified radical mastectomy and axillary dissection (MRM-AD). We compared PECS versus Paravertebral Block (PVB) in providing an opioid free, nerve block-based regimen. Outcomes of interest were post-operative analgesic requirement, duration of analgesia, PONV and patient and surgeon satisfaction. Material and Methods: This randomised controlled study involved 58 adult ASA I-III patients posted for MRM-AD. After randomization patients were induced with propofol and maintained on spontaneous ventilation with isoflurane (0.8-1.0 MAC) through i-gel. Ultrasound-guided PECS or PV blocks (30 ml of 0.1% lignocaine + 0.25% bupivacaine + 1 μg/kg dexmedetomidine) were administered. Post-operative pain scores, non-opioid analgesic requirement over 24 hours, PONV, satisfaction of surgeon and patient were measured. Results: Between the two groups, there was no difference in demographics, ASA status, location and volume of breast tumour excised or the duration of surgery. The time from block to incision was significantly longer in the PV group (P = 0.01). There was no difference between the two groups in terms of intra and post-operative parameters, and the median VAS scores for pain at rest or during shoulder abduction were similarly low in both the groups. Conclusion: Both blocks result in equally prolonged analgesia and preclude requirement of opioid analgesics intra and post-operatively. PECS block is associated with lesser time to allow incision. Complications are low in both the groups. Routine use of these blocks to avoid opioids may be studied further. Clinical trial number – Registered in Clinical Trials Registry of India (CTRI/2017/02/007897). http://ctri.nic.in. [ABSTRACT FROM AUTHOR]

Background Axillary lymph node status is the single most important prognostic factor in breast cancer. Sentinel lymph node biopsy (SLNB) can give an idea about the axillary nodal status, with a high rate of identification. Because the upper outer quadrant is the most common site for breast cancer, most studies of SLNB of the breast have been performed in patients with breast cancer mostly located in this quadrant of the breast, whereas the medial quadrants have much been less studied. In this study, we evaluate the axillary SLNB in medially located breast cancer only, using methylene blue injection technique, regarding identification rate, accuracy rate, and false negativity rate (FNR). Patients and methods The study included 42 female patients with medially located breast cancer and negative axilla, scheduled for modified radical mastectomy or conservative breast surgery. Overall, 4 milliliters of methylene blue 1% was injected in the peritumoral tissue. Sentinel lymph node(s) (SLN) and other axillary nodes were individually sent for pathological assessment. Results Average time taken from methylene blue injection until SLN(s) identification and dissection reached 45 min. SLN identification rate was 92.9% of the patients. The number of SLN removed per patient ranged from 1 to 3 nodes. The number of axillary lymph node removed during axillary lymph node dissection ranged from 10 to 22 nodes. Accuracy rate was 88.1%, and SLN FNR was 4.8%. Conclusion Axillary SLNB is highly valid in medially located breast cancer, with high identification and accuracy rates and low FNR. [ABSTRACT FROM AUTHOR]

Background Seroma formation is considered the most frequent postoperative complication after breast cancer surgery. Serous fluid is collected just under the skin flaps or in the axillary pace immediately following mastectomy preventing adherence of the flaps to the underlying fascia and muscles leading to delay wound healing, infected wound due to repeated aspiration, wound dehiscence, prolonged hospital stay, delay of adjuvant treatment, and finally generating additional costs. Patients and methods A randomized, controlled study was carried out among 138 female patients, who were candidates for mastectomy and axillary clearance. A control group without quilting (69 patients) had a traditional wound closure and the intervention (quilted) group (69 patients) had a sutured flap fixation. Results There were significant differences regarding seroma formation between both groups since it was detected in 22 (31.9%) of the 69 in the suture group and in 39 (56.5%) of 69 in the control group (P<0.004). There were significant differences between means of the number of seroma aspirations among patients with seroma (n=61) by study groups being significantly reduced in in the quilting group (4.3%) versus (18.8%) in the nonquilting group in comparison to the nonquilting group with P value less than 0.008. The range of operative time was 146 (80–160) in the quilting group and 100 (70–135) in the control group. Conclusion Quilting sutures postmastectomy is the most advised technique to minimize seroma formation and its complications. Hence, we recommend quilting of flaps as a routine step at the end of any mastectomy. [ABSTRACT FROM AUTHOR]

Background and Aims: Patients undergoing breast cancer surgeries face significant post-operative pain. We aimed to compare pectoral nerve (PECS) block with erector spinae (ESP) block in these patients in terms of analgesic efficacy and adverse effects. Methods: Sixty four American Society of Anesthesiologists' status I and II female patients between age 18 to 60 years scheduled for unilateral modified radical mastectomy (MRM) under general anaesthesia, were enrolled in this prospective randomised study. Patients in group I received ultrasound guided (USG) ESP block (20 cc 0.2% ropivacaine) while group II received USG guided PECS II block (25 cc 0.2% ropivacaine). General anaesthesia was administered in a standardised manner to both the groups. The various parameters observed included sensory blockade, duration of analgesia and any adverse effects. The primary outcome was the total morphine consumption in 24 hours. Results: The total morphine consumption in 24 hours was less in group II (4.40 ± 0.94 mg), compared to group I (6.59 ± 1.35 mg; P = 0.000). The mean duration of analgesia in patients of group II was 7.26 ± 0.69 hours while that in the group I was 5.87 ± 1. 47 hours (P value = 0.001). 26 patients in group II (PECS) had blockade of T2 as compared to only 10 patients in group I. (P value = 0.00). There was no incidence of adverse effects in either group. Conclusion: PECS II block is a more effective block when compared to ESP block in patients of MRM in terms of postoperative analgesia and opioid consumption. [ABSTRACT FROM AUTHOR]

Background and Aims: Pecs block and its variations provides perioperative analgesia, reduce PONV and other opioid related side effects. We hypothesized that COMIBPES block in addition to general anaesthesia will provide better postoperative analgesia when compared to general anaesthesia alone in breast cancer surgery patients. Methods: After obtaining permission from the institutional review board and registering the trial with Clinical Trials Registry of India (CTRI), we conducted a double blinded randomized controlled trial of 100 patients posted for elective breast surgery with axillary dissection. Patients were divided into two groups, P (Pecs block) and C (control). Intraoperative analgesia, postoperative analgesia, postoperative nausea vomiting (PONV) and shoulder mobility on first postoperative day (POD1) were noted. Primary outcomes were the pain scores measured by visual analog scale (VAS) and cumulative intravenous morphine consumption from patient controlled analgesia (PCA) pump at measurement intervals of 0, 1, 4, 8, 12 and 24 hours postoperatively. Results: Intraoperatively, Group P patients did not require any additional analgesia, whereas all the patients in Group C required additional intraoperative morphine (mean, SD: 5.12, 2.63 mg, compared to nil in group P, P < 0.01). COMBIPECS block group had lower pain scores and PCA morphine requirements, less PONV and better shoulder mobility on POD1. Conclusion: COMBIPECS block is a valuable addition to general anaesthesia for breast cancer surgery as it reduces pain and PONV while allowing better postoperative shoulder mobility. [ABSTRACT FROM AUTHOR]

Background: Harmonic scalpel is considered as a promising surgical tool for breast cancer, while its advantage over conventional approach is still controversial. Therefore, we performed this meta-analysis to compare the outcomes of harmonic scalpel and conventional tools in the surgery for breast cancer.Materials and Methods: Studies reporting the outcomes of harmonic scalpel and conventional technologies were systematically searched from online databases, PubMed and EMBASE up to April 30, 2018. Data were presented as odds ratio, risk ratio (RR), and mean difference (MD) with 95% confidence interval (CI).Results: Intraoperative blood loss (I2 = 96%, P < 0.05, MD = -68.78, 95% CI -93.31 to -44.24), seroma (I2 = 3%, P = 0.41, RR = 0.63, 95% CI 0.46-0.86) and hematoma formation (I2 = 0%, P = 0.64, RR = 0.41, 95% CI 0.23-0.73), drainage volume (I2 = 89%, P < 0.05, MD = -105.33, 95% CI -161.33 to -49.33) and time (I2 = 93%, P < 0.05, MD = -2.18, 95% CI -3.75 to -0.61), necrosis (I2 = 35%, P = 0.20, RR = 0.37, 95% CI 0.16-0.86), surgical duration (I2 = 79%, P < 0.05, MD = -8.49, 95% CI -16.56 to -0.43), and hospital stay (I2 = 97%, P < 0.05, MD = -0.94, 95% CI -1.74 to -0.14) are significantly different between the two groups.Conclusions: Harmonic scalpel is superior to conventional tools in terms of decreasing intraoperative blood loss, seroma and hematoma formation, drainage volume and time, necrosis prevalence, surgical duration, and hospital stay, which should be strongly recommended in the surgery for breast cancer. [ABSTRACT FROM AUTHOR]

Introduction: Use of intraoperative ultrasound (IOUS) has been shown to help achieve satisfactory cosmesis and negative margins in breast conserving surgery (BCS). This study has been done to compare the oncological and cosmetic outcomes following BCS using conventional palpatory method and IOUS.Materials and Methods: This is a prospective randomized controlled trial conducted at a tertiary care teaching and research institute in India. Patients with early operable breast cancer willing for BCS were included. Tumors were excised with 1 cm margin. In palpatory group, tumor was palpated and 1 cm margin was taken with a measuring scale while in the second group, IOUS was used to mark the margins. Histopathological evaluation was done to assess margins and cosmesis was assessed by patient, resident doctor, and nurse independently.Results: Sixty patients were included, 32 in the ultrasonography-guided and 28 in palpation-guided wide local excision. The mean age of patients was 48.78 years. In both groups, mean tumor size was 3.18 cm. Margin thickness and positivity was higher in palpatory group (though P > 0.05). Most patients were satisfied with cosmesis. There was no significant difference in complications and specimen volume in both groups. Presence of ductal carcinoma in situ component and expression of Her2neu by tumor cells had a significant impact on margin positivity.Conclusions: Intraoperative use of ultrasound offers a real-time assessment of margin status and may reduce the margin positivity rate compared to conventional palpation-guided method. [ABSTRACT FROM AUTHOR]

Introduction Oncoplastic techniques expanded the spectrum of breast conservative surgery for the management of early breast cancer. Planning for resection of medial breast tumors is difficult. The scars are apparent and deformity is eminent. Mammaplasty techniques do not leave scars in the medial area and reshaping can avoid deformity. Aim The study was carried out to evaluate the use of superior lateral pedicle and its inferior extension to fill the medial defects that occur after resection of medial breast tumors exploring the technical issues and results in terms of resection volume, adequacy of resection, deformity, complications, and esthetic results. Patients and methods Thirty consecutive patients with early breast cancer and medial tumors underwent wide excision to negative margins followed by reconstruction of defects using the extended superior lateral pedicle technique. Results All cases had negative resection margins. The weight of the specimen ranged from 65 to 565 g with an average weight of 262.47±165.31 g. Complications occurred in eight patients. No major complications or nipple loss occurred. Esthetic results were considered very good to excellent by both surgeons and patients. Conclusion Oncoplastic techniques for medial breast quadrants enabled wide resection, achieved adequate resection to negative margins with minimal complication rates and favorable esthetic results. [ABSTRACT FROM AUTHOR]

Background Breast-conserving surgery is the standard procedure for early breast cancer. Local recurrence after conservation is the main problem, and many factors can predict this local recurrence. Aim To highlight factors that may contribute to local recurrence after conservative breast surgery for early breast cancer in our Egyptian patients. Patients and methods A prospective cohort study was conducted that included 137 patients from breast clinic, Ain Shams University Hospitals. All patients were candidates for conservative breast surgery for primary early-stage breast cancer. They were followed up from January 2016 to December 2017 based on a fixed schedule. Results Incidence of local recurrence was 2.9%. Mean time to local recurrence was 14 months (range: 12–16 months). Tumor grade and estrogen receptor and progesterone receptor status were the most important prognostic factors affecting local relapse. On the contrary, age, family history, tumor size, safety margin, tumor type, lymph node (LN) status, HER-2 status, Ki-67, and intraductal component did not have a significant effect on local recurrence. Conclusion Patients with high-grade tumors, estrogen receptor and progesterone receptor negativity should be treated aggressively. As all cases of local recurrence occurred in the first 16 months in our study, we strongly recommend that the scheduling of surveillance visits should be more frequent during the first 2 years (at least every 3 months). [ABSTRACT FROM AUTHOR]

Introduction: Thoracic paravertebral block (TPVB) is an effective method for intra- and post-operative pain management in thoracic surgeries. For a long time, various adjuvants have been tried for prolonging the duration of TPVB. Objective: In this prospective study, we have compared the analgesic sparing efficacy of dexmedetomidine and clonidine, two α2 adrenergic agonists, administered along with ropivacaine for TPVB for breast cancer surgery patients. Materials and Methods: Forty-four breast cancer surgery patients undergoing general anesthesia (GA) were randomly divided into Group C and Group D (n = 44 each) receiving preoperative TPVB at T3-5 level with 0.5% ropivacaine solution admixture with clonidine and dexmedetomidine, respectively. Cancer surgery was performed under GA. Intraoperative fentanyl and propofol requirement was compared. Visual analogue scale was used for pain assessment. Total dose and mean time to administration of first rescue analgesic diclofenac sodium was noted. Side effects and hemodynamic parameters were also noted. Results: Intraoperative fentanyl and propofol requirement was significantly less in dexmedetomidine group than clonidine. The requirement of diclofenac sodium was also significantly less and later in Group D than Group C. Hemodynamics, and side effects were comparable among two groups. Conclusion: Dexmedetomidine provided better intraoperative as well as postoperative analgesia than clonidine when administered with ropivacaine in TPVB before breast cancer surgery patients without producing remarkable side effects. [ABSTRACT FROM AUTHOR]

Background and Aims: In centers with high turnover of breast surgeries, pectoral nerve block (Pec II) is time-consuming and requires ultrasound familiarity for administration. We decided to block the same nerves under vision after resection to evaluate postoperative analgesic effects. Material and Methods: Sixty patients scheduled for modified radical mastectomy were enrolled in this prospective, randomized, placebo-controlled, triple-blinded study. All patients received standardized general anesthesia. After surgical resection, infiltration of either ropivacaine (Group A) or saline (Group B) was given under vision at two points: 20 ml in the fascia over serratus anterior and 10 ml in the fascia between pectoralis major and minor at the level of the third rib. The primary outcomes measured were the time to first request for analgesia after extubation and total dose of analgesics needed, and secondary outcome included pain scores using the Numerical Rating Scale over 24 h. Analgesics used postoperatively were fentanyl citrate and paracetamol. We used Student's t-test to analyze quantity of analgesics needed, the nonparametric Mann–Whitney U-test for time to first request of analgesic, and Fisher's exact test for pain scores. Results: No patient in Group A required fentanyl. The mean time to first request for analgesia and mean dose of paracetamol required was 353.93 ± 135.03 min and 2.71 ± 0.462.71 g in Group A and 27.17 ± 18.08 min and 3.53 ± 1.074 g in Group B [P = 0.002]. Significantly more patients in Group A had mild pain scores compared to Group B. Conclusion: Pec II block with ropivacaine delivered under vision reduced analgesic requirement and pain scores significantly. [ABSTRACT FROM AUTHOR]

Background The round block technique is a unique breast resection through a periareolar doughnut incision. However, it is more technically challenging and time consuming. The aim of this study was to introduce our round block technique and to evaluate the results of oncological and cosmetic outcomes. Patients and methods A total of 60 female patients diagnosed with early stages of breast cancer (T1–2, N0–1, ≤M0) were treated with breast-conserving surgery using the round block technique at Ain Shams University Hospitals from March 2014 to March 2017. Patients with advanced breast cancer, with tumors less than 1.5 cm from the nipple, multicentric breast cancer, and pregnant women were excluded from the study. We minimized the extent of skin removal and used the purse–string technique in doughnut closure. Patients’ related complications, oncologic safety, cosmetic outcome, and patient satisfaction were assessed. Results The mean size of the tumors was 2.7 cm (range: 0.9–4.5 cm). The mean distance of the tumors from the nipple was 6.25 cm (range: 1.5–11 cm) on sonogram and most of the tumors were located on the upper breast (46.6%). The median operative time was 120 min (range: 90–145 min), including axillary surgeries. The median follow-up duration was 12 months (range: 2–36 months). Up to the longest 3 years of follow-up, favorable cosmetic results have been found in patients treated with the round block technique, with no cases of local recurrence. Conclusion The round block technique is oncologically safe and feasible for early stages of breast cancer, with favorable cosmetic results. [ABSTRACT FROM AUTHOR]

Background and Aims: Breast cancer surgery can be carried out as day-care procedure to increase patient turnover, decrease disease progression and financial burden. The present study was carried out to assess the role of dexmedetomidine in breast cancer surgery as a day-care procedure. Methods: This prospective randomised, double-blind study was carried out on 100 patients screened for day-care breast cancer surgery. They were divided into two groups of 50 each; who received either normal saline (Group NS) or 0.6 µg/kg/h dexmedetomidine (Group D) infusion from 10 min before induction until skin closure. All patients were given general anaesthesia. The incidence of discharge, post-operative pain (POP), average rescue analgesia (fentanyl) required and side effects were noted. Statistical analysis was performed using Student's t-test and Chi-square test. Results: Incidence of discharge in group NS was 60% compared to 88% in Group D (P = 0.001). Average rescue analgesia requirement by group NS was 136.07 ± 43.06 µg, whereas it was 77.5 ± 29.86 µg in Group D (P = 0.01). The incidence of POP in 6 h and within 2 h of expected discharge time in Group NS was 56% and 28%, respectively, and in Group D, it was 8% in both the periods (P < 0.001 and 0.01). Side effects such as post-operative nausea, vomiting and bleeding were encountered in eight and two patients, respectively, in Group NS and two and one patients, respectively, in Group D. Conclusion: Dexmedetomidine as an anaesthetic adjuvant makes breast cancer surgery feasible on day-care basis. [ABSTRACT FROM AUTHOR]

Background and Aims: Opioids are associated with postoperative nausea, vomiting, drowsiness, and increased analgesic requirement. A nonopioid anesthesia technique may reduce morbidity, enable day care surgery, and possibly decrease tumor recurrence. We compared opioid-free, nerve block-based anesthesia with opioid-based general anesthesia for breast cancer surgery in a prospective cohort study. Material and Methods: Twenty four adult American Society of Anesthesiologists grade I-III patients posted for modified radical mastectomy (MRM) with axillary dissection were induced with propofol and maintained on isoflurane (0.8-1.0 minimum alveolar concentration) through i-gel on spontaneous ventilation and administered ultrasound-guided PECS 1 and 2 blocks (0.1% lignocaine + 0.25% bupivacaine + 1 mcg/kg dexmedetomidine, 30 ml). Postoperative nausea, pain scores, nonopioid analgesic requirement over 24 h, stay in the recovery room, and satisfaction of surgeon and patient were studied. Twenty-four patients who underwent MRM and axillary dissection without a nerve block under routine opioid anesthesia with controlled ventilation were the controls. Results: MRM and axillary dissection under the nonopioid technique was adequate in all patients. Time in the recovery room, postoperative nausea, analgesic requirement, and visual analog scale scores were all significantly less in the nonopioid group. Surgeon and patient were satisfied with good patient quality of life on day 7. Conclusion: Nonopioid nerve block technique is adequate and safe for MRM with axillary clearance. Compared to conventional technique, it offers lesser morbidity and may allow for earlier discharge. Larger studies are needed to assess the long-term impact on chronic pain and tumor recurrence by nonopioid techniques. [ABSTRACT FROM AUTHOR]

Peri-operative factors, including anaesthetic drugs and techniques, may affect cancer cell biology and clinical recurrence. In breast cancer cells, we demonstrated that sevoflurane promotes migration and angiogenesis in high fractional oxygen but not in air. Follow-up analysis of the peri-operative oxygen fraction trial found an association between high inspired oxygen during cancer surgery and reduced tumor-free survival. Here we evaluated effects of acute, high oxygen exposure on breast cancer cell viability, migration and secretion of angiogenesis factors in vitro. MDA-MB-231 and MCF-7 breast cancer cells were exposed to 21%, 30%, 60%, or 80% v/v O2 for 3 hours. Cell viability at 24 hours was determined by MTT and migration at 24 hours with the Oris™ Cell Migration Assay. Secretion of angiogenesis factors at 24 hours was measured via membrane-based immunoarray. Exposure to 30%, 60% or 80% oxygen did not affect cell viability. Migration of MDA-MB-231 and MCF-7 cells was increased by 60% oxygen (P = 0.012 and P = 0.007, respectively) while 30% oxygen increased migration in MCF-7 cells (P = 0.011). These effects were reversed by dimethyloxaloylglycine. In MDA-MB-231 cells high fractional oxygen increased secretion of angiogenesis factors monocyte chemotactic protein 1, regulated on activation normal T-cell expressed and vascular endothelial growth factor. In MCF-7 cells, interleukin-8, angiogenin and vascular endothelial growth factor secretion was significantly increased by high fractional oxygen. High oxygen exposure stimulates migration and secretion of angiogenesis factors in breast cancer cells in vitro. [ABSTRACT FROM AUTHOR]

Background and Aims: Postoperative pain after breast cancer surgery is unavoidable. Thoracic paravertebral block (TPVB), a locoregional anesthetic technique, has been proven successful for postoperative pain management in different thoracic surgical procedures, such as thoracotomy, breast cancer surgeries. Clonidine, an adjuvant, in TPVB may enhance the quality and prolong the duration of analgesia. This prospective study was to evaluate the effectiveness of clonidine; administered with TPVB; in addition to conventional local anesthetic solution. Materials and Methods: Fifty-two patients (25-55 years) scheduled for breast cancer surgery under general anesthesia were randomly divided into Group A (n = 26) receiving preoperative TPVB at T3 with clonidine added to local anesthesia solution and Group B (n = 26) receiving identical TPVB with local anesthesia but without any adjuvant. This was followed by balanced general anesthesia. A visual analog scale was used to assess pain postoperatively up to 48 h. Meantime to administration of the first dose of rescue analgesic was noted. Total dose of fentanyl consumption, hemodynamic parameters, and side effects were all recorded for each patient. Results: The dosage of fentanyl required in the intraoperative period was significantly lower in Group A. Mean time to administration of rescue analgesic was found to be significantly longer in clonidine group. Hemodynamics and side effects were quite comparable among two groups. Conclusion: Clonidine as adjuvant in TPVB provided profound analgesia for up to 48 h postoperatively for patients undergoing breast cancer surgery without any appreciable side effects. [ABSTRACT FROM AUTHOR]

Objective: The aim of this study is to investigate the effect of transdermal fentanyl (TDF) as an adjuvant to paravertebral block (PVB) for pain control after breast cancer surgery. Patients and Methods: This randomized, double‑blind trial included fifty females with breast cancer scheduled for surgery. They were randomly allocated into one of two equal groups. The TDF group used transdermal fentanyl patches (TFPs) 25 μg/h applied 10 h preoperative then PVB with 20 mL of bupivacaine 0.25% was done before induction of general anesthesia. The PVB group used placebo patches in addition to PVB the same way as TDF group. Postoperative pain was assessed with a visual analog scale (VAS) score up to 48 h. Intravenous morphine 0.1 mg/kg was given when the VAS is ≥ 3 or on patient request. The primary outcome measures were the time to first request for analgesia and the total analgesic consumption in the first 48 h. Results: Relative to the VAS score reading was 30 min. After the end of surgery, VAS score decreased significantly in the two groups up to 48 postoperative hours and was significantly lower in TDF group up to 24 h. The time to first request of additional analgesia was significantly longer, and total dose of morphine consumption was significantly lower in TDF group (P < 0.001, and P = 0.039, respectively). Conclusion: TFPs releasing 25 μg/h is a safe and effective adjuvant to PVB after breast cancer surgery. It provides adequate analgesia with reduction of opioid consumption and minimal adverse effects. [ABSTRACT FROM AUTHOR]

Background and Aim: Recent studies have advised narcotic less anaestheic techniques for breast cancer surgeries due to altered immune system by use of opioids. So we planned this study to compare the efficacy of dexmedtomidine with fentanyl in breast cancer surgery in terms of haemodynamic stability, anaesthetic sparing effects, recovery profile and postoperative analgesia. Material and Methods: In this randomized prospective controlled trial, a total of 60 female patients were randomly assigned into two groups. Patients in group F (n = 30) received a loading dose of fentanyl 2 μg/kg with maintenance dose of 0.5 μg/kg/h and in group D (n = 30) received dexmedetomidine 1 μg/kg as loading dose with maintenance dose of 0.25 μg/kg/h till the end of surgery. Hemodynamic parameters, desflurane requirement, recovery profile and postoperative analgesia were monitored and compared in both the groups. Results: Mean HR was less in group D compared to group F intraoperatively, before and after extubation with a significant p value. The mean MAP was also lower in group D compared to group F at all the time points. MAC requirements were found lower in group D compared to group F with a significant P < 0.001. Cognitive recovery in the form of time to respond to verbal commands, time to extubation, time to orientation was early in dexmedetomidine group. Conclusion: Dexmedtomidine can be used as suitable alternative to fentanyl in breast cancer surgeries due to better hemodynamic stability, anaesthetic sparing effects and better recovery profile. [ABSTRACT FROM AUTHOR]

Background: Molecular subtypes of carcinoma breast show a particular pattern of distant metastasis, the knowledge of which can help to diagnose and intervene early in the course of the disease.Aim: The aim of this study was to investigate and establish an association between the molecular subtypes of carcinoma breast and the pattern of distant metastasis.Settings and Design: Single arm, retrospective study.Materials and Methods: Totally 400 patients of carcinoma breast (Stage I and II) were selected who were treated between January 2010 and December 2013. All these patients were treated with the standard treatment protocol for breast cancer. The estrogen receptor, progesterone receptor, human epidermal growth factor receptor-2 (HER-2) Neu status, and Ki-67 were done, and patients were classified into luminal A/B, HER-2 enriched, luminal/HER-2, and triple-negative subtypes. All patients were followed up until December 2015, and the pattern of local failure as well as distant metastasis was correlated with the molecular subtypes.Results: A total of 143 patients developed distant metastasis and local recurrence. Bone was the most common site of metastasis overall. It was the most common type of metastasis in luminal A/B (53.3%) and luminal-HER (57.1%). Brain metastasis was most common in HER-2-enriched subtype (30.3%), whereas liver was the most common site of metastasis in HER-2-enriched subtype (45.45%). The incidence of brain metastasis was comparatively lower in luminal A/B subtype. Local recurrence was most common in HER-2-enriched subtype. The results were statistically significant for lung metastasis and local recurrence (with P = 0.004 and 0.047, respectively).Conclusion: A strong association exists between the molecular subtypes and the site of distant metastasis in breast cancer which can be used for greater vigilance to detect site-specific distant metastasis beforehand. [ABSTRACT FROM AUTHOR]