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Articles supporting issues mentioned on Surgery FAQ page
Int J Clin Pract. 2002 Apr;56(3):188-90
Timing of surgery for breast cancer.
Hedley Atkins Breast Unit, Guy's Hospital, London, UK.
Several studies have now shown that premenopausal women with early breast cancer have a
significantly better prognosis if their tumours are excised during the luteal phase of the cycle. The 10-
year survival for node positive cases undergoing follicular phase surgery was 33% compared with
78% in those having surgery at other times of the menstrual cycle. Further work has shown that
there is an improved survival in those with plasma progesterone levels >4 ng/ml(-1), associated with
the luteal phase. Luteal phase surgery is also associated with a decreased risk of vascular invasion,
implying that the tumour is more cohesive at that time. Similarly, in the heaviest quartile of
postmenopausal patients, with the highest endogenous oestrogen levels, there was vascular invasion
around tumours in 45% compared with only 11% of the lightest quartile. Changing the hormonal
milieu at the time of surgery for breast cancer may have the ability to improve the prognosis for some
patients with early breast cancer.
OTHER CITATIONS FOR TIMING SURGERY
2: Lemon HM, Rodriguez-Sierra JF.
Timing of breast cancer surgery during the luteal menstrual phase may improve prognosis.
Nebr Med J. 1996 Mar;81(3):73-8. Corrected and republished in: Nebr Med J. 1996 Apr;81(4):110-5.
3: Lemon HM, Rodriguez-Sierra JF.
Timing of breast cancer surgery during the luteal menstrual phase may improve prognosis.
Nebr Med J. 1996 Apr;81(4):110-5. PMID: 8628449
4: Pujol P, Daures JP, Brouillet JP, Chang S, Rouanet P, Bringer J, Grenier J, Maudelonde T.
A prospective prognostic study of the hormonal milieu at the time of surgery in premenopausal breast
carcinoma. Cancer. 2001 May 15;91(10):1854-61.
5: Cooper LS, Gillett CE, Patel NK, Barnes DM, Fentiman IS.
Survival of premenopausal breast carcinoma patients in relation to menstrual cycle timing of surgery
and estrogen receptor/progesterone receptor status of the primary tumor. Cancer. 1999 Nov 15;86
(10):2053-8. PMID: 10570431
6: Saad Z, Bramwell V, Duff J, Girotti M, Jory T, Heathcote G, Turnbull I, Garcia B, Stitt L.
Timing of surgery in relation to the menstrual cycle in premenopausal women with operable breast
cancer. Br J Surg. 1994 Feb;81(2):217-20. PMID: 8156340
7: Badwe RA, Bettelheim R, Millis RR, Gregory W, Richards MA, Fentiman IS.
Cyclical tumour variations in premenopausal women with early breast cancer. Eur J Cancer. 1995
Dec;31A(13-14):2181-4. PMID: 8652239
8: Badwe RA, Wang DY, Gregory WM, Fentiman IS, Chaudary MA, Smith P, Richards MA, Rubens
RD. Serum progesterone at the time of surgery and survival in women with premenopausal operable
breast cancer. Eur J Cancer. 1994;30A(4):445-8. PMID: 8018400
Cancer Res. 2002 Aug 1;62(15):4491-8. Related Articles, Links
Morphine stimulates angiogenesis by activating proangiogenic and survival-promoting signaling and
promotes breast tumor growth.
Gupta K, Kshirsagar S, Chang L, Schwartz R, Law PY, Yee D, Hebbel RP.
Department of Medicine, University of Minnesota Medical School, Minneapolis, Minnesota 55455,
Morphine is used to treat pain in several medical conditions including cancer. Here we show that
morphine, in a concentration typical of that observed in patients' blood, stimulates human
microvascular endothelial cell proliferation and angiogenesis in vitro and in vivo. It does so by
activating mitogen-activated protein kinase/extracellular signal-regulated kinase phosphorylation via
Gi/Go-coupled G protein receptors and nitric oxide in these microvascular endothelial cells. Other
contributing effects of morphine include activation of the survival signal PKB/Akt, inhibition of
apoptosis, and promotion of cell cycle progression by increasing cyclin D1. Consistent with these
effects, morphine in clinically relevant doses promotes tumor neovascularization in a human breast
tumor xenograft model in mice leading to increased tumor progression. These results indicate that
clinical use of morphine could potentially be harmful in patients with angiogenesis-dependent
LOCAL ANESTHESIA WITH MASTECTOMY
The Breast Journal
Volume 11 Issue 2 Page 100 - March 2005
Total Mastectomy Under Local Anesthesia: The Tumescent Technique
Grant W. Carlson, MD
The management of breast cancer in elderly women is controversial. Breast cancer in this age group
tends to be biologically less aggressive and is highly responsive to hormonal intervention. The risk of
dying of other causes often exceeds the risk of cancer recurrence. For these reasons, older patients
tend to be treated less aggressively. One large study of elderly women with breast cancer found that
half of the patients were undertreated. Four patients (mean age 72 years, range 6195 years)
underwent a unilateral total mastectomy for cancer under local anesthesia using the tumescent
technique of infiltrating dilute lidocaine with epinephrine (25 ml of 1% lidocaine [250 mg] and 1 ml
of 1:1000 epinephrine [1 mg] to 1 L of Ringers lactate) via an infusion pump. Three of the patients
had estrogen receptor (ER)-negative tumors and one patient had tumor progression despite switching
from tamoxifen to anastrozole. All four patients were class IV as defined by the American Society of
Anesthesiology (ASA). There was no morbidity related to the surgery in the form of hematoma, wound
infection, or skin flap necrosis. The patients were discharged 14 days after surgery. The anesthesia
was adequate in all four cases and there was no deviation from the described technique. The mean
operative time was 35 minutes (range 2446 minutes). The tumescent technique is a safe, effective
method for performing a total mastectomy in patients who would not be considered candidates for
RECONSTRUCTION COMPLICATION RATE
Plast Reconstr Surg. 2003 Aug;112(2):467-76.
Infectious complications following breast reconstruction with expanders and implants.
Nahabedian MY, Tsangaris T, Momen B, Manson PN.
Department of Surgery, Johns Hopkins Medical Institutions, Baltimore, Maryland 21287, USA.
The incidence of infection following breast reconstruction with expanders and implants ranges from
1 to 24 percent. Numerous factors associated with infection have been described; however, a one-
variable at time setting and multifactorial analysis have not been performed. The purpose of this
study was to analyze a set of factors that may predispose women to infection of the expander or
implant. Between 1997 and 2000, a total of 168 implant reconstructions were performed in 130
women at a single institution. The mean age for all women was 48.2 years (range, 25 to 77 years).
The factors that were analyzed included axillary lymph node dissection, chemotherapy, radiation
therapy, tumor stage, timing of implant insertion, number of sides (unilateral versus bilateral),
tobacco use, and presence or absence of diabetes mellitus. Statistical analysis was performed with
stepwise logistic regression. Mean time to follow-up for all patients was 29 months (range, 12 to 47
months). Infectious complications occurred in 10 women (7.7 percent) and in 10 expanders or
implants (5.9 percent). Infected implants were removed an average of 116 days following insertion
(range, 14 to 333 days). Cultured bacteria included Staphylococcus aureus and Serratia marcescens.
A significant association (p < 0.04) was detected between implant infection and radiation therapy.
The chance for implant infection was 4.88 times greater for implants that were exposed to radiation
therapy compared with those that were not. In addition, there was suggestive (p < 0.09) evidence that
the chance of implant infection following lymph node dissection was 6.29 times higher than when no
lymph nodes were removed. No significant association between implant infection and age, diabetes,
tobacco use, tumor stage, timing of implant insertion, or chemotherapy was found.
Breast implants following mastectomy in women with early-stage breast cancer: prevalence and
impact on survival
Gem M Le1 , Cynthia D O'Malley1 , Sally L Glaser1 , Charles F Lynch2 , Janet L Stanford3 , Theresa
HM Keegan1 and Dee W West1
1Northern California Cancer Center, Fremont, California, USA
2Iowa Cancer Registry, University of Iowa, Iowa City, Iowa, USA
3Fred Hutchison Cancer Research Center, Division of Public Health Sciences, Seattle, Washington,
Breast Cancer Res 2005, 7:R184-R193
Few studies have examined the effect of breast implants after mastectomy on long-term survival in
breast cancer patients, despite growing public health concern over potential long-term adverse
We analyzed data from the Surveillance, Epidemiology and End Results Breast Implant Surveillance
Study conducted in San Francisco–Oakland, in Seattle–Puget Sound, and in Iowa. This population-
based, retrospective cohort included women younger than 65 years when diagnosed with early or
unstaged first primary breast cancer between 1983 and 1989, treated with mastectomy. The women
were followed for a median of 12.4 years (n = 4968). Breast implant usage was validated by medical
record review. Cox proportional hazards models were used to estimate hazard rate ratios for survival
time until death due to breast cancer or other causes for women with and without breast implants,
adjusted for relevant patient and tumor characteristics.
Twenty percent of cases received postmastectomy breast implants, with silicone gel-filled implants
comprising the most common type. Patients with implants were younger and more likely to have in
situ disease than patients not receiving implants. Risks of breast cancer mortality (hazard ratio, 0.54;
95% confidence interval, 0.43–0.67) and nonbreast cancer mortality (hazard ratio, 0.59; 95%
confidence interval, 0.41–0.85) were lower in patients with implants than in those patients without
implants, following adjustment for age and year of diagnosis, race/ethnicity, stage, tumor grade,
histology, and radiation therapy. Implant type did not appear to influence long-term survival.
In a large, population-representative sample, breast implants following mastectomy do not appear to
confer any survival disadvantage following early-stage breast cancer in women younger than 65 years
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