Abstract OT2-2-02: Hypnosis and paravertebral block in breast cancer surgery: A pilot study to evaluate pain management and surgical margin status

Background

Postoperative pain after breast cancer surgery is usually short and moderate, but as a risk factor for chronic pain, it should be a critical target. Moreover, it is crucial for these patients during this early stage of their treatment not to step into a vicious circle of deconditioning, fatigue and chronic pain. Therefore, fast rehabilitation methods should be promoted.

Partial mastectomy with sentinel lymph node dissection can be performed under general anesthesia or paravertebral block, either alone or associated with sedation or general anesthesia. Paravertebral blockade provides an efficient analgesia, allowing a reduction of morphine consumption and postoperative nausea and vomiting, has been showed to prevent chronic pain and may reduce the risk of recurrence or metastasis. It is a long-known regional anesthetic technique, but has been more commonly used recently for thoracic surgery, including breast surgery, since generalization of ultra-sound guidance brought security and reliability to the procedure. However, a sedation is often necessary to reduce anxiety, which can be high in this type of surgery.

Hypnosis is an excellent alternative to sedation and general anesthesia. It improves patient comfort and reduces anxiety, without impending surgical quality. Therefore hypnosis and paravertebral block are an interesting association for the perioperative management of breast cancer patients.

We propose to study the efficacy of associated paravertebral block and hypnosis, compared to general anesthesia, on acute pain. The results of this pilot study will ground a future randomized trial on the subject.

Trial design

This is a pilot, non-interventional, observational, prospective study.

Patients will receive either remifentanil for general anesthesia, or a paravertebral block with hypnosis. A hypnotic trance will be maintained until the end of surgery, and a small dose of remifentanil (0,025 μg.Kg-1.min-1) and/or a supplementary local anesthesia can be administered in case of discomfort during surgery. Should this discomfort persist, general anesthesia can be induced.

Postoperative analgesia includes level I and II analgesics, with morphine in case of severe pain.

Eligibility criteria

Patients with primitive breast cancer scheduled for elective partial mastectomy with sentinel lymph node dissection.

Specific aims

The objective is to demonstrate the superiority of paravertebral block with hypnosis, compared to general anesthesia with opioid analgesia, in the postoperative acute pain management.

Primary endpoint will be pain intensity on a numeric rating scale 24 hours after surgery. Secondary endpoints include pain intensity 1, 6 hours and 3 months after surgery, morphine consumption, nausea and vomiting, patient comfort and satisfaction on a 0 to 10 scale. Additionnally, an analysis of surgical oncologic criteria is aimed to prove that there is no significant difference in the margin status between these two groups.

Statistical methods

For quantitative variables, T Student test or Mann Whitney test will be used as appropriate. Fisher's exact test will be used for categorical data.

Accrual

Accrual as for June 11, 2013 is 7 patients. Target accrual is 40 patients.

Citation Information: Cancer Res 2013;73(24 Suppl): Abstract nr OT2-2-02.

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Presence of leukaemia inhibitory factor (LIF) and LIF-receptor chain (gp190) in osteoclast-like cells cultured from human giant cell tumour of bone. Ultrastructural distribution

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Ultrastructural and electron diffraction of the bone-ceramic interfacial zone in coral and biphasic CaP implants

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Oncostatin M stimulates macrophage-polykaryon formation in long-term human bone-marrow cultures

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Ultrastructural study of degradation of calcium phosphate ceramic by human monocytes and modulation of this activity by HILDA/LIF cytokine

Biodegradation of ceramics in vivo is achieved essentially by monocytes and multinuclear cells (osteoclasts). Monocytes are the key element in this process because they intervene first at the biomaterial implantation site during inflammatory reaction. In this work, in vitro studies were conducted on an ultrastructural scale to determine the specific behavior of these cells with regard to a calcium phosphate (CaP) ceramic. Two types of phagocytosis were observed when cells came into contact with the biomaterial: either CaP crystals were taken up alone and then dissolved in the cytoplasm after disappearance of the phagosome membrane or they were incorporated together with large quantities of culture medium, in which case dissolution occurred after the formation of heterophagosomes. Phagocytosis of CaP coincided with autophagy and the accumulation of residual bodies in the cells. Addition of HILDA/LIF factor to these cultures induced a very marked decrease in phagocytotic activity directed at the capture of CaP crystals and culture medium. Autophagy was reduced, and residual bodies were rare or absent. This study specifies the role of monocytes in CaP biodegradation and demonstrates for the first time that HILDA/LIF has a biological effect on this cell line.

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