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Intercostal Nerves Block for Mastectomy in Two Patients with Advanced Breast Malignancy

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Intercostal Nerves Block for Mastectomy in Two Patients with Advanced Breast Malignancy Intercostal Nerves Block for Mastectomy in Two Patients with Advanced Breast Malignancy Israel K. Kolawole, DA, FWACS; Michael D. Adesina, FWACS; and lyiade 0. Olaoye, FWACS llorin, Nigeria Regional anesthesia is recognized as an altemafive to gener- INTRODUCTION al anesthesia for modern breast cancer sury. Vrious tech- The era of regional anaesthesia dates back to niques of block have ben descrbed. Each has its unique 1884 when Koller discovered the anesthesia proper- problems. Regionl anesthesia was chosen for simple mos- ties of cocaine.' Since then, the scope of regional tectomy in two pafients with'advanced breast malignancy, anesthesia has continued to widen and clinicians due to compromised pulmonary status resulting from wide- have succeeded in gaining access to almost every spread malignant infiltrtfion of both lungs. We used inter- nerve in the body. Consequently, patients who for costalnerves block. The bloc was supplementne with an infr- one reason or another are considered unsuitable for aclicula infiltration to interrupt the branches of the general anesthesia may now have their operations superficiatcervical pexustt provide sensation to the upper done under regional anesthesia. Such was the situa- chest wall and subcutaneous infiltration in the midline to tion with the two patients discussed in this report. block the nerve supply from the contralateral side. Anesthesia Since the breasts are ectodermal organs, which arose was generally effective and the operations were uneveniful. as a modification ofthe sweat glands,2 they are more Both patienit and surgeo 0pressed satisfaction. or less superficial structures, which can be isolated and selectively blocked for surgical excision. Com- We conclude that where patients have signifknt comor- bining intercostal nerves block with infraclavicular bidifies that make general anesthesia undesirable, the use and midline subcutaneous infiltration with local of intercostal nerves block remains a safe and reliable anes- anesthetic provided effective and reliable anesthesia thetic option that allows the patient access to surgery for for simple mastectomy in the two patients. simple mgstectomy. Key wOr: intercostal block U mostecto breast CASE 1 cancer U lung cancer Uanesthesia A 55-year-old postmenopausal woman presented with a four-month history ofrecurrence ofa previous- ly excised mass in the left breast. The mass had increased rapidly in size within two months prior to presentation. There was associated pain and left axil- lary swelling. She denied any history of nipple dis- charge, weight loss or cough. The mass was first noticed 16 months earlier, for which she had two pre- vious excisions under local infiltration anesthesia in two different lower-level hospitals. The excised tis- sues were not subjected to histological examination. Physical examination revealed a middle-aged obese woman (weight 90 kg) in no apparent distress. Her pulse was 86 beats/min-', regular, full volume and blood pressure was 130/80 mmHg. She had a radial scar over an approximately 6-cm-x-3-cm tumor mass on the upper inner quadrant of the left breast. The ©2006. From Departments of Anesthesia (Kolawole) and General Surgery (Adesina, Olaoye), University of Iliorin Teaching Hospital, llorin, Nigeria. Send tumor was nontender but fixed to the chest wall over correspondence and reprint requests for J NatI Med Assoc. 2006;98:450-453 the fourth-through-sixth ribs and adjacent part of the to: Dr. IK. Kolawole, P.O. Box 6414, llorin 240001, Kwara State, Nigeda; phone: sternum. There were few discrete mobile ipsilateral 2348033781032,234031220180; e-mail: [email protected] axillary lymph nodes enlargement. The chest was 450 JOURNAL OF THE NATIONAL MEDICAL ASSOCIATION VOL. 98, NO. 3, MARCH 2006 INTERCOSTAL NERVES BLOCK FOR MASTECTOMY clear and there was no palpable hepatomegaly. Hema- spinal needle and the technique described by Brown.3 tological and serum biochemistry results were essen- The mid-axillary approach was used in the lower tially normal. Fine-needle aspiration cytology three thoracic levels (T5-T7), while the posterior (FNAC) of the tumor mass and axillary nodes was approach was used for the remaining three upper lev- positive for malignant cells. Radiological examina- els (T2-T4) because of the technical difficulties tion of the chest showed cannon-ball metastasis in encountered with the former approach due to the size both lung fields (Figure 1). Abdominal ultrasound of the patient. The block was supplemented with an scan was normal. A diagnosis of stage-IV carcinoma infraclavicular infiltration of 5 ml of the same local of the left breast with pulmonary metastasis was anesthetic to interrupt the branches ofthe superficial made. She was commenced on intravenous cyclo- cervical plexus that provide sensation to the upper phosphamide, methotrexate and 5-fluorouracil and part of the breast, and subcutaneous infiltration of oral tamoxifen. By the time she presented two weeks another 5 ml in the midline in an "upside down" L- later, she had developed persistent unproductive pattern to block those intercostal nerve fibers that cough, fever, dyspnea, tachypnea (respiratory rate 24 cross the midline from the contralateral side. cycles/min-') and tachycardia (pulse 102 beats/min-'). After demonstration ofadequate blockade by loss A repeat chest radiograph showed minimal pleural of sensation to pinprick about 15 minutes following effusion on the right and fluid in the horizontal fissure placement of the block, the patient was transferred of the right lung, in addition to the numerous malig- to the operating room. During the surgery, the nant infiltrates in both lung fields (Figure 2). patient was sedated with intermittent intravenous Hemograms showed PCV of 28% and WBC 11,800 diazepam and pethidine as required. The doses of mm3. Following a course of antibiotics and therapeu- these drugs were titrated to ensure a minimally tic thoracocentesis instituted by the cardiothoracic depressed patient who was able to maintain airway surgical team, the patient's condition improved and independently and responded to verbal command. the hemograms normalized (PCV 32%, WBC 6,200 The anesthetist maintained communication with the mm3). There was, however, a progression ofthe tumor patient throughout the surgery. The pulse rate and mass, as demonstrated by an increase in size to about oxygen saturation monitored continuously, and the 8 cm x 4 cm and worsening pain. noninvasive blood pressure monitored every five After due consultation with the patient, a deci- minutes using the Nellcor Puritan Bernett multipara- sion was taken to do palliative surgery (simple mas- meter monitor all remained two hours and were tectomy) to prevent fungation of the mass and pro- uneventful. Anesthesia was generally effective. mote hygiene. The patient was observed in the recovery room The decision to employ regional anesthesia for for about one hour before being transferred to the the surgery was jointly taken by the anesthetic and ward. She tolerated oral intake within four hours surgical teams because of the widespread malignant after the operation. The first dose of postoperative infiltration of both lungs. This was discussed with analgesic was given on request about five hours the patient. She consented to this anesthetic option after the surgery. She had an uneventful postopera- with intraoperative sedation and conversion to gen- tive course and was discharged home to continue on eral anesthesia ifnecessary. cytotoxic drugs and tamoxifen, while awaiting radiotherapy. Anesthetic Management The patient was sedated overnight with oral diazepam 10 mg and premedicated with another 10 Figure 1. Chest x-ray of case 1 showing mg diazepam orally just before being transferred to metastasis in both lung fields the theater on the morning ofoperation. In the preoperative holding area, the patient was connected to a Nellcor Puritan Bernnet multiparame- ter patient monitor and the baseline vital signs were recorded. The noninvasive blood pressure was 120/80 mmHg, pulse 90 beats/min-' and peripheral arterial oxygen saturation 97% on room air. A peripheral intravenous access was established and the patient was sedated with intravenous diazepam 2.5 mg and pethidine 50 mg. This was followed by intercostal nerves block on the left side at thoracic levels 2-7, with 4 ml 0.375% bupivacaine with 1:200,000 epi- nephrine per nerve, using a size-22 gauge quincke JOURNAL OF THE NATIONAL MEDICAL ASSOCIATION VOL. 98, NO. 3, MARCH 2006 451 INTERCOSTAL NERVES BLOCK FOR MASTECTOMY CASE 2 node was positive for malignant cells. A 60-year-old postmenopausal woman presented A diagnosis of stage-IV carcinoma of left breast with 10 months history of painless left breast mass with pulmonary metastasis was made. Patient was that increased rapidly in size three months prior to commenced on daily oral dose of tamoxifen 20 g as presentation. There was an associated productive an outpatient, and scheduled for palliative simple cough, which subsided with cough mixture. Patient mastectomy. A decision was taken jointly by the was a known hypertensive on nifedipine, moduretic anesthetic and surgical teams to employ regional and atenolol. There was no history of previous sur- anesthesia with intraoperative sedation. This was gery. Family and social history was not contributory. discussed with the patient with an assurance of con- Physical examination revealed a middle-aged version to general anesthesia if necessary. Patient woman who weighed 63 kg. Her pulse was 96 consented to this anesthetic option. beats/min-', full, regular and blood pressure was 140/90. Respiratory rate was 22 cycles/min-'. The Anesthetic Management chest was clinically clear with good air entry bilater- The patient was sedated overnight with oral ally. She had an enlarged firm left breast with invert- diazepam 10 mg and premedicated with another 10 ed nipple and peau d'orange skin change. There was mg orally just before being transferred to the theater associated ipsilateral non-tender, matted axillary on the morning ofoperation. lymph nodes and a few discrete, firm, nontender The patient was brought to the preoperative hold- contralateral axillary lymph node enlargements.
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