Timing Of Surgery In Relation Research Articles

Outcomes of Resectional Thoracic Surgery for the Treatment of Pulmonary Nontuberculous Mycobacterial Disease in 105 Patients in the United States

Outcomes of Resectional Thoracic Surgery for the Treatment of Pulmonary Nontuberculous Mycobacterial Disease in 105 Patients in the United States

P-22 Role of timing to laparoscopic or robotic surgery after neoadjuvant chemoradiotherapy for rectal cancer: The TiMiSNAR trial

Chemoradiotherapy (CRT) is a well-known, risk-reducing treatment of local recurrence in the treatment of rectal cancer, followed by total mesorectal excision (TME). In low rectal tumors, surgery alone has the 30% overall survival and a local recurrence rate of about 55-65%, with a disease-free survival of 30%-35%. Preoperative administration of fluorouracil-based chemotherapy improves local recurrence rates by 7%. The optimal timing of surgery in relation to chemoradiation is still controversial and it is the target of numerous studies, either retrospective or randomized controlled trials.

Intracerebral Hemorrhage Volume Reduction and Timing of Intervention Versus Functional Benefit and Survival in the MISTIE III and STICH Trials.

The extent of intracerebral hemorrhage (ICH) removal conferred survival and functional benefits in the minimally invasive surgery with thrombolysis in intracerebral hemorrhage evacuation (MISTIE) III trial. It is unclear whether this similarly impacts outcome with craniotomy (open surgery) or whether timing from ictus to intervention influences outcome with either procedure. To compare volume evacuation and timing of surgery in relation to outcomes in the MISTIE III and STICH (Surgical Trial in Intracerebral Hemorrhage) trials. Postoperative scans were performed in STICH II, but not in STICH I; therefore, surgical MISTIE III cases with lobar hemorrhages (n=84) were compared to STICH II all lobar cases (n=259) for volumetric analyses. All MISTIE III surgical patients (n=240) were compared to both STICH I and II (n=722) surgical patients for timing analyses. These were investigated using cubic spline modeling and multivariate risk adjustment. End-of-treatment ICH volume ≤28.8mL in MISTIE III and ≤30.0mL in STICH II had increased probability of modified Rankin Scale (mRS) 0 to 3 at 180d (P=.01 and P=.003, respectively). The effect in the MISTIE cohort remained significant after multivariate risk adjustments. Earlier surgery within 62 h of ictus had a lower probability of achieving an mRS 0 to 3 at 180d with STICH I and II (P=.0004), but not with MISTIE III. This remained significant with multivariate risk adjustments. There was no impact of timing until intervention on mortality up to 47 h with either procedure. Thresholds of ICH removal influenced outcome with both procedures to a similar extent. There was a similar likelihood of achieving a good outcome with both procedures within a broad therapeutic time window.

Standard (8 weeks) vs long (12 weeks) Timing to Minimally-Invasive Surgery after NeoAdjuvant Chemoradiotherapy for Rectal cancer: a multicenter randomized controlled parallel group trial (TiMiSNAR)

Background: The optimal timing of surgery in relation to chemoradiation is still controversial. Retrospective analysis has demonstrated in the recent decades that the regression of adenocarcinoma can be slow and not complete until after several months. More recently, increasing pathologic Complete Response rates have been demonstrated to be correlated with longer time interval. Moreover, since the response to nCHT is heterogeneous valid biomarkers are needed to monitor tumor response.

Standard (8\u2009weeks) vs long (12\u2009weeks) timing to minimally-invasive surgery after NeoAdjuvant Chemoradiotherapy for rectal cancer: a multicenter randomized controlled parallel group trial (TiMiSNAR)

BackgroundThe optimal timing of surgery in relation to chemoradiation is still controversial. Retrospective analysis has demonstrated in the recent decades that the regression of adenocarcinoma can be slow and not complete until after several months. More recently, increasing pathologic Complete Response rates have been demonstrated to be correlated with longer time interval. The purpose of the trial is to demonstrate if delayed timing of surgery after neoadjuvant chemoradiotherapy actually affects pathologic Complete Response and reflects on disease-free survival and overall survival rather than standard timing.MethodsThe trial is a multicenter, prospective, randomized controlled, unblinded, parallel-group trial comparing standard and delayed surgery after neoadjuvant chemoradiotherapy for the curative treatment of rectal cancer. Three-hundred and forty patients will be randomized on an equal basis to either robotic-assisted/standard laparoscopic rectal cancer surgery after 8 weeks or robotic-assisted/standard laparoscopic rectal cancer surgery after 12 weeks.DiscussionTo date, it is well-know that pathologic Complete Response is associated with excellent prognosis and an overall survival of 90%. In the Lyon trial the rate of pCR or near pathologic Complete Response increased from 10.3 to 26% and in retrospective studies the increase rate was about 23–30%. These results may be explained on the relationship between radiation therapy and tumor regression: DNA damage occurs during irradiation, but cellular lysis occurs within the next weeks. Study results, whether confirmed that performing surgery after 12 weeks from neoadjuvant treatment is advantageous from a technical and oncological point of view, may change the current pathway of the treatment in those patient suffering from rectal cancer.Trial registrationClinicalTrials.gov NCT3465982.

Comparison of Outcomes of Early Versus Delayed Laparoscopic Cholecystectomy in Acute Calcular Cholecystitis

Background: acute cholecystitis is the most common cause of hospitalization for gastrointestinal disease. Although cholecystectomy is the definitive management, the timing of surgery in relation to the first episode of acute cholecystitis remains an area of considerable practice variation. Objective: The aim of this study was to evaluate the results of early laparoscopic cholecystectomy versus conservative management and delayed elective cholecystectomy in acute calcular cholecystitis. Patients and Methods: the present study is a prospective randomized study done during the period from November 2018 to June 2019. The study included 40 patients with acute calcular cholecystitis presented to Al-Azhar University Surgical department. They had been classified randomly by taking every two patients; one patient to the group A, the other patient to group B, and each group consisted of 20 patients. Results: the mean operative time in the early group was more than the mean operative time in the delayed group. The conversion rate to open cholecystectomy in the early group was less than the conversion rate in the delayed group. The mean total hospital stay in the early group was less than the mean total hospital stay in the delayed group. Finally the overall complications in the early group were less than complications occurred in the delayed group. Conclusion: early laparoscopic cholecystectomy for patients with acute cholecystitis has both medical and socioeconomic benefits and it is the preferred approach in comparison to delayed approach.

Comparison of patient reported symptom burden on an enhanced recovery after surgery (ERAS) care pathway in patients with ovarian cancer undergoing primary vs. interval tumor reductive surgery

ObjectiveTo compare symptom burden and functional recovery in women undergoing primary cytoreductive surgery (PCS) or neoadjuvant chemotherapy (NACT) and interval cytoreductive surgery (ICS) within an enhanced recovery after surgery program (ERAS). MethodsSymptom burden was measured using the MD Anderson Symptom Inventory-Ovarian Cancer, a 27-item validated tool that was administered preoperatively, daily while hospitalized, and weekly for 8 weeks after hospital discharge. Mixed-effect modeling was performed. Results196 patients (71 PCS, 125 ICS) participated. Patients in the PCS group were younger, median age of 59 vs. 63 in ICS group. Median length of stay was 4 days for PCS and 3 days for ICS group. PCS pts had a significantly higher median surgical complexity score (4 vs. 2, p = 0.002), and longer median surgical time (257 min vs. 220 min, p = 0.03). While patients undergoing PCS had significantly different symptom burden profiles prior to surgery compared to those undergoing ICS, there were no significant differences in symptoms in the immediate in-hospital and extended post-hospital discharge period. Irrespective of the timing of surgery in relation to chemotherapy, patients undergoing intermediate or high complexity surgery had more nausea, fatigue, and higher total interference scores compared to patients undergoing low complexity surgery. ConclusionWithin a center with a standardized, systematic method for patient selection for PCS and a standardized ERAS care pathway, there were not significant differences in surgery-related symptoms related to recovery between patients undergoing PCS or ICS. However, patient-reported symptom burden and symptom interference did meaningfully differentiate based on surgical complexity score.

Liver transplantation and sleeve gastrectomy in the medically complicated obese: New challenges on the horizon.

In the last 30 years, operative, technical and medical advances have made liver transplantation (LT) a life-saving therapy that is used worldwide today. Global industrialization has been a contributor to morbid obesity and this has brought about the metabolic syndrome along with many downstream complications of such. Non-alcoholic steatohepatitis (NASH) has become a recognized hepatic manifestation of the metabolic syndrome and NASH cirrhosis is predicted to be the primary indication for LT in the United States by 2025. Several case series and database reviews have begun analyzing the efficacy of weight reduction surgery in the LT recipient. These data have reasonably demonstrated that weight reduction surgery in the LT recipient is a feasible endeavor. However, several questions have been raised regarding the type of weight reduction surgery, timing of surgery in relation to LT, patient and allograft survival and post-LT maintenance of weight loss to name a few. We look forward to a time when weight reduction surgery will work to improve the technical conduct of LT, improve perioperative benchmarks such as blood transfusions, intensive care unit length of stay and help to prevent recurrence of NASH cirrhosis in the medically complicated obese patient. In the meantime, well-designed prospective clinical trials that focus on the issues highlighted will help guide us in the care of these complicated patients who will soon account for the majority of the patients in our clinics.

Timing is everything—colectomy performed on Monday decreases length of stay

BackgroundPerioperative care of patients undergoing colon resection requires a multidisciplinary approach by the operating surgeon, residents, and nurses. Operations performed on Monday take full advantage of hospital resources throughout the week to meet expected discharge by Friday. In a current health care environment of diminishing means, improving the timing of surgery in relation to expected length of stay may play an important role in preserving health care resources. MethodsA retrospective review of a prospectively collected colorectal surgical database identified all patients who underwent segmental colon resection at a single tertiary care referral center from 2004 to 2010. Length of stay for patients undergoing elective open and minimally invasive segmental colectomy was compared for Monday versus Tuesday through the weekend. Patient and surgeon demographics were recorded as well as postoperative outcomes and complications. ResultsA total of 868 segmental colectomies were performed during the study period. Length of stay was significantly decreased by .73 days (P < .01) for all segmental colectomies performed on Monday compared with those performed Tuesday through Sunday. There was also a significant decrease in length of stay looking independently at right (.96 days, P < .01) and left or sigmoid colectomies (.56 days, P < .01). There was no significant difference in patient or surgeon demographics to account for this difference. ConclusionsSegmental colectomies have a significantly decreased length in stay when performed on Monday compared with the rest of the week. The decrease is independent of surgeon, comorbidities, and complications. This difference may be the result of patients' taking full advantage of hospital resources and ancillary support. Cost-effective measures may be evaluated and directed at adjustment of resources available throughout the week to reduce length of stay.

A single institution series of cavernomas of the brainstem

We retrospectively analyzed a series of patients with brainstem cavernomas of the medulla, pons, or midbrain to attempt to define the natural history, indications for surgery, and outcome after surgical resection. Between 1993 and 2008, 52 patients with cavernomas of the brainstem presented to our institute and were managed either surgically or conservatively. Twenty-three patients underwent surgical excision using standard skull base approaches. Outcomes were correlated to the number of preoperative hemorrhages, location of the cavernoma, timing of surgery in relation to the hemorrhage and the preoperative neurological status. Nine patients improved after surgery, 12 deteriorated and two died. In the conservatively managed group, 15 patients had a good outcome, 11 deteriorated and one died. Multiple hemorrhages, poor preoperative neurological status and surgery during the acute phase were predictive of the surgical outcome. Excision of brainstem cavernomas should be considered in patients with symptomatic hemorrhages whose lesions approach the pial surface. Patients with minimal stable neurologic deficits without recurrent bleeds should be managed conservatively.

HER2-Positive Early Breast Cancer and Trastuzumab: A Surgeon’s Perspective

Although the treatment of patients with early-stage breast cancer is provided by a multidisciplinary team, surgeons must ensure they are well informed about all aspects of patient care. For example, understanding the importance of human epidermal growth factor receptor 2 (HER2) gene amplification and/or protein overexpression and the effect on patient prognosis can guide therapeutic decision making. In addition, surgeons should also be knowledgeable about the wide variety of available postsurgical treatments, from traditional chemotherapy and radiotherapy to novel agents such as the HER2-targeted monoclonal antibody trastuzumab. Trastuzumab was recently approved for adjuvant treatment of invasive, HER2-positive, node-positive breast cancer. Its approval was based on the combined results of two large-scale trials, which demonstrated that adding trastuzumab to chemotherapy significantly improves disease-free and overall survival. Knowledge about the indications, schedules, and safety profiles of therapies such as trastuzumab will enable surgeons to optimize the timing of surgery in relation to these therapies, and to make informed decisions about the team member to whom a particular patient should ideally be referred for postsurgical care. In the future, results from large-scale trials evaluating the clinical utility of neoadjuvant trastuzumab will become available. Early results from ongoing phase III trials of the addition of trastuzumab to presurgical chemotherapy suggest that high response rates, including pathologic complete responses, are achievable. If trastuzumab is approved for use in neoadjuvant regimens, the need for surgeons to be well informed about the appropriate use of this particular agent will become even more important.

Timing of breast cancer surgery in relation to menstrual cycle phase: no effect on 3-year prognosis: The ITS Study

The effect of breast cancer surgery timing during the menstrual cycle on prognosis remains controversial. We conducted a multicentre prospective study to establish whether timing of interventions influences prognosis. We report 3-year overall and disease-free survival (OS/DFS) results for ‘primary analysis’ patients (regular cycles, no oral contraceptives within previous 6 months). Data were collected regarding timing of interventions in relation to patients’ last menstrual period (LMP) and first menstrual period after surgery (FMP). Hormone profiles were also measured. Cox's proportional hazards model incorporated LMP in continuous form. Exploratory analyses used menstrual cycle categorisations of Senie, Badwe and Hrushesky. Hormone profiles with LMP and FMP data were also used to define menstrual cycle phase. Four hundred and twelve ‘primary analysis’ patients were recruited. Three-year OS from first surgery was 90.7, 95% confidence interval (CI) [87.9, 93.6%]. Menstrual cycle according to LMP was not statistically significant (OS: hazard ratio (HR)=1.02, 95%CI [0.995,1.042], P=0.14; DFS: HR=1.00, 95%CI [0.980,1.022], P=0.92). Timing of surgery in relation to menstrual cycle phase had no significant impact on 3-year survival. This may be due to 97% of patients receiving some form of adjuvant therapy. Survival curves to 10 years indicate results may remain true for longer-term survival.

Early vs. Delayed Elective Laparoscopic-Assisted Colectomy in Sigmoid Diverticulitis: Timing of Surgery in Relation to the Acute Attack

The timing of elective surgery in acute sigmoid diverticulitis in relation to the acute attack is not clear. Early elective surgery during the same hospitalization as the acute attack or delayed surgery after an interval of several weeks are the options. This study was designed to evaluate the influence of timing on morbidity, conversion rate, histologic findings, and costs. A total of 178 patients with elective laparoscopic-assisted sigmoid resections for diverticulitis between 1997 and 2005 were retrospectively assessed; 77 patients underwent early and 101 delayed surgery. Outcomes were surgical morbidity, conversion rate, histologic findings, and financial impact of timing. The two groups showed no significant difference apart from a higher body mass index in the delayed group (25.5 vs. 26.6 kg/m2, P = 0.035). Surgical morbidity was not significantly different. Conversion rate was significantly higher in the early group (P < 0.001). Converted patients had an increased surgical morbidity of 23.8 vs. 19.1 percent (P = 0.323) and hospitalization was significantly longer (13.5 vs. 10.5 days; P < 0.001). Histology revealed inflammation in 75.3 percent in the early group compared with 23.8 percent in the delayed group. Total treatment costs were not different between groups, whereas total earnings were higher in the delayed group resulting in a lower hospital deficit. Early elective surgery in patients with acute sigmoid diverticulitis results in a higher conversion rate. If patients respond to initial antibiotic therapy, delayed colectomy after an interval of six weeks or more is recommended.

Timing of surgery in relation to the menstrual cycle in premenopausal women with operable breast cancer.

Recent studies have suggested that the timing of surgery in relation to the menstrual cycle might influence survival of premenopausal women with operable breast cancer. The data of 96 premenopausal patients who underwent primary surgery for operable breast carcinoma between 1975 and 1988 were analysed. At 10 years, disease-free and overall survival rates of patients whose initial surgery was 1-12 days after the starting date of the last menstrual period (follicular phase) were significantly poorer compared with survival of those who underwent operation more than 12 days after the last menstruation (luteal phase) (disease-free survival rate 40 versus 72 per cent, P = 0.002; overall survival rate 40 versus 79 per cent, P = 0.001). These differences in survival remained significant in a second analysis based on the menstrual phase at the time of both initial and definitive operation. Menstrual phase had the greatest impact on the survival of patients with positive axillary nodes (P = 0.009). Prospective studies are required to elucidate the relationship between the timing of all surgical procedures during the menstrual cycle and survival.

O-4. Does timing of breast cancer surgery in relation to the menstrual cycle phase affect prognosis? The Yorkshire Breast Cancer Group Intervention, Timing and Survival Study

O-4. Does timing of breast cancer surgery in relation to the menstrual cycle phase affect prognosis? The Yorkshire Breast Cancer Group Intervention, Timing and Survival Study

Perioperative survival rates after surgery for diaphragmatic hernia in dogs and cats: 92 cases (1990–2002)

To determine the survival rates of dogs and cats that underwent surgical treatment for traumatic diaphragmatic hernia within 24 hours of admission and determine whether timing of surgery affected perioperative survival rate. Retrospective study. 63 dogs and 29 cats treated surgically for traumatic diaphragmatic hernia. Medical records were reviewed to evaluate associations between perioperative survival rates and variables including timing of surgery in relation to admission and acute versus chronic diaphragmatic hernia. Among the 92 animals, 82 (89.1%) were discharged alive after surgery. Sixty-four (69.6%) patients received surgical intervention within 12 hours of admission, and 84 (91.3%) received surgical intervention within 24 hours of admission. Median time from admission to discharge was 4 days (2 to 33 days). Data for acute cases (68 dogs and cats) were analyzed separately. Sixty-three (92.6%) patients with acute diaphragmatic hernia received surgical intervention within 24 hours of admission to the hospital, and 59 (93.7%) of these patients were discharged alive. Twenty-nine (42.6%) patients with acute diaphragmatic hernia received surgical intervention within 24 hours of trauma, and 26 of 29 (89.7%) patients were discharged alive. An overall acute and chronic perioperative survival rate of 89.7% was observed in dogs and cats that received surgical intervention within 24 hours of admission. Results in 68 dogs and cats that underwent surgery within 24 hours of admission suggested that early surgical intervention for acute diaphragmatic hernia was associated with good perioperative survival rates.

Does timing of breast cancer surgery in relation to the menstrual cycle phase affect prognosis? The Yorkshire Breast Cancer Group Intervention, Timing and Survival Study

536 Background: The effect of breast cancer surgery timing during the menstrual cycle on prognosis remains controversial. We conducted a multi-centre prospective observational study to establish whether timing of interventions influences prognosis. Here we report 3-year survival results for ’primary’ patients (regular cycles, no oral contraceptives within last 6 months). Methods: Data were collected regarding timing of interventions (first tumor handling & subsequent surgeries) in relation to patients’ last menstrual period (LMP) & first menstrual period after intervention (FMP); hormone profiles (follicle stimulating & luteinizing hormone, oestradiol, progesterone) were also measured. Overall & disease-free survival (OS, DFS) were assessed using Cox’s Proportional Hazards model adjusting for intervention type, Nottingham Prognostic Index & adjuvant therapy. Initial analysis incorporated LMP in its continuous form & subsequent exploratory analyses used categorizations of Senie, Badwe & Hrushesky. Hormone profiles with LMP & FMP data were also used to define menstrual phase. Results: 611 patients were recruited from 25 centers between ’93 & ’00. Median age was 43 (range 19–55) years. At a median follow-up of 58 (range 0–132) months there have been 115 deaths; 56 occurred within 3 years of surgery. Types of first surgery were excision biopsy (18%), lumpectomy (48%) & mastectomy (33%). 14% of tumors were grade I, 42% grade II, 40% grade III; 51% were node positive. Menstrual cycle according to LMP was not statistically significant at the 5% level for the 412 patients in the ’primary’ group (OS hazard ratio (HR)=1.02, 95% confidence interval (CI) 0.99,1.04, p=0.14; DFS HR=1.00, 95% CI 0.98,1.02, p=0.92). Exploratory analyses indicated possible increased OS when surgery occurred in the follicular phase of the menstrual cycle. Conclusions: In this analysis timing of surgery in relation to the menstrual cycle phase had no significant impact on 3-year survival. This may be explained by our lower than expected event rate. Unlike previous studies this cohort has received modern adjuvant treatments, some of which will have caused ovarian suppression. No significant financial relationships to disclose.

Delayed Benefit of Mammography Screening in Premenopausal Women

TO THE EDITOR: Demicheli et al point out that in the mammography screening trials, an early excess in breast cancer mortality is seen among premenopausal women who undergo screening. Yet a reduction in breast cancer mortality in the screened group is evident much later (after approximately 12 years). The authors suggest that surgery may perturb the natural history of breast cancer (perhaps by releasing cytokines that could bestow autonomy on micrometastases), and that the early excess in mortality among premenopausal women who undergo mammography screening might be attributed to surgery (early detection of breast cancer results in early surgery, and this in turn produces an early excess in mortality). However, the authors fail to provide an explanation for the apparent long-term benefit of mammography screening in premenopausal women. We suggest that surgical perturbation of the natural history of breast cancer might explain this observation. At the conclusion of the mammography screening trials, women in the control (unscreened) groups were often invited to undergo screening. As a result, an excess of cancers were diagnosed and treated surgically in the control groups following completion of the screening trials. If surgery does indeed perturb the natural history of breast cancer, then inviting the controls to undergo delayed screening may have resulted in a delayed increase in breast cancer mortality in those women. Thus long-term comparisons of breast cancer mortality trends between control and study groups may give the false impression that screening has a delayed benefit in the study groups, when, in fact, the better long-term outcome of women in the study groups might actually be due to a delayed one-time increase in breast cancer mortality in the controls. Demicheli et al suggest that the potential effects of surgery might differ between preand postmenopausal women. If so, then the hormonal milieu at the time of surgery may influence early breast cancer mortality. Several retrospective studies have suggested that this is indeed the case, and that the timing of surgery in relation to the menstrual cycle may have an impact. Clearly, randomized prospective trials are needed to resolve these issues. Neoadjuvant hormonal therapy may ultimately prove effective in modulating these effects.

Morphological Changes in Breast Tissue with Menstrual Cycle

Whether the breast tissue undergoes morphologic changes in relation to the menstrual cycle had been a subject of debate. Elegant studies performed in the early 1980s provided conclusive evidence of cyclical changes in the normal breast lobules. These studies were almost entirely based on autopsy material and have not been validated in the clinical setting. In the present study, we examine breast tissues from surgical specimens from 73 premenopausal women and use morphological criteria to characterize the stage of the menstrual cycle. Patients taking oral contraceptives or hormonal therapy were excluded from this study. The following histological parameters were used to assess the menstrual stage: number of cell layers in the acini and presence and degree of vacuolation of the myoepithelial cells, stromal edema, infiltrate, mitosis, and apoptosis. The morphological stage was then correlated with the stage of the cycle, as determined by last menstrual period and the usual menstrual cycle length and in some patients with serum estrogen and progesterone levels. The morphologic stage was concordant with dates in 54 of the 73 patients (74%, P =.001). In 31 of these patients, serum levels of estradiol and progesterone at the time of surgery were available for correlation. Twenty-five (80%) of these were phase concordant by morphology and progesterone levels (P =.01), and 25 (80%), by dates and progesterone levels (P =.007). Women with a high morphologic score were seven times as likely to be in luteal phase as were women with a low score (odds ratio, 7.1; 95% confidence interval). Menstrual phase can be determined by the morphology of the normal lobules present within the surgically excised breast specimens. This will permit retrospective analysis of large archival databases to analyze the effect of timing of surgery in relation to menstrual cycle phase. It will also aid the design of epidemiological studies for breast cancer risk assessment.

Correlation between timing of surgery in relation to the menstrual cycle and prognosis of premenopausal breast cancer patients

The timing of surgery in relation to menstrual phase might affect the progress of disease in premenopausal women with operable breast cancer. In the present study, the records were examined of 28 such cases treated between 1990 and 1999, and compared for recurrence-free survival with reference to the phases of the menstrual cycle defined by Hrushesky and Senie. During the follow-up period, breast cancer relapse occurred in five patients, and one patient died of another disease unconnected with recurrent breast cancer. The recurrence rate was not significantly different between two phases classified by either Hrushesky or Senie. However, patients with early-stage breast cancer operated during the perimenstrual phase and those with advanced breast cancer which was resected during the peri-ovulatory phase appeared to have a better prognosis than patients operated on during the other phases. Since the prognosis for breast cancer patients is dependent not only on the menstrual cycle but also on many other factors, it is concluded that the menstrual cycle cannot constitute an absolute prognostic factor.