Oncologic safety of autologous fat grafting in primary breast reconstruction after mastectomy for cancer.

INTRODUCTION: Autologous fat transfer (AFT) is widely used to improve results of breast reconstructive surgery, but its safety is controversial. Our objective was to evaluate the oncologic safety of AFT in a homogeneous population of patients who underwent a total mastectomy with immediate reconstruction for breast cancer. METHODS: We performed a retrospective cohort study by identifying all patients who underwent immediate breast reconstruction after mastectomy for breast cancer from 2007 to 2015 in our center. A patient group with AFT performed in the 24 months after mastectomy was compared to a control group. RESULTS: Five hundred fifty cases were included, of whom 136 (24.7%) underwent at least one fat graft transfer. Median age was 51 years. Reconstruction was performed in 465 (84.5%) with an implant reconstruction. The median time from mastectomy to AFT was 13.8 months. The median follow up was 55.2 months. A total of 53 events were observed, including 10 (7.4%) in the AFT group and 43 (10.4%) in the control group. There was no difference in 5-year recurrence-free survival (RFS) between the groups. In the subgroup analysis, only lymph node involvement in patients who underwent AFT in the first 24 months after oncologic surgery appeared as a risk factor of recurrence. Among the 104 patients with lymph node involvement, 5-year RFS was 69.2% in patients with lipofilling vs 92.5% in patients without it (p = 0 0.0351). CONCLUSION: Performing early lipofilling in primary breast reconstruction after mastectomy for cancer seems to be oncologically safe. Lymph node involvement increases the risk of recurrence in this population.

Management of tumor volume changes during preoperative radiotherapy for extremity soft tissue sarcoma: a new strategy of adaptive radiotherapy.

BACKGROUND: Using adaptive radiotherapy (ART), to determine objective clinical criteria that identify extremity soft tissue sarcoma (ESTS) patients requiring adaptation of their preoperative radiotherapy (RT) plan. PATIENTS AND METHODS: We included 17 patients with a lower extremity ESTS treated between 2019 and 2021 with preoperative RT, using helicoidal intensity-modulated RT (IMRT) tomotherapy, before surgical resection. We collected clinical, tumor parameters and treatment data. Repositioning was ascertained by daily Megavoltage computed tomography (MVCT) imaging. Using the PreciseART technology we retrospectively manually delineated at least one MVCT for each patient per week and recorded volume and dosimetric parameters. A greater than 5% change between target volume and planned target volume (PTV) dosimetric coverage from the initial planning CT scan to at least one MVCT was defined as clinically significant. RESULTS: All 17 patients experienced significant tumor volume changes during treatment; 7 tumors grew (41%) and 10 shrank (59%). Three patients (18%), all undifferentiated pleomorphic sarcomas (UPS) with increased volume changes, experienced significant reductions in tumor dose coverage. Seven patients required a plan adaptation, as determined by practical criteria applied in our departmental practice. Among these patients, only one ultimately experienced a significant change in PTV coverage. Three patients had a PTV decrease of coverage. Among them, 2 did not receive plan adaptation according our criteria. None of the patients with decreased tumor volumes had reduced target volume coverage. Monitoring volume variations by estimating gross tumor volume (GTV) on MVCT, in addition to axial and sagittal linear tumor dimensions, appeared to be most effective for detecting reductions in PTV coverage throughout treatment. CONCLUSIONS: Variations in ESTS volume are evident during preoperative RT, but significant dosimetric variations are rare. Specific attention should be paid to grade 2-3 UPSs during the first 2 weeks of treatment. In the absence of dedicated software in routine clinical practice, monitoring of tumor volume changes by estimating GTV may represent a useful strategy for identifying patients whose treatment needs to be replanned.

Outcomes of DIEP flap reconstruction after pelvic cancer surgery: A retrospective multicenter case series.

BACKGROUND: Flap reconstruction is often required after pelvic tumor resection to reduce wound complications. The use of perforator flaps has been shown to reduce donor site morbidity. The purpose of this study was to evaluate the outcomes of pedicled deep inferior epigastric perforator (pDIEP) flap reconstruction. METHODS: This was a retrospective multicenter study of patients who underwent immediate pDIEP flap reconstruction for a pelvic or perineal defect after tumor resection between November 2012 and June 2022. The primary outcome was abdominal donor site morbidity, and the secondary outcome was perineal morbidity. RESULTS: Thirty-four patients (median age, 57.5 years) who underwent pelvic exenteration (n = 31), extralevator abdominoperineal excision (n = 2), or extended vaginal hysterectomy (n = 1) were included. The most common indications were recurrent cervical (n = 19) and anal (n = 4) squamous cell carcinoma. Twenty-nine patients (85%) had a history of radiotherapy. Only one patient (3%) had major (Clavien-Dindo ≥ III) donor site complications (surgical site infection due to tumor recurrence). Eleven patients (32%) had at least one major recipient site complication (surgical site infection [n = 1], total [n = 2] or partial [n = 1] flap loss, perineal dehiscence [n = 2], hematoma [n = 1], fistula [n = 5]). No incisional or perineal hernias were observed during follow-up. Ninety-day survival was 100%. CONCLUSION: Pedicled DIEP flap reconstructions performed by experienced surgical teams had good outcomes for perineal or vaginal reconstruction, with low abdominal morbidity, in patients with advanced pelvic malignancies who had undergone median laparotomy. The risks and benefits of this procedure should be carefully evaluated preoperatively using clinical and imaging data.

Clinical reliability of pedicled perforator flaps in the management of adult limb and trunk soft tissue sarcomas: Experience of two French expert centres.

INTRODUCTION: Limb-sparing surgery combined with radiation has become the standard treatment for soft tissue sarcomas. Despite the many advantages of reconstruction procedures, such as muscle-sparing flap and local reconstruction, the use of pedicled perforator flaps remains non-consensual due to doubts about their reliability when associated with radiotherapy. This study evaluated their surgical reliability in reconstructive surgery for limb and trunk soft tissue sarcomas, in terms of healing time, wound disorders, and postoperative complications, regardless of radiation timing. PATIENTS AND METHODS: We realized a retrospective, observational, bi-center study (Cancer University Institute of Toulouse Oncopole, France and Bergonié Institute Bordeaux, France) and describes pedicled perforator flaps performed between January 2015 and January 2021. RESULTS: A total of 74 flaps were included. The median age of the population was 70-year-old. The group consisted of 68.8% (n = 51/74) propeller flaps. We found a partial necrosis rate of 28.4% (n = 21/74), scar disunion of 48.6% (n = 36/74), local infection of 10.8% (n = 8/74), and venous congestion of 13.5% (n = 10/74). Only 16.2% (n = 12/74) required secondary surgical repair to a local complication. The average length of stay was 7.3 days  [1.0-25.0]. The mean operating time of our flaps was 133.4 min [38.0-280.0]. CONCLUSIONS: Pedicled perforator flaps are a surgical technique that can be used in reconstructive surgery for limb and trunk soft tissue sarcomas in adults, regardless of radiation timing. However, these flaps carry a high rate of postoperative complications so they should be reserved for expert surgeons in referral centers.

Delayed Hypersensitivity Reaction to Titanium-coated Polypropylene Mesh in Breast Reconstruction.

Breast implant reconstructions increasingly incorporate meshes like the synthetic nonresorbable titanium-coated polypropylene mesh commercialized as Tiloop (Pfm medical). We report the case of a 48-year-old woman, with a medical history of nickel allergy, who presented with an extensive erythematous eruption, a periprosthetic reaction, and an axillary node reaction, 18 months after a unilateral prophylactic mastectomy. We excluded infectious, sarcoidosis and carcinomatosis. The patient's medical history, the clinical evolution, and the particularly fast and complete healing after removal of the mesh were suggestive of an unusual allergic reaction to the titanium in the titanium-coated polypropylene mesh. Titanium allergies are very rare events, predominantly described in the dental and orthopedic fields. We also discussed the hypothesis of a tardive red breast syndrome related to a synthetic mesh, also mediated by immunological response as described recently in another case report.

Augmentation mammaplasty by superolateral thoracic flap: a case report.

BACKGROUND: The lateral chest wall is intimately associated with the esthetics of the breast. Patients with massive weight loss often have excess skin and fat in the lateral thoracic region causing functional, esthetic, and psychological discomfort. In addition, the breasts exhibit extreme ptosis after weight loss due to a reduction in volume and projection that is exacerbated by qualitative changes in the skin, with loss of its natural elasticity. This article describes a reliable new technique for simultaneous autologous breast augmentation and lateral thoracic dermolipectomy to provide autologous tissue for breast augmentation and simultaneous rejuvenation of the chest wall. CASE PRESENTATION: A 30-year-old Caucasian woman who had lost 58 kg after bariatric surgery had major skin excess sequelae combined with major breast ptosis. She wanted to correct her brachial and lateral thoracic skin and fat excess, as well as rejuvenate her breasts. The lateral thoracic panicle present was harvested and transposed in the retroglandular plane to perform autologous breast augmentation with lateral thoracic dermolipectomy. RESULTS: The patient was totally healed and complication-free at day 15. Both esthetic results and patient satisfaction were good at 6 months post-surgery. CONCLUSIONS: Superolateral thoracic flap augmentation mammaplasty during thoracic dermolipectomy is a simple and safe procedure for selected patients. Durable and natural autologous breast augmentation may be achieved in a single step without the need for a breast implant, while rejuvenating the thoracic region.

Axillary node dissection in outpatient procedure, is it feasible and safe?

BACKGROUND: Outpatient procedure in cancer surgery is one of the tracks to guarantee the quality of care respecting the delay of support. The aim of this study was to assess the feasibility and safety of outpatients with axillary lymphadenectomy and the postoperative morbidity after outpatient's procedures compared to patients with classic hospitalization. METHODS: Patients who underwent axillary lymphadenectomy for breast cancer or melanoma were analyzed. We selected patients having axillary lymphadenectomy only or associated with another operative act compatible with outpatient's procedure (partial mastectomy, lumpectomy or skin excisions). RESULTS: Three hundred and forty-nine patients were included. Outpatient procedures were performed in 142 patients (40.7%) and inpatient procedures were performed in 207 patients (59.3%). All time complications combined, we found 148 patients with at least one complication: 77 patients (52.0%) and 71 patients (48.0%) in outpatient and inpatient group, respectively (p=0.0002). The main complication was seroma formation, it concerned 104 patients Among them, Seroma formation was more frequent in ambulatory group, 60 patients (57.7%) and 44 patients (42.3%) in traditional hospitalization (p<0.0001) but 58.7% (61/104) needed only one aspiration and all complications were managed in outpatient. CONCLUSION: Complications (mostly seroma) appeared usually after hospitalization discharge and they were known and simple to take in charge. A precise preoperative information concerning post-operative morbidity, specially seroma allows a better comprehension and acceptation of this side effect. We believe that this surgery is feasible and safe in outpatient procedure.

[Satisfaction survey within the context of remote iconographic follow-up of wounds in an oncology centre]. / Enquête de satisfaction dans le cadre d'un suivi iconographique de plaies à distance dans un centre de cancérologie.

Over 40 patients benefited from remote iconographic follow-up of wounds in an oncology centre. This system is piloted by three expert nurses. They carry out an initial analysis of the photographs received, seek medical expertise if necessary and liaise with the city's professionals. This system makes it possible to expertly accompany professionals and patients while avoiding unnecessary travel. The satisfaction survey conducted in 2018 established full satisfaction of patients and professionals (> 95%) and a guarantee in terms of the safety and quality of care of the wounds.

Correction to: Elbow flexion reconstruction after arm-sparing excision for high-grade triton sarcoma: a case report.

An amendment to this paper has been published and can be accessed via the original article.

Elbow flexion reconstruction after arm-sparing excision for high-grade triton sarcoma: a case report.

BACKGROUND: Soft tissue sarcomas affecting the root of an upper extremity raise the question of limb amputation depending on their location, size, and malignancy. Malignant triton tumors are a rare subtype of neurofibrosarcomas that have been poorly reported in the literature. We report the case of a challenging reconstruction of the upper extremity using a pedicled latissimus dorsal flap. CASE PRESENTATION: A 25-year-old Occidental man was referred to our sarcoma unit for the management of a large, high-grade malignant peripheral nerve sheath tumor with no regional or distant extension and very fast progression. He was treated first by concomitant neoadjuvant radiotherapy and chemotherapy. Carcinologic excision was performed "en bloc" including the skin, the tumor, and the flexor muscles of our patient's elbow. Coverage of the skin defect and elbow flexion restoration were achieved by using a homolateral pedicled musculocutaneous latissimus dorsi flap. Histological analysis showed an R0 resection. The reconstruction process recovered a complete bending of his elbow. He is still in remission at 26 months follow-up. CONCLUSIONS: A malignant triton tumor is a rare, aggressive, and high-grade sarcoma. It was successfully treated and this case report describes an effective treatment modality. Reconstructive surgery, allowing large, complete tumor removal, is indispensable after neoadjuvant chemotherapy and radiotherapy.

Management of Pilonidal Sinus Disease with the Aesthetically Shaped Parasacral Perforator Flap: Multicenter Evaluation of 228 Patients.

BACKGROUND: The management of pilonidal sinus disease is still not standardized. Currently, the two main procedures are a lay-open excision procedure with secondary healing or coverage with local flaps. The authors present their experience with a one-stage excision-coverage with an innovative parasacral artery perforator flap propeller designed to respect the aesthetic unity of the buttocks. METHODS: Study patients were managed with this procedure in the Toulouse, Montpellier, and Rennes university hospitals between 2012 and 2018. Data were collected on clinical and surgical details, immediate and late postoperative complications, and long-term recurrence. Aesthetic satisfaction was evaluated with a self-evaluation questionnaire. RESULTS: The authors operated on 228 consecutive patients for pilonidal sinus disease with an aesthetically shaped parasacral artery perforator flap. The median patient age was 23.5 years, the median operative time was 46 minutes, the median flap length was 9.3 cm (range, 6.5 to 14 cm), and the median flap width was 4.1 cm (range, 4 to 6.5 cm). There were five distal necroses but no complete flap necrosis. There were six postoperative hematomas, 11 infections, and 18 wound dehiscences. The median follow-up period was 27.9 months. Median hospital length of stay was 4.2 days. Three recurrences of pilonidal sinus disease and six instances of hidradenitis suppurativa were detected. Approximately 82 percent of the women and more than 85 percent of the men were "satisfied" or "very satisfied" with the aesthetic outcome, without significant differences between the sexes (p = 0.901). CONCLUSIONS: The aesthetically shaped parasacral artery perforator flap combines very satisfactory results regarding recurrence and postoperative recovery with cosmetic outcome. This procedure is technically more demanding than other flap procedures, although it is accessible to numerous surgeons as the first-line treatment for pilonidal sinus disease after initial learning. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, IV.

A comparison of flap reconstruction vs the laying open technique or excision and direct suture for pilonidal sinus disease: A meta-analysis of randomised studies.

Many treatments have been described for pilonidal disease, but recurrence cannot be completely eliminated. The aim of this study was to perform a meta-analysis of randomised, controlled trials comparing flap repair vs the laying open technique and/or excision and direct closure techniques in the treatment of chronic pilonidal sinus disease. The primary outcome measure was the recurrence rate. Secondary outcomes were complete wound-healing time, duration of the incapacity to work, quality of life and patient satisfaction, postoperative pain, wound infection, bleeding or haematoma, skin wound complications, and duration of hospital stay. Seventeen studies were included. The meta-analysis demonstrated a lower risk of recurrence, a shorter duration of incapacity to work, a lower risk of wound infections, a lower risk of skin wound complications, and a shorter duration of hospitalisation in favour of flap vs direct closure. A shorter time to complete wound healing and a shorter duration of incapacity to work for flap vs the laying open technique were observed. Superiority of flap repair vs direct closure in pilonidal sinus treatment was demonstrated in this meta-analysis. These results suggest avoiding primary direct closure in clinical practice. Compared with the laying open technique, flaps result in faster healing and a shorter time to return to activities.

Long-Term Follow-up of Immediate Latissimus Dorsi Flap Reconstruction After Neoadjuvant Chemotherapy and Radiotherapy for Invasive Breast Cancer.

BACKGROUND: The treatment sequence involving a mastectomy and immediate breast reconstruction (IBR) via the latissimus dorsi flap technique after chemotherapy and radiotherapy is not common. Our experience of this alternative to the standard treatment at our institute is reported herein. PATIENTS AND METHODS: This was a single-center, retrospective study. We enrolled patients who received this so-called "inverse" sequence for invasive, nonmetastatic breast cancer between 2009 and 2016. RESULTS: Fifty-two patients, aged between 24 and 65 years, with a mean body mass index of 24.5 underwent this treatment. Most involved T2 (59.6%, n = 32), multifocal (55.8%, n = 29) tumors, and 57.7% (n = 30) of the patients presented with axillary lymph node involvement. All patients had received sequential chemotherapy and 50 Gy of radiation. Pathological complete response (pCR) was found in 51.3% (n = 20), of cases in the traditional inverse sequence group, using Chevalier and Sataloff classifications (T and N pCR). Postoperatively, 1 patient required surgical revision because of a hematoma, 42 (80.8%) presented with lymphocele, 3 had impaired would healing, and 2 had more than 5 cm of skin necrosis on the front flap. Median follow-up was 61.9 months and the median time between diagnosis and surgery was 9.7 months. Three patients presented with metastases, 2 with local recurrence, and 1 patient died of cancer. No contralateral or lymph node recurrence was discovered. CONCLUSION: This treatment sequence, the feasibility of which was shown in this study, is an alternative for patients who want an IBR to avoid the time spent without one breast. This practice requires upstream multidisciplinary cooperation for optimal patient screening.

Breast desmoid tumor management in France: toward a new strategy.

PURPOSE: Desmoid tumors (DTs) are rare tumors that originate from myofibroblastic tissue. Recently, initial wait and see was recommended (ESMO guidelines Ann Oncol 2017) in the most frequent locations. This study investigates the outcome of breast desmoid tumor (BDT) according to the initial strategy. METHOD: Data from all consecutive patients treated from a BDT in four referral centers were collected. Only intra-mammary desmoid tumors were included. A pathological review and a molecular analysis (CTNNB1 gene mutation) were performed (National re-reading network of sarcomas-RRePS). Patients were grouped according to initial strategy: surgery group (SG) and active surveillance group (ASG). RESULTS: A total of 63 patients (61 women, 2 men) met the inclusion criteria. Median age was 50 years (16-86). CTNNB1 mutation was found in 61% (n = 36). SG included 46 patients (73%) (41 partial mastectomies, 2 mastectomies, and 3 mastectomies associated to parietectomies). Surgical margins were positive in 15 patients (33.3%). Median follow-up of SG was 24.9 (0.5-209) months; and 4 patients (8.7%) developed recurrence. ASG included 17 patients (27%). Their median follow-up was 42.2 (0-214) months, and 15 patients (88.2%) did not require any additional treatment. Six patients (35%) had a spontaneous regression, 9 patients (52%) were stable, and 2 patients presented a significant progression that was treated by partial mastectomy. CONCLUSION: This study supports an initial nonsurgical approach to BDTs followed by surgery based on tumor growth in select cases, which is consistent with current ESMO recommendations.

Does needle biopsy cause an increased risk of extracapsular extension in the diagnosis of metastatic lymph node in melanoma?

BACKGROUND: Needle biopsy is a rapid, reliable, and reproducible procedure for histological confirmation of metastatic melanoma localization. Nonetheless, this procedure presents a theoretical risk of a mechanical weakening of the lymph node capsule with perinodal tumor seeding. The objective of the study was to evaluate the incidence of extracapsular extension after needle biopsy in comparison with surgical adenectomy in patients suspected of metastatic lymph node of melanoma. METHODS: We conducted a retrospective study of 1056 patients who underwent lymphadenectomy for melanoma between 2000 and 2016 in our unit. Sixty-nine patients were clinically and/or radiologically suspected of metastatic lymph node of melanoma. Patients were divided according to external lymph node biopsy or surgical adenectomy before lymphadenectomy. The primary endpoint was the histopathological identification of extracapsular extension in analyzed lymph nodes. RESULTS: The two populations were comparable except for the mitotic index, which was more frequently > 1/mm2 in the group with surgical adenectomy (P = 0.005). The proportion of extracapsular extension was significantly greater in the needle biopsy group (28/37) than in patients who underwent surgical adenectomy (14/32) (P = 0.0067; OR = 4 [95% CI: 1.4-11]). CONCLUSION: Our results suggest an increased risk of extracapsular extension after external lymph node biopsy in cases of suspicion of metastatic lymph node of melanoma. Thus, this encourages us to prefer surgical adenectomy in patients with suspected adenopathy accessible surgically. In other cases, needle biopsy should be carried out under radiological guidance using devices limiting tumor seeding.

Surgical Treatment of Facial Basal Cell Carcinoma: Patient-Based Assessment of Clinical Outcome in a Prospective Cohort Study.

BACKGROUND: There are limited data on the esthetic, functional, and morphological outcomes of surgical treatment of facial basal cell carcinoma (BCC). OBJECTIVE: The aim of our study was to assess the determinants of the evaluation of both the patients and the investigator of the esthetic, functional, and morphological impact of the surgical treatment of facial BCC. METHODS: A prospective observational study evaluated 111 patients treated surgically for facial BCCs (n = 135 BCCs), using the Patient and Observer Scar Assessment Scale (POSAS), a validated and reliable scale designed for the evaluation of all types of scars by professionals and patients. RESULTS: Scar assessment rated by the patients was very good. Skin aging was associated with a better surgical outcome as evaluated by POSAS (OR = 0.30, 95% CI: 0.09-0.98; p = 0.04). Conversely, histologically infiltrative or sclerosing BCC (OR = 2.33, 95% CI: 0.95-5.71; p = 0.06) was independently associated with poorer POSAS. In terms of the investigator's evaluation, aging signs (protective factor: OR = 0.17, 95% CI: 0.04-0.73; p = 0.01), location on the H-zone of the face (risk factor: OR = 2.95, 95% CI: 1.07-8.15; p = 0.03), and histologically infiltrative or sclerosing BCC (risk factor: OR = 2.89, 95% CI: 1.01-8.29; p = 0.04) were independently associated with POSAS. CONCLUSION: Esthetic, functional, and morphological outcomes of facial BCC surgery provide high patient satisfaction overall. Taking wider margins requires specific measures to improve the surgical outcome.