Axillary lymph node micrometastases decrease triple-negative early breast cancer survival.

BACKGROUND: Triple-negative breast cancers (TNBCs) are the most deadly form of breast cancer (BC) subtypes. Axillary lymph node involvement (ALNI) has been described to be prognostic in BC taken as a whole, but its prognostic value in each subtype is unclear. We explored the prognostic impact of ALNI and especially of small size axillary metastases in early TNBCs. METHODS: We analysed in this multicentre study all patients treated for early TNBC in 12 French cancer centres. We explored the correlation between clinicopathological data and ALNI, with a specific focus on the dichotomisation between macrometastases and occult metastases, which is defined as the presence of isolated tumour cells or micrometastases. The prognostic value of ALNI both in terms of disease-free survival (DFS) and overall survival (OS) was also explored. RESULTS: We included 1237 TNBC patients. Five-year DFS and OS were 83.7% and 88.5%, respectively. The identified independent prognostic features for DFS were tumour size >20 mm (hazard ratio (HR)=1.86; 95% CI: 1.11-3.10, P=0.018), lymphovascular invasion (HR=1.69; 95% CI: 1.21-2.34, P=0.002) and ALNI both in case of macrometastases (HR=1.97; 95% CI: 1.38-2.81, P<0.0001) and occult metastases (HR=1.72; 95% CI: 1.1-2.71, P=0.019). DFS and OS were similar between tumours with occult metastases and macrometastases. Tumours presenting at least two pejorative features (out of ALNI, lymphovascular invasion and large tumour size) displayed a significantly poorer DFS in both the training set and validation set, independently of chemotherapy administration. Tumours with no more than one of the above-cited pejorative features had a 5-year OS of ⩾90% vs 70% for other cases (P<0.0001). CONCLUSIONS: Axillary lymph node involvement is a key prognostic feature for early TNBC when isolated tumour cells were identified in lymph nodes. This impact is independent of chemotherapy use.

Characteristics and clinical outcome of T1 breast cancer: a multicenter retrospective cohort study.

BACKGROUND: A subgroup of T1N0M0 breast cancer (BC) carries a high potential of relapse, and thus may require adjuvant systemic therapy (AST). PATIENTS AND METHODS: Retrospective analysis of all patients with T1 BC, who underwent surgery from January 1999 to December 2009 at 13 French sites. AST was not standardized. RESULTS: Among 8100 women operated, 5423 had T1 tumors (708 T1a, 2208 T1b and 2508 T1c 11-15 mm). T1a differed significantly from T1b tumors with respect to several parameters (lower age, more frequent negative hormonal status and positive HER2 status, less frequent lymphovascular invasion), exhibiting a mix of favorable and poor prognosis factors. Overall survival was not different between T1a, b or c tumors but recurrence-free survival was significantly higher in T1b than in T1a tumors (P = 0.001). In multivariate analysis, tumor grade, hormone therapy and lymphovascular invasion were independent prognostic factors. CONCLUSION: Relatively poor outcome of patients with T1a tumors might be explained by a high frequency of risk factors in this subgroup (frequent negative hormone receptors and HER2 overexpression) and by a less frequent administration of AST (endocrine treatment and chemotherapy). Tumor size might not be the main determinant of prognosis in T1 BC.

[Progress in immediate breast reconstruction with skin sparing mastectomy]. / Reconstruction mammaire immédiate: les progrès apportés par la mastectomie avec conservation de l'etui cutané

Skin sparing mastectomy (SSM) and subcutaneous mastectomy (SCM) are recent techniques. They are always associated with immediate breast reconstruction (IBR). Their safety from an oncologic point of view and indications are of great concern. In early breast cancer, SSM and SCM are associated with the same risk of local recurrence as a modified radical mastectomy, when correctly indicated. This has been validated by numerous studies. In these non-randomised studies, overall survival cannot be evaluated. Such techniques can now be validated in the oncologic setting when correctly indicated and when decision-making is always concerted and multidisciplinary. Skin-sparing techniques are obviously associated with better cosmetic results than secondary reconstructions. Thus SSM with IBR are ideally indicated for ductal carcinoma in situ, pure infiltrating or mixed carcinomas requiring mastectomy without subsequent radiotherapy. The selection criterion of no postoperative radiotherapy allows the right candidates to be chosen for SSM. But often this criterion cannot be obtained preoperatively. In such cases, performing a two-step operation could be a good option. The interval between operations can be used by the patient to obtain more information and to make a mature decision regarding her choice of treatment. It seems essential to be able to offer every patient SSM with IBR which are validated standardised indications. Such is not the case everywhere in France today. The organisation of primary care through professional networks should provide us with an opportunity to fulfil these needs.

Impact of completion axillary lymph node dissection in patients with breast cancer and isolated tumour cells or micrometastases in sentinel nodes.

BACKGROUND: Omission of completion axillary lymph node dissection (ALND) is a standard practice in patients with breast cancer (BC) and negative sentinel nodes (SNs) but has shown insufficient evidence to be recommended in those with SN invasion. METHODS: A retrospective analysis of a cohort of patients with BC and micrometastases (Mic) or isolated tumour cells (ITCs) in SN. Factors associated with ALND were identified, and patients with ALND were matched to patients without ALND. Overall survival (OS) and recurrence-free survival (RFS) were estimated in the overall population, in Mic and in ITC cohorts. FINDINGS: Among 2009 patients analysed, 1390 and 619 had Mic and ITC in SN, respectively. Factors significantly associated with ALND were SN status, histological type, age, number of SN harvested and absence of adjuvant chemotherapy. After a median follow-up of 60.4 months, ALND omission was independently associated with reduced OS (hazard ratio [HR] 2.41, 90 confidence interval [CI] 1.36-4.27, p = 0.0102), but not with increased RFS (HR 1.21, 90 CI 0.74-2.0, p = 0.52) in the overall population. In matched patients, the increased risk of death in case of ALND omission was found only in the Mic cohort (HR 2.88, 90 CI 1.46-5.69), not in the ITC cohort. The risk of recurrence was also significantly increased in the subgroup of matched Mic patients (HR 1.56, 90 CI 0.90-2.73). INTERPRETATION: A separate analysis of Mic and ITC groups, matched for the determinants of ALND, suggested that patients with Mic had increased recurrence rates and shorter OS when ALND was not performed. Our results are consistent with those of previous studies for patients with ITC but not for those with Mic. Randomised controlled clinical trials are still warranted to show with a high level of evidence if ALND can be safely omitted in patients with micrometastatic disease in SN.

[Lobular invasive breast cancer prognostic factors: About 940 patients]. / Facteurs pronostiques des carcinomes lobulaires infiltrants du sein : à propos de 940 cas.

OBJECTIVES: To assess the prognostic factors of T1 and T2 infiltrating lobular breast cancers, and to investigate predictive factors of axillary lymph node involvement. METHODS: This is a retrospective multicentric study, conducted from 1999 to 2008, among 13 french centers. All data concerning patients with breast cancer who underwent a primary surgical treatment including a sentinel lymph node procedure have been collected (tumors was stage T1 or T2). Patients underwent partial or radical mastectomy. Axillary lymph node dissection was done systematically (at the time of sentinel procedure evaluation), or in case of sentinel lymph node involvement. Among all the 8100 patients, 940 cases of lobular infiltrating tumors were extracted. Univariate analysis was done to identify significant prognosis factors, and then a Cox regression was applied. Analysis interested factors that improved disease free survival, overall survival and factors that influenced the chemotherapy indication. Different factors that may be related with lymph node involvement have been tested with univariate than multivariate analysis, to highlight predictive factors of axillary involvement. RESULTS: Median age was 60 years (27-89). Most of patients had tumours with a size superior to 10mm (n=676, 72%), with a minority of high SBR grade (n=38, 4%), and a majority of positive hormonal status (n = 880, 93, 6%). The median duration of follow-up was 59 months (1-131). Factors significantly associated with decreased disease free survival was histological grade 3 (hazard ratio [HR]: 3,85, IC 1,21-12,21), tumour size superior to 2cm (HR: 2,85, IC: 1,43-5,68) and macrometastatic lymph node status (HR: 3,11, IC: 1,47-6,58). Concerning overall survival, multivariate analysis demonstrated a significant impact of age less than 50 years (HR: 5,2, IC: 1,39-19,49), histological grade 3 (HR: 5,03, IC: 1,19-21,25), tumour size superior to 2cm (HR: 2,53, IC: 1,13-5,69). Analysis concerning macrometastatic lymph node status nearly reached significance (HR: 2,43, IC: 0,99-5,93). There was no detectable effect of chemotherapy regarding disease free survival (odds ratio [OR] 0,8, IC: 0,35-1,80) and overall survival (OR: 0,72, IC: 0,28-1,82). Disease free survival was similar between no axillary invasion (pN0) and isolated tumor cells (pNi+), or micrometastatic lymph nodes (pNmic). There were no difference neither between one or more than one macromatastatic lymph node. But disease free survival was statistically worse for pN1 compared to other lymph node status (pN0, pNi+ or pNmic). Factors associated with lymph node involvement after logistic regression was: age from 51 to 65 years (OR: 2,1, IC 1,45-3,04), age inferior to 50 years (OR 3,2, IC: 2,05-5,03), Tumour size superior to 2cm (OR 4,4, IC: 3,2-6,14), SBR grading 2 (OR 1,9, IC: 1,30-2,90) and SBR grade 3 (OR 3,5, IC: 1,61-7,75). CONCLUSION: The analysis of this series of 940 T1 and T2 lobular invasive breast carcinomas offers several information: factors associated with axillary lymph node involvement are age under 65 years, tumor size greater than 20mm, and a SBR grade 2 or 3. The same factors were significantly associated with the OS and DFS. The macrometastatic lymph node involvement has a significant impact on DFS and OS, which is not true for isolated cells and micrometastases, which seem to have the same prognosis as pN0.

Quality of life after sentinel lymph node biopsy in early breast cancer.

AIM: This study assessed the effects of multiple therapeutic factors on quality of life (QOL) in the treatment of breast cancer. METHODS: We surveyed 179 recurrence-free women with early breast cancer who had undergone a sentinel lymph node procedure, between January 1999 and June 2001. Age, tumour size, breast and axillary procedure, nodal status, chemotherapy, supra-clavicular fossa radiotherapy, and hormone therapy were tested as possible factors associated with poor QOL. RESULTS: Information on QOL was obtained for 148 out of 179 patients. Age less than 55 years and chemotherapy were factors associated with impairment of physical well-being. Tumour size was associated with poor socio-familial well-being. Factors associated with altered arm subscale scores were age <55, axillary procedure, nodal status, chemotherapy and supra-clavicular fossa radiotherapy. Unexpectedly, sentinel lymph node (SLN) procedure delayed the onset of chemotherapy if the metastatic status of SLN was not diagnosed intra-operatively. CONCLUSION: Efforts are needed to improve the QOL of young patients. Axillary procedure affects only QOL related to arm morbidity.

Sentinel lymphadenectomy without systematic axillary dissection in breast cancer patients: predictors of non-sentinel lymph node metastasis.

AIMS: To identify factors predicting metastatic involvement of non sentinel axillary lymph nodes in breast cancer patients who underwent sentinel lymph node (SLN) biopsy followed by complete axillary dissection only in case of metastatic sentinel lymph node. METHODS: A prospective database including 165 breast cancer patients who underwent SLN biopsy without further complete axillary dissection in case of non-metastatic SLN was reviewed. Primary tumor size, pathologic grade, lymphatic invasion in the primary tumor, estrogen receptor status, tumor size in the SLN and number of metastatic SLNs were tested as possible predictors of metastatic involvement of non-SLN. RESULTS: The sentinel lymph node detection rate was 97% (160/165 patients). The mean number of SLNs per patient was 1.8 (range: 1-5). Fifty patients (31.3%) had a metastatic axillary SLN: 10 of the 42 patients with T1a or T1b breast tumors and 40 of the 118 patients with T1c< or = 15mm tumors. Fifteen of the 50 patients with metastatic SLN had metastatic non-SLN. Primary tumor size, tumor size in the SLN, pathologic grade, estrogen receptor status and age were not significantly associated with metastatic involvement of non-SLN. Number of metastatic SLNs fell short of reaching statistical significance (P: NS). Lymphatic invasion in the primary tumor was the only factor significantly associated with the presence of tumor in the non SLN (P<0.01). CONCLUSION: In our series, only lymphatic invasion in the primary tumor was correlated with metastases detection in the non-SLN. We could not identify a subset of patients without metastatic non-SLN in patients with metastatic SLN.

Electrochemotherapy: a new treatment of solid tumors.

Electrochemotherapy is a new local treatment of the solid tumors that can be defined as the local potentiation, by means of permeabilizing electric pulses, of the antitumor activity of non-permeant (e.g. bleomycin) or low-permeant (e.g. cisplatin) anticancer drugs. The electric pulses are delivered locally on the solid tumors, after the intravenous or intralesional injection of the chemotherapy agent. In this review, the basis of the electrochemotherapy are recalled. Then, after summarizing clinical data, we present some results of the European project Cliniporator, as well as the new pulse generator, the Cliniporator, that incorporates new features resulting from this research project, and that is fully conceived for a clinical use. Finally, future perspectives are discussed.

[Clinical prognostic factors in breast cancer. Retrospective study of 5609 cases]. / Les facteurs cliniques de pronostic dans le cancer du sein. Etude rétrospective de 5609 cas.

We studied the clinical factors of metastatic risk of breast cancer in 5609 consecutive cases of unilateral invasive breast cancer, wholly treated and followed at René-Huguenin Center from 1962 to 1988, and without any other cancer (even a controlateral breast cancer). All these patients were protocolary treated; these protocols, especially medical treatments (chimio and hormonotherapy), being modified along with years. At 20 years, the global metastasis free survival was 56%. Clinical size, existence of inflammatory signs, UICC clinical stage, clinical nodal status were highly significant in the Cox multivariate analysis (P < 0.000001). Age (P < 0.0008) and adherence to skin or underlying parietal (P < 0.007) were also but less significant. On the other hand, location of the tumor, time between first signs and diagnosis were not predictive. The women under 35 years had more metastatic locations during their evolution (P < 0.05) and maybe more visceral metastasis (NS).

[Standards, Options and Recommendations (SOR): clinical practice guidelines for diagnosis, treatment and follow-up of cutaneous melanoma. Fédération Nationale des Centres de Lutte Contre le Cancer]. / Standards, Options et Recommandations (SOR) pour la prise en charge des patients atteints de mélanome cutané.

CONTEXT: The "Standards, Options and Recommendations" (SOR) project, started in 1993, is a collaboration between the Federation of the French Cancer Centres (FNCLCC), the 20 French Cancer Centres and specialists from French Public Universities, General Hospitals and Private Clinics. The main objective is the development of clinical practice guidelines to improve the quality of health care and outcome for cancer patients. The methodology is based on literature systematic review and critical appraisal by a multidisciplinary group of experts, with feedback from specialists in cancer care delivery. OBJECTIVES: To develop clinical practice guidelines according to the definitions of Standards, Options and Recommendations for the management of patients with cutaneous melanoma. METHODS: Data have been identified by literature search using Medline - until December 1998 - and the personal reference lists of the expert group. Once the guidelines were defined, the document was submitted for review to national and international independent reviewers and to the medical committees of the 20 French Cancer Centres. RESULTS: The main recommendations for the management of cutaneous melanoma (CM) are: 1) The primary prevention of melanoma is based on a reduction in exposure to ultraviolet rays (solar or artificial). 2) The diagnosis of CM requires the surgical removal and histological examination of the lesion (standard). 3) The pathological report must include the diagnosis of primary malignant melanoma, the maximum thickness of the tumour in millimeters (Breslow), the clearance of surgical margins, the level of invasion (Clark), the presence and extension of regression and the presence of any ulceration (standard). 4) The standard treatment of a primary melanoma without lymph node involvement is based on surgery that must ensure adequate margins depending on the thickness of the tumour (standard, level of evidence B). 5) After surgery of a stage I melanoma, there is no indication for additional treatment outside a prospective therapeutic study (standard, level of evidence B, French Consensus Conference). 6) For a local recurrence without node involvement, in the absence of other metastases, surgical excision is the standard treatment. 7) In the case of metastatic regional lymph nodes, a complete regional lymphadenectomy is required. There is no indication for additional treatment outside a prospective therapeutic study (standard, level of evidence B). The inclusion of these patients in controlled studies of immunotherapy is recommended. 8) There is no standard therapeutic strategy for metastatic melanoma. Conventional palliative treatment is chemotherapy with dacarbazine (level of evidence B). 9) Follow-up is based on physical examination (standard). Patient information must encourage self-surveillance. Clinical surveillance and self-detection are indicated in all cases throughout life (standard).

[Standards, Options and Recommendations (SOR) for endocrine therapy in patients with non metastatic breast cancer. FNCLCC]. / Standards, Options et Recommandations (SOR): hormonothérapie dans les cancers du sein non métastatiques.

CONTEXT: The "Standards, Options and Recommendations" (SOR) project, started in 1993, is a collaboration between the Federation of the French Cancer Centres (FNCLCC), the 20 French Cancer Centres and specialists from French Public Universities, General Hospitals and Private Clinics. The main objective is the development of clinical practice guidelines to improve the quality of health care and outcome for cancer patients. The methodology is based on literature systematic review and critical appraisal by a multidisciplinary group of experts, with feedback from specialists in cancer care delivery. OBJECTIVES: To develop clinical practice guidelines according to the definitions of Standards, Options and Recommendations for endocrine therapy in patients with non metastatic breast cancer. METHODS: Data have been identified by literature search using Medline, Embase, Cancerlit and Cochrane databases - until july 1999 - and the personal reference lists of the expert group. Once the guidelines were defined, the document was submitted for review to 125 independent reviewers. RESULTS: The main recommendations for the endocrine therapy of patients with non metastatic breast cancer are: 1) Endocrine therapy modalities depend on menopausal status or age of women: ovarian suppression for premenopausal women, antiestrogen drug therapy for postmenopausal women (standard). 2) Tamoxifen (20 mg/d - 5 years) is beneficial to women with positive estrogen receptor tumor (standard, level of evidence A). There is no indication of tamoxifen treatment for women with negative estrogen receptor tumor (standard, level of evidence A). 3) For postmenopausal women with positive estrogen receptor tumor, tamoxifen is the standard adjuvant treatment (level of evidence A). For postmenopausal women with negative estrogen receptor, adjuvant chemotherapy has to be considered (option, level of evidence A). No adjuvant treatment has to be considered for women with poor health condition (option). 4) For premenopausal women with estrogen receptor tumor, results of clinical trials of chemotherapy versus endocrine therapy, suggest a benefit for endocrine therapy. However, there is no sufficient evidence to consider endocrine therapy alone as a standard adjuvant treatment. 5) For premenopausal women, chemotherapy + ovarian suppression or chemotherapy + tamoxifen are not better than chemotherapy alone (level of evidence A). 6) For postmenopausal women, administration of chemotherapy plus adjuvant tamoxifen versus the same tamoxifen alone, is of additional benefit in reducing recurrences but not in prolonging overall survival (standard, level of evidence A). 7) Balance of known benefits (delay to recurrence and death) and risks (side-effects of therapy) for adjuvant chemoendocrine therapy has to be taken into consideration before decision making. Chemoendocrine therapy can be indicated for women at high risk of developing metastatic disease (recommendation, experts agreement).

[Partial irradiation of the breast: why, how?]. / Irradiation partielle du sein: pourquoi, comment ?

Radiation therapy represents a very important part of breast conservative treatment. The classic schedule consists in delivering a total dose of 50 Gy in 25 fractions on 5 weeks, sometimes associated with a 10 to 16 Gy boost. For elderly women with difficulties to move or for younger women having professional activity or with young children in charge, a 5 to 6 weeks radiation therapy with long and frequent transportations is sometimes difficult to achieve. The aim of partial breast irradiation (PBI) is to prevent, in a short period (5 to 8 days) and less transportations, the risk of local recurrence into the tumor bed. Different techniques have been described, using either interstitial brachytherapy (low or high dose rate) or intra-operative radiation therapy (IORT photons or electrons) or external beam radiation therapy. Phase II PBI trials using interstitial brachytherapy showed a local control rate of 0 to 4% with a follow-up of 20 to 75 months. The rate of good/excellent cosmetic results is 67 to 100%. Results analysis of trials using very new PBI techniques (MammoSite), IORT) remains more difficult. If phase III randomized trials could confirm that PBI achieved, for selected patients, local controls equivalent to those obtain with whole breast irradiation, PBI could improve quality of life during radiation therapy, and maybe contribute to have a cost effective breast cancer conservative treatment.

["Standards, Options and Recommendations 2001" for radiotherapy in patients with non-metastatic infiltrating breast cancer. Update. National Federation of Cancer Campaign Centers (FNCLCC)]. / Standards, Options et Recommandations 2001 pour la radiothérapie des patientes atteintes d'un cancer du sein infiltrant non métastatique, mise à jour. Fédération nationale des centres de lutte contre le cancer (FNCLCC).

CONTEXT: The "Standards, Options and Recommendations" (SOR) project, started in 1993, is a collaboration between the Federation of french cancer centers (FNCLCC), the 20 french cancer centers, and specialists from french public universities, general hospitals and private clinics. The main objective is the development of clinical practice guidelines to improve the quality of health care and the outcome of cancer patients. The methodology is based on a literature review and critical appraisal by a multidisciplinary group of experts, with feedback from specialists in cancer care delivery. OBJECTIVES: To develop clinical practice guidelines for non metastatic breast cancer patients according to the definitions of the Standards, Options and Recommendations project. METHODS: Data were identified by searching Medline, web sites, and using the personal reference lists of members of the expert groups. Once the guidelines were defined, the document was submitted for review to 148 independent reviewers. RESULTS: This article presents the chapter radiotherapy resulting from the 2001 update of the version first published in 1996. The modified 2001 version of the standards, options and recommendations takes into account new information published. The main recommendations are: (1) Breast irradiation after conservative surgery significantly decrease the risk of local recurrence (level of evidence A) and the decrease in the risk of local recidive after chest wall irradiation is greater as the number of risk factors for local recurrence increases (level of evidence A). (2) After conservative surgery, a whole breast irradiation should be performed at a minimum dose of 50 Gy in 25 fractions (standard, level of evidence A). (3) A boost in the tumour bed should be performed in women under 50 years, even if the surgical margins are free (standard, level of evidence B). (4) Internal mammary chain irradiation is indicated for internal or central tumours in the absence of axillary lymph node involvement (expert agreement) and in the presence of lymph node involvement (standard, level of evidence B1). (5) Sub- and supra-claviculr lymph node irradiation is indicated in patients with axillary node involvement (standard, level of evidence B1).

[Sentinel node biopsy in breast cancer. Will this lead to the end of lymphadenectomy for small tumors without suspected axillary adenopathy?]. / Le ganglion sentinelle dans le cancer du sein. Est-ce la fin du curage pour les petites tumeurs NO?

Sentinel node (SN) biopsy in breast cancer is still in a crucial stage of evaluation. Many teams have obtained excellent results using this method, with a detection rate always higher than 90% and a false negative rate between 0 and 8%, in prospective series. The main question is to know if lymphadenectomy can now be avoided when the SN is negative. The answer will come from the results of the two ongoing trials comparing sentinel node biopsy to axillary lymphadenectomy. But their results will be available only in two or three years. However, many teams, as at Institute Gustave Roussy, are now applying the technique routinely, because of the excellent results obtained during their learning curve. But there are some methodological differences between teams, which can influence the detection and false negative rates. Thus, several methodological standards remain to be defined. This review enable us to clarify a certain number of questions. Today, SN biopsy can only be performed by trained teams, with prospective evaluation of their results or participation in phase III trials.

[Axillary lymphadenectomy with muscular padding, without drainage]. / Le curage de l'aisselle avec capitonnage musculaire sans drainage.

OBJECTIVE: Axillary padding without drainage appeared to be a valuable alternative technique to vacuum drainage. The technique employs local muscles or the axillary aponeurosis for padding. We report here the clinical evaluation of muscular padding without drainage. The analysis of these results prompted us to also do a literature search for other alternatives aimed at reducing morbidity due to vacuum drainage. PATIENTS AND METHODS: Muscular padding was prospectively performed by 8 different surgeons on a total of 152 patients at the Centre Rene-Huguenin (Saint-Cloud, France). Follow-up has attained 3.5 years. A comparative assessment of pain was conducted in 30 patients operated on with vacuum drainage. RESULTS: This technique is easy to learn and reproducible. It facilitates post-operative follow-up, always allowing discharge at the 2nd or 3rd post-operative day without any home nursing. The late sequels are not increased. In contrast, pain was twice more intense during the first post-operative weeks compared with vacuum drainage, and the seroma rate was also increased. DISCUSSION AND CONCLUSION: Despite good efficacy, this worsening of pain is a major obstacle to the routine use of muscular padding. A technical improvement has been published very recently where the axillary aponeurosis was used to pad the axilla. It seems to be equally efficient but less painful than muscular padding. This technique is under clinical evaluation and could appear as a valuable option to vacuum drainage. Other alternatives are discussed. Most studies lack a direct comparison with vacuum drainage and a satisfactory evaluation of quality of life is also omitted. New studies with quality of life scales are ongoing. They should allow us to choose options that take this aspect into account in the future.

[When will we stop mastectomies for intraductal carcinoma?]. / Quand cessera-t-on les mastectomies pour carcinome intracanalaire?

There has been growing interest in intraductal carcinomas of the breast (DCIS) over the last ten years mainly because of their increasing frequency and their difficult diagnosis. Their natural history is often surprising. For the time being, it is impossible to establish which proportion of DCIS might turn into an infiltrating carcinoma, and which factors are predictive for such a risk. These uncertainties are responsible for many controversies about their treatment. Based on a critical review of the latest publications, this paper deals with the possibilities of conservative treatment, challenging the remarkable results of total mastectomy (nearly 100% survival at 10 years). The risk of conservative treatment depends on the frequency of local recurrence, and on the potential vital risk of such recurrences, knowing that half of these recurrences will develop in an invasive, and no longer in situ, pattern. Randomized trials are being conducted on this question; they will not give an answer before the year 2000. In the mean time, conservative treatment seems to be reasonable for small low grade histologic lesions widely excised by surgery, and with rigorous possibilities of follow-up. The operation is followed by external irradiation. In case of recurrence, mastectomy has to be. It is not impossible that, performed under these conditions, a slight increase in mortality might follow such a strategy, thus heavily balancing the benefits of conserving the breast. Besides, surgical excision alone should only be performed as part of randomized trials, or for infra-centimetric lesions discovered by histology after resection of supposed benign lesions.

[Elastofibroma dorsi. Apropos of 5 cases]. / Elastofibrome dorsal. A propos de cinq observations.

Elastofibroma is a rare tumor mainly found under the scapula. Based on a recent study of five cases, we would like to stress the importance of making the diagnosis of elastofibroma, as this lesion simply consists of dysplasia of the elastic fibres and is not malignant as could be suggested by clinical examination.

[Esthetic results of breast reconstruction after amputation for cancer. 323 cases]. / Résultats esthétiques de la reconstruction mammaire après amputation pour cancer. A propos de 323 cas.

323 reconstructions of the breast were carried out at the Gustave-Roussy Institute and were analysed in order to assess the aesthetic results and the sequelae of these reconstruction operations. The majority of the patients were operated on between 1984 and 1989 with a median follow-up of 3.5 years (1 to 9 years). Three types of reconstruction were carried out: simple prosthesis behind the muscle (P, 69% of this population), latissimus dorsi flap (G.D., 11%), or transverse rectus abdominis flap (TRAM, 20%). These reconstructions were either carried out immediately (RMI, 23.5%) or later (RMD, 76.5%). The unanimous enthusiasm of the patients for reconstruction was the greatest encouragement for us to continue in this way. From the aesthetic point of view the transverse rectus abdominis flap (TRAM) proved to be superior to the others. Scar and functional sequelae of the latissimus dorsi flap (GD) were by no means nil in this series (table 9) in contrast with other studies that have been carried out. All the same the majority of these sequelae were larger scars. The functional poor sequelae were minor. TRAM sequelae were less frequent and usually mainly in the abdominal wall. A more accurate technique should lower the incidence. As far as the timing of surgery is concerned, immediate reconstruction did not alter the quality of results which were better (but not significantly statistically). This has already been published. On the other hand patients were more satisfied with RMD (p less than 10(-4)). The analysis of this unexpected result show the great significance of psychological factors in interpreting these results.(ABSTRACT TRUNCATED AT 250 WORDS)

[Conformal accelerated partial breast irradiation: state of the art]. / Irradiation partielle accélérée conformationnelle du sein : état des lieux.

Breast conserving treatment (breast conserving surgery followed by whole breast irradiation) has commonly been used in early breast cancer since many years. New radiation modalities have been recently developed in early breast cancers, particularly accelerated partial breast irradiation. Three-dimensional conformal accelerated partial breast irradiation is the most commonly used modality of radiotherapy. Other techniques are currently being developed, such as intensity-modulated radiotherapy, arctherapy, and tomotherapy. The present article reviews the indications, treatment modalities and side effects of accelerated partial breast irradiation.

[Accelerated partial breast irradiation: bifractionated 40Gy in one week. A French pilot phase II study]. / Étude pilote française de phase II d'irradiation partielle accélérée du sein conformationnelle tridimensionnelle bi-fractionnée hebdomadaire de 40Gy.

PURPOSE: Since 2009, accelerated partial breast irradiation (APBI) in North America has been allowed to be used for selected group of patients outside a clinical trial according to the ASTRO consensus statement. In France, accelerated partial breast irradiation is still considered investigational, several clinical trials have been conducted using either intraoperative (Montpellier) or Mammosite(®) (Lille) or brachytherapy modality (PAC GERICO/FNCLCC). Here, we report the original dosimetric results of this technique. PATIENTS AND METHODS: Since October 2007, Institut Gustave-Roussy has initiated a phase II trial using 3D-conformal accelerated partial breast irradiation (40 Gy in 10 fractions BID in 1 week). Twenty-five patients with pT1N0 breast cancer were enrolled and were treated by two minitangent photons beams (6MV) and an "en face" electron beam (6-22 MeV). RESULTS: The mean clinical target volume and planning target volume were respectively 15.1cm(3) (range: 5.2-28.7 cm(3)) and 117 cm(3) (range: 52-185 cm(3)). The planning target volume coverage was adequate with at least a mean of 99% of the volume encompassed by the isodose 40 Gy. The mean dose to the planning target volume was 41.8 Gy (range: 41-42.4 Gy). Dose inhomogeneity did not exceed 5%. Mean doses to the ipsilateral lung and heart were 1.6 Gy (range: 1.0-2.3 Gy) and 1.2 Gy (range: 1.0-1.6 Gy), respectively. CONCLUSION: The 3D conformal accelerated partial breast irradiation using two minitangent and "en face" electron beams using a total dose of 40 Gy in 10 fractions BID over 5 days achieves appropriate planning target volume coverage and offers significant normal-tissue sparing (heart, lung). Longer follow-up is needed to evaluate the tissue tolerance to this radiation dose.