Upper outer boundaries of the axillary dissection. Result of the SENTIBRAS protocol: Multicentric protocol using axillary reverse mapping in breast cancer patients requiring axillary dissection.

BACKGROUND: Two thirds of node-positive breast cancer patients have limited pN1 disease and could benefit from a less extensive axillary lymph node dissection (ALND). METHODS: 172 breast cancers patients requiring an ALND were prospectively enrolled in the Sentibras Protocol of Axillary Reverse Mapping (ARM). Radioisotope was injected in the ipsilateral hand the day before surgery. ALND was standard. Removed lymph nodes were classified into non radioactive nodes and radioactive nodes (ARM nodes). Among ARM nodes, nodes located in the upper outer part of the axilla, above the second intercostal brachial nerve and lateral to the lateral thoracic vein were identified as "zone D ARM nodes". The main objective was: feasibility of identification of the zone D ARM nodes. Secondary objectives were: metastatic involvement and lymphedema rate. RESULTS: 100% of patients had ARM nodes identified. The "zone D ARM nodes" were identified in 92% of cases. The rate of metastatic nodes was 60% in the all cohort, 31% in ARM nodes and 9% in zone D ARM nodes. Among those, metastatic rate was 6% in patients undergoing ALND for a positive sentinel node biopsy, 6% in case of primary ALND versus 14% after neo-adjuvant chemotherapy (p < 0.05). After 34 months of median follow up, 27% of interviewed patients had a lymphedema. CONCLUSION: The ARM technique reliably identifies the "zone D ARM nodes". These nodes can also easily be identified using knowledge of axillary anatomy. In selected patients, a selective ALND sparing the zone D ARM nodes could be performed.

[Breast-conserving therapy of breast cancer]. / Le traitement chirurgical conservateur du cancer du sein.

Breast-conserving treatment for breast cancer combines lumpectomy, axillary nodes treatment and radiotherapy of the breast. Conservative surgery and radiotherapy is now the standard treatment for unifocal, non inflammatory tumors, less than 3 cm in diameter. The widespread use of mammographic screening leads to a significant increase in the proportion of non palpable breast carcinomas, and has contributed to increase the proportion of breast conserving treatments. Neoadjuvant treatments (chemotherapy, radiotherapy and hormonotherapy) can also extend the indications of breast conservation to breast carcinomas larger than 3 cm. Furthermore, in the last ten years, new surgical procedures (sentinel node biopsy, oncoplastic surgery, minimal invasive surgery) have been developed, increasing the surgical possibilities. After a learning phase to establish new standards for these procedures, all these techniques are now part of our standard surgical apparel, thus extending the possibilities of breast conserving surgery.

[Explosive growth of uterine leiomyomas and carcinologic ovarian risk in a non-menopausal patient with BRCA1-BRCA2 mutation treated by tamoxifen]. / Croissance explosive de myome utérin et risque carcinologique ovarien sous tamoxifène chez une patiente non ménopausée porteuse d'une mutation BRCA1-BRCA2.

OBJECTIVE: To report the case of significant growth of a myoma in a premenopausal woman with a suspicion of BRCA1 and BRCA2 mutation, treated by tamoxifen for a hormonodependent breast cancer and to point out the carcinologic ovarian risks with a mutation BRCA1-BRCA2 in this context. Case. Four months after surgical treatment, chemotherapy and the beginning of tamoxifen, an explosive growth of the abdomen justified pelvic echography and laparoscopy confirming the diagnosis of uterine myoma. A polymyomectomy by laparotomy was performed. CONCLUSION: Use of tamoxifen in premenopausal woman with subjacent gynecological pathologies, whether BRCA1-BRCA2 mutation is present or not can prove to be delicate. A regular clinical and echographic monitoring is necessary.

Recurrence of leiomyomata after laparoscopic myomectomy.

STUDY OBJECTIVE: To assess recurrence of leiomyomata after laparoscopic myomectomy (LM) and evaluate predictive factors of recurrence. DESIGN: Observational study (Canadian Task Force classification II-2). SETTING: University hospital. PATIENTS: One hundred ninety-six women. INTERVENTION: Laparoscopic myomectomy with mean follow-up of 47 months. MEASUREMENTS AND RESULTS: Myoma recurrence included recurrence of initial symptomatology before LM, recurrence at clinical examination, and appearance of a myoma 2 cm or larger on ultrasound examination. Recurrence was observed in 45 patients (22.9%). The mean time before recurrence was 42 months (range 4-95 mo). Eight women (4.08%) required reoperation. The cumulative recurrence risk was 12.7% at 2 years and 16.7% at 5 years. Predictive factors for recurrence were number of myomas and nulliparity. CONCLUSION: According to our results, the cumulative rate of myoma recurrence within 5 years appears greater after LM than after laparotomy. However, this should not lead us to reject laparoscopy, which has many advantages compared with laparotomy, in particular its low morbidity.