Tolerance of latissimus dorsi in immediate breast reconstruction without implant to radiotherapy.

INTRODUCTION: Immediate breast reconstruction (IBR) improves the quality of life of patients who undergo mastectomy. The latissimus dorsi flap (LDF) method provides particularly good aesthetic results, but its tolerance to subsequent radiotherapy remains unclear. We thus sought to assess tolerance and esthetic results and satisfaction, as reported by patients who underwent IBR by LDF with or without subsequent radiotherapy. MATERIALS AND METHODS: We performed a retrospective case-control study in a population of women who were diagnosed with breast cancer between January 1999 and January 2014 and who had mastectomies with IBR by LDF without prostheses. We paired 29 patients who needed postoperative radiotherapy to 58 control patients who did not. These patients responded to a questionnaire to evaluate tolerance and their satisfaction with the aesthetic results of the reconstruction. RESULTS: In total, 86.2% of all patients reported "very good" or "good" overall aesthetic satisfaction. Consistency was judged as "very good" or "good" by 82.7% of control patients and by 93.1% of case patients. No statistically significant differences were identified between the two groups with regard to reconstruction results. The number of surgical procedures needed did not differ significantly between the two groups. CONCLUSION: In our study, IBR by LDF appeared to have excellent tolerance to subsequent radiotherapy, the latter having no impact on patient aesthetic satisfaction. Our results suggest that the possibility of postoperative radiotherapy should not prevent physicians from proposing this method to women who are candidates for it.

Breast reconstruction with fat grafting and BRAVA(®) pre-expansion: Efficacy evaluation in 45 cases.

INTRODUCTION: Fat grafting for breast surgery, in reconstruction or aesthetics, gained a lot of popularity over the last years. As an addition to breast reconstruction with flaps or prosthesis, lipofilling improved the aesthetic result, increasing the patients' satisfaction rate. The demand for breast reconstruction using only fat grafting increased, because patients want a natural result in breast reconstruction and also the body contouring associated with liposuction of specified fat areas. The pre-expansion BRAVA(®) system has been used for several years in the United States to prepare the receiving site for lipofilling. We wanted to gain our own experience in associating BRAVA-lipofilling in breast reconstruction. The aim of our study is to evaluate the BRAVA efficiency as an adjuvant for fat grafting in breast surgery. MATERIAL AND METHODS: A retrospective study was undertaken, using a homogenous series of consecutive patients, operated by one surgeon (the first author), that had breast reconstruction using only fat grafts associated with BRAVA(®). RESULTS: The retrospective homogenous study identified 45 cases of breast surgery associating fat grafting alone with BRAVA(®) assistance. The number of intervention of fat grafting associating BRAVA(®) was 1 or 2 for conservative treatment sequelae or for flap reconstruction improvement, and 2 to 4 for immediate and delayed breast reconstruction. The total volume of fat grafting was 205 cc for the contralateral balancing, 317 cc for flap reconstructions, 531 cc for the conservative treatment sequelae, 790 cc for the immediate breast reconstruction and 1165 cc for the delayed breast reconstruction. The satisfaction rate of the surgical team and the patients was satisfying and very satisfied in 82% of cases, average in 8% of cases, and insufficient in 10% of cases. CONCLUSIONS: Breast reconstruction with fat grafting alone is, in our experience, a reliable and reproducible technique, that gives excellent and stable results. The high satisfaction rate of patients is explained by the supple and natural consistency of the new breast, with no added scars, associating the benefits of liposuction of the donor sites. The BRAVA(®) system seems to be, in cases with good indications, an adjuvant for receiving site preparation, making the reconstruction easier for the surgeon and for the patient. We believe that breast reconstruction with fat grafting alone is going to become more popular in the future. Associating fat grafting with BRAVA(®) creates a new way of natural breast reconstruction for the patients with mastectomy that want a stable result with less aggressive procedures. It is a new tool that is going to increase the autologous breast reconstruction in France.

[Lipofilling and breast cancer: Literature review in 2015?]. / Lipofilling et cancer du sein : où en sommes-nous en 2015 ?

INTRODUCTION: The clinical surveillance of a patient treated for breast cancer involves many specialists: a surgeon, an oncologist, a radiotherapist, a gynecologist, and a general practitioner. The patients diagnosed with breast cancer will require regular clinical examination in order to identify possible recurrences. In our team, fat grafting has been used since 1998 for breast reconstruction because its results are natural breasts. Usually used as an adjuvant for flap or implant breast reconstruction, the lipofilling increases the aesthetic result and has a high satisfaction rate among patients. Despite of this advantage, some teams do not use lipofilling in patients with breast cancer history, because of doubts about oncology safety and screening difficulty. We performed an extensive review of the literature available regarding this subject. The purpose of this article is to evaluate the oncology safety of lipofilling in breast reconstruction after breast cancer. MATERIAL AND METHOD: A literature review was undertaken using PubMed. The key words searched were: breast lipofilling, breast reconstruction, breast cancer, and recurrence. RESULTS: The results of the literature review showed a reduced number of articles reporting recurrence after lipofilling. The retrospective studies included few patients and searched for multiple variables: histological type, stage, surgery, marginal invasion, distance between cancer surgery and lipofilling. In our research, we found no correct control group, except the series of Petit. The follow-up is relatively short (between 1 and 3years), except for the series of Rigotti. The recurrence cases after lipofilling in patients with extensive in situ carcinoma, in the series of Petit, raised the problem to be cautious with lipofilling after extensive in situ carcinoma. Other factors involved are the age of the patient and the distance between the cancer surgery and the lipofilling. CONCLUSION: Breast cancer is a disease that is well managed regarding treatment and follow-up. After reviewing the available literature, we consider that the lipofilling does not have a negative impact on the recurrence of breast cancer. There are however several precautions that must be taken into account in the sequelae of the conservative treatment (image exam before and after surgery, 3years delay of the procedure after the oncology treatment) and in the extensive in situ carcinoma. For this particular case of breast reconstruction using lipofilling, a multidisciplinary discussion of the reconstruction options might be a reasonable approach. It is important that the patients treated for breast cancer continue a clinical and imaging exam regardless of the breast reconstruction method, in order to identify a possible relapse as early as possible.

[Axillary lymph node dissection after breast reconstruction by pedicled Latissimus dorsi: Operative steps and outcomes]. / Curage axillaire après reconstruction mammaire par lambeau de grand dorsal: principes chirurgicaux et résultats.

OBJECTIVES: We retrospectively reviewed all the cases of axillary lymph node dissection (ALND) performed within a year after an immediate breast reconstruction procedure by a pedicled Latissimus dorsi, which is transferred to the anterior thoracic wall through an axillary funnel. Operative technical steps are described taking account of the new anatomical relationship of the axilla. METHODS: We assessed postoperative immediate complications and late sequelaes. RESULTS: From 1999 to 2013, 21 ALND were performed. Immediate postoperative period was free of complication in 85% of cases when following the operative steps described in this work. Partial or total necrosis of the reconstructed breast did not occur. With a median follow-up of 64 months, 6 patients (28% of the whole population) presented at least one sequelae like a feeling of heavy arm (n=2, 9%) or a lymphedema (n=3, 14%), a chronic neuropathic pain (n=4, 19%) or a limitation in the arm range of motion (n=2, 9%). CONCLUSION: ALND after immediate breast reconstruction by a pedicled Latissimus dorsi is feasible and safe, without any additional postoperative complication in comparison with a classic ALND.

[Axillary lymph node metastases with an occult breast: About 16 cases from a cohort of 7770 patients]. / Envahissement ganglionnaire axillaire sans tumeur primitive mammaire retrouvée : à propos de 16cas issus d'une cohorte de 7770patientes.

OBJECTIVES: Isolated axillary lymph node metastases is an unusual clinical presentation of breast carcinoma. We studied its different issues. METHODS: This study is a follow-up study of 16patients, treated between 1996 and 2012, presenting with axillary metastases with an occult breast carcinoma, which could not be identified by physical examination nor by a conventional imaging or a breast MRI. Clinical characteristics, histological analysis, treatment, monitoring and five-year survival rate were studied. RESULTS: The incidence of this kind of breast cancer was 0.20%. A breast MRI was performed in 75% of the patients. The histology of these tumors showed a rate of hormono-sensibility of 50% and an HER2 overexpression of 44%. Sixty-nine percent of the patients had no breast surgery or radiotherapy; global five-year survival rate for these women was 77.4%±11.5. CONCLUSION: The survival rates of this study should lead the practitioner to choose a less aggressive breast therapy. Moreover, the histological characteristics explain the high metastatic potential of these tumors, and relate them to the HER2+ subclass of gene expression patterns of breast carcinomas.

[Tolerance of latissimus dorsi without implant to radiotherapy in immediate breast reconstruction]. / Tolérance du lambeau de grand dorsal sans prothèse à la radiothérapie en reconstruction mammaire immédiate.

OBJECTIVES: Rates of immediate breast reconstruction (IBR) after mastectomy are currently increasing, leading us to evaluate outcomes of breast reconstruction with latissimus dorsi without implant followed by adjuvant radiotherapy. MATERIALS AND METHODS: From January 1999 to August 2013, 31 breast reconstructions with latissimus dorsi have been irradiated. Patients have been selected from a prospective database and contacted to evaluate outcomes of breast reconstruction, and 2 patients have been lost. RESULTS: Median follow-up was 6.5 years. Breast reconstruction outcomes were evaluated as very good or good in 86% of cases, with breast reconstructed consistency as very good or good in 93% of cases. An additional fat grafting has been performed for 58% of cases (mean volume transferred of 250 cc) and was associated with contralateral breast reduction in 32% of the whole population. IBR was judged as essential for 79% of women a posteriori. CONCLUSION: In our experience, latissimus dorsi has a good tolerance to adjuvant irradiation, and may be offered to patients willing to benefit of an IBR even if postoperative radiotherapy is scheduled.

[Postoperative morbidities after modified posterior pelvic exenteration for ovarian cancer]. / Complications après exentération pelvienne postérieure modifiée selon Hudson dans le cadre de tumeurs malignes ovariennes.

OBJECTIVE: Complication and survival analysis of cytoreduction surgery with modified posterior pelvic exenteration in the surgical treatment of the ovarian malignant tumor. METHODS: A retrospective monocentric study between 2000 and 2013 in Rhone-Alpes cancer treatment center. One hundred and fifty-two patients with ovarian cancer and treated by surgery with modified posterior pelvic exenteration were included. Complication in the 30 days after surgery was analysed by the Clavien-Dindo classification. RESULTS: In our study, rate of global complication was 62.5% with a morbidity rate of grave complication of 7.9%. Our rate of complete resection was 82.2%. Three fistulas (2.2%) were found. On average, there was 6.6±1.8 (2-11) surgery gesture associated with Hudson resection during surgery. In univariate analysis, there was a statistic significant association between complication from the rank II of Clavien-Dindo classification and supraradical surgery, post-chemotherapy surgery, recurrent surgery, the resection of a diaphragmatic dome, and the partial gastric resection. This association was also observed with the number of surgical gesture associated with Hudson resection. CONCLUSIONS: The main prognostic surgical factor in ovarian cancer is to obtain a no macroscopic residual disease. The modified posterior pelvic exenteration allowed to obtain it. Our study demonstrates a low rate of grave complication further to this type of surgery.

[Satisfaction in ambulatory patients with breast-conserving surgery and sentinel node biopsy for breast cancer]. / Satisfaction des patientes opérées par tumorectomie-ganglion sentinelle pour cancer du sein en ambulatoire.

OBJECTIVE: The objective of this study was to evaluate outpatient satisfaction for breast cancer surgery and compare with inpatient satisfaction. PATIENTS AND METHODS: Our observational prospective study included all patients who underwent breast cancer surgical procedure (breast-conserving surgery and sentinel node biopsy) between July and December 2013 in a cancer center. Patients were asked to answer a questionnaire at discharge and 30 days after surgery. RESULTS: One hundred and fifty-five patients (exclusively women) were included; the outpatient group comprised 102 patients and the inpatient group 53. The study showed no statistical difference in patients' satisfaction betweeen the two groups at discharge (P=0.20) and 30 days after surgery (P=0.30); 101 (99%) outpatients and 44 (95.7%) inpatients had very good or excellent level of satisfaction at discharge and 88 (92,7%) and 49 (98%), respectively 30 days after surgery. The overall mean satisfaction score was 9.1±1.2 [3-10] at discharge and 8.7±1.3 [3-10] 30 days after surgery. DISCUSSION AND CONCLUSION: Our study found high degree of satisfaction after breast surgery for cancer both for outpatients and inpatients. This suggests that ambulatory surgery is possible and valid for this type of oncologic breast surgery.

[Glandular posterior flap of the breast for oncoplastic surgery]. / Apport du lambeau glandulaire postérieur du sein en chirurgie oncoplastique.

INTRODUCTION: Breast conservative surgeries, associated with radiotherapy within the framework of conservatives treatments for breast malignant tumors, can occur deformation of the breast in 10 to 15% of cases. The deformity can be more or less important according to the size of the initial lesion and the glandular reshaping reconstruction. Our experience in oncologic and reconstructive surgery of the breast reflects us about difficult cases of breast conservative surgeries in a glandular reshaping to obtain the best aesthetic result. In this approach, the posterior glandular flap of the breast was used in specific indications. The study aims to estimate the efficiency and the tolerance of the posterior glandular flap in difficult cases of breast oncoplastic surgeries. MATERIAL AND METHODS: We realized a consecutive serie of 24 breast oncoplastic surgeries. We noticed 15 breast conservative surgeries of superior quadrants. The posterior glandular flap was realized in 15 cases. We used the posterior part of the breast, vascularized by musculo-cutaneous intercostal arteries to give the volume lacking in the breast. We estimated efficiency and tolerance of the posterior glandular flap than one-year operating comment, as well as the oncologic follow-up long-term. RESULTS: In this serie of 15 cases, we did not note acute complications like infection, hematoma or cutaneous necrosis. We listed 13 cases of malignant tumors with indication of radiotherapy, and 2 cases of benign tumors. In one year, we found two patients presenting a cyst of cytosteatonecrosis (1cm and 3cm) in the site of surgery, compared to posterior flap. The glandular total average excision was 333g (30-1200). An oncologic surgical resumption was necessary in 2 cases (a case of preventive mastectomy for BRCA1, and a case of insufficient margins). We realized 12 cases of controlateral surgery at the same time for symmetry. The aesthetic result was judged at one year post-operatory: good or very good in 74% of the cases, correct in 20% of the cases, and insufficient in 6% of the cases. The oncologic follow-up did not find locoregional recurrence. CONCLUSION: The posterior glandular flap is an interesting contribution in oncoplastic surgery of superior quadrants of the breast to replace harmoniously the missing volume. This flap, reliable and reproductible, offers an alternative to bring of the custom-made volume without residual deformation of the breast. The aesthetic results allowed, in spite of the radiotherapy, to decrease the aftereffects of breast conservative surgery treatments, and this interesting approach deserves a wider distribution.

Hyperthermic intraperitoneal chemotherapy with oxaliplatin and without adjuvant chemotherapy in stage IIIC ovarian cancer.

OBJECTIVE: To assess the feasibility and efficacy of cytoreductive surgery (CRS) followed by hyperthermic intraperitoneal chemotherapy (HIPEC) without adjuvant chemotherapy for relapsed or persistent advanced ovarian cancer. METHODS: This observational study included stage IIIC ovarian cancer patients due to undergo CRS (interval debulking or recurrent surgery) followed by HIPEC with oxaliplatin (460 mg/m2) for 30 min. RESULTS: Twenty-two patients (12 interval debulking procedures and 10 recurrence procedures) were enrolled between September 2003 and September 2007. HIPEC was not performed in four patients because of operative findings. No patient received adjuvant chemotherapy after HIPEC. Patients were followed up routinely until recurrence or death. Median peritoneal cancer index at surgery was 6 (range: 1-18). Before HIPEC, all patients had completeness of cytoreduction scores of 0 or 1. Median length of hospital stay was 21 days (range 13-65). Ten patients (55.6%) had CTCAE grade 3-4 toxicity, including three patients (16.7%) requiring reoperation. No postoperative mortality was observed. With a median follow-up of 38 months (CI 95% 23.8-39.2), median overall survival was not reached. The 3-year overall survival rate was 83% (CI 95% 54-95). Median disease-free survival was, respectively, 16.9 months (CI 95% 10.2-23.2) and 10 months (CI 95% 4.5-11.3) for patients undergoing interval debulking or recurrence surgery. CONCLUSION: HIPEC without adjuvant chemotherapy is both feasible and safe, but with a high rate of grade 3-5 toxicity. Survival results are encouraging but should be confirmed in a randomized trial.