Oncoplastic Level 2 Mammoplasty for Large DCIS: 5-Year Results.

BACKGROUND: Oncoplastic surgery (OPS) allows wider resections with immediate breast reshaping by mammoplasty. This study reviews our experience with level 2 mammoplasties in patients with histology-proven pure ductal carcinoma in situ (DCIS). METHOD: From a prospectively maintained database of 392 consecutive oncoplastic level 2 mammoplasties, 68 patients presented with pure DCIS. Involved margin rates and locoregional recurrence rates were calculated, with 76 months (0-166 months) median follow-up. RESULTS: The mean pathological tumor size was 34 mm (median 26 mm, range 2-106 mm). The mean resection weight was 191 g (median 131 g, range 40-1150 g). Margins were clear in 58 cases (85.3%) and involved in 10 cases (14.7%). Margins were involved in 1 out of 54 (1.9%) cases with tumor size under 50 mm and in 9 out of 14 (64.3%) cases with tumor size higher than 50 mm (p < 0.001). On multivariable analysis, only tumor size > 50 mm [odds ratio (OR) 95.400; p < 0.001] was independently associated with involved margins. Seven patients had mastectomy. The overall breast conservation rate was 89.4%, and 100% for tumors less than 5 cm. There were three local recurrences. The 5-year cumulative incidence for local recurrence was 5.5% (0-11.5%). CONCLUSIONS: OPS is a safe solution for large DCIS up to 50 mm, with an involved margin rate of only 1.9%, and can thus reduce the mastectomy rate in this group. As margin involvement significantly increases for tumors larger than 5 cm, better preoperative localization and/or wider excisions are necessary in this group.

A prospective randomized study comparing centrifugation and sedimentation for fat grafting in breast reconstruction.

BACKGROUND: Fat grafting is an efficient method to correct large volumetric defects after mastectomy. There is an ongoing debate regarding the best method of processing the harvested fat before fat grafting. This study aimed to introduce a new MRI model and to compare two fat processing techniques measuring the gain in soft tissue thickness after fat grafting to the chest wall. METHODS: Fifty-one mastectomy patients (one double sided), who required delayed implant reconstruction, with poor skin conditions were proposed fat grafting prior to implant reconstruction. At the time of fat grafting, patients were randomly assigned to centrifugation or sedimentation of the aspirated fat. The trial was undertaken in a single-center private practice setting. The gain in soft tissue thickness of the chest wall was measured using an MRI model, with 12 predefined points for measurement. Two MRIs were performed, one prior to fat grafting and one 8 weeks thereafter. The radiologist was blinded to the fat graft processing method used. RESULTS: Seven cases were excluded because they did not complete their second MRI. The analyses were thus based on 44 patients (one double sided). Centrifugation was performed in 21 cases and sedimentation in 24 cases. The mean gain in soft tissue thickness was +7.0 mm in the centrifugation group and +8.8 mm in the sedimentation group (p = .268). The mean operative time was 88 min in the centrifugation group and 78 min in the sedimentation group (p = .11). There were no adverse events for any of the patients. CONCLUSIONS: We developed a simple and reproducible MRI model to objectively measure and evaluate different fat processing techniques prior to fat grafting. At a median time of 8 weeks after one session of fat grafting, there was no benefit of centrifugation over sedimentation.

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.

Occult cancer in specimens of reduction mammaplasty aimed at symmetrization. A multicentric study of 2718 patients.

Women who have undergone surgical treatment for breast cancer often benefit from a contralateral reduction mammaplasty (CRM) aimed at symmetrization of the contralateral breast unaffected by the initial cancer. In our 7-year multicentric study (12 centers) of 2718 patients, incidence of CRM cancers (CRMc) was 1.47% (n = 40) [95% CI 1.05%-2.00%]. The CRMc group had significantly more initial mammary cancers of invasive lobular carcinoma (ILC, 22.5% vs 12.0%) and ductal carcinoma in situ (DCIS, 35.0% vs 21.6%) types than the healthy CRM group (p = 0.017). 35.0% (n = 14) of patients had en bloc resection; 25.0% (n = 10) of surgical specimens were correctly oriented. En bloc resection and orientation of surgical specimens enable precise pinpointing of the CRMc. A salvage lumpectomy may be proposed as an option when margins are invaded. The histological distribution of the 40 CRMc (mean size 12.7 mm) was carcinoma in situ (CIS) 70%, ILC 12.5%, invasive ductal carcinoma (IDC) 12.5% and tubular carcinoma (TC) 5.0%.

A new level 1 oncoplastic technique for breast conserving surgery: rotation glandular flap.

BACKGROUND: When performing conservative surgery for breast cancer, breast reshaping can be a challenging procedure. Level 1 oncoplastic surgery (OPS) techniques, i.e., advancement or rotation of glandular flaps, should be performed when less than 20 per cent breast volume is excised. OBJECTIVE: A new Level 1 OPS technique is described. A wide centro-lateral glandular flap is created after extensive undermining of the skin and nipple-areolar complex, and rotated into the cavity. DISCUSSION: This rotation glandular flap is a new technique for use following a wide excision, in glandular, not fatty, breasts, and when standard closure of the cavity would not leave a satisfactory cosmetic result.

Oncoplastic surgery for breast cancer based on tumour location and a quadrant-per-quadrant atlas.

BACKGROUND: The majority of published techniques for oncoplastic surgery rely on an inverted-T mammoplasty, independent of tumour location. These techniques, although useful, cannot be adapted to all situations. A quadrant-per-quadrant atlas of mammoplasty techniques for large breast cancers was developed in order to offer breast surgeons a technique dependent on tumour location, which reduces the risk of postoperative complications and delay to adjuvant therapy. METHODS: From 2005 to 2010, a series of eligible women with breast cancer were treated by quadrant-specific oncoplastic techniques. All complications and any delay to adjuvant treatment were recorded prospectively, along with local and distant cancer recurrences. Cosmetic outcome was evaluated using a five-point scale. RESULTS: A total of 175 patients were analysed. The median tumour size, after histological examination, was 25 (range 4-90) mm. Twenty-three patients (13.1 per cent) had involved margins. Seventeen of these patients were treated by mastectomy and three had a re-excision. Complications occurred in 13 patients (7.4 per cent), which led to a delay to adjuvant treatment in three (1.7 per cent). After a median follow-up of 49 (range 23-96) months, three patients had developed a local recurrence. The mean score after cosmetic evaluation was 4.6 of 5. CONCLUSION: A quadrant-per-quadrant approach to oncoplastic techniques for breast cancer was developed that tailors the mammoplasty for each tumour location. This panel of techniques should be a useful guide for breast surgeons, and extends the possibilities for breast conservation for large or poorly limited cancers, with a low complication rate and good cosmetic results.

Reconstrucción mamaria por turbo tram: estudio prospectivo, comparativo / Tram breast reconstruction by turbo

Hoy una reconstrucción mamaria (RM) por cualquierade los métodos deben ser consideradas en casi todoslos casos. El colgajo autólogo que corresponde al excesograso-cutáneo abdominal inferior ligado al músculo rectoanterior, ocupa un lugar importante en reconstrucción delseno, visto sus ventajas cosméticas y de estabilidad en eltiempo. . En los casos deriesgo de necrosis se ha optado en el servicio por la opciónde una micro-anastomosis de tal manera a mejorar laperfusión y drenaje del colgajo.Este estudio prospectivo realizado en el InstitutoCurie esta basado en 35 casos de reconstrucciones mamariaspor CMC (colgajo músculo-cutáneo) del recto anterior del abdomen según dos modalidades; monopediculadossimples (14 pacientes), monopediculado turbo(21 pacientes). Se ha evaluado la fuerza de la pared abdominalen pre y posoperatorio, considerando dos gruposmusculares. (Recto anterior y oblicuos). Así mismolas complicaciones y resultados cosméticos a nivel de lapared abdominal y del seno reconstruido. Hemos constatado25% de eventraciones y seudo-eventraciones, todoscasos de utilización de mallas reabsorvibles para el cierreabdominal. La evaluación pre operatoria de la fuerza dela porción supra umbilical (PSU) de recto anterior del abdomenmuestra que el 80% de los pacientes obtuvieronpuntuaciones satisfactorias según la escala de Lacote. Entanto que para la porción infla umbilical (PIU), más del90% de los pacientes obtuvieron igual puntaje. Las cifrasdel postoperatorio se alejan, revelando estabilidad de lospuntajes en apenas 30% de casos para la PSU, contra 80%para la PIU. Los análisis evidencian una deterioración superioral 50% para la PSU del recto anterior, alcanzandoapenas el 30 para la PIU. Confirmamos en este estudio que la disminución dela fuerza muscular del recto anterior es más marcada parala PSU que para la PIU, independientemente del tipo detécnica de TRAM utilizada.

Adipose-tissue grafting to the post-mastectomy irradiated chest wall: preparing the ground for implant reconstruction.

INTRODUCTION: Breast implant reconstruction after radiotherapy carries a high risk of failure and complication. Nevertheless, it may be the only alternative for patients who are not suitable for autologous reconstruction or who refuse this option. As clinical and experimental studies have demonstrated that grafting adipose tissue (lipofilling) in an irradiated area improves the quality of the skin, we made the assumption that preliminary fat grafting of the chest wall might reduce the complication and failure rates of implant reconstruction by improving the implant coverage. PATIENTS AND METHODS: From 2007 to 2009, 28 patients had fat transfer to the chest wall, prior to implant reconstruction. All patients had had mastectomy and irradiation for breast cancer. Lipofilling was initiated 6 months after the end of radiotherapy. The mean number of fat-grafting sessions was 2 (range 1-3). An average volume of 115 cc (70-275 cc) was injected each time. Once the chest wall's skin seemed to have gained enough thickness, implant reconstruction was performed. RESULTS: The mean follow-up period was 17 months. Three minor complications occurred. Implant explantation was performed in one case for exposition. The cosmetic results were good and very good in >80% of the cases. CONCLUSION: This study points out the benefits of fat grafting to the irradiated chest wall prior to implant placement and demonstrates that lipofilling prepares the ground to implant breast reconstruction. This approach could be considered as an alternative to flap reconstruction for selected patients.

Clear margins for invasive lobular carcinoma: a surgical challenge.

BACKGROUND: The main goal of breast conservative surgery (BCS) is the complete removal of cancer with clear margins and no deformity of the breast. However, in invasive lobular carcinoma (ILC) this goal is hard to achieve because of the underestimation of tumor size. Our study was the first to show the role of surgical techniques in the achievement of clear margins for ILC. METHODS: We reviewed 73 patients with ILC who underwent BCS at Paris Breast Center between January 2005 and June 2008. Full thickness excision (FTE) was performed in a routine basis and oncoplastic surgery (OPS) upon tumor location, volume ratio and overall density of the breast. Margin status was evaluated as positive, close or clear. RESULTS: Positive/close margins were found in 39% of cases and were lower than what was described in the literature (49-63%). FTE was performed in 47 (64%) patients and OPS in 26 (36%) patients. No positive/close margins were observed in patients with lesions located in the lower/central quadrants. Multivariate analysis showed multifocality, larger tumor size and FTE to be independent risk factors for positive margins at final surgery. CONCLUSIONS: Our rate of positive/close margins for ILC was lower than what was described in the literature. The determinant key difference was in our surgical procedures with FTE or OPS differing from the standard BCS described in the literature and we suggest that OPS is to be considered for ILC. It allows larger breast conservative surgery with good cosmetic results and lower rate of compromised margins.

New anatomical classification of the axilla with implications for sentinel node biopsy.

BACKGROUND: The exact anatomical location of the sentinel lymph node (SLN) in the axilla has not ascertained clinically, but could be useful both for teaching purposes and to reduce the morbidity of SLN biopsy. The aim of the study was to determine the position of the SLN in the axilla and to demonstrate that this location is not random. METHODS: A consecutive series of 242 patients with stage I breast cancer (T1/T2 N0) or ductal carcinoma in situ who underwent SLN localization by peritumoral injection were included in a prospective study to map the location of the SLN in the axilla. A new anatomical classification of the lower part of the axilla based on the intersection of two anatomical landmarks, the lateral thoracic vein (LTV) and the second intercostobrachial nerve (ICBN), is described. These two constant elements form the basis of four axillary zones (A, B, C and D). RESULTS: In 98.2 per cent of patients the axillary SLN was located medially, alongside the LTV, either below the second ICBN (zone A, 86.8 per cent) or above it (zone B, 11.5 per cent). In only four patients (1.8 per cent) was the SLN located laterally in the axilla. CONCLUSION: Regardless of the site of the tumour in the breast, 98.2 per cent of SLNs were found in the medial part of the axilla, alongside the LTV. This information should help to avoid unnecessary lateral dissections.

[Partial reconstruction after conservative treatment for breast cancer: classification of sequelae and treatment options]. / Séquelles esthétiques du traitement conservateur des cancers du sein: une classification pour les reconstructions après tumorectomie.

Most patients presenting with breast cancer are treated by breast conserving treatment (BCT). Some of these patients present with poor cosmetic results and ask for partial breast reconstruction. These reconstructions following BCT are presenting more frequently to plastic surgeons as a difficult management problem. We have defined and published a classification of the different cosmetic sequelae (CS) after BCT into three types. This classification helps to analyse these complex deformities aggravated by radiotherapy. Furthermore, our classification helps to choose between the different surgical techniques and propose the optimal option for their surgical correction. Our initial publications reported 35 and 85 patients: we have currently operated more than 150 cases of CS after BCT. Type-1 CS are defined by an asymmetry between the two breasts, with no distortion or deformity of the radiated breast. Type-2 CS are those with an obvious breast deformity, that can be corrected with a partial reconstruction of the breast. Type-3 CS are those with such a deformity that only a mastectomy with total reconstruction of the breast can be performed. Most of the patients present with type-2 CS, but are reluctant to undergo what they feel is a major reconstructive procedure: in a initial prospective series of 85 patients operated for CS after BCT, 48 (56.5%) had type-1 CS, 33 patients (38.8%) type-2 CS and four patients (4.7%) type-3 CS. Type-1 patients should be managed essentially by contralateral symmetrizing procedures. One should limit any surgery on the radiated breast, as a mammoplasty or an augmentation is at high risk of complications. Type-2 is the most difficult to manage and requires all the surgical armamentarium of breast reconstructive surgery. The insetting of a myocutaneous flap is often necessary and autologous fat grafting is a promising tool in selected cases. Type-3 CS requires mastectomy and immediate reconstruction with a myocutaneous flap. The major development though in the past 10 years has been the development of oncoplastic techniques at the time of the original tumour removal, in order to avoid most of type 2 and type 3 deformities. This paper reaffirms the validity of the Cosmetic Sequelae classification as a simple, practical guide for breast reconstructive surgeons. It discusses the various choices of reconstructive procedures available, the importance of "preventing" these CS and defining the role of the plastic surgeon in the management of these patients.

[Breast reconstruction: late cosmetic results of implant reconstruction]. / Reconstruction mammaire par prothèse: vieillissement et résultats esthétiques tardifs.

The long cosmetic outcome of breast implant reconstruction is unknown. The morbidity and cosmetic outcome of 360 patients who underwent immediate breast reconstruction with various types of implant has been prospectively analysed over a 10-year period. 334 patients who completed their reconstruction were suitable for evaluation of their cosmetic outcome. The early complication rate (<2 months) was 9.1%, with an explantation rate of 1.6%. The late complication rate (>2 months) was 23%, with a pathological capsular contracture rate of 11% at two years and 15% at five years, and an implant removal rate of 7%. The revisional surgery rate was 30.2%. The cosmetic results were prospectively assessed using an objective five point global scale. Every patient was scored at each visit once surgery was completed. The overall cosmetic outcome deteriorates in a linear fashion from an initial acceptable result in 86% of patients two years after completion of their reconstruction to only 54% at five years. This fall off in the cosmetic outcome was not associated with the type of implant used, the volume of the implant, the age of the patient or the type of mastectomy incision employed. Radiotherapy was not a significant factor as only 28 patients were irradiated. However, on Cox model analysis pathological capsular contracture was the only factor which significantly contributed to a poor cosmetic outcome(P<0.0001 (relative risk 6.3). In spite of a high revisional surgery rate, deterioration still occurred, suggesting that other unaccounted for variables were responsible. On photographic retrospective review of those patients without a capsular contracture who demonstrated a deterioration in their cosmetic scores, it became clear that a possible reason for their poor result was late asymmetry produced by the failure of both breasts to undergo symmetrical ptosis as the patients aged.

[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.

Neo adjuvant Tamoxifen in post menopausal patients with operable breast cancer.

AIMS: Tamoxifen is widely used as adjuvant therapy in receptor positive post menopausal breast cancer. Little is known about its efficacy as neo adjuvant therapy in terms of breast conservation and improved survival. METHODS: We analyzed the tumour response to 20-30 mg Tamoxifen for 6 months in post menopausal patients with oestrogen receptor positive tumours. Treatment included Tamoxifen for 6 months, surgical resection, and irradiation for post menopausal patients refusing initial mastectomy; aged > or =70 years; or with other factors delaying surgery. RESULTS: Between April 1994 and June 1998, 102 patients, age 73+/-87 (54-90) were studied. There were 24 T1, 56 T2, 14 T3, and 8 T4 tumours. Clinical response to Tamoxifen was observed in all patients, with a median size reduction from 31+/-15 (9-70) to 16+/-9 mm (0-50), 15 clinical and 6 complete responses. 88/102 patients were treated conservatively. Radiotherapy was given to 80 and a flash technique to 8 patients. All patients but one are still alive. CONCLUSION: Neo adjuvant Tamoxifen in operable post menopausal ER positive breast cancer is associated with a good clinical response rate and facilitates conservative surgery. Tamoxifen has a valuable role as neo-adjuvant treatment in terms of breast conservation and survival.

Prediction of tumour involvement in remaining axillary lymph nodes when the sentinel node in a woman with breast cancer contains metastases.

BACKGROUND: In a significant proportion of women with breast cancer, the sentinel node is the only involved node in the axilla. The purpose of this study was to identify factors associated with histologically positive non-sentinel lymph nodes. METHODS: Between 1997 and 2002, 800 women with early breast cancer underwent sentinel node biopsy. In 263 patients the node contained metastases, including 83 with micrometastases detected by immunohistochemistry (IHC), 40 micrometastases detected on haematoxylin, eosin and safranine (HES) staining, and 140 macrometastases. All clinical and histological criteria were recorded and analysed with reference to histology of the non-sentinel node. RESULTS: The risk of metastasis in the non-sentinel lymph node was related to the volume of the tumour in the sentinel node. Non-sentinel nodes were involved in five (6.0 per cent) of 83 women when the sentinel node contained only micrometastatic cells detected on IHC, and in three (7.5 per cent) of 40 women when micrometastases were detected by HES, compared with 55 (39.3 per cent) of 140 when the sentinel node contained macrometastases on HES staining. Univariate analysis revealed a significant association between non-sentinel node involvement and type of metastasis within the sentinel node, clinical primary tumour size, palpable axillary lymph nodes before operation, pathological primary tumour size and the presence of peritumoral lymphovascular invasion. On multivariate analysis, the type of metastasis within the sentinel node (P < 0.001), histological tumour size greater than 20 mm (P = 0.017) and the presence of palpable axillary nodes before operation (P = 0.014) remained significant. CONCLUSION: Clinical and pathological factors associated with sentinel node histology can reliably predict women for whom further axillary clearance is recommended, but it is not yet possible to determine a subgroup of patients in whom the sentinel node is the only involved node and for whom further axillary treatment may be unnecessary.