Incidence of occult contralateral carcinomas of the breast following mastoplasty aimed at symmetrization.

INTRODUCTION: Breast carcinomas are the most frequent form of cancer in French women. Following a total mastectomy, only an estimated 25% of patients wish to undergo breast reconstruction. After mammary volume reconstitution, the plastic surgeon often attempts to harmonize the two breasts by carrying out contralateral reduction mammaplasty (CRM). In the literature, the incidence of occult contralateral carcinomas incidentally discovered in surgical specimens ranges from 1.12 to 4.5%. The main objective of this study was to evaluate occurrence of carcinoma in the CRM specimens in the framework of a breast reconstruction operation. The secondary objective was to determine the consequences of the incidentally discovered carcinoma in the contralateral breast. MATERIAL AND METHODS: This was a 6-year, bicentric, retrospective study involving women having undergone breast cancer surgery who later underwent contralateral reduction mammaplasty (CRM), that is to say reconstruction aimed at harmonization of the two breasts. RESULTS: Three hundred and nineteen patients were included in the study. Mean age during the CRM was 55years (29-79). Mean weight of the surgical specimens was 323grams (12-2500). Incidence of occult carcinomas found in the specimens was 0.94% (3 patients). The mean age for these 3 cases was 58years (47-64). All 3 patients had superior pedicle mammaplasty. One of the patients benefited from monobloc resection with orientation of the surgical specimen. In the other 2 cases, there existed 3 surgical resection specimens; in one case, they were oriented; in the other, they were not. In all 3 cases, the histological findings were unifocal ductal carcinomas in situ (DCIS). Mean tumor size was 5.7mm (3-9). Only the patient having had monobloc resection with orientation of the specimen underwent salvage surgery, which consisted in partial mastectomy, otherwise known as secondary lumpectomy. Adjuvant radiotherapy was administered to all of the patients. After 17months of mean follow-up (12-22), no recurrence was found in any of the three cases. CONCLUSION: Incidence of occult contralateral breast carcinomas after symmetrization CRM approximates 1%. Our observations are in agreement with the data in the literature. Incidence is greater than in mammaplasty carried out for esthetic or functional reasons; this is probably due to the higher age and the previous breast cancer history of the breast reconstruction population. Monobloc resection and orientation of the surgical specimens with surgeon's knots facilitate precise pinpointing of the occult carcinoma. A secondary lumpectomy may take place when margins of excision are invaded or inadequate.

[Quality of life after lipomodelling: retrospective study of 42 patients]. / Qualité de vie après lipomodelage: étude rétrospective à propos de 42 patientes.

OBJECTIVES: Study of the quality of life of 42 patients who underwent a lipofilling in our institution between 2009 and 2010. PATIENTS AND METHOD: Analysis of cosmetic outcomes, side effects, emotional life and preoperative information received by a cohort of 42 patients contacted by anonymous questionnaires. Comparisons between patients with a single prothesis, latissimus dorsi flap with prothesis, autologous latissimus dorsi flap and rectus abdominal flap. RESULTS: The response rate was 56% (42 patients). The average volume of fat injected was 80mL. The aspect of the reconstructed breast and the harmony between two breasts were better after lipofilling (P=0.0001, P=0.0005). The evolution of the aesthetic result is satisfying for 64.1% of the patients. In 29% of cases, patients noticed adhesions at the injection site. Apprehension to touch the reconstructed breast and to wear a swimsuit decreases after lipofilling (P=0.0345;P=0.0284). All patients declared to be satisfied with the presurgery information. Half of the patients declare that the final result corresponds to their wishes. DISCUSSION: The side effects of lipofilling were studied from an oncological point of view. Less publications describe the patients quality of life after lipofilling. This surgery improves the breast reconstruction results and helps patients in a social, affective and aesthetic way. Overall, lipofilling improves more consistency in patients reconstructed by single prothesis and improves more appearance in patients reconstructed by single flap. CONCLUSION: Lipofilling improves significantly patients' quality of life. A clinical research protocol (GRATSEC) is currently underway to extend its indications. The lipofilling should not replace a bad indication of breast reconstruction.

Pure tubular carcinoma of the breast and sentinel lymph node biopsy: a retrospective multi-institutional study of 234 cases.

BACKGROUND: Pure Tubular Carcinoma (PTC) of the breast is a rare histological subtype of invasive breast cancer characterized by a low rate of lymph node involvement. Currently there is no consensus on less surgical axillary node staging according to this histological subtype. METHODS: We performed a retrospective multi-institutional study. Inclusion criteria were PTC, sentinel lymph node detection (SLND) and conservative breast surgery. RESULTS: From January 1999 to December 2006, 234 patients were included in the study from 9 institutions. The median pathological tumor size was 9.59 (1-22) mm. SLN were successfully detected in 98% (229/234) of patients. Among the 234 patients, a macrometastasis was found in 6 cases (2.5%), micrometastasis in 15 cases (6.4%), and isolated cells in 2 cases (0.8%). In the case of patients with SLND macrometastasis, half of them had macrometastasis in the complementary axillary lymphadenectomy, and none in the case of SLN only micrometastasis or isolated cells. Of the 122 patients with a pathological tumor size <10 mm, none had sentinel node macrometastasis. According to a multivariate analysis, pathological tumor size (>10 mm) was the only parameter significatively linked to the risk of lymph node involvement (p = 0.007). CONCLUSION: In a large multi-institutional series with SLND, we have shown that the risk of axillary lymph node involvement in PTC is very low. In the case of PTC <10 mm, we suggest that surgical axillary evaluation, even with SLND, may not be warranted.

Prognostic factors for patients treated for a recurrent FIGO stage III ovarian cancer: a retrospective study of 108 cases.

AIMS: To determine overall survival of patients treated for a first relapse of FIGO stage III ovarian cancer, outside of randomized trial, with a long term follow-up and to identify prognostic factors. MATERIALS AND METHODS: A consecutive series of 108 patients treated for a first relapse of a FIGO stage III ovarian cancer was retrospectively included from December 1999 to November 2004. Each patient was treated with platinum-based chemotherapy in case of late (>6 months) relapse and with salvage chemotherapy without platinum in case of <6 months relapse. For statistical analysis the studied parameters were age, histological subtype, the completeness of initial surgery, disease-free period, localization of the relapse, clinical response to second-line chemotherapy, the completeness of secondary cytoreductive surgery (SCS) when it was performed. RESULTS: Median follow-up from the first relapse was 40 months. From the 108 patients, 35 underwent SCS. Median overall survival from the first relapse was 13 months in case of no SCS or non-optimal SCS and 35 months for patient with an optimal SCS (p = 0.006). In a multivariate analysis age, disease-free period, the clinical presentation of the relapse, completeness of SCS and response to second line chemotherapy appeared to be independent prognostic factors. CONCLUSIONS: Prognostic factors of ovarian cancer relapse are directly or indirectly linked with the feasibility of a complete SCS. Thus in the case of an ovarian cancer relapse, the feasibility of SCS must be considered in order to give the patient the best chance to experience its complete removal.

[Oncologic, functional, and aesthetics results; evaluation of the quality of life after latissimus dorsi flap breast reconstruction. About a retrospective series of 450 patients]. / Résultats oncologiques, fonctionnels et esthétiques ; évaluation de la qualité de vie après reconstruction mammaire par lambeau de muscle grand dorsal. À propos d'une série rétrospective de 450 patientes.

Retrospective assesssment from 1998 to 2005 from women who have a breast reconstruction by autologus latissimus flap or by latissimus flap and silicone breast implant for differed breast reconstruction (DBR) or mastectomy and immediate breast reconstruction (MIBR). PATIENTS AND METHOD: Analysis of oncologic results on 450 patients. Analysis of aesthetic, functional results and of quality of life by an anonymous questionnaire in the non progressive patients (407): 263 appraisable answers (13 DBR, 127 MIBR). Middle age: 49.8 years. RESULTS ONCOLOGIC: Forty-three patients (9.5%) had a relapse of their disease, 33 patients died (7.2%). The relapse of the disease was done in the form of metastasis alone: 29 (67.4%), metastasis and local recurrence: three (7%), local recurrence only: four (9.3%), not specified: seven (16.3%). The average time between the breast reconstruction and the relapse was 18.25±15.4 months. AESTHETIC RESULTS: The overall assessment is of 7.68/10. There is no statistical difference between immediate reconstruction and delayed reconstruction. A total of 11.2% patients considered it to be bad (<5/10). The symmetry between the two breasts in time is of 6.6/10 and 19.9% patients considered it to be bad (<5/10). The scar ransom, considered to be most important, is mostly in the back (4.1/10) then on the controlateral breast and then the breast reconstruction. This ransom is not easily acceptable in 15 to 20% of the patients. FUNCTIONAL RESULTS: The discomfort and the pain prevail above all in the back (3.56 and 2.59/10). Weaker symptoms in the event of immediate reconstruction than delayed reconstruction. We noted that 77.2% had kinesitherapy after surgery and 18.9% continues to have kinesitherapy, long time after surgery, mainly for massages of the back. The handicap is considered to be overall low 2.5/10 but 10% of the patients keep a feeling of important handicap (>7.5/10). QUALITY OF LIFE RESULTS: Seventy-one of the patients are serene. The discomfort to wear a bathing suit or to look at bare-chested is low (2.59 and 2.44/10). However 8.9% are in a very discomfort to see themselves bare-chested and 17.6% to show themselves to their spouse, with an impact on their emotional and sexual life in 36.4% of the cases. There is no significant difference between MIBR and DBR but on the other hand according to the judgement of the woman of her aesthetic result. A total of 95.7% do not regret having made this breast reconstruction. CONCLUSION: This study makes it possible to concentrate on the group of non satisfied patient for better determining the causes and the improvements of the surgical techniques to bring but also the overall surgical management of the patient even if most of the patients were mainly satisfied with their breast reconstruction.

[Lemierre syndrome and influenza A (H1N1)]. / Syndrome de Lemierre et grippe A(H1N1).

Lemierre syndrome is an anaerobic bacteremia associated with a septic thrombophlebitis of the internal jugular vein. Septic emboli can be found in many organs. It often occurs after pharyngitis. Today, Lemierre syndrome is quite rare, but without rapid treatment, it may become life-threatening. A 4-year-old child presented with a febrile headache and torticollis. He was influenza A (H1N1)-positive. He also had beta-hemolytic streptococcal pharyngitis. A secondary CT scan was taken because of clinical worsening (non reducible torticollis). Parapharyngeal abscess and septic thrombophlebitis in the left jugular vein were revealed. In spite of negative blood cultures, our patient may have presented Lemierre syndrome. The outcome was favorable using intravenous antibiotics (metronidazole and penicillin) and curative anticoagulation. The thrombophlebitis vanished during a 2-month course of anticoagulation. Lemierre syndrome may occur after viral infections such as EBV or CMV infections. Like those viruses, influenza A (H1N1) virus may induce transient immunosuppression that predisposes to bacterial infections. Our patient had Lemierre syndrome occurring during an influenza A (H1N1) infection.

[Evaluation of an information network and nurse consultation for breast reconstruction]. / Évaluation d'un dispositif d'annonce et d'information adapté à la reconstruction mammaire en cancérologie.

UNLABELLED: To evaluate the installation of a nurse consultation and an interactive support DVD in breast reconstruction. To judge utility of these new tools of information for the patients. MATERIAL AND METHOD: The nurse consultation is carried out after the initial consultation of the surgeon; during this consultation, a DVD containing of the interviews is given taking again the information given as well as patients' evidence on their path of care. Evaluation of the information given by the surgeon and the nurse (eight items from surgical techniques to convalescence). Evaluation of the interest and comprehensibility. Quotation from 0 to 10. RESULTS: Evaluation by anonymous questionnaire on 110 women, between February and December 2007. Rate of participation: 72.7% (80/110); mean age: 51.5±9.2. Information given is considered to be useful (surgeon: quotation above 9.3/10 in function of the items, nurse: quotation above 9.4) and comprehensible (quotation above 8.7/quotation above 8.9). The information made by the nurse is more comprehensible than that done by the surgeon, for over all items. The nurse consultation is considered to be very useful (9.45). Seventy percent of the patients learned from extra informations, compared to the consultation of the surgeon. This consultation does not have a direct influence on the choice of the technique (5.45/10), the consultation of the surgeon remaining predominant. Fifty percent of the women still learned from new informations, by using the DVD. On the other hand, it has little influence on the choice of the technique (4.84/10). The nurse consultation and the DVD are well conceived because 80% of the women did not need more information. The predominant elements in the choice of the patients are the surgeon consultation, then the nurse consultation and then the DVD. The total index of satisfaction is very good 9.31/10 (surgeon: 9.24, nurse 9.56, DVD 9.11). CONCLUSION: The nurse consultation and the DVD are not replacement components of the surgeon consultation. They are complementary and have an important role in the acquisition of information and the psychological support of the patients. The surgeon initial consultation remains predominent in the decision of choice by the patients, it must remain the most complete possible.

[Patient follow-up after treatment for breast cancer]. / Surveillance d'une femme traitée pour cancer du sein.

Patient follow-up after treatment for a breast cancer is based on the local recurrence risk. Annual mammography remains the main point of this follow-up and tumor markers detection has still no interest. Absence of benefit of an intensive clinical, biological and radiological surveillance has been proved for a long time but expert recommendations still are a subject of discussion although they knew no evolution for more than 10 years. Evolution of those follow-up modalities will depend on the future indications of MRI and PET. About distant recurrence, a better knowledge of the risk is now possible thanks to the tumor biological profile study. Nevertheless, intensification of follow-up for some kind of high-risk tumors will have interest only if we can propose a therapeutic alternative in metastatic situation.

[Surgery for invasive breast cancer]. / Chirurgie des cancers invasifs du sein (à l'exception de la reconstruction mammaire).

As most solid tumors, surgery is often the first step of the multidisciplinary management for breast cancers. Although mastectomy and axillar lymphadenectomy still have indications, conservative treatment and sentinel node detection are commonly used. Thanks to induction chemotherapy and oncoplastic techniques, surgery is conservative in most cases, even for important tumors without overall survival prejudice. There is no consensus about resection margins status but a limit of 2 to 3 mm seems to be reasonable while oncoplastic surgery allows large resection and good cosmetic outcomes. In this overview, we present the state of the art for breast cancer surgery including conservative and radical treatments, axillar lymphadenectomy and sentinel lymph node detection, margins status, oncoplastic techniques.

[Prevention of osseous defaults in the craneosinostosis surgery using calvarian cranial particulate bone]. / Utilización de hueso craneal particulado de calota para prevención de defectos óseos en la cirugía de las craneosinostosis.

It is considered that up to 20% of the craniosinostosis patients require secondary surgeries. Different techniques have been used in craneofacial surgery for the reconstruction of great osseous defects in pediatric patients for many years. This paper is about a new technique to obtain osseous graft for covering osseous cranial defects, using particulate bone, harvested from the patient calvarian using a hand-driven brace and covered with a fibrin adhesive. This is a very simple technique, which provides a great amount of bone from the patient himself, therefore producing a small morbidity. Since 2007 the authors have been using autologous particulate bone harvested from de patient calvarian for the reconstruction of different size osseous defects found in craneofacial surgery, especially in pediatrics patients. Although alloplastic materials and bone substitutes have been used for cranial reconstruction, the best option is the autogenous bone. In contrast to synthetic materials autologous grafts have a faster osteointegration, due to their osteogenic, osteoinductive and osteconductive properties. Harvesting the bone from the calvarian patient produces a minimal morbidity compared to the extraction of grafts from other donor sites such as rips or hip. The use of autologous particulate bone in craniosinostosis surgery reduces the risk of second interventions due to secondary ossifications defects. On the other hand, the harvest is easy and the supply of bone it is enough in pediatric patients.

Utilización de hueso craneal particulado de calota para prevención de defectosóseos en la cirugía de las craneosinostosis / Prevention of osseous defaults in the craneosinostosis surgery using calvarian cranial particulate bone

considera que hasta un 20% de intervenidos decraneosinostosis requieren cirugías secundarias. Sonvarias las técnicas que se han venido utilizando dentrode la cirugía craneofacial para la reconstrucción degrandes defectos óseos en pacientes pediátricos a lolargo de los años. Presentamos una nueva técnica deobtención de injerto de hueso para el recubrimientode defectos óseos craneales, en la que se utiliza huesoparticulado, obtenido de la calota del paciente medianteun berbiquí y unificado con un adhesivo de fibrina.Está técnica es sencilla y provoca poca morbilidad enel paciente. Además, permite obtener una importantecantidad de hueso.Desde el año 2007 utilizamos el hueso particuladoautólogo obtenido de la calota del paciente para lacorrección de defectos óseos grandes o pequeños que senos presentaban en la cirugía craneofacial practicadasobre todo en pacientes pediátricos.Aunque los materiales aloplásticos y sustitutos dehueso han sido utilizados para la reconstrucción de cráneos,el hueso autógeno es la mejor opción. A diferenciade los materiales sintéticos, los injertos autógenos tienenuna más rápida osteointegración ya que son osteogénicos,osteoinductivos y osteoconductivos, siendo ademásel injerto de la misma naturaleza que el hueso donante.La morbilidad producida al paciente por la obtencióndel hueso de la calota con esta técnica es mínima, encomparación con otras zonas donantes como costilla ocadera.La utilización del hueso particulado autólogodurante la cirugía de las craneosinostosis reduce lanecesidad de segundas intervenciones por defectos deosificación secundarios. Por otro lado, su obtención esfácil y la cantidad de hueso extraído es suficiente paralos pacientes pediátricos (AU)

It is considered that up to 20% of the craniosinostosispatients require secondary surgeries. Differenttechniques have been used in craneofacial surgery forthe reconstruction of great osseous defects in pediatricpatients for many years. This paper is about a newtechnique to obtain osseous graft for covering osseouscranial defects, using particulate bone, harvested fromthe patient calvarian using a hand-driven brace andcovered with a fibrin adhesive. This is a very simpletechnique, which provides a great amount of bone fromthe patient himself, therefore producing a small morbidity.Since 2007 the authors have been using autologousparticulate bone harvested from de patient calvarianfor the reconstruction of different size osseous defectsfound in craneofacial surgery, especially in pediatricspatients.Although alloplastic materials and bone substituteshave been used for cranial reconstruction, the bestoption is the autogenous bone. In contrast to syntheticmaterials autologous grafts have a faster osteointegration,due to their osteogenic, osteoinductive andosteconductive properties. Harvesting the bone fromthe calvarian patient produces a minimal morbiditycompared to the extraction of grafts from other donorsites such as rips or hip.The use of autologous particulate bone in craniosinostosissurgery reduces the risk of second interventionsdue to secondary ossifications defects. On theother hand, the harvest is easy and the supply of bone itis enough in pediatric patients (AU)

[Management of retroperitoneal lymphadenectomy in advanced epithelial ovarian cancer]. / Cancer de l'ovaire à un stade avancé : la place des curages ganglionnaires.

The standard management for advanced-stage epithelial ovarian cancer is optimum cytoreductive surgery followed by aggressive cytotoxic chemotherapy. However retroperitoneal remains controversial. The multiple directions of the lymph drainage pathway in ovarian cancer have been recognized. The incidence and pattern of lymph node involvement depends on the extent of disease progression and the histological type. Thus, it is difficult to specify a single node as the sentinel node. In this chapter, we review and discuss the actual benefits of lymph node dissection in patients with ovarian cancer, analysing previously reported and ongoing trials. A recent large randomized trial in patients with advanced ovarian cancer revealed that systemic lymphadenectomy had no impact on survival compared with removing only macroscopic lymph nodes but improves progression-free survival significantly. Further studies are needed to balance risks and benefits of systematic lymphadenectomy in advanced-stage disease.

Influence of tooth cryopreservation and storage time on microleakage.

OBJECTIVES: This study was conducted to compare microleakage of two new dentin bonding agents on freshly extracted teeth, cryopreserved teeth, or teeth stored in water containing 0.5% chloramine at 4 degrees C. METHODS: Rectangular Class V cavity preparations were made on the buccal and the lingual surface of wisdom teeth. They were filled with either Scotchbond Multi-Purpose and Z100 (3M Dental Products) or with Gluma 2000 and Pekafill (Bayer Dental). After thermocycling, silver staining penetration was evaluated under a light microscope. SEM examination and EDX analysis were performed to evaluate the microleakage pattern. The results were analyzed by the use of a two-way analysis of variance. RESULTS: Cryopreservation for 13 wk or 12 d refrigeration did not produce changes in the amount of microleakage. However, 48 d or longer of refrigeration increased microleakage. There was no correlation between changes in microleakage and storage time. Specimens prepared with both dentin bonding agents exhibited the same microleakage values and the same microleakage pattern. SIGNIFICANCE: Refrigeration at 4 degrees C in 0.5% chloramine for 48 d or longer may cause an increase in microleakage. Cryopreservation for 13 wk or short-term refrigeration did not affect the microleakage.

[Tumors of the choroid plexus: morphologic and immunohistochemical study]. / Tumores de plexos coroides: estudio morfológico e inmunohistoquímico.

We present a morphological and immunohistochemical study on three papillomas and one carcinoma of the choroid plexus. Clinical characteristics are analysed. Morphological criteria for malignancy are: solid histological pattern, cellular polymorphism, nuclear atypia and infiltration of nervous tissue. The immunohistochemical study shows the value of GFAP, S-100 protein, HNK-1 and Vimentin as specific markers. In the discussion we point out the differential diagnosis between these types of tumors and the metastasis from papillary carcinomas and ependymomas.

Radiocirurgia estereotaxica. / Stereotaxic radiosurgery

Baseado nos principios fisicos e biologicos das radiacoes, a radiocirurgia estereotaxica tem como meta permitir a chegada no interior do cranio, de fotons de alta energia, em alvos pre-selecionados estereotaxicamente, com a finalidade de destruir determinada patologia sem, no entanto, afetar o tecido normal circundante. Os autores sintetizam a essencia do metodo, bem como a indicacao e experiencial atual