Lymphatic mapping and sentinel node biopsy of operable breast cancer.

The aim of this study was to evaluate the reliability and accuracy of sentinel node biopsy for invasive breast cancer and the predictability of axillary node status. Between January 1996 and June 1997 a total of 73 patients underwent patent blue dye lymphatic mapping and sentinel node biopsy followed by standard (level I and II) axillary node dissection (one bilateral procedure). The sentinel node was identified in 82.4% (61/74) of the cases and was predictive of axillary status in 96.7% (59/61). The false-negative rate of the procedure was 8.0% (2/25). The sentinel node was involved in 37.7% (23/61) and was the only one invaded in 30.4% (7/23). The sensitivity of the procedure was 92% (CI95% 74-99%) and its specificity 100%. It is currently considered to be an attractive new procedure undergoing evaluation in prospective controlled trials. This study confirmed the reliability and reproducibility of intraoperative lymphatic mapping and sentinel node biopsy. This is the first step toward a new era of minimally invasive axillary surgery for breast cancer.

[Germ-line mutations of the BRCA1 gene in northeastern France]. / Mutations germinales du gène BRCA1 dans le Nord-Est de la France.

Thirty-seven breast/ovarian or breast-only cancer families selected on a regional basis have been analyzed for mutations at BRCA1. By combining direct sequence analysis and protein truncation test, mutations were detected in 14 families (38%). We found seven different mutations, two of which have not been described before. Mutations at BRCA1 were present in 60% of breast/ovarian and 32% of breast-only cancer families. Mutations were frequent in families with at least one breast cancer case before age 40 (44%) and/or one bilateral breast cancer case (54%). Two mutations, namely 3600del11 and G1710X, are frequent in the population native from northeastern France. Oriented BRCA1 analysis should facilitate carrier detection in breast and/or ovarian cancer families stemming from this French area.

Sentinel lymph node procedure--a valid selection criterion?

Sentinel node biopsy is currently considered to be an outstanding advance in surgical oncology and represents significant evolution toward minimally invasive breast cancer surgery. Detected by blue dye, radiopharmaceutical or combined techniques, the sentinel lymph node can be selectively used for the detection of micrometastasis through extensive histopathologic analysis. Nevertheless, before considering the sentinel lymph node concept as a new standard of care, the standardization of both detection methods and histopathological protocols is of critical importance. The future of this attractive technique is strictly dependent on the quality of teaching, training and evaluation in prospective controlled multicentric studies.

Sentinel node biopsy in vulvar malignancies: a preliminary feasibility study.

Sentinel lymph node biopsies (SLNB) were investigated in 8 cases (6 squamous cell carcinomas, 2 melanomas) of vulvar malignancy. The sentinel node was detected by patent blue dye injection (1 case), pre operative lymphoscintigraphy with intra-operative gamma hand-held probe (2 cases), and combined techniques (5 cases). The procedure was successful in all cases but one (1 invasive squamous cell carcinoma) in which there was medial groin recurrence at 6 months. Nodal invasion was observed in only one case and was confined to the sentinel node. No specific morbidity related to the SLNB procedure occurred. SLNB appears to be a feasible and promising technique, however, requiring further evaluation before being considered as a reliable method to spare inguinofemoral lymphadenectomy in early-stage patients free of sentinel node metastasis, or to be substituted in screening elderly clinically node-negative females.

Radiopharmaceutical-guided surgery in primary malignant melanoma of the vagina.

The sentinel lymph node located in the right iliac basin was successfully pre- and intraoperatively identified by radiopharmaceutical-directed mapping in a case of primary malignant melanoma of the vagina.

[Effect of preoperative administration of Lugol's solution on thyroid blood flow in hyperthyroidism]. / Effet de l'administration pré-opératoire du soluté de Lugol sur le débit sanguin thyroïdien dans l'hyperthyroïdie.

A study of 50 patients with hyperthyroidism was conducted to evaluate the effect of preoperative administration of Lugol's iodine solution on thyroid blood flow. Highly significant reductions in diameter, time-averaged velocity, and volume flow of the superior thyroid artery were demonstrated after administration of Lugol's solution. The Duplex ultrasound scanning used in this study is a noninvasive, inexpensive, accurate, and reproducible technique suitable for analysis of thyroid blood flow in hyperthyroidism. On the basis of current ultrasonographic results and low postoperative morbidity in patients, Lugol's solution is well tolerated and may be recommended for use before thyroidectomy, especially for diffuse toxic goiters and Graves disease.

[Identification of axillary sentinel node by lymphotropic dye in breast cancer. Feasibility study apropos of 128 cases]. / Individualisation du ganglion axillaire sentinelle par colorant lymphotrope dans les cancers du sein. Etude de faisabilité à propos de 128 cas.

AIM OF THE STUDY: The goal of this study was to evaluate the technical feasibility of sentinel node biopsy in breast cancer and its predictivity of axillary node status. PATIENTS AND METHODS: Between January 1996 and June 1997, 128 patients with invasive breast carcinomas, referred to the Cancer Center of Strasbourg and Lyon (France), underwent lymphatic mapping (Patent Blue dye) and sentinel node biopsy followed by axillary clearance (Berg's level I to II). RESULTS: Sentinel node was identified in 76.5% of cases and was predictive of axillary status in 94.9% of cases. The false negative rate of the procedure was 5.1%. Sentinel lymph node was involved in 43.9% of cases and it was the only one involved in 30.2% of cases. The sensitivity of the procedure was 94% (CI: 95% = [88%-98%]) and its specificity 100%. CONCLUSION: Actually considered as new attractive procedure under ongoing evaluation in prospective controlled trials, this study confirms the feasibility and reproductibility of lymphatic mapping and sentinel node biopsy, first stage before entering a new era of minimally invasive axillary surgery in breast cancer.

[Evaluating the risk of axillary lymph node involvement in inferior breast cancer measuring 3 centimeters. Analysis of a predictive model based on 893 cases]. / Evaluation du risque d'envahissement ganglionnaire axillaire dans les cancers du sein inférieurs à 3 centimètres. Analyse d'un modèle prédictif à partir de 893 cas.

STUDY AIM: The aim of the study was to assess, by clinical and histological predictive factors, the axillary lymph-node involvement (pN+) in early breast cancers. MATERIALS AND METHODS: Eight hundred ninety-three patients with unilateral invasive breast cancer were studied. The evaluated parameters included clinical size (T), pathological size (pT), histological subtype (ductal infiltrating, according to grading 1, 2, 3, lobular infiltrating and others), age (less than 40, 40 to 60 and above 60). Furthermore, a new parameter, the dosimetric breast size, recently described, was included (Eur J Cancer 1997; 33: 2432-4). RESULTS: The global rate of pN+ was 25.3%, with respectively, pN1: 10%, pN2-3: 8.4% and pN > 3: 6.9%. According to T, the pN+ rates were, respectively, 13.8%, 19.8% and 36.2% in the T0, T1 and T2 < or = 3 cm groups. According to pT, the pN+ rates were, respectively, 11.1%, 17.7%, 23.5%, 30.1% and 36% in the following groups: 0-9.9 mm, 10-14.9 mm, 15-19.9 mm, 20-24.9 mm and 25-29.9 mm. For the ductal infiltrating carcinoma, according to the gradings 1, 2 and 3, we found, respectively, 18.3%, 27.2% and 37.8% of pN+. For the lobular infiltrating carcinoma and the other histological subtypes, the rates were 22.7% and 10%, respectively. For the three age categories cited above the pN+ rates were, respectively, 30.3%, 25.8% and 22.4%. According to breast size we found 30.1% and 24.4% of pN+ respectively for small and medium or large dosimetric breast size. After a multivariate analysis, three factors were significant for pN+ risk: clinical tumor size (P = 0.0001), histological subtype (P = 0.0005) and dosimetric breast size (P = 0.004). With a combination of these three factors, the pN+ rates varied from 5% to 50%. CONCLUSIONS: The authors conclude that both clinical and pathological characteristics of the primary tumor (specified by previous core biopsy) can indicate the risk for axillary node metastases, and allow selection of candidates for limited axilla surgery (sentinel node).

[Cervical lymphadenopathy revealing differentiated thyroid cancer. Review of the literature and therapeutic approach]. / Adénopathie cervicale révélatrice d'un cancer différencié de la thyroïde. Revue de la littérature et attitude thérapeutique.

Well-differentiated thyroid cancer (i.e. papillary microcarcinoma) may be revealed by a clinically palpable cervical node, especially in young patients. Primary tumor specificity (small-sized, superior location, invasion, multifocality) and characteristics of cervical node involvement (with synchronous central and lateral multiple node spread) require appropriate treatment by a skilled surgeon. Contrary to the primary tumor treatment (total thyroidectomy), surgical management of the cervical node basins remains controversial. Only a special knowledge of the specificity of this disease and cervical lymphatic anatomy will ensure a good prognosis for the patient.

[Oncocytic cancers of the thyroid. Hürthle cell cancers]. / Les cancers oncocytaires de la thyroïde. Cancers à cellules de Hürthle.

Hürthle cell cancers of the thyroid have been a subject of debate for many years because it is difficult to differentiate between benign and malignant tumours. Diverse therapeutic strategies have thus ensued. Recent work describing the morphologic and biologic criteria for a more precise diagnosis have led to better therapeutic strategies. We report a series of 85 tumours of the thyroid with Hürthle cells including 19 Hürthle cell tumours (22%) operated between 1976 and 1994. Hürthle cell tumour represented 6.7% of 282 thyroid cancers operated during the same period. The mean age of the patients was 56.6 years (range 23 to 78 years) and 63% of the tumours were large > or = 4 cm (classed T3T4). Treatment was total thyroidectomy in 79% of the cases. 5-year survival was 58.3% and 25% of the cases had metastatic extension at the time of initial treatment. Hürthle cell cancer have now been recognized as a particular anatomic and clinical entity. They were formerly confounded with vesicular cell cancers but now have been separated into a single entity due to a poor prognosis, lack of response to radioactive iodine and high incidence of metastasis. The current histological criteria make diagnosis more precise and allow more logical treatment with total thyroidectomy. A few familial cases have been reported. Although less frequent than in medullary cancer, this form would suggest that a genetic survey should be conducted for this particular type of thyroid cancer.

[Conservative radiosurgical treatment in in situ ductal cancer of the breast. Analysis of 86 cases]. / Traitement conservateur radiochirurgical dans le cancer canalaire in situ du sein. Analyse de 86 observations.

OBJECTIVES: With effective screening programmes, the global incidence of in situ ductal carcinoma of the breast has risen to 15%, representing 20 to 30% of the mammographically detected T0 tumours. Prognosis is generally good in these tumours, but treatment has in the past, paradoxically, relied on extensive surgery. We report our experience with conservative radiosurgery performed in such cases from 1980 to 1990. METHODS: There were 86 patients with a mean age of 52 years. Initial TNM classification was T0 = 57, T1 = 17, T2 = 9 and Tx = 3. All underwent limited surgery (quadrantectomy: 17; lumpectomy: 69) and 49 had axillary dissection. All received breast irradiation with scar boost (46-50 Gy + 10-14 Gy with classical fractionation). Thirty one postmenopausal women received adjuvant tamoxifen. The quality of the resection was good in 77 cases, doubtful or incomplete in 9. In one case axillary nodal involvement was found. The histological subtype was clearly identified in 63 cases. With a median follow-up of 58 months, 3 local relapses occurred (3.4%), at 27, 48 and 52 months respectively. One was in situ and two invasive. All were clinical lesions (2 T1 and 1 T2); two had incomplete or doubtful excision and all received less than 60 Gy on the tumour bed. All had mastectomy. Two are alive and well but one developed multiple metastasis. Five other women had subsequent surgery for suspicion of local relapse but all had benign disease. One developed contralateral disease 20 months later. Two women died subsequently due to a second cancer. CONCLUSION: These results confirm the importance of the excision quality and suggests a possible dose-effect in the control of in situ ductal carcinoma by radiotherapy. The recent results of the B-17 NSBAP trial also conclude that the radiosurgical conservative treatment, for limited in situ ductal carcinoma, is a reasonable alternative to mastectomy.

[Cuniculatum carcinoma. 6 cases and review of the literature]. / Le carcinome cuniculatum. 6 observations et revue de la littérature.

The cuniculatum carcinoma is a rare type of epidermoid carcinoma. We report 6 cases with different localizations ("oral cavity and larynx", vulva, lower limb) treated over a 23-year period. Diagnosis is particularly difficult and requires careful clinical examination completed by deep surgical biopsy for histology. The aetiology of the tumour is not well defined. It presents as a slow growing wart with local malignancy and chronic suppuration. Extension to lymph nodes is rare. Histologically there is proliferative deep malpighian infiltration with an aspect of normal cell maturation. Galeries are hollowed out giving the aspect of a rabbit burrow (cuniculatum). Surgery is the only treatment, generally without lymph node curage. Radiotherapy is contraindicated due to anaplastic transformation.

[Role of pelvic exenterations in the treatment of cervix cancers. Apropos of 41 surgically treated cases]. / La place des exentérations pelviennes dans le traitement des récidives des cancers du col utérin. A propos de 41 cas opérés.

The Department of surgical oncology of the Paul-Strauss Cancer Center of Strasbourg (France) reports its experience about pelvic exenterations in recurrent cervix carcinomas. Based on a series of 41 cases (median age: 48.5 years), all patients, but one, have been primarily treated by sole external beam irradiation or surgery combined with radiotherapy. Salvage ultraradical surgical procedures were total (25 cases), anterior (7 cases) and posterior exenterations (9 cases). Overall 5 and 10 years crude survival were 39 and 27.5%, respectively. Advances in surgical procedures, new developments in techniques of pelvic floor reconstruction and improvement in devices of urinary diversions have mainly contributed to a decrease of postoperative morbidity associated with the obtaining of long survivals in selected patients previously treated, in a curative intent, by other therapeutic modalities. The current place of palliative pelvic exenterations and the support of intraoperative radiotherapy are discussed according to recent literature data.