Liver metastases from breast cancer: Surgical resection or not? A case-matched control study in highly selected patients.

AIM: To determine whether, in a highly selected patient population, medical treatment combined with surgical resection of liver metastases from breast cancer is associated with improved survival compared with medical treatment alone. PATIENTS AND METHODS: Between 1988 and 2007, 100 liver resections for metastatic breast cancer were performed at Institut Curie, 51 of which met the criteria for inclusion in this case-control study. With the exception of bone metastases, patients with other distant metastasis sites were excluded. Surgery was only performed in patients with stable disease or disease responding to medical treatment evaluated by imaging evaluation. Surgical cases were individually matched with 51 patients receiving medical treatment only. All patients had 4 or fewer resectable liver metastases. The study group was matched with the control group for age, year of breast cancer diagnosis, time to metastasis, TNM stage, hormone receptor status and breast cancer tumour pathology. RESULTS: Univariate analysis confirmed a survival advantage for patients lacking bone metastases and axillary lymphadenopathy at the time of breast cancer diagnosis and for surgically treated patients. Multivariate analysis indicated that surgery and the absence of bone metastases were associated with a better prognosis. A multivariate Cox model adapted for paired data showed a RR = 3.04 (CI: 1.87-4.92) (p < 0.0001) in favour of surgical treatment. CONCLUSION: Surgical resection of liver metastases from primary breast cancer appears to provide a survival benefit for highly selected patients.

Outcome in early cervical cancer following pre-operative low dose rate brachytherapy: a ten-year follow up of 257 patients treated at a single institution.

OBJECTIVE: To report the outcome of preoperative low dose rate uterovaginal brachytherapy (LDR-UVBT) followed by radical surgery in the treatment of early cervical carcinoma. METHODS: 257 patients treated at Institut Curie from 1985 to 2008 for cervical carcinoma less than 4cm (FIGO stages Ib1, IIA and IIB) were studied. Patients received preoperative LDR-UVBT followed by hysterectomy Piver II type, with pelvic lymph nodes dissection (PLND). Predictive factors for pathological response to brachytherapy were analyzed with logistic regression, as well as survival rates. RESULTS: 44% of patients had residual tumor, 4.3% of patients had parametrial invasion and 17.9% of patients had lymph node involvement. Predictive factors for an incomplete pathological response were: initial clinical tumor size 20mm (OR 2.1), pN1 (OR 2.77), glandular carcinoma (OR 2.51) and lymphovascular invasion (OR 4.35). 7.4% and 2.7% of patients had respectively grade 2 and grade 3 post-therapeutic late complications. Median follow up was 122 months [1-282]. Five-year actuarial overall survival and disease free survival were respectively 83% CI [78.3-87.5] and 80.9% CI [76.3-85.7]. In multivariate analysis, factors affecting significantly the overall survival and disease free survival rates were: lymph node involvement (RR 4.53 and 8.96 respectively), parametrial involvement (RR 5.69 and 5.62 respectively), smoking (RR 3.07 and 2.63 respectively). CONCLUSIONS: Preoperative LDR-UVBT results in good disease control with a low complications rate. Its accuracy could be improved by a better selection of patients. Lymph nodes and parametrial evaluation remains a challenging issue that should be achieved with imaging and minimal invasive surgery.

Management of exposed, infected implant-based breast reconstruction and strategies for salvage.

INTRODUCTION: Complications of implant-based breast reconstruction are rare but mastectomy flap necrosis and peri-implant infection are the most frequent and remain an important cause of early implant failure. This study aimed to compare the results of three different management strategies employed to deal with these complications at our institution. PATIENTS AND METHODS: A consecutive series of 71 infected/exposed prostheses in 68 patients over a 20-year period were analysed. Management strategies included explantation and delayed reconstruction, implant salvage and explantation and immediate autologous reconstruction. RESULTS: Only 19 of 45 (42%), managed with implant removal, went on to delayed reconstruction. Methods of delayed reconstruction were distributed equally between implant-only, implant and autologous tissue and autologous-only reconstructions. The implant was successfully salvaged in nine cases, but reducing the implant size or introducing new tissue as a flap increased the success from 45% to 53%. Three patients with infected implant-only breast reconstruction underwent explantation and immediate conversion to autologous-only reconstructions. CONCLUSIONS: All the three interventions reviewed here have their place in the management of infected implant-based breast reconstructions. It is noteworthy that following implant removal, the likelihood of the patient proceeding to delayed reconstruction of any kind is similar to the likelihood of successful salvage (42% vs. 45%). This study population had high numbers of exposed implants in irradiated fields. Reducing implant size or introducing new tissue in the form of a flap increases the chances of successful implant salvage. In the presence of mild infection, removal of exposed/infected implants and immediate conversion to an autologous-only reconstruction can prove to be successful.

Preoperative staging of liver metastases from uveal melanoma by magnetic resonance imaging (MRI) and fluorodeoxyglucose-positron emission tomography (FDG-PET).

BACKGROUND: Microscopically complete (R0) resection of metastases from uveal melanoma prolongs median overall survival compared to incomplete surgery. The aim of this study was to compare the sensitivity of dynamic-enhanced magnetic resonance imaging (MRI) with fluorodeoxyglucose-positron emission tomography (FDG-PET) in the preoperative diagnosis of liver metastases from uveal melanoma. PATIENTS AND METHODS: Fifteen consecutive patients (mean age: 56 years) underwent FDG-PET and liver MRI. Extrahepatic metastatic disease was excluded by whole body computed tomography and bone scintigraphy. MRI and FDG-PET were performed with a mean of 19 days (range: 1-30) before surgery. Imaging findings were compared with surgical (including intraoperative ultrasonography) and histological findings on a lesion by lesion analysis. RESULTS: R0 resection was performed in 12 patients. A total of 28 lesions were resected with 27 histologically proven metastases. Nine lesions were smaller than 5mm, 7 measured 5-10mm and 11 were larger than 10mm. Sensitivity and positive predictive value were 67% and 95% for MRI compared to 41% and 100% for FDG-PET. The difference between the two modalities was statistically significant (p=0.01; McNemar test). In remaining 3 patients, diffuse miliary disease (>10 capsular lesions) was discovered intraoperatively, and was suspected on preoperative MRI in 2 cases. Only one extrahepatic lesion identified by FDG-PET was falsely positive. CONCLUSIONS: In this preliminary study, MRI was superior to FDG-PET for staging of liver metastases from uveal melanoma. Although miliary disease was suggested by MRI in some cases, preoperative confirmation remains imperfect.

Oncoplastic breast surgery: a review and systematic approach.

Oncoplastic breast surgery (OBS) is relatively new, but has made rapid progress from its tentative steps of infancy in the 1990s. The recent Milanese Consensus Conference on Breast Conservation concluded that, firstly, oncoplastic techniques are warranted to allow wide excision and clear margins without compromising cosmesis. Secondly, such surgery is ideally performed at the same time as oncological excision. Whilst technically more challenging than standard breast conserving therapy (BCT), OBS is well proven, if not yet widely practised, both oncologically and aesthetically and a review of the available techniques is perhaps timely. The roots of breast conserving therapy can be traced to the 1930s, actually due to advances made in radiotherapy, and the last 20 years have seen it become firmly established. This review aims to summarise the key historical developments and latest innovations in OBS. Not only are our patients, who expect not only safe cancer treatment but a satisfactory aesthetic outcome, increasingly informed and demanding, but longer follow up has stimulated surgeons to improve outcomes. In many cases, particularly with ptosis and macromastia, the cancer can be treated, usually with wider excision margins, simultaneously improving the aesthetic appearance. Present at the birth of OBS, the Institut Curie has continued to introduce innovative techniques over the last two decades and a systematic approach, comprising nine basic techniques, has evolved to allow high quality treatment of any and all breast cancers suitable for OBS.

Lateral mammaplasty reconstruction after surgery for breast cancer.

BACKGROUND: Up to 60 per cent of cancers develop laterally in the breast and breast-conserving surgery frequently produces superolateral nipple-areolar complex (NAC) distortion aggravated by postoperative irradiation. Correction is technically demanding and the outcomes are variable. Lateral mammaplasty may allow wider excision margins and prevent such deformities. METHODS: This was a review of 86 consecutive patients who had lateral mammaplasty: combined wide tumour excision with NAC repositioning on a reliable dermoglandular pedicle. Simultaneous axillary surgery was performed via a separate or combined incision. Aesthetic outcomes were assessed. RESULTS: The median age of the women was 54 (range 29-75) years; 55 (64 per cent) had palpable tumours and 73 (85 per cent) underwent simultaneous axillary surgery. Median radiological and histological tumour sizes were 29.8 and 33.6 mm, respectively, and median weight of excised tumour was 150 g. Two patients required haematoma evacuation. Eleven women required revisional surgery for involved or close margins. Aesthetic outcomes were excellent or good in 93 per cent. CONCLUSION: Lateral mammaplasty produced clear margins in 87 per cent of women. It is an option when a deformity is anticipated after breast-conserving surgery, and is particularly valuable when neoadjuvant chemotherapy has downgraded a large tumour.

[Stoutness and prognosis of female non-metastatic breast cancer: results from a French observational cohort study]. / Corpulence et pronostic du cancer du sein non métastatique de la femme: résultats d'une étude de cohorte observationnelle française.

AIM: Our objective was to study the prognostic value of stoutness in non-metastatic breast cancer, from a population of French women. METHODS: We constituted a large observational cohort of patients followed since a first unilateral breast cancer without distant dissemination. Stoutness was assessed using the body mass index (BMI, in kg/m(2)) at the time of diagnosis. Patients were classified into the four main categories of BMI, defined according to the World Health Organization recommendations. The risk of prognosis events was analyzed according to the BMI categories. To this end, survival analyses were achieved. RESULTS: The patients having a BMI value of at least 25 kg/m(2) presented significantly higher risks of death and metastasis recurrences when they were compared to the patients having a normal value of BMI. The multivariate analyses found a modest increase of risk, about 10 to 20%, depending on the degree of fatness. It reached about 20 to 50% according to the univariate analyses. The obese patients (BMI >or= 30 kg/m(2)) had an increase of 50% of the risk of second primary cancers, comparatively to the patients having a normal value of BMI. Regarding contralateral, nodal and local recurrences, the survival analyses did not achieve any significant relationship with stoutness. CONCLUSION: A poorer prognosis is observed when breast cancer patients have a value of BMI that matches at least with overweight. Contrary to the results of few recent surveys, underweight patients do not present a poorer prognosis than normal weight patients. Excess of weight represents a modifiable factor in order to improve female breast cancer prognosis.

Surgical management of liver metastases from uveal melanoma: 16 years' experience at the Institut Curie.

BACKGROUND: Uveal melanoma is characterised by a high prevalence of liver metastases and a poor prognosis. AIM: To review the evolving surgical management of this challenging condition at a single institution over a 16-year period. PATIENTS AND METHODS: Between January 1991 and June 2007, among 3873 patients with uveal melanoma, 798 patients had liver metastases. We undertook a detailed retrospective review of their clinical records and surgical procedures. The data was evaluated with both uni- and multivariate statistical analysis for predictive survival indicators. RESULTS: 255 patients underwent surgical resection. The median interval between ocular tumour diagnosis and liver surgery was 68 months (range 19-81). Liver surgery was either microscopically complete (R0; n = 76), microscopically incomplete (R1; n = 22) or macroscopically incomplete (R2; n = 157). The median overall postoperative survival was 14 months, but increased to 27 months when R0 resection was possible. With multivariate analysis, four variables were found to independently correlate with prolonged survival: an interval from primary tumour diagnosis to liver metastases >24 months, comprehensiveness of surgical resection (R0), number of metastases resected (< or = 4) and absence of miliary disease. CONCLUSIONS: Surgical resection, when possible, is able to almost double the survival and appears at present the optimal way of improving the prognosis in metastatic uveal melanoma. Advances in medical treatments will be required to further improve survival.

[Secondary breast reconstruction using exclusive lipofilling]. / Reconstruction mammaire secondaire par lipomodelage exclusif.

Lipofilling is usually performed in breast surgery for treatment of aesthetics sequelae after breast conserving surgery or correction after breast reconstruction by prothesis or musculocutaneous flaps. We present a case of a patient where exclusive lipofilling breast reconstruction has been successfully performed. Aesthetic result is assessed by the patient and the surgeon as very satisfactory after one year of follow-up. This technology not much used in this present indication have important advantages in terms of tolerance or morbidness but the long-term results depend on not controlled factors such as volumetric cast iron or fatty resorption. Further studies are necessary to define the patients will be able to benefit from this technology and to assess the modalities of follow-up but also to measure evenly practicability, stability of reconstruction and its evolution in time. However, aesthetic result and contentment of the patient allow us to envisage the broadcasting of this technology of mammary reconstruction for selected patients.

Abdominoperineal resection for anal cancer.

PURPOSE: Following initial radiotherapy or chemoradiotherapy for the treatment of anal cancer, patients who present with either persistent or locally recurrent disease are treated by abdominoperineal resection. The aim of this retrospective study was to review the long-term survival and prognostic factors after such surgery in a single institution. METHODS: Over a 34-year period (1969-2003), 422 patients with nonmetastatic anal cancer were treated with a curative intent. Of these, 83 (median age 61 years; 74 women) underwent abdominoperineal resection. RESULTS: Forty-one patients underwent abdominoperineal resection for persistent disease and 42 for locally recurrent disease. Postoperative mortality was 4.8 percent and morbidity was 35 percent with 18 percent having perineal wound infections. Median follow-up was 104 months (range, 3-299). The 3-year and 5-year actuarial survival was 62.8 and 56.5 percent respectively. Using univariate analysis, patients below 55 years, females, T1-2 tumors, N0-N1 lymphadenopathy and the absence of locally advanced tumor were associated with significantly improved survival. Surgery, whether for persistent or locally recurrent disease, did not affect the 5-year survival rate. CONCLUSIONS: Abdominoperineal resection for nonmetastatic anal cancer is associated with a high morbidity rate but may result in long-term survival regardless of the indication.

[Nipple and areola reconstruction by tattooing, "F" and "Z" flaps]. / La reconstruction de la plaque aréolo-mamelonnaire par tatouage, lambeaux << F >> et << Z >>

Nipple and areola reconstruction is very important in the evaluation of the quality of breast reconstruction. It can be done during the primary or secondary breast reconstruction or later. We have performed the techniques of nipple reconstruction routinely since 1992. Under local anesthesia during a second operative time or general anesthesia during breast reconstruction, the local "F" and "Z" skin flaps and tattooing grant a quality result in the wound and the long-term projection. They are easily reproduced, rapid and as there is no graft the choice of the incisions grants a good tolerance. Complications are rare and it is always possible to use other techniques in case of poor result. We also present the main techniques of nipple and areola reconstruction with their advantages and limits.

[Breast cancer surgery: use of mammaplasty. Results. Series of 298 cases]. / Résultats carcinologiques et esthétiques du traitement du cancer du sein par plastie mammaire. 298 cas.

Breast cancer surgery has long consisted in the sole use of mastectomy. Then, it was proved that, in terms of global survival, conservative treatments associated with radiotherapies could give the same results. But breast deformations due to classic conservative treatments led some authors to use plastic surgery procedures: breast plastic surgery. Some breast plastic surgery procedures are well-known, others have been adapted to breast cancer treatment and more particularly in case of tumor of superior and internal quadrants. After the retrospective analysis of a series of 298 cases from the Institute Curie, the aim of this survey is to find whether there is a difference between: breast plastic surgery and usual treatments like mastectomy and classic conservative treatments. For most cases, the tumors were invasive ductal carcinoma and T2N0M0 carcinoma. This survey showed, among these cases, 94.56% of global survival, 86.81% of survival without metastasis and a five-year 93.47% without local recurrence, which is comparable to the results for mastectomies and classic conservative treatments. In selected cases, the use of mammaplasty could be interesting for breast cancer surgery treatment.

Vacuum-assisted large-core needle biopsy (VLNB) improves the management of patients with breast microcalcifications - analysis of 1009 cases.

AIMS: To evaluate the surgical management of patients who underwent VLNB for breast microcalcifications. METHODS: This retrospective study compared the histological results and the surgical procedures in two groups of patients, group 1: large-core needle biopsy n=1009, and group 2: surgical biopsy n=270. RESULTS: After VLNB, 54% patients were not operated on after stereotactic large-core needle biopsy, 42% underwent one operation, 4% underwent two operations and 0.2% underwent three operations. No surgery was performed for 95% of benign lesions. Multiples operations were necessary in 12% of patients with malignant lesions of VLNB group compared to 45% in the surgical biopsy group. The rate of underdiagnosis of borderline lesions and ductal carcinomas in situ was 16% by the large-core biopsy technique. CONCLUSION: VLNB constitutes an alternative to surgical biopsy. This procedure avoids surgery for most benign lesions and reduces the number of surgical procedures in malignant lesions.