[Comparing outcomes of Immediate Breast reconstruction with and without use of radiotherapy]. / Comparaison des résultats de reconstruction mammaire immédiate par prothèse avec et sans radiothérapie.

BACKGROUND: Breast cancer and its treatment remains a public health problem. There is still a lack of epidemiological data concerning complications and aesthetic results bound to radiotherapy after an immediate breast reconstruction. The objective of this study was to compare outcomes of immediate breast reconstruction regardless to the use of radiotherapy (history of radiotherapy or adjuvant radiation therapy), in order to determine risk factor of complications and bad aesthetic results. METHODS: We conducted a retrospective study between January 2014 and December 2016 at the hospital "Gustave Roussy" in Paris, concerning breast cancer patients who needed immediate breast reconstruction after total mastectomy. The primary endpoint was to assess the failure rate of reconstruction and the aesthetic result, the secondary endpoint assessed the early and late rate of complications. We realized a multivariate analysis in order to identify risks factors that may predict complications. RESULTS: Three hundred and thirty three patients have been included: 157 in the "radiotherapy group" compared to 176 in the "no radiotherapy group". Preoperative characteristics were comparable. Average follow-up was between 1 and 3years without missing. Patients who benefited from radiotherapy had an equal risk failure of reconstruction. The subgroup analysis revealed non-significant differences: 12.7% failure rate reconstruction in the "radiotherapy group" vs. 12.5%. We could notify a better rate of "excellent results" in the "no radiotherapy group": 35% vs. 8.2%. Secondary outcomes were comparable. CONCLUSIONS: Radiotherapy related to immediate breast reconstruction didn't increase the failure rate of reconstruction or aesthetic results, comparatively to non-irradiated patients. It is therefore permissible to suggest an immediate breast reconstruction to any patients which would benefit from a total mastectomy followed by radiotherapy; in order to prevent them from a secondary breast reconstruction, who could be physically and psychologically more impactful.

Squamous cell carcinoma of the breast, are there two entities with distinct prognosis? A series of 39 patients.

PURPOSE: Squamous cell carcinoma (SCC) of the breast is a rare entity of breast cancer, with a very poor prognosis, and whose pathophysiology is still unwell established. Therapeutic management is very heterogeneous due to its incomplete understanding. Nevertheless, it seems that two histological entities can be distinguished: pure SCC close to the cutaneous origin, and metaplastic squamous breast cancer (MSBC). The aim of this study is therefore to assess the difference in survival according to the histological type (SCC or MSBC) and to describe the demographic, clinical, and therapeutic characteristics of the two underlying populations. METHODS: Our data came from a monocentric retrospective series of 39 patients treated between 1985 and 2018 at the Gustave Roussy Institute (France) for a breast SCC. RESULTS: Of the 39 patients included, 64% had MSBC and 36% had a pure form. The overall and recurrence-free survival at 3 years [CI 95%] was 72.3% [56.9%; 87.0%] and 67.2% [51.2%; 83.2%], respectively. The overall 3-year survival of patients with MSBC was significantly lower than that with pure SCC: HR [CI 95%] 9.5 [1.2; 73.1], p = 0.008. The 3-year recurrence-free survival of patients with MSBC was also poorer: HR [CI 95%] 11.9 [1.6; 90.7], p = 0.002. Patients with MSBC also tended to be younger, have a large lesion size, and be more metastatic. CONCLUSION: The histological nature of SCC seems to bring fundamental new elements to the therapeutic management as it impacts recurrence and survival. It should therefore be better characterized at diagnosis in order to possibly adapt treatments.

[Decision algorithm in immediate breast reconstruction]. / Algorithmes décisionnels en reconstruction mammaire immédiate.

Immediate breast reconstruction showed many advantages in terms of aesthetic and functional results and improvement of quality of life when compared to delayed breast reconstruction. Previous radiotherapy or the use of adjuvant treatments such as radiation therapy, or chemotherapy are no longer a contraindication for immediate breast reconstruction. However, it is important to respect certain rules in order to decrease the risk of complications: the choice of reconstruction technique, the management of the skin envelope according to the breast shape you want to create, the time delay between the first and the second stage of reconstruction depending on a possible adjuvant treatment.

[Mastectomy and immediate reconstruction: Indications, techniques and decision algorithm]. / Mastectomie avec reconstruction mammaire immédiate : indications et techniques, algorithme de décision d'une reconstruction immédiate.

Immediate breast reconstruction indications extend to infiltrating carcinomas, due to new matrix implant coverage techniques and the development of perforator flaps. These techniques allow adjuvant treatments. However, the decision of immediate reconstruction must be discussed with the oncological multidisciplinary team and the benefits/risks must also be evaluated in relation to the morphology of the patients and their co-morbidities. The chosen type of mastectomy: conventional or skin sparing and/or nipple sparing depends on the shape and volume of the breast, the localization of the tumor in the breast and the distance from the nipple areola complex (NAC). We describe an algorithm to allow, in the case of therapeutic mastectomy with or without adjuvant radiotherapy, an immediate reconstruction with implants or free or pedicled flaps.

The ongoing emergence of robotics in plastic and reconstructive surgery.

Robot-assisted surgery is more and more widely used in urology, general surgery and gynecological surgery. The interest of robotics in plastic and reconstructive surgery, a discipline that operates primarily on surfaces, has yet to be conclusively proved. However, the initial applications of robotic surgery in plastic and reconstructive surgery have been emerging in a number of fields including transoral reconstruction of posterior oropharyngeal defects, nipple-sparing mastectomy with immediate breast reconstruction, microsurgery, muscle harvesting for pelvic reconstruction and coverage of the scalp or the extremities.

[Lumbar artery perforator flap for breast reconstruction]. / Reconstruction mammaire autologue par lambeau perforant lombaire.

Even though DIEP-SIEA flaps or latissimus dorsi musculocutaneous flap are the most frequently used, a wide variety of flaps have been described for autologous breast reconstruction. Concerning the choice of donor-site, the aim is to prevent and to limit the morbidity. That is why the donor-site should be carefully chosen, according to the morphology of the patient. Lumbar artery perforator flap (LAP) is an option for breast reconstruction, but it is not well known and its use is limited. This study summarizes the authors' early experience with free LAP flap for breast reconstruction. Three patients underwent immediate or delayed autologous breast reconstruction using a LAP flap. No vascular by pass was required to lengthen the pedicle. No partial or complete flap necrosis has been reported. There was no surgical donor-site complication. Mean operative time was 7hours. LAP flap can be considered as a good option for autologous breast reconstruction, especially in patients with unfavorable abdominal donor-site, and impossibility to use a DIEP flap.

[Use of indocyanine green angiography in oncological and reconstructive breast surgery]. / Utilisation du vert d'indocyanine en chirurgie sénologique et reconstruction mammaire.

The Indocyanine green (ICG) is a soluble dye that is eliminated by the liver and excreted in bile. When illuminated by an near-infrared light, the ICG emits fluorescence in the near-infrared spectrum, which can be captured by a near-infrared camera-handled device. In case of intravenous injection, ICG may be used as a marker of skin perfusion. In case of interstitial injection, it may be useful for lymphatic network mapping. In oncological and reconstructive breast surgery, ICG is used for sentinel lymph node identification, to predict mastectomy skin flap necrosis, to assess the perfusion of free flaps in autologous reconstruction and for diagnosis and treatment of upper limb secondary lymphedema. Intraoperative indocyanine green fluorescence might also be used to guide the excision of nonpalpable breast cancer.

[Fasciae latae perforator flap for breast reconstruction: An attractive alternative in case of DIEP contraindication]. / Le lambeau perforant de fascia lata en reconstruction mammaire : une option intéressante en cas de contre-indication au DIEP.

The musculocutaneous tensor fascia latae flap was one of the first free flaps described. It is possible to harvest a flap with the same skin paddle, vascularized by a septo-cutaneous perforator running through the tensor fascia lata muscle septum and coming from the ascending branch of the lateral circumflex femoral artery. The DIEP is currently the workhorse of autologous breast reconstruction, but there are some contraindications. The septo-cutaneous tensor fascia latae perforator flap may be an alternative for women with lateral upper thigh lipodystrophy. Between 2010 and 2014, three flaps have been performed in two patients for delayed breast reconstruction (one case of unilateral reconstruction, and one bilateral). Perforators were identified by preoperative angiography. The intervention was performed in a two-team approach, in only one operative position. Perforators were located in the horizontal axis of the upper rim of the pubis bone. One perforator artery was dissected for each flap. The mean caliber of the pedicle was 2.8mm, and the mean length was 6.4cm. The operative time was 240minutes for unilateral flap, 375minutes for bilateral flap. There was no case of total or partial necrosis, or complications on the donor site. Cosmetic results were considered satisfying by patients and surgeons with the reconstructed breast as well as the donor site. Septo-cutaneous fascia lata perforator flap is an attractive flap for breast reconstruction in patients with DIEP contraindication and lateral upper thigh lipodystrophy. It has many advantages: easy to harvest, length and calibre of the pedicle, double team approach, only one operating position, quality of reconstruction. It is necessary to carry out a larger series of cases to study the complication rate in the donor site.

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%.

Toward a new strategy in desmoid of the breast?

AIM: To report initial results of observation as well as surgery in patients with desmoid tumors (DTs) of the breast, a rare tumor for which data are scarce. PATIENTS AND METHODS: The initial approaches were categorized as either front-line loco-regional treatment [(surgery or radiotherapy group, SRG) n = 20] or initial observation [(no surgery/no radiotherapy group, NSRG) n = 11]. RESULTS: A total of 27 women and 4 men were assessed between 1992 and 2013 and included in this study. Patient characteristics were adequately balanced in the 2 groups. Fifteen patients (48.4%) had a past history of breast surgery in the previous 24 months. The median initial DT size on MRI was 50 mm. The median follow-up was 36 months. In the SRG, 8/20 patients (40%) experienced recurrence. The median time to recurrence was 29 months. During the study period, 6 patients in the SRG (30%) received a mastectomy at the time of diagnosis (n = 3) or at relapse (n = 3), 7 patients (35%) received a thoracic wall resection and 8 patients (40%) received radiotherapy at the time of diagnosis (n = 2) or at recurrence (n = 5). In the NSRG, the median tumor size change was -4 mm (range -13 to +20). Three patients changed treatment strategies during the observation period; one received surgery, and 2 were administered anti-hormonal treatment. CONCLUSIONS: Loco-regional treatments of breast DTs resulted in undesired disfigurement. Front-line observation yielded encouraging results and could enable the identification of patients who require loco-regional treatment. This strategy needs further evaluation.

Is preoperative radiotherapy suitable for all patients with primary soft tissue sarcoma of the limbs?

AIM: To evaluate the indications and results of preoperative radiotherapy (RT) on a series of selected patients treated at our institution with curative intent for a limb sarcoma (STS). PATIENTS AND METHODS: From 05/1993 to 12/2011, 64 STS patients received preoperative RT. RESULTS: RT was delivered as a "limb salvage treatment" prior to surgery for the following reasons: as the preferential induction treatment in 53 patients (83%) or as a second intent (17%) after the failure of neoadjuvant systemic chemotherapy/isolated limb perfusion. Surgery was performed after RT in 54 (84%) patients and final limb salvage was performed in 98%. Musculo-cutaneous flap reconstruction was planned upfront in 44% patients, and 19% had a skin graft. Seven patients (13%) had a postoperative RT boost. Thirteen (20%) patients had grade (G) 3/4 adverse events, one after RT and 12 after surgery. At a median follow-up of 3.5 years, the 3-year actuarial overall survival (OS) and distant relapse (DR) rates were 83% and 31%, respectively. Two patients developed a local relapse and two a local progression (non-operated patients). In the multivariate analysis (MVA), histological subtype (leiomyosarcoma) and grade 3 were predictive of poorer survival. Patients with >3 month delay between the start of RT and surgery at our institution had an increased risk of DR in the MVA. CONCLUSION: Induction RT should be personalised according to histological subtype, tumour site and risks-benefit ratio of preoperative radiotherapy and is best managed by a multidisciplinary surgical and oncology team in a specialist sarcoma centre.

[Breast reconstruction: state of the arts]. / Reconstruction mammaire et irradiation adjuvante des cancers du sein.

Radical mastectomy is still required in many cases, such as inflammatory breast cancer, multicentric breast cancer, large tumour volume and small breast size. In this setting, immediate breast reconstruction is more and more offered for breast cancer patients. But such plastic surgery is still debated, owing to risks of implant complications when postoperative radiotherapy of chest wall is mandatory in locoregional breast cancer management. Here, the review is focused on different type of immediate breast reconstruction and on risk of implants complications with or without postoperative radiotherapy.

[Intensity modulated radiotherapy as adjuvant post-operative treatment for retroperitoneal sarcoma: acute toxicity]. / Radiothérapie avec modulation d'intensité dans le traitement postopératoire des sarcomes rétropéritonéaux: profil de toxicité aiguë.

PURPOSE: To assess the acute toxicity of intensity modulated radiotherapy as post-operative adjuvant treatment for retroperitoneal sarcoma. PATIENTS AND METHODS: Patients who received adjuvant intensity modulated radiotherapy from January 2009 to September 2010 were retrospectively reviewed. RESULTS: Fourteen patients entered the study (seven primary tumours and seven relapses). All tumours were liposarcoma and had macroscopically complete resection, epiploplasty was systematically realized. Median tumour size was 21 cm (range: 15-45), median planning target volume was 580 cm(3) (range: 329-1172) and median prescribed dose was 50.4 Gy (range: 45-54). Median follow-up was 11.5 months (range: 2-21.4). Acute toxicity was mild: acute digestive toxicity grade 1-2 occurred in 12/14 patients (86%). However, there was no weight loss of more than 5% during radiotherapy and no treatment interruption was required. Two months after completion of radiotherapy, digestive toxicity grade 1 remained present in 1/14 patients (7%). One case of grade 3 toxicity occurred during follow-up (transient abdominal pain). Three relapses occurred: two were outside treaded volume and one was both in and outside treated volume. CONCLUSIONS: Intensity modulated radiotherapy in the postoperative setting of retroperitoneal sarcoma provides low acute toxicity. Longer follow-up is needed to assess late toxicity, especially for bowel, kidney and radio-induced malignancies.

[What is new in the local approach of limb sarcomas and desmoid tumours?]. / Actualisation de la stratégie thérapeutique locorégionale dans les sarcomes des tissus mous et les tumeurs desmoïdes des membres.

The treatment of soft tissue sarcomas of limbs should be discussed within an experienced multimodality team. Surgical resection remains the cornerstone of therapy for localized disease and achieves a five years overall survival around 75% and a local recurrence rate as low as 10% in the best series. In complex cases, neo-adjuvant treatments may be used such as systemic chemotherapy, isolated limb perfusion, or radiotherapy to achieve an optimal conservative approach. Molecular genetics of sarcomas and quality of margins are essential to guide diagnosis and therapeutic selection. In case of marginal or incomplete resection, a new enlarged surgical resection should always be discussed before administration of any adjuvant treatments. Many retrospective studies and two randomized studies (one of adjuvant brachytherapy and one of external beam radiotherapy) have shown that adjuvant radiotherapy after complete surgery significantly reduces the risk of local recurrence in extremity soft tissue sarcomas. A randomized study has compared pre- to postoperative radiotherapy. The results in terms of local control are similar in both arms. The risk of surgical complications is higher in the preoperative arm and the risk of late sequelae is higher in the postoperative arm. A randomized study within the French sarcoma group is ongoing evaluating the omission of postoperative radiotherapy in favourable cases. Presently, the role of systematic first-line invasive treatment (including surgery and/or radiotherapy) of desmoids is debated. It is becoming evident that up to 50% of patients with desmoids benefit from a front-line non-aggressive policy, because growth arrest is a common feature of this disease. Additional study of the molecular determinants of desmoid behaviour is needed to guide treatment.

[Surgical news of soft tissue sarcomas, fibromatosis and GIST]. / Actualités chirurgicales des sarcomes, des fibromatoses et des tumeurs stromales gastro-intestinales.

Excellent local control rates can be achieved using multidisciplinary approach and combined surgical technics. Better vascular and nervous dissections, use of different flaps and isolated limb perfusion have been determinant. Resection's extent of retroperitoneal sarcoma is still debated, but compartmental surgery seems to achieve better local control. The impact of pre operative radiotherapy will be explored soon in a randomized EORTC trial. Concerning desmoids, authors address the question whether surgery and other aggressive treatments should systematically be part of first-line treatment, as growth arrest occurred in 2/3 of non-operated patients. The objective of on going biological studies is to use molecular findings to individualize the selection of management protocols. In the same way, surgical indications for gastrointestinal stromal tumors evolved: with the development of investigations, more micro-GIST are discovered, rising the question of wait and see policy for some of them. In locally advanced inoperable patients and metastatic patients, imatinib is the standard treatment. Secondary excision of residual disease has been shown to be related to a good prognosis in responding patients to imatinib, but it is still not demonstrated whether this is due to surgery itself or to a selection bias. An ongoing phase III EORTC randomises this secondary surgery after 6 to 12 months of imatinib in responding patients.

[Indications and technical procedures of mastectomy with immediate breast reconstruction]. / Indications, conditions de réalisation et techniques de la mastectomie avec reconstruction immédiate dans le cancer du sein.

Achieving a mastectomy occurs in one third of the acts of breast cancer surgery. In the present context, the increase in the diagnosis of early breast cancer, including widespread or multifocal forms, the possibility of a reconstruction at the same time is discussed. It will be proposed in a specific context, taking into account various factors: oncological (characteristics of the tumor, adjuvant treatments), clinical (smoking, comorbidity) and psychological (choice of the patient). The technique of mastectomy will be adapted to the indication and choice of reconstruction procedure. Including the preservation of the nipple-areola complex, or the skin envelope will be possible for some guidance. The reconstruction is possible with the use of breast implants, or musculocutaneous flaps or by the combination of both. Some of these techniques are associated with significant morbidity, and appropriate selection of procedure to the patient will guarantee a lower risk of complications.

Extra-abdominal primary fibromatosis: Aggressive management could be avoided in a subgroup of patients.

OBJECTIVE: To evaluate the impact of surgery as first-line treatment on event-free survival (EFS) of primary aggressive fibromatosis. PATIENTS AND METHODS: Treatments were categorized into: surgery with or without radiotherapy and nonsurgical strategies with systemic treatment alone or wait and see policy. Eighty-nine patients had initial resection of their primary tumour followed by postoperative radiotherapy in 13 cases. Twenty-three did not undergo surgery but received systemic treatment or watch and wait policy. RESULTS: Median follow-up was 76 months. Overall 3 years EFS was 49%. In the univariate analysis, patients with microscopically complete surgery had a similar outcome to patients in the no-surgery group (3 years EFS of 65% and 68%, respectively). Gender, age, tumour size, treatment period and strategy (surgery versus no-surgery) were not statistically significant. Quality of resection according to margins and the tumour site were the only prognostic factors. There was a significant correlation between tumour site and quality of surgery (p=0.0002). CONCLUSIONS: A subset of patients with extra-abdominal fibromatosis could be managed with a nonaggressive policy, as growth arrest concerned 2/3 of nonoperated patients. When surgery is finally necessary, it should be performed with the aim of achieving negative margins.

[Marjolin's ulcer in chronic osteomyelitis: seven cases and a review of the literature]. / Ulcère de Marjolin sur ostéite chronique: diagnostic et résultats du traitement: 7 cas.

PURPOSE OF THE STUDY: Malignant degeneration of chronic wound inflammation is a rare complication which almost always develops late. Unstable wounds and scar tissue related to chronic osteitis can degenerate after a long period of chronic inflammation. We report seven cases. CASE REPORTS: Seven patients presented squamous-cell carcinoma of the skin which had developed on wounds related to deep bone infections. Three patients had chronic bone infections subsequent to posttraumatic osteitis, two after hematogenous osteomyelitis, one after osteitis which developed on a zone of radiation-induced necrosis, and one after a deep burn was complicated by osteitis. The skin lesions developed over a period of 43 years on average before the diagnosis of malignant degeneration was established. Most of the lesions presented as budding malodorous ulcers. The pathological diagnosis was spinocellular squamous-cell carcinoma in five cases and verrucous squamous-cell carcinoma in two. Conservative treatment with wide resection and flap cover was attempted in all seven patients. RESULTS: Treatment failed in four patients and three required amputation. One patient died two years after amputation with local recurrence and metastatic dissemination to the brain. DISCUSSION: The diagnosis of malignant degeneration requires pathological proof. Biopsy material should be obtained whenever there is a modification leading to the development of a fistula or the formation of a scar tissue over a focus of chronic osteitis. Prevention requires adapted treatment of chronic bone infections, avoiding directed wound healing which can lead to fragile unstable scar tissue subject to degeneration.

Bacteriological investigation of infected pressure ulcers in spinal cord-injured patients and impact on antibiotic therapy.

STUDY DESIGN: Retrospective. OBJECTIVES: To improve the use of bacteriological results for treating spinal cord-injured patients with infected pressure ulcers. SETTING: Microbiology and Orthopaedics Department, Ambroise Paré University Hospital, Boulogne-Billancourt, France. METHODS: Tissue specimens, sampled at the end of the surgical intervention from unbridled and cleaned ulcers were analysed. Drainage liquids were cultured at day 1 (D1) and day 5 (D5) postsurgery. For part of the patients, a presurgery superficial sample was analysed and compared with the surgical and postsurgical samples. RESULTS: In all, 168 surgical samples from 101 patients, 183 D1 and 104 D5 wound drainage liquids were included in this study. Out of the 168 surgical samples 17 (10%) had a negative culture, whereas 151 (90%) had a positive culture. For drainage liquids, the culture was negative in 48% and 56% of the samples at D1 and D5, respectively. The most frequently isolated species were enterobacteria, followed by staphylococci and streptococci. CONCLUSION: Culturing deep tissue specimens sampled from the surgically cleaned and unbridled ulcers allows for the isolation of the bacterial species that are really involved in the ulcer infection. As the identification of these bacteria and their antibiotic susceptibility are available, when the culture results of the D1 postsurgical drainage liquid is also available, it is easier to choose targeted antibiotic treatment.