[Are decisions of multidisciplinary tumor boards in accordance with the guidelines? Experience of an university reference center for breast cancer]. / Les décisions des RCP sont-elles conformes au référentiel utilisé ? Expérience d'un centre de référence universitaire pour le cancer du sein.

OBJECTIVE: Multidisciplinary meeting (MDM) should ensure a homogeneous management of the patients by following breast cancer guidelines. Are these guidelines really applied in MDM decisions? PATIENTS AND METHODS: We reviewed the last 200 cases of patients operated in our department for breast cancer. We searched for each case if MDM had been consulted, at which step of the management and if the decision was in accordance with our guidelines. RESULTS: Mean age of the 200 patients was 56 (range 27-87)years old and 145 of them (72,5%) had an invasive breast cancer. All cases were presented to the MDM, 148 (74%) preoperatively and 200 (100%) postoperatively. Only four decisions did not follow our guidelines. In three cases, the decision was explained within the MDM report and in one case, the decision was not explained but could be understood. DISCUSSION AND CONCLUSION: We found a significant relation between MDM decisions and our guidelines. However, complex cases require adapting the guidelines to the particularity and the wishes of the patients.

Predictive factors for breast cancer in patients diagnosed with ductal intraepithelial neoplasia, grade 1B.

BACKGROUND: For ductal intraepithelial neoplasia, grade 1B, studies that predict breast cancer risk after an 11-gauge vacuum-assisted breast biopsy have yielded contradictory results. In order to identify a predictive model of breast cancer risk, we assessed the underestimation rate according to radiological and clinical findings. PATIENTS AND METHODS: Our study involved 212 patients. We compared the area under the receiver operating characteristic curves and the clinical utility of a logistic regression and partitioning model. RESULTS: Overall upgrade to malignancy occurred in 42 (19.8%) out of the 212 cases. The area under the curve for the logistic regression and partitioning model were 0.65 (95% confidence interval=0.61-0.70) and 0.58 (95% confidence interval=0.54-0.62), respectively. The lowest predicted underestimation rate obtained with the logistic regression model was 9.5%. CONCLUSION: From this large series, we were unable to define any accurate safety model for breast cancer. Surgery should be thus recommended.

Contribution of pelvic and para-aortic lymphadenectomy with sentinel node biopsy in patients with IB2-IIB cervical cancer.

OBJECTIVE: Detection of lymph node involvement in women with IB2-IIB cervical cancer could have a positive effect on survival. We set out to evaluate the incidence of pelvic and/or para-aortic lymph node involvement using the sentinel node (SN) biopsy and its impact on survival. METHODS: From 2002 to 2010, 66 women with IB2-IIB cervical cancer underwent a pelvic and paraaortic lymphadenectomy with SN biopsy. Survival between groups according to lymph node status was evaluated. RESULTS: Mean tumour size was 43.5 mm. At least one SN was detected in 69% of the 45 SN procedures performed. Sixteen of these patients had metastatic SN and the false negative rate was 20%. Metastatic pelvic SNs or non-SNs were detected in 33 patients (50%), including pelvic-positive nodes in 26 (40%), pelvic- and paraaortic-positive lymph nodes in seven (11%), and paraaortic skip metastases in two (6%). Positive paraaortic node was the sole determinant for disease-free survival (DFS) and overall survival (OS; P<0.001). Differences in DFS and OS between groups according to the nodal status were observed (P<0.001). CONCLUSION: SN procedure gave a higher rate of metastasis detection. Further studies are required to evaluate whether pre-therapeutic node staging, including paraaortic and pelvic lymphanedectomy, should be performed.

Scoring to predict the possibility of upgrades to malignancy in atypical ductal hyperplasia diagnosed by an 11-gauge vacuum-assisted biopsy device: an external validation study.

BACKGROUND: Ko's scoring system was developed to predict malignancy upgrades in patients diagnosed with atypical ductal hyperplasia by core needle biopsy. The Ko algorithm was able to identify a subset of patients who were eligible for exclusively clinical follow-up. The current study statistically investigated the patient outcomes to determine whether this scoring system could be translated and used safely in clinical practice. METHODS: We tested the statistical performance of the Ko scoring system against an external independent multicentre population. One hundred and seven cases of atypical ductal hyperplasia diagnosed by an 11-gauge biopsy needle were available for inclusion in this study. The discrimination, calibration and clinical utility of the scoring system were quantified. In addition, we tested the underestimation rate, sensitivity, specificity, and positive and negative predictive values according to the score threshold. RESULTS: The overall underestimation rate was 19% (20/107). The area under the receiver operating characteristic curve for the logistic regression model was 0.51 (95% confidence interval: 0.47-0.53). The model was not well calibrated. The lowest predicted underestimation rate was 11%. The sensitivity, specificity, positive predictive value, and negative predictive values were 90%, 22%, 20%, and 89%, respectively, according to the most accurate threshold proposed in the original study. CONCLUSION: The scoring system was not sufficiently accurate to safely define a subset of patients who would be eligible for follow-up only and no additional treatment. These results demonstrate a lack of reproducibility in an external population. A multidisciplinary approach that correlates clinicopathological and mammographic features should be recommended for the management of these patients.

[Prognostic and predictive factors in multifocal breast carcinoma]. / Facteurs prédictifs et pronostiques des cancers du sein multifocaux.

OBJECTIVES: Multicentricity is not listed as a major prognostic parameter in invasive breast carcinoma, and is not by itself an indication of systemic adjuvant treatment. Furthermore, evaluating the size of these tumors is discussed. The aims of this study are to evaluate prognostic value of multicentricity, and to compare different way for measuring multicentric breast carcinomas. PATIENTS AND METHODS: Between 2001 and 2008, 1458 patients having breast invasive carcinoma were included in Tenon Hospital, Paris, France; 16% had a multicentric cancer. We have compared impact of multicentricity on lymph node (LN) involvement, and compared 3 ways for measuring these cancers. RESULTS: LN involvement was significantly associated with multicentricity. We found an over-risk of 20% for LN involvement in patients having multicentric cancer, whatever the size of the tumors. Considering the diameter of the largest focus is the best way for measuring these cancers. DISCUSSION AND CONCLUSION: We did not find a subgroup of patients at low risk of LN involvement when having a multicentric breast cancers. These results lead us to extend indications of adjuvant chemotherapies in all multicentric breast cancer. These results should be validated by randomized prospective studies.

Interest in cavity shaving in breast conservative treatment does not depend on lumpectomy technique.

In breast conserving surgery (BCS), the usefulness to perform systematic cavity shaving is actively debated. Some investigators argued that systematic cavity shaving could avoid surgical re-excision and make diagnosis of unexpected multifocality. Others argued that usefulness of cavity shaving depends on volumes of resection. In this study one hundred patients undergoing BCS with systematic cavity shaving were included. Margins less than 3 mm were considered to be insufficient. We tested clinico-pathological characteristics in order to identify predictive model of cavity margin shaving utility and we sought to determine if cavity margin shaving usefulness depends on volumes of resection. We showed that cavity shaving avoids the need for re-excision in 24% of cases as well as diagnosis of multifocality in 6% of cases. However, the clinical usefulness of cavity shaving was not related to the volumes of resection.

[Clinicopathological and genomics predictors of response to neoadjuvant chemotherapy in breast cancer]. / Prédicteurs clinicopathologiques et génomiques de la réponse à la chimiothérapie néoadjuvante dans les cancers du sein.

Breast cancer is a frequent and heterogeneous disease. The choice of systemic treatments such as chemotherapy is based on predicting factors of response that did not much evolve. Preoperative chemotherapy provides an opportunity to directly assess tumor response to therapy. Predictors based on mathematical models could optimize those treatments. To go on this way, three different concepts have been developed to predict the preoperative chemotherapy complete response. Predictors based on clinical and pathological variables are specific of a tumor. They combine into mathematical models variables that have been previously identified as predicting the preoperative chemotherapy complete response. Predictors based on gene expression profile have been developed from groups of patients who received preoperative chemotherapy. They integrate multigene information to predict the tumor behaviour in front of several cytotoxic agents. Those predictors developed for each type of drug characterize the genetic chemoresistance of a tumor. In the same time, predictors of chemosensitivity developed from cell lines of diverse human cancer appeared. The authors established a genetic profile involved into chemoresistance and extrapolated the drug sensitivity for another type of cancer which was not represented, as breast cancer. All those predictors seem interesting but evolution of patients' characteristics and treatments induces a perpetual reassessment to optimize our predictive abilities.

[Feasibility of the sentinel node biopsy in breast cancer in case of histological multifocality diagnosis]. / Faisabilité du ganglion sentinelle dans le cancer invasif du sein en cas de découverte histologique de la multifocalité.

OBJECTIVES: The use of sentinel node biopsy (SNB) has replaced axillary lymph node dissection (ALND) as the new standard of care in early unifocal breast cancer. In multifocal breast cancer, this procedure remains controversial. The real problem is when a multifocal tumor is discovered during or after the surgery, with a SNB negative which has been already done. Should we do an additional ALND or not? PATIENTS AND METHODS: We performed a retrospective study of 43 multifocal breast cancer patients who underwent SNB. RESULTS: The mean histological primary tumor size was 16.8 mm (range, 1-52 mm). The mean number of SN removed was 2.07 (range, 1 to 5). Sixteen (34.1%) of the 43 patients had at least one positive SN. Twenty-seven patients had subsequent axillary dissection. Negative predictive value of SN procedure was 100% (95% confidence interval: 87.1-100%) with a FN rate of 0%. Moreover, not any patient has developed axillary recurrence with a mean follow-up of 20.8 months (1-77). DISCUSSION AND CONCLUSION: Our data are not powerful enough to validate the SNB in multifocal breast tumor discovered after an initial surgery. However, the FN rate of 0% is encouraging and prospective studies with a systematic ALND can help surgeons to respond to the question.

[Models to predict non sentinel lymph node status in breast cancer patients with metastatic sentinel lymph node]. / Modèles prédictifs d'envahissement des ganglions non sentinelles en cas de métastases des ganglions sentinelles dans le cancer du sein.

In breast cancer, nine models have been developed to predict non SN status in patients with SN metastasis. Four models are nomograms: the Memorial Sloan-Kettering Cancer Center nomogram (MSKCC nomogram), the nomogram of Degnim et al. (Mayo nomogram), the nomogram of Pal et al. (Cambridge nomogram), and the nomogram of Kohrt et al. (Stanford nomogram). Three models are scoring systems: the Tenon score, the score from the M.D. Anderson Cancer Center (MDA score), and the score of Saidi et al. Finally, two are recursive partitioning tools developed by Kohrt et al. Before being used in routine, these models have to be validated in independent populations based on discrimination and calibration. However, the main issue is their clinical utility based not only on the low false negative rate but also its potential to discriminate patients with a low risk of non SN involvement. Several institutions have tested the MSKCC nomogram, with AUC ranging from 0.58 to 0.86. It was not validated by four studies which did not recommend its use even in patients with micrometastasis.The external validation of the Tenon score confirmed its relevance with an AUC of 0.82.

The sentinel lymph node procedure for patients with preoperative diagnosis of ductal carcinoma in situ: risk factors for unsuspected invasive disease and for metastatic sentinel lymph nodes.

BACKGROUND: Occult invasive disease could be found at definitive histology in patients initially diagnosed with large ductal carcinoma in situ (DCIS). Sentinel lymph node (SLN) biopsy is a reliable and minimally invasive procedure providing axillary information and avoiding a second operation in this particular group of patients. The aim of our study was to assess the value of SLN biopsy in patients with large DCIS who are at highest risk for being upstaged to invasive carcinoma. PATIENTS AND METHODS: The study included 195 patients diagnosed with DCIS upon initial core biopsy and undergoing SLN biopsy. Many features were correlated with the presence of unsuspected invasive disease and positive SLN biopsy using univariate and multivariate analyses. RESULTS: Of the 110 patients with pure DCIS, seven patients (6%) had a metastatic lymph node; 31 patients (16%) were found to have invasive disease upon final histology. Univariate analysis of predictors of unsuspected invasive carcinoma showed that patients having a preoperative biopsy that indicated DCIS with microinvasion (DCISM) or large DCIS were at a higher risk of invasive carcinoma after histological examination of the operative specimen. Of the 31 patients who were upstaged to invasive carcinoma at final histology, seven patients (22%) had a positive SLN biopsy. The analysis of predictors of positive SLN in our study shows that diffuse DCIS requiring mastectomy is the main risk factor for SLN metastasis. CONCLUSION: There are no real predictive factors for invasive disease in patients with an initial diagnosis of DCIS or DCISM. Our study supports the value of SLN biopsy in patients with a preoperative DCISM biopsy or patients with a large pure DCIS biopsy requiring mastectomy.