Palpable Nodules After Autologous Fat Grafting in Breast Cancer Patients: Incidence and Impact on Follow-up.

INTRODUCTION: Autologous fat grafting (AFG) is a promising breast reconstruction technique, following surgery. However, fat necrosis after AFG can cause palpable nodules, inducing anxiety and prompting additional investigations. We aimed to determine the occurrence rate and to identify the risk factors of palpable nodules in breast cancer patients prompting complementary explorations. MATERIALS AND METHODS: We retrospectively reviewed the computerized files of consecutive breast cancer patients who underwent AFG after mastectomy or breast conservative treatment (BCT) at our center from January 2013 to December 2016. We collected data regarding palpable nodule incidences and suspicious breast imaging findings that led to additional explorations. RESULTS: Of the 252 patients reviewed, 222 (88%) underwent AFG for breast reconstruction, while 30 (12%) underwent AFG for correction of defects after BCT. The follow-up period ranged from 0 to 74 months (median: 27 months), and 201 patients had follow-ups beyond 1 year. Of the 252 patients, 66 (26.2%) underwent at least one control imaging and 24 (10%) underwent a biopsy, including 6 (2.4%) locoregional recurrence. Sixty patients (24%) were diagnosed with nodules during follow-ups. Among them, 52 (87%) patients had additional imaging, and 17 patients (28%) had a biopsy, including 82% benign histology. Patients with BCT had significantly more palpable nodules at 1 year than patients who underwent total mastectomy (odds ratio = 2.50, 95% confidence interval: 1.04. 6.03, p = 0.04). CONCLUSION: This study underlines the importance of preoperative patient information. This intervention and its follow-up should be reserved for experienced teams to limit unnecessary additional explorations. LEVEL OF EVIDENCE IV: This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .

Functional Cerebral MRI Evaluation of Integration of Breast Reconstruction into the Body Schema.

BACKGROUND: The objective of breast reconstruction (BR) is to erase the after-effects of total mastectomy by allowing patients to restore their breast shape. The aim of our study was to investigate the body map integration of different types of BR using functional magnetic resonance (fMRI). PATIENTS AND METHODS: We prospectively enrolled all women undergoing BR for breast cancer to the Remasco study (NCT02553967). Participants were categorized into four groups according to the standard of care they required: immediate BR (IBR), delayed BR (DBR), flap (autologous), or implant BR. Each patient performed sensorimotor tasks during the fMRI acquisition. RESULTS: Data of 38 patients were analyzed. We identified the cingulate region as the area of interest in the brain. In the case of DBR, the brain area activated during palpation of the total mastectomy scar (before BR) was different from the brain area activated during palpation of the reconstructed breast (Brodmann areas 31 versus 32). Palpation of the native breast and reconstructed breast activated the same Brodmann area 32. Comparing the brain activation signal during palpation of the native breast and the reconstructed breast did not reveal any significant difference in the overall population (P = 0.41) or in the groups: autologous (P = 0.32), implant (P = 0.10), IBR (P = 0.72), or DBR (P = 0.10). CONCLUSIONS: This experimental study allowed us to describe and understand the brain plasticity processes that accompany BR. The results suggest that the reconstructed breast is integrated into the body schema, regardless of the type of BR or the timing.

Prospective Multicenter Study Validate a Prediction Model for Surgery Uptake Among Women with Atypical Breast Lesions.

BACKGROUND: Diagnosis of atypical breast lesions (ABLs) leads to unnecessary surgery in 75-90% of women. We have previously developed a model including age, complete radiological target excision after biopsy, and focus size that predicts the probability of cancer at surgery. The present study aimed to validate this model in a prospective multicenter setting. - METHODS: Women with a recently diagnosed ABL on image-guided biopsy were recruited in 18 centers, before wire-guided localized excisional lumpectomy. Primary outcome was the negative predictive value (NPV) of the model. RESULTS: The NOMAT model could be used in 287 of the 300 patients included (195 with ADH). At surgery, 12 invasive (all grade 1), and 43 in situ carcinomas were identified (all ABL: 55/287, 19%; ADH only: 49/195, 25%). The area under the receiving operating characteristics curve of the model was 0.64 (95% CI 0.58-0.69) for all ABL, and 0.63 for ADH only (95% CI 0.56-0.70). For the pre-specified threshold of 20% predicted probability of cancer, NPV was 82% (77-87%) for all ABL, and 77% (95% CI 71-83%) for patients with ADH. At a 10% threshold, NPV was 89% (84-94%) for all ABL, and 85% (95% CI 78--92%) for the ADH. At this threshold, 58% of the whole ABL population (and 54% of ADH patients) could have avoided surgery with only 2 missed invasive cancers. CONCLUSION: The NOMAT model could be useful to avoid unnecessary surgery among women with ABL, including for patients with ADH. CLINICAL TRIAL REGISTRATION: NCT02523612.

Reducing the seroma volume by quilting suture after breast reconstruction with a latissimus dorsi flap: Single institutional experience.

INTRODUCTION: After breast reconstruction (BR) with latissimus dorsi flap (LDF) postoperative seroma is a frequent source of functional discomfort. The aim of this study was to evaluate the quilting suture on reducing the seroma volume by reducing the dead space created by LDF harvest for BR. MATERIAL AND METHODS: This retrospective monocenter study was designed to compare patients who underwent BR using LDF with or without quilting suture. The primary endpoint was the seroma volume drained during hospitalization and percutaneous puncture. Complications and painful or functional sequelae were also evaluated in both groups. RESULTS: One hundred eight patients were included in the study. The mean (standard deviation, SD) age of our population was 49.7 years (9.3) and the mean body mass index (BMI) 26.9kg/m2 (4.1). Sixty-nine patients (63%) underwent quilting suturing in the latissimus dorsi compartment, 41% with overedge and 59% with simple stitches. The mean total volume of fluid drainage was 1238mL (1111). In multivariate analysis, the use of quilting suture was associated with a significant reduction in the total volume of drainage (-502mL, P=0.03); reduction was greater using overedge stitches than simple stitches (P=0.02). The beneficial effect of quilting suture appears to be more important in patients with a BMI greater than 30kg/m2 (interaction test, P=0.01). CONCLUSION: This study shows the efficacy of quilting suture in reducing postoperative seroma formation in BR using LDF. Efficacy was greater when overedge stitches were used. Obese patients benefited more from quilting suture than patients with BMI<25.

Decision-making determinants for breast reconstruction in women over 65 years old.

Despite the positive effects that breast reconstruction (BR) has on quality of life, access to it remains limited for older women. The aim of this study was to identify decision-making determinants for BR in women over 65 years old, using a specifically designed questionnaire. We included in a case-control study 134 patients treated by mastectomy for breast cancer with or without BR in a cancer center performing BR. We showed higher motivation scores and quality of delivered information in the BR group. Surgeons are a key in convincing elderly patients that their age should no longer be an obstacle to BR.

[Ductal carcinoma in situ diagnosis: 3 French national guidelines]. / Diagnostic du carcinome canalaire in situ : 3 recommandations nationales françaises.

OBJECTIVE: Since the last guidelines published by the French National Cancer Institute (INCa) and the learning society "Société française de sénologie et de pathologie mammaire (SFSPM)" in 2009 about diagnosis and management of ductal carcinoma in situ, new data raised issues about overdiagnosis and its consequences, overtreatment. Therefore, an update was necessary, to provide healthcare professionals up-to-date guidelines and study therapeutic desescalation in particular. METHODS: The clinical practice guidelines development process is based on systematic literature review and critical appraisal by a multidisciplinary experts workgroup. The recommendations are thus based on the best available evidence and experts agreement. Prior to publication, the guidelines are also reviewed by more than 100 independent practitioners in cancer care delivery. RESULTS: This article presents French guidelines about MRI and vacuum assisted breast biopsy indications for DCIS diagnosis and the management of low-grade DCIS.

Clinical practice guidelines from the French College of Gynecologists and Obstetricians (CNGOF): benign breast tumors - short text.

Screening with breast ultrasound in combination with mammography is needed to investigate a clinical breast mass (Grade B), colored single-pore breast nipple discharge (Grade C), or mastitis (Grade C). The BI-RADS system is recommended for describing and classifying abnormal breast imaging findings. For a breast abscess, a percutaneous biopsy is recommended in the case of a mass or persistent symptoms (Grade C). For mastalgia, when breast imaging is normal, no MRI or breast biopsy is recommended (Grade C). Percutaneous biopsy is recommended for a BI-RADS category 4-5 mass (Grade B). For persistent erythematous nipple or atypical eczema lesions, a nipple biopsy is recommended (Grade C). For distortion and asymmetry, a vacuum core-needle biopsy is recommended due to the risk of underestimation by simple core-needle biopsy (Grade C). For BI-RADS category 4-5 microcalcifications without any ultrasound signal, a minimum 11-G vacuum core-needle biopsy is recommended (Grade B). In the absence of microcalcifications on radiography cores additional samples are recommended (Grade B). For atypical ductal hyperplasia, atypical lobular hyperplasia, lobular carcinoma in situ, flat epithelial atypia, radial scar and mucocele with atypia, surgical excision is commonly recommended (Grade C). Expectant management is feasible after multidisciplinary consensus. For these lesions, when excision margins are not clear, no new excision is recommended except for LCIS characterized as pleomorphic or with necrosis (Grade C). For grade 1 phyllodes tumor, surgical resection with clear margins is recommended. For grade 2 phyllodes tumor, 10mm margins are recommended (Grade C). For papillary breast lesions without atypia, complete disappearance of the radiological signal is recommended (Grade C). For papillary breast lesions with atypia, complete surgical excision is recommended (Grade C).

Shear Wave Elastography (SWE): An Analysis of Breast Lesion Characterization in 83 Breast Lesions.

Qualitative and quantitative shear wave elastography (SWE) criteria were assessed to differentiate between malignant and benign breast lesions. This prospective study included 83 lesions. SWE features measured included maximal stiffness values inside the lesion (E(lesion)) and in the peri-lesion area (E(perilesion)) and ratio values (R(lesion) and R(perilesion)) according to the formula E(lesion) or E(perilesion)/E(fat), with E(fat) corresponding to normal fatty tissue. We compared ultrasonography (B-mode), SWE and histologic sizes. With qualitative and quantitative SWE analysis, sensitivity was 94% and specificity 73%. Malignant lesions appeared more heterogeneous, with higher stiffness and ratio values than benign lesions (p < 0.001). For malignant lesions, SWE size was better correlated to histologic size than B-mode size. Using benign SWE signs to selectively downgrade category 4a and 4b lesions, the specificity improved from 13% to 51% without loss in sensitivity (100%) compared to ultrasound.

Implications of a two-step procedure in surgical management of patients with early-stage endometrioid endometrial cancer.

OBJECTIVE: Since European Society for Medical Oncology (ESMO) recommendations and French guidelines, pelvic lymphadenectomy should not be systematically performed for women with early-stage endometrioid endometrial cancer (EEC) preoperatively assessed at presumed low- or intermediate-risk. The aim of our study was to evaluate the change of our surgical practices after ESMO recommendations, and to evaluate the rate and morbidity of second surgical procedure in case of understaging after the first surgery. METHODS: This retrospective single-center study included women with EEC preoperatively assessed at presumed low- or intermediate-risk who had surgery between 2006 and 2013. Two periods were defined the times before and after ESMO recommendations. Demographics characteristics, surgical management, operative morbidity, and rate of understaging were compared. The rate of second surgical procedure required for lymph node resection during the second period and its morbidity were also studied. RESULTS: Sixty-one and sixty-two patients were operated for EEC preoperatively assessed at presumed low-or intermediate-risk before and after ESMO recommendations, respectively. Although immediate pelvic lymphadenectomy was performed more frequently during the first period than the second period (88.5% vs. 19.4%; p<0.001), the rate of postoperative risk-elevating or upstaging were comparable between the two periods (31.1% vs. 27.4%; p=0.71). Among the patients requiring second surgical procedure during the second period (21.0%), 30.8% did not undergo the second surgery due to their comorbidity or old age. For the patients who underwent second surgical procedure, mean operative time of the second procedure was 246.1±117.8 minutes. Third operation was required in 33.3% of them because of postoperative complications. CONCLUSION: Since ESMO recommendations, second surgical procedure for lymph node resection is often required for women with EEC presumed at low- or intermediate-risk. This reoperation is not always performed due to age/comorbidity of the patients, and presents a significant morbidity.

Ultrasound-guided high-intensity focused ultrasound treatment of breast fibroadenoma-a multicenter experience.

BACKGROUND: The aim of our multicenter study was to assess the clinical outcome and safety of ultrasound (US)-guided high-intensity focused ultrasound (HIFU) in patients with breast fibroadenoma (FA). METHODS: From May 2011 to February 2013, 42 women with 51 FA in one or both breasts were selected for treatment with US-guided HIFU. Eight of 51 FA were treated twice. Patients' age ranged from 16 to 52 years (mean 32 years). All patients with FA underwent core needle biopsy with histological confirmation. HIFU treatment was performed as an outpatient procedure under conscious sedation. Exclusion criteria were pregnant or lactating women, microcalcifications within the lesion at mammogram, history of breast cancer, previous laser or radiation therapy, and breast implant in the same breast. All patients signed written informed consent. After the treatment, follow-up US with volume evaluation was performed at 2, 6, and 12 months. RESULTS: The FA mean baseline volume was 3.89 ml (0.34-19.66 ml). At 2-month follow-up, the mean volume reduction was 33.2% ± 19.1% and achieved significance at 6-month (59.2% ± 18.2%, p < 0.001) and 12-month (72.5% ± 16.7%, p < 0.001) follow-up. Related side effects as superficial skin burn with blister-like aspect in three patients and hyperpigmentation over the treated area in one patient were transient and resolved spontaneously. In one patient, asymptomatic subcutaneous induration persisted at the end of the study. CONCLUSIONS: US-guided HIFU treatment is an effective noninvasive method for the treatment of breast FA and well tolerated by the patients. Preliminary results are encouraging and show that HIFU could be an alternative to surgery for breast FA.

[Genital prolapse surgery: state of the art of the vaginal approach]. / Le prolapsus génital état des lieux de la chirurgie par voie vaginale.

Treatment of genital prolapse is mainly surgical. The vaginal approach is a shorter procedure than the abdominal approach with a quicker resumption of activity for the patients. We describe different techniques which are most often performed in our daily practice. For the complete prolapse affecting the three components of the pelvic floor, we most often associate a colpohysterectomy, a native tissue reinforcement for the treatment of cystocele, sub-symphyseal crossing of the uterosacral ligaments using the technique of Campbell and finally a suspension of the vaginal vault according to Richter with a levator myorraphy. Currently, native tissues used in these techniques tend to be superseded in our service by reinforcement prosthetic implants, which according to the latest French Health Higher Authority guidelines (November 14, 2007) "could be of interest in relapse surgery, if a clinical element raises fears of high risk of recurrence." In any case, patients seeking a surgical treatment of their genital prolapse must be fully informed of the specific risk related to each technique. They must also be informed of the long-term results or of the lack of available data, regarding techniques using native tissue or prostheses.

Benefit of robot-assisted laparoscopy in nerve-sparing radical hysterectomy: urinary morbidity in early cervical cancer.

OBJECTIVE: To evaluate the feasibility of nerve-sparing radical hysterectomy in early cervical cancer by robot-assisted laparoscopy and atonic bladder rate. METHODS: This was a retrospective study with consecutive patients in three gynecological oncology departments. Patients with <2 cm cervical cancer had nerve-sparing radical hysterectomy by robot-assisted laparoscopy and pelvic lymphadenectomy. Two days after surgery, we systematically removed the Foley bladder catheter. RESULTS: The median (range) age and body mass index of the 30 patients were 44 (33-68) years and 23.9 (17.7-39.4) kg/m(2), respectively. The median (range) tumor diameter at the time of surgery was 13 (4-38) mm. The median (range) operative time, blood loss, and number of pelvic lymph nodes (any common iliac lymph nodes) were 305 (180-405) min, 100 (30-1,500) ml, and 18 (7-28). The overall complication rate was 52.3 %, of which 6.7 % atonic bladder. Twenty-eight patients (93.3 %) were discharged 2 days after surgery with spontaneous voiding and no residual urine >100 ml. CONCLUSIONS: Nerve-sparing radical hysterectomy by robot-assisted laparoscopy is feasible in early cervical cancer (<2 cm). A total of 93.3 % of the patients were discharged 2 days after surgery with spontaneous voiding. The next step would be a prospective study with objective urodynamic investigations.

Adenoid basal hyperplasia of the uterine cervix: a lesion of reserve cell type, distinct from adenoid basal carcinoma.

Adenoid basal hyperplasia is an underrecognized cervical lesion, resembling adenoid basal carcinoma, except the absence of deep invasion into the stroma. We report a series of 10 cases, all extending less than 1 mm from the basement membrane. Our results support the hypothesis that adenoid basal hyperplasia arises from reserve cells of the cervix. Lesions were found close to the squamocolumnar junction, in continuity with the nearby subcolumnar reserve cells. They shared the same morphology and immunoprofile using a panel of 4 antibodies (keratin 5/6, keratin 14, keratin 7 and p63) designed to differentiate reserve cells from mature squamous cells and endocervical columnar cells. We detected no human papillomavirus infection by in situ hybridization targeting high-risk human papillomavirus, which was concordant with the absence of immunohistochemical p16 expression. We demonstrated human papillomavirus infection in 4 (80%) of 5 adenoid basal carcinoma, which is in the same range as previous studies (88%). Thus, adenoid basal hyperplasia should be distinguished from adenoid basal carcinoma because they imply different risk of human papillomavirus infection and of subsequent association with high-grade invasive carcinoma. In our series, the most reliable morphological parameters to differentiate adenoid basal hyperplasia from adenoid basal carcinoma were the depth of the lesion and the size of the lesion nests. Furthermore, squamous differentiation was rare in adenoid basal hyperplasia and constant in adenoid basal carcinoma. Finally, any mitotic activity and/or an increase of Ki67 labeling index should raise the hypothesis of adenoid basal carcinoma.

Fetal microchimerism: benevolence or malevolence for the mother?

For a long time, the conventional view was that the fetus and maternal vascular system are kept separate. In fact there is a two way traffic of cells through the placenta and the transplacental passage of cells is in fact the norm. The fetal cells can persist in a wide range of woman's tissues following a pregnancy or an abortion and she becomes a chimera. Fetal cells have been found in the maternal circulation and they were shown to persist for the entire life in humans, thus demonstrating long-term engraftment and survival capabilities. Microchimerism is a subject of much interest for a number of reasons. Studies of fetal microchimerism during pregnancy may offer explanations for complications of pregnancy, such as preeclampsia, as well as insights into the pathogenesis of autoimmune diseases which usually ameliorate during pregnancy. The impact of the persistence of allogenic cells of fetal origin and of the maternal immunological response to them on the mother's health is still not clear. On the beneficial side, it has been proposed that genetically disparate fetal microchimerism provides protection against some cancers, that fetal microchimerism can afford the mother new mechanisms of protection to some diseases, that fetal microchimerism can enlarge the immunological repertoire of the mother improving her defense against aggressor. Fetal cells are often present at sites of maternal injury and may have an active role in the repair of maternal tissues.

Bacteriological analysis of meshes removed for complications after surgical management of urinary incontinence or pelvic organ prolapse.

The aim of this study is to examine the role of bacterial infection in complications following surgical management of urinary incontinence and genital prolapse using meshes. There were sixteen prostheses removed. Eight were monofilament polypropylene-knitted meshes, one was a silicone-coated polypropylene mesh, another was a collagen-coated polypropylene mesh, four were silicone-coated polyester meshes and two were polyester meshes. The most frequent cause for removal was symptomatic vaginal erosion (62%). Cultures were performed under aerobic, anaerobic and enrichment conditions. Infection was multimicrobial for 31% of meshes. When only one bacteria was found, it was Proteus mirabilis in 25% of cases. Forty-three per cent of bacterial quantifications were under 10(3) colony-forming units per millilitre. Bacterial contamination was found in all meshes, quantification was often low, and therefore, its exact role is not yet clear.

Study of the biomechanical properties of synthetic mesh implanted in vivo.

OBJECTIVE: The objective was to assess in an animal model the mechanical properties of five prostheses used for pelvic floor repair. STUDY DESIGN: Two months after pre-peritoneal implantation of the five types of prosthesis: Prolene, Prolene Soft, Mersuture, Vicryl and Vypro, we sacrificed the animals to measure retraction of the prosthesis, maximal resistance to traction, and maximal elongation. RESULTS: Non-absorbable prostheses retracted least. Forces at rupture were disparate with a significant difference in favor of Prolene (p<0.001). Resistance was variably affected by cicatrization. There were no significant differences in elongation. CONCLUSIONS: This study is an introductory exploration. Monofilament and macroporous propylene prostheses seem, after implantation, to have the best mechanical performance and best tissue integration. This underlines the need for experimental prostheses, which are increasingly used, but still lack the extensive evaluation needed by the surgeon. Knitted polypropylene seems to be one of the best materials at present, but is probably not sufficient.

Objective analysis of mechanical resistance of tension-free devices.

INTRODUCTION: The "tension-free" procedures are widely used by surgeons for the treatment of urinary incontinence and prolapse. The clinical results are largely in favour of these procedures. The aim of our study is to determine objectively the mechanical tissue resistance when using these techniques, before healing begins. MATERIAL AND METHODS: We measured the mechanical resistance using four different routes: the retro-pubic space, the transobturator, the translevator ani muscle and the trans-sacrospinous ligament. We compared five different meshes, TVT, IVS, Lift, Prolene and Prolene Soft. In order to study the effect of increasing dimensions, we tested Prolene tapes measuring 1, 1.5 and 2 cm in width. We performed traction tests on meshes implanted in cadavers. Measurements were made with a dynamometer and the results expressed in Newtons. RESULTS: This study shows that TVT offers a better resistance to traction via the retro-pubic space route. There was no significant difference among the four routes when the same type of mesh measuring 1cm was used. However, an increase in the dimensions of Prolene tapes improves their resistance in the tissues, thereby facilitating fixation before healing begins. Also, these increasing dimensions (in width) show that there is better resistance with the trans-sacrospinous ligament compared with the transmuscular one. DISCUSSION: The increasing size of prosthetic meshes does not show the superiority of certain routes with commercial meshes of 1cm in width. The higher resistance obtained with wider tapes is probably due to an increased surface area between the tissues and meshes. This increase in resistance does not seem to be important for the treatment of urinary incontinence. However, it should be of interest for the treatment of prolapse where traction and surface are more important. CONCLUSION: Two different recommendations can be deduced from our study. On one hand, the arms of prosthetic meshes for pelvic floor repair should measure more than 1cm in width in order to improve their maintenance in the tissues in the immediate post-operative period. On the other hand to improve fixation, the posterior arms of the transperineal mesh should be passed through the sacrospinous ligament rather than via the transmuscular route. The resistance of tissues is also influenced by the armature of the prosthetic mesh. They must therefore be developed commercially specifically for "tension-free" fixation. Our results need to be confirmed by further studies including more cadavers and younger patients.

Tissue integration and tolerance to meshes used in gynecologic surgery: an experimental study.

OBJECTIVE: To evaluate the tissue integration of and tolerance to five different mesh types used in genital prolapse surgery to provide mechanical support. STUDY DESIGN: We placed five different meshes (Vicryl, Vypro, Prolene, Prolene soft, and Mersuture) on the peritoneums of 12 pigs. After 10 weeks, we used light microscopy to analyze the tissue integration of and tolerance to these meshes. We looked for inflammation, vascularization, fibroblasts, collagen fibers and the organization of connective tissue. RESULTS: The absorbable prostheses made of polyglactin 910 (Vicryl) and the non-absorbable prostheses made of polypropylene (Prolene and Prolene soft) induced the least severe inflammatory reactions. Tissue integration was best with the polypropylene meshes, which allowed the development of a well-organized, fibrous, mature, connective tissue. CONCLUSION: The tissue response to prosthetic meshes depends on the material used and its structure. This work highlights the feasibility of carrying out experimental studies to test the tolerance to and integration of biomaterials used in gynecology. Such studies need to be carried out whenever new prostheses become available to validate their use in common practice.