[Resection of the thoracic wall in oncology]. / La résection de la paroi thoracique en cancérologie.

Based on our experience with 12 patients who underwent wide anterior chest wall resection in our institute, we attempt to define the indication of the different techniques for reconstruction by musculo-cutaneous flaps according to the extent of resection and location in the chest wall. The pectoralis major flaps are simple and important in the reconstruction of sternal defects; especially when dense retrosternal fibrosis has already developed after radiotherapy. The latissimus dorsi flaps are reliable and thick and suitable for coverage of major tissue loss. A new technique is also described for reconstruction of major anterolateral chest wall defects as well as sternal defects by a latissimus dorsi osteo-muscular flap. The external oblique musculo-cutaneous flaps are used to cover defects in the lateral chest wall below the 5th rib. Pedicled omental flaps are complementary flaps and can be used when muscle flaps are insufficient to replace significant tissue loss. Respiratory problems arising from paradoxical chest wall movement are temporary and may be encountered in the immediate post-operative period. Because of the development of fibrosis and of a better adaptation of the patient, this condition is well tolerated during the month following operation.

[Treatment of radiation necrosis of skin, muscle and bone in oncology]. / Le traitement des radionécroses de plans de couverture en cancérologie.

Following the wide excision of radiation necrosis, the treatment of these lesions has been transformed by the use of the myocutaneous flap technique. The most widely used, flaps are latissimus dorsi flaps for chest wall, subclavicular defects, pectoralis major flaps for defects of the neck and lower part of the face, fascia lata flaps to treat lesions of the groin and lower abdominal wall, gracilis flaps for perineal defects, gluteus maximus flaps for the ischial and sacral region. Due to their good blood supply and their thickness, they can be used to repair large defects and they ensure very good protection against infection. Omentum can be useful when a myocutaneous flap cannot be performed or in association with this flap. Good cosmetic results can be obtained with free myocutaneous flaps for lesions located on the head or on the limbs. Such flaps require micro vascular anastomoses.

Using the costal muscle flap with latissimus dorsi muscle to repair full-thickness anterior chest wall defects.

Musculoosseous flaps with latissimus dorsi muscle are used for reconstruction of full-thickness anterior chest wall defects. The 11th and 12th ribs and the posterior parietal pleura are elevated with the latissimus dorsi muscle. The blood supply of the compound flap comes from the thoracodorsal pedicle and from perforating segmental vessels. The posterior thoracic wall island is transferred to the anterior chest wall defect to restore a skeletal plane and the transposed latissimus dorsi obliterates all the dead spaces that cannot be collapsed. The latissimus dorsi compound flap with the 11th and 12th ribs appears to be a "safe" procedure to reconstruct full-thickness anterior chest wall defects.

[Isolated increase in the bleeding time: the hemorrhagic risk and therapeutic problems]. / Allongement isolé du temps de saignement: risque hémorragique et problème thérapeutique.

An isolated increase of the bleeding time is rare. In the young, there may exist a history of bleeding disorders such as epistaxis. In middle age, the increased risk of bleeding during surgery is low but real, and depending on the type of surgery. There are many drugs responsible for increased bleeding time; these must be avoided: the principle that one haemostatic defect is often well tolerated whereas two are not is very real. So the management of such patients during surgery must be meticulous and the use of some drugs must be avoided. Careful surgical management with regard to haemostasis undoubtedly allows many patients with this sort of defect to undergo surgery without excessive bleeding. Some treatments are possible (e.g. steroids, DDAVP), but their routine use is not warranted.

Prognostic value of the topographic grid method in women with T2 N- breast cancer. Statistical results from a series of 203 patients.

In 1977, the authors described the grid method, a topographic technique for mapping the microscopic spread of breast cancer. The current report describes the relapse-free survival of a series of 203 patients with T2 N- mammary cancer (T2 N0 N1 ab N-) who were treated by mastectomy and regional lymph node dissection and have been followed since 1974. A good prognosis did not prevent relapse in 15% to 20% of patients within the first 5 years. To determine whether the grid method can identify patients at high risk within this group, disease-free survival and survival were compared in two subsets, a "limited" group (L) and a "diffuse" group (D). The difference between the two groups was statistically significant for both parameters (88%) versus 77% and 93% versus 85% after 5 years) (P less than 0.01 and P less than 0.02). Other prognostic measures were uniformative. Thus, the grid method has a good prognostic score when compared with the factors usually measured--menopausal status, estrogen receptors, histologic type--and could be used to select appropriate adjuvant therapy in breast cancer.