Autologous latissimus breast reconstruction: a 3-year clinical experience with 100 patients.

This article presents our technique of autologous breast reconstruction using the latissimus dorsi flap and studies the advantages, disadvantages, and results that can be expected. A consecutive sample of 100 patients was studied. The average length of follow-up was 20 months (range 8 to 44 months), and all of the subjects were reviewed in consultation without loss to follow-up. The supplementary volume of the latissimus dorsi was obtained from five fatty zones: fat on the cutaneous paddle, fat taken from the surface of the muscle, the scapular fat pad, the anterior fatty zone, and the supra-iliac fat pad. This technique must be measured against the transverse rectus abdominis muscle (TRAM) flap, free or pedicled, when the patient needs an autologous breast reconstruction. It can be used when the TRAM flap is contraindicated (this corresponds to 45 percent of patients of our sample) or when the dorsal donor site is preferred (55 percent of cases of our sample). The major complications are rare (1 percent partial necrosis and 1 percent total necrosis of the flap). The minor complications are represented mainly by the dorsal seroma. This is the main drawback of the technique, as it occurs in 79 percent of cases and regularly in obese patients. In view of this frequency, patients should be warned of its likely occurrence. The dorsal donor-site morbidity is relatively low; 4 percent of dorsal sequelae were classed as moderate, and 96 percent were considered low. The scapular sequelae have been classed as low in 97 percent of cases, and temporary scapular sequelae aggravation has been noted in 3 percent. Results of breast reconstruction using this technique are most encouraging. The level of patient satisfaction is high; 87 percent of them were deeply satisfied, 10 percent were satisfied, and only 3 percent were poorly satisfied. This group of poorly satisfied subjects (3 percent) consists of patients who suffered a serious postoperative complication. The aesthetic results have been judged excellent by surgeons in 85 percent of the cases, good in 12 percent of the cases, and poor in 3 percent of the cases; no result has been judged bad. This technique of breast reconstruction by autologous latissimus dorsi brings a major advance in breast reconstruction. The best indications of this technique are when one can bury the cutaneous paddle: cases of skin-sparing mastectomy, cases where the latissimus dorsi flap can be combined with an abdominal advancement flap, and cases of conversion of implant reconstruction to an autologous reconstruction.

[Breast reconstruction with the autologous latissimus dorsi flap. Preliminary report of 60 consecutive reconstructions]. / Reconstruction mammaire par lambeau de grand dorsal sans prothèse. Expérience préliminaire à propos de 60 reconstructions.

Many women who have undergone or will undergo mastectomy request breast reconstruction and feel that it is an important part of their total cancer treatment. Autogenous tissue methods take a place more and more important in breast reconstruction. The autologous latissimus dorsi flap, is a recent method of autologous breast reconstruction. We have done a retrospective study based on a series of 60 consecutive reconstructions operated between march 1993 and april 1995. The advantages of the autologous latissimus dorsi flap are the same of the others autologous breast reconstruction methods: the reconstructed breasts are soft and match an opposite normal breast more successfully than those made with implants. The disadvantages of this technique is mainly the dorsal seroma that was observed in 70% of cases but was easily managed by aspirations. The aesthetics results have been judged by two surgeons as very good in 85% of cases, good in 11.6% and low in 3.3%. The satisfaction rate of the patients in high: 86.6% are pleased and 13.3% are satisfied. The autologous latissimus dorsi breast reconstruction is a safe and reliable technique and provides an excellent alternative to the TRAM flap, when the patient prefer the dorsal donor site or when there are some risk factors to do a TRAM flap. Finally this technique bring a major advance in the field of breast reconstruction, immediate or delayed.

[Endometrial cancer and tamoxifen. Discussion apropos of a series of cases]. / Cancer de l'endomètre et tamoxifène. Discussion à partir d'une série de cas.

Tamoxifen is widely used nowadays in the management of breast cancer, having established its efficacy in this indication, especially for postmenopausal patients with ER-positive breast tumours. However, tamoxifen has recently been recognized as carcinogenic for the human endometrium, probably with an effect of duration of treatment. Moreover, this drug may be associated with the occurrence of endometrial cancers of unusual histological types and/or of a more aggressive nature. We describe a case series of 11 patients who developed such cancers after having previously received tamoxifen for breast cancer. Several assumptions on the mechanisms underlying the attributed carcinogenic properties of tamoxifen, for the endometrium and potentially for other organs, are discussed on the basis of current knowledge.

Radiation induced sarcomas following treatment for breast cancer: presentation of a series of 14 cases treated with an aggressive surgical approach.

According to the criteria established by Cahan et al., we report 14 radiation induced sarcomas occurring in the treated volume after radiation therapy for adenocarcinoma of the breast. All these sarcomas were treated by wide surgical resection. In spite of a macroscopic free margin, only patients who underwent major amputation could hope to be cured. All the centrally located sarcomas recurred.

[Angiosarcoma of the breast. Apropos of 4 cases with a review of the literature]. / L'angiosarcome du sein. A propos de quatre cas avec revue de la littérature.

Four cases of angiosarcoma of the breast were treated at Centre Léon-Bérard in Lyon. It is a rare malignant vascular tumor, constituting < 1% of all primary breast lesions. Radical local surgery is the treatment of choice; however, local recurrences and metastases are frequently observed. The 3-year disease-free survival rate is < 15%. The role of irradiation and adjuvant chemotherapy remains to be evaluated. Doxorubicin-ifosfamide-GM CSD gave a positive response in one case with metastases.

[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.

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.

Results of combined chemosurgical therapy for pulmonary metastases.

The authors study the results of the combined surgery and postoperative chemotherapy, for treatment of pulmonary metastases. At Léon-Bérard Center, 50 patients have been operated on since 1963. The sites and histologies of the primitive cancers are varied, corresponding to 12 epidermoid cancers, 12 adenocarcinomas, 10 osteogenic sarcomas, 1 Ewing's tumor, 3 malignant melanomas, 6 testicular tumors, and 4 others. The total survival rate is 30% in 4 years. The prognosis is influenced by different factors, which are studied. It depends on the histology of the primitive cancer and the type of the pulmonary excision. It is suggested that postoperative chemotherapy improves the results. It appears that the longer the free interval is between the treatment of the primitive cancer and the discovery of the pulmonary metastasis, the better the prognosis. The correlation between the time lapse of the free interval and the survey after pulmonary excision is studied. The conclusions of the authors are: The association of surgery and chemotherapy improves the results and enforces the indications for surgical excision of pulmonary metastases.