Quality of life after mastectomy with or without immediate breast reconstruction.

BACKGROUND: Mastectomy with immediate breast reconstruction (IBR) is a surgical strategy in breast cancer when breast-conserving surgery is not an option. There is a lack of evidence showing an advantage of mastectomy plus IBR over mastectomy alone on health-related quality of life (QoL). METHODS: A large prospective multicentre survey, STIC-RMI (support of innovative and expensive techniques - immediate breast reconstruction), was undertaken to study the changes in QoL in patients treated by mastectomy with or without IBR. Patients were recruited between 2007 and 2009. European Organisation for Research and Treatment of Cancer QLQ-C30 and QLQ-BR23 instruments were used to assess QoL before operation, and at 6 and 12 months after surgery. A propensity score was used to compare QoL between mastectomy alone and mastectomy plus IBR, with limited bias. RESULTS: A total of 595 patients were included from 22 French academic hospitals, of whom 407 (68·4 per cent) underwent IBR. One-year data were available for 71·1 per cent of patients. Factors associated with IBR were age, histological tumour type, palpable nodes and an attempt at breast-conserving surgery. At inclusion, QoL was significantly better in the IBR group (P < 0·001) and there was no significant change in either group during 1 year compared with baseline. Results for the QLQ-BR23 functional dimension varied according to propensity score quartiles; IBR had no influence in the lowest quartile. In the upper quartiles, QoL increased slightly over the year among patients who had IBR, whereas it decreased among those who had mastectomy alone (P = 0·037). Satisfaction with the cosmetic outcome strongly influenced QoL, especially in upper quartiles (P < 0·001). However, an unsatisfactory outcome after IBR was still considered a better condition than simple mastectomy. CONCLUSION: The QoL benefit provided by IBR depends on patients' life status at inclusion; young active women with an in situ tumour are more likely to preserve their QoL after IBR.

Cost comparison of axillary sentinel lymph node detection and axillary lymphadenectomy in early breast cancer. A national study based on a prospective multi-institutional series of 985 patients 'on behalf of the Group of Surgeons from the French Unicancer Federation'.

BACKGROUND: Our objective was to assess the global cost of the sentinel lymph node detection [axillary sentinel lymph node detection (ASLND)] compared with standard axillary lymphadenectomy [axillary lymph node dissection (ALND)] for early breast cancer patients. PATIENTS AND METHODS: We conducted a prospective, multi-institutional, observational, cost comparative analysis. Cost calculations were realized with the micro-costing method from the diagnosis until 1 month after the last surgery. RESULTS: Eight hundred and thirty nine patients were included in the ASLND group and 146 in the ALND group. The cost generated for a patient with an ASLND, with one preoperative scintigraphy, a combined method for sentinel node detection, an intraoperative pathological analysis without lymphadenectomy, was lower than the cost generated for a patient with lymphadenectomy [€ 2947 (σ = 580) versus € 3331 (σ = 902); P = 0.0001]. CONCLUSION: ASLND, involving expensive techniques, was finally less expensive than ALND. The length of hospital stay was the cost driver of these procedures. The current observational study points the heterogeneous practices for this validated and largely diffused technique. Several technical choices have an impact on the cost of ASLND, as intraoperative analysis allowing to reduce rehospitalization rate for secondary lymphadenectomy or preoperative scintigraphy, suggesting possible savings on hospital resources.

[Mastectomy and immediate breast reconstruction using a prosthesis and lower dermal flap: description of five cases]. / Mastectomie avec reconstruction immédiate par prothèse et lambeau inférieur dermique : à propos de cinq cas.

INTRODUCTION: When performing mastectomy involving immediate reconstruction with prosthesis, it is required to obtain a complete cover of the implant. However, this is hardly ever possible for patients having a significant breast volume, despite the use of the skin-reducing technique. Using the lower dermal flap makes it possible to fully cover the implant for these patients. PATIENTS AND METHODS: We will describe five cases of patients on whom skin-reducing mastectomy and immediate reconstruction with prosthesis and lower dermal flap were performed. Preoperative drawings were made following the so-called "Saint-Louis" pattern. During surgery, the future skin flap representing the skin cover of lower breast quadrants was de-epidermised. Mastectomy was then performed via an incision at the upper limit of the future flap. Then, a retro-pectoral pocket was created by lifting the pectoralis major muscle. The implant was introduced into this pocket and covered up at its lower part by the dermal flap, the upper edge of which was sutured to the lower edge of the pectoralis major muscle. The implant was thereby fully covered. Finally, the skin was closed with inverted T-scars. RESULTS: Postoperative effects were minor. Two patients suffered from skin pain at the junction between the vertical and horizontal scars of the inverted T. These injuries were treated via healing by secondary intention. We have not observed any infection. Cosmetic results assessed by the patients and surgical team were considered as satisfactory. CONCLUSION: Mastectomy with immediate reconstruction using a prosthesis and lower dermal flap makes it possible to fully cover the implant in patients who require the skin-reducing technique. This technique seems to minimise the risk of major complications and generates satisfactory cosmetic results.

Prognostic factors in 1,038 women with metastatic breast cancer.

BACKGROUND: Treatment of metastatic breast cancer (MBC) remains palliative. Patients with MBC represent a heterogeneous group whose prognosis and outcome may be dependent on host factors. The purpose of the present study was dual: first, to draw up a list of factors easily available in everyday clinical practice requiring no sophisticated or costly methods and second, to provide results from a large cohort of women who underwent diagnostic and treatment at a single institution. PATIENTS AND METHODS: From 1975 to 2005, a total of 1,038 women with MBC during their follow-up were included in this retrospective analysis. Patients were subsequently assigned to five groups according to the period of metastatic diagnosis. RESULTS: It is shown that age at initial diagnosis, hormonal receptor status and site of metastasis are the most relevant prognostic factors for predicting survival from the time of metastastic occurrence. It is also shown that a metastasis-free interval is an easily and immediately available multifactorial prognostic index reflecting the multiparametric variability of the disease. CONCLUSION: These fundamental observations may assist physicians in evaluating the survival potential of patients and in directing them toward the appropriate therapeutic decision.

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.

[Accelerated partial breast irradiation using interstitial high dose rate brachytherapy: preliminary clinical and dosimetric results after 61 patients]. / Irradiation insterstitielle partielle et accélérée du sein de haut débit de dose: résultats préliminaires cliniques et dosimétriques sur 61 patientes.

PURPOSE: Among all the accelerated and partial breast irradiation (APBI) techniques, low then high dose rate, interstitial brachytherapy (HDIB) was the first to be used in this field. This study presents the preliminary clinical and dosimetric results of the APBI using HDIB, performed in Antoine Lacassagne Cancer Center of Nice. PATIENTS AND METHODS: From June 2004 to March 2008, 61 patients (37 primary tumors and 24 second conservative treatments after local recurrence) presenting with T1-2 pN0 non-lobular invasive breast carcinoma, underwent lumpectomy with sentinel lymph node dissection and intraoperative tube placement for HDIB. Dose distribution analysis, using dose-volume histograms, was achieved based on a postoperative CT scan. A comparative dosimetric study was performed between optimized (O) and non-optimized (NO) dose distribution. Then, based on conformal index calculation, a novel index was proposed taking into account not only the conformity but also the homogeneity of HDIB implant. An analysis of dose gradient impact on HDIB biological equivalence dose was also conducted. Statistical analysis used T test confirmed by Wilcoxon test for cohort including less than 30 patients. RESULTS: The comparative dosimetric analysis between O and NO dose distributions shown that conformity indexes (conformal index, conformal number, and D90%) were significantly increased after optimization. Improving conformity leads to increasing hyperdosage volumes (V150% and V200%). A new index named conformity and homogeneity index (CHI) including V150% values, modified the conformal index. A total dose of 34 Gy, delivered through HDIB in 10 fractions over five days was biologically equivalent to 41.93 Gy assuming alpha/beta = 4 Gy and 75.76 Gy if the dose gradient was considered in the calculation. CONCLUSIONS: HDIB is considered as one of the best IPAS technique. HDIB allows dose distribution optimization, skin spearing and accurate clinical target volume definition. Furthermore, HDIB dose gradient could play a key role for breast cancer local control.

Early versus late local recurrences after conservative treatment of breast carcinoma: differences in primary tumor characteristics and patient outcome.

OBJECTIVES: To investigate whether some aspects of patient or tumor characteristics influence the timing of local recurrence (LR) in breast cancer treated conservatively, and to assess the impact of the timing of LR on patient outcome. METHODS: A retrospective analysis was conducted on patients treated with conservative breast surgery followed by radiotherapy for breast carcinoma who developed LR. Out of 2,008 cases treated in our Institute between 1977 and 2002, 180 ipsilateral LR were observed. Of these, 46 LR were observed within 36 months after treatment, called early local recurrence (ELR), 44 developed between 37 and 60 months, called medium local recurrence (MLR), and 90 occurred after 60 months, called late local recurrence (LLR). Patient and tumor characteristics were analyzed in the 2 groups and compared. RESULTS: Primary tumors >20 mm were more frequently found in patients with ELR (31%) than in patients with LLR (17%, p = 0.047). Grade 3 tumors were more often encountered in patients with ELR than in patients with LLR (27 versus 7%, p = 0.0002). Patients with ELR more frequently had tumors with negative estrogen receptors than patients with LLR (37% versus 6%, p < 0.0001). There was no statistically significant difference in the axillary lymph node (LN) status between patients with ELR and those with LLR (35 and 23% of positive LN, respectively, p = 0.24). Tumor size, grade, LN status, hormone receptors and the timing of LR affected the specific survival (SS) from initial surgery. On multivariate analysis, only LN status and the timing of LR retained an independent prognostic value, with an odds ratio of 6.7 for ELR. After LR, the SS was also influenced by all of the above factors, and on multivariate analysis, LN status, hormone receptors and the timing of LR were independent predictors with an odds ratio of SS of 2.50 in case of ELR (p = 0.006). The 5-year SS after LR for ELR, MLR and LLR were 55.8, 74.8 and 79.5%, respectively. CONCLUSIONS: Unfavorable tumor characteristics such as big size, high grade, lack of hormone receptors, but not LN status, were associated with ELR. These findings suggest that patients with such aggressive tumor characteristics who do not recur early will have a lower risk of LLR than patients with more favorable factors.

[Sternalis muscle in breast surgery]. / Le muscle sternalis: derrière quel sein se cache-t-il?

The sternalis muscle is a normal anatomic variant, which exists in about 5 to 8% of people. It runs longitudinally superficial to pectoralis major, alongside the sternum. Although the sternalis seems common in cadaveric studies, physicians are not familiar with it, which may lead to confusion in diagnosis. Occasionally, the sternalis may be misinterpreted as a breast mass on mammogramm. In that case, computed tomography and magnetic resonance imaging are useful. We report herein two cases of sternalis muscles encountered during mastectomy.

[Role of imaging in the evaluation of axillary nodes and metastatic disease from breast carcinoma]. / Imagerie dans le bilan d'extension ganglionnaire et métastatique du cancer du sein.

Disease staging of patients with breast cancer is based on the probability of metastatic disease, the reliability of complementary examinations, and therapeutic possibilities, evaluated on a cost/benefit basis. For regional disease staging, nodal status can be assessed by ultrasound, and the value of this approach can be optimized by imaging-guided biopsies. Ultrasound examination of nodes upstream of the sentinel node allows determination of the utility of this node and the indications for axillary resection. Work-up of metastatic spread is performed only after evaluation of risk factors for metastasis. Prior to therapy, and in the absence of any clinical warning signs for resectable tumors, there are no indications for imaging, which is reserved solely for locally advanced tumors.

Intraoperative radiological margin assessment in breast-conserving surgery.

UNLABELLED: A prospective study was lead in order to analyze the accuracy of an X-ray device settled in the operating room for margin assessment, when performing breast-conserving surgery. PATIENTS AND METHODS: One hundred and seventy patients were included. All lesions were visible on the preoperative mammograms. An intraoperative X-ray of the lumpectomy specimen was systematically performed for margins assessment. Final histological data were collected and the accuracy of intraoperative specimen radiography (IOSR) for margin assessment was analyzed. RESULTS: IOSR allowed an evaluation of margins status in 155 cases (91.2%). After final histological examination, the positive margins rate would have been 6.5% if margin assessment had relied only on IOSR. CONCLUSION: Margin assessment with a two-dimensional X-ray device would have allowed the achievement of negative margins in 93.5% of the cases. Moreover, this procedure allows important time-saving and could have a substantial economical impact.

MRI for the size assessment of pure ductal carcinoma in situ (DCIS): a prospective study of 33 patients.

OBJECTIVE: To determine whether MRI assesses the size of ductal carcinomas in situ (DCIS) more accurately than mammography, using the histopathological dimension of the surgical specimen as the reference measurement. MATERIALS AND METHODS: This single-center prospective study conducted from March 2007 to July 2008 at the Antoine-Lacassagne Cancer Treatment Center (Nice, France) included 33 patients with a histologically proven DCIS by needle biopsy, who all underwent clinical examination, mammography, and MRI interpreted by an experienced radiologist. All patients underwent surgery at our institution. The greatest dimensions of the DCIS determined by the two imaging modalities were compared with the histopathological dimension ascertained on the surgical specimen. The study was approved by the local Ethical Research Committee and was authorized by the French National Health Agency (AFSSAPS). RESULTS: The mean age of the 33 patients was 59.7 years (± 10.3). Three patients had a palpable mass at clinical breast examination; 82% underwent conservative surgical therapy rather than radical breast surgery (mastectomy); 6% required repeat surgery. MRI detected 97% of the lesions. Non-mass-like enhancement was noted for 78% of the patients. In over 50% of the cases, distribution of the DCIS was ductal or segmental and the kinetic enhancement curve was persistent. Lesion size was correctly estimated (± 5 mm), under-estimated (<5mm), or over-estimated (>5mm), respectively, by MRI in 60%, 19% and 21% of cases and by mammography in 38%, 31% and 31% (p = 0.05). Mean lesion size was 25.6mm at histopathology, 28.1mm at MRI, and 27.2mm on mammography (nonsignificant difference). The correlation coefficient between histopathological measurement and MRI was 0.831 versus 0.674 between histopathology and mammography. The correlation coefficient increased with the nuclear grade of the DCIS on mammography; this coefficient also increased as the mammographic breast density decreased. CONCLUSION: MRI appears to assess the size of DCIS better than mammography by limiting the number of under- and over-estimations compared to histopathology findings.

[Second conservative radiosurgical treatment for ipsilateral breast cancer recurrence]. / Second traitement conservateur radiochirurgical dans les récidives locales du cancer du sein.

PURPOSE: Currently, radical mastectomy represents the gold standard for ipsilateral breast cancer recurrence. However, we already showed that a second conservative treatment was feasible combining lumpectomy plus low-dose rate interstitial brachytherapy. In this study, we reported the preliminary results of a second conservative treatment using a high-dose rate brachytherapy. PATIENTS AND METHODS: From June 2005 to July 2009, 42 patients presenting with an ipsilateral breast cancer recurrence underwent a second conservative treatment. Plastic tubes were implanted intra-operatively at the time of the lumpectomy. After a post-implant CT scan, a total dose of 34 Gy in 10 fractions over 5 consecutive days was delivered through an ambulatory procedure. The toxicity evaluation used the Common Terminology Criteria for Adverse Events v3.0. RESULTS: The median follow-up was 21 months (6-50 months), median age at the time of the local recurrence was 65 years (30-85 years). The median delay between the primary and the recurrence was 11 years (1-35 years). The location of the recurrence was in the tumor bed for 22 patients (52.4%), in the same quadrant for 14 patients (33.3%) and unknown for six patients (14.3%). The median tumor size of the recurrence was 12 mm (2-30 mm). The median number of plastic tubes and plans were nine (5-12) and two (1-3) respectively. The median CTV was 68 cm(3) (31.2-146 cm(3)). The rate of second local control was 97%. Twenty-two patients (60%) experienced complications. The most frequent side effect consisted in cutaneous and sub-cutaneous fibrosis (72% of all the observed complications). CONCLUSION: A second conservative treatment for ipsilateral breast cancer recurrence using high-dose rate brachytherapy appears feasible leading to encouraging results in terms of second local control with an acceptable toxicity. Considering that a non-inferiority randomized trial comparing mastectomy versus second conservative treatment could be difficult to perform, what proof level will be necessary to achieve in order to change the medical procedures?

[Uterine rupture due to unrecognized uterine scarring]. / Rupture utérine sur utérus cicatriciel méconnu.

Uterine rupture affecting the pregnant uterus has become rare. It occurs essentially in the presence of scarring. The cases reported here described rupture following evacuation curettage which had caused an unrecognized uterine perforation. While such perforations often have no serious consequences, this explaining the usual abstention from treatment, it is nevertheless important that acute complications (intestinal or vascular trauma) or long term (uterine rupture of pregnant uterus) should not pass unrecognized.