Early Locoregional Breast Surgery and Survival in de novo Metastatic Breast Cancer in the Multicenter National ESME Cohort.

OBJECTIVE: The aim was to evaluate the impact of local surgery performed during the year after MBC diagnosis on patients' outcomes from a large reallife cohort. SUMMARY BACKGROUND DATA: Locoregional treatment for patients with MBC at the time of diagnosis remains debated. METHODS: Women with newly diagnosed, de novo stage IV MBC and who started MBC treatment between January 2008 and December 2014 in one of the 18 French Comprehensive Cancer Centers were included (NCT03275311). The impact of local surgery performed during the first year on overall survival (OS) and progression-free survival (PFS) was evaluated by the Cox proportional hazards model in a 12 month-landmark analysis. RESULTS: Out of 16,703 patients in the ESME database, 1977 had stage IV MBC at diagnosis, were alive and progression-free at 12 months and eligible for this study. Among them, 530 (26.8%) had received primary breast cancer surgery within 12 months. A greater proportion of patients who received surgery had less than 3 metastatic sites than the no-surgery group (90.8% vs 78.2%, P < 0.0001). Surgery within 12 months was associated with treatment with chemotherapy, HER2-targeted therapy (89.1% vs 69.6%, P < 0.0001) and locoregional radiotherapy (81.7% vs 32.5%, P < 0.0001). Multivariable analyses showed that surgery performed within 12 months was associated with longer OS and PFS (adjusted HR [95%CI] = 0.75 [0.61-0.92] and 0.72 [0.63-0.83], respectively), which were also affected by pattern and number of metastatic sites, histological subtype, and age. CONCLUSIONS: In the large ESME cohort, surgery within 1 year after de novo MBC diagnosis was associated with a significantly better OS and PFS.

Surgical management of soft tissue tumors of the abdominal wall: A retrospective study in a high-volume sarcoma center.

BACKGROUND: The aim of the study is to evaluate functional and oncological outcomes of patients undergoing abdominal wall soft tissue tumors (AWSTT) surgery. METHODS: All consecutive patients that underwent surgery for malignant and intermediate AWSTT from 1999 to 2019 were retrospectively analyzed. RESULTS: Ninety-two patients were identified, 20 (22%) operated on for a desmoid tumor and 72 (78%) for a soft tissue sarcoma (STS). Fifty-two patients (57%) had in toto resection of the abdominal wall (from the skin to the peritoneum) and 9 (10%) required simultaneous visceral resection. The closure was direct in 28 patients (30%) and requiring a mesh, a flap or a combination of the two in respectively 42, 16, and 6 patients (47%, 17%, 6%). The postoperative complications rate was 26%. Thirteen patients (14%) developed an incisional hernia after a median delay of 27 months. After a median follow-up of 40 months, out of the 72 patients operated on for STS, 7 (10%) developed local recurrence and 11 (15%) distant recurrence. The median recurrence-free and overall survivals were 61 and 116, months respectively. CONCLUSIONS: Management of AWSTT requires extensive surgery but allows good local control with an acceptable rate of incisional hernia.

Robotic Prophylactic Nipple-Sparing Mastectomy with Immediate Prosthetic Breast Reconstruction: A prospective Study of 138 Procedures.

Bachground: Robotic breast surgery is an emergent procedure with encouraging preliminary results. The aim of this study is to assess the feasibility and the safety of robotic nipple sparing mastectomy (RNSM) with immediate prosthetic breast reconstruction (IPBR). Methods: This is a prospective study including from December 2015 to January 2020 all RNSM surgeries with IPBR, in patients with moderate ptosis and A B or C cup. The primary endpoint was the rate of major necrosis. Secondary endpoints were conversion rate, postoperative complications (infections, hematoma, implant exposure), aesthetic results and quality of life. Results: 79 patients underwent 138 RNSM with IPBR. The average follow-up was 28 months. 2 procedures required conversion. Two cases of major necrosis occurred (1.4%). 9 surgical site infections were observed (6.5%), 4 infections could be treated with implant replacement. Unfortunately, 5 others resulted in implant loss. 4 other implant losses occurred: 2 due to major necrosis, and 2 due to periprosthetic capsula. In total, 9 implants were lost (6.5%). Esthetical results were mostly very satisfying and quality of life was not affected by the mastectomy. Conclusions: RSNM with IPBR was associated with low rates of major necrosis. It is a safe and reproducible procedure that allows breast reconstruction without visible scar.

Pregnancy after Breast Reconstruction.

Breast cancer is one of the most commonly diagnosed malignancies in women of childbearing age. One of the surgeries performed in the management of the disease is mastectomy , which might negatively affect body image and quality of life, and breast reconstruction is seen as a remedy to this problem. However, for the women who are interested in having children after treatment of breast cancer, the debate is whether they can have a successful pregnancy and delivery after breast reconstruction.

Robotic Prophylactic Nipple-Sparing Mastectomy with Immediate Prosthetic Breast Reconstruction: A Prospective Study.

BACKGROUND: Robotic nipple-sparing mastectomy (RNSM) could be a significant advancement in the treatment of breast cancers and prophylaxis because the mastectomy is performed without leaving any scar on the breast. The aim of this study was to assess the feasibility and the safety of RNSM with immediate prosthetic breast reconstruction (IPBR). METHODS: In this prospective study, RNSM with IPBR was offered to patients with breast cup size A, B or C and ptosis grade ≤ 2. In case of oncologic surgery, RNSM was proposed only if the tumor was located more than 2 cm away from the nipple-areola complex (NAC) and if postoperative radiation was not indicated. In case of prophylactic surgery, RNSM was proposed only if a high-risk genetic mutation had been identified. The primary endpoint was the rate of skin or NAC necrosis. The rate of conversion to open technique, the duration of the procedure, and postoperative complications were also analyzed. RESULTS: Sixty-three RNSM with IPBR were performed in 33 patients. There were no cases of mastectomy skin flap or NAC necrosis. We had to convert to an open technique in one case (1.6%). Three infections occurred (4.8%), one leading to implant loss (1.6%). No other major complications were observed. CONCLUSIONS: Preliminary data attest to the feasibility, the reproducibility, and the safety of this approach. However, long-term data are needed to confirm the oncological safety and the esthetic stability of the result. Trial registration identifier NCT02673268.

Robotic da Vinci Xi-assisted nipple-sparing mastectomy: First clinical report.

Nipple-sparing mastectomy (NSM) is increasingly popular for the treatment of selected breast cancers and prophylactic mastectomy. Surgical scarring and esthetic outcomes are important patient-related cosmetic considerations. Today, the concept of minimally invasive surgery has become popular, especially using robotic surgery. The authors report the first case of NSM using the latest version of the da Vinci Xi surgical system (Xi). The final incision used to remove the entire mammary gland was located behind the axillary line. In this position, hidden by the arm of the patient, the incision was not visible and was compatible with immediate breast reconstruction.

Jejunum free flap for head and neck reconstruction, a step-by-step surgical technique videos.

Circular pharyngolaryngectomy for oncologic resection requires a tubular reconstruction. Different options can be proposed to the patient: digestive free flap, fasciocutaneous flap, or musculocutaneous flap. The jejunum free flap is a tubular flap commonly used in esophageal and pharyngeal reconstruction with good functional outcomes and an acceptable rate of complications. Reconstruction with a jejunum free flap is an ideal choice. Patients at Gustave Roussy Institute (Villejuif, France) were offered a jejunum flap free flap for all circular pharyngolaryngectomies. The surgical technique is explained with a step-by-step video. The jejunum flap free flap has many advantages in circular pharyngolaryngectomy. This video article explains surgical steps for other teams.

Surgical cervicothoracic-flap repair of neoesophagus-airway fistula after esophagectomy for esophageal cancer: A retrospective cohort study.

Objective: To evaluate outcomes of surgical repair of postesophagectomy neoesophagus-airway fistulas (NEAFs). Methods: We retrospectively included consecutive patients with NEAF managed by various techniques at our center between August 2009 and July 2021. Result: Of the 11 patients (median age, 60 years; interquartile range, 58, 62), 4 had received induction chemoradiotherapy and 4 others induction chemotherapy. NEAF was mainly a complication of anastomotic leakage (n = 6) or attempted stenosis treatment (n = 3). The airway mainly involved was the trachea (n = 8). Airway defects were repaired by resection-anastomosis (n = 5), perforator flaps (n = 4), pedicled pericardium (n = 1), and/or direct suturing (n = 2). Gastric conduit defects were repaired by perforator flaps (n = 6), direct suturing (n = 2), or pedicled pericardium (n = 1). Of the 7 perforator flaps, 4 were internal mammary-artery, two dorsal intercostal-artery, and one supraclavicular-artery flaps. After a median follow-up of 100 months, 2 patients died on early postoperative course from NEAF repair failure and 3 from late NEAF recurrence at 4, 11, and 33 months. Among the remaining 6 patients, 1 died from local tumoral recurrence at 13 months, 1 was last on follow-up at 27 months, alive and eating normally. The other 4 were free from NEAF recurrence and dysphagia or swallowing disorder at 50 months' follow-up. These 4 results were obtained thanks to perforator flap interposition and airway resection anastomosis. Conclusions: Surgical NEAF repair using perforator flap interposition may provide satisfactory long-term function after strong prehabilitation.

Swallowing outcomes over time after total pharyngolaryngectomy and free flap reconstruction.

BACKGROUND: One of the challenges after total pharyngolaryngectomy (TPL) is to restore the swallowing function. The aim of this study was to compare swallowing outcomes between patients who underwent reconstruction with jejunum free flap (JFF) and other free flaps (OFFs). METHODS: This retrospective study included patients who underwent TPL and free flap reconstruction. The endpoints were the evolution of swallowing outcomes during the first five years after treatment assessed by the Functional Oral Intake Scale (FOIS), and outcomes associated with complications. RESULTS: One hundred and eleven patients were included, 84 patients in the JFF group and 27 in the OFF group. The patients in the OFF group experienced more chronic pharyngostoma (p = 0.001) and pharyngoesophageal stricture (p = 0.008). During the first year, a lower FOIS score tended to be associated with OFF (p = 0.137), and this result remained stable over time. CONCLUSIONS: This study suggests that JFF reconstruction provides better swallowing outcomes than OFF reconstruction, stable over time.

Latissimus dorsi free flap reconstruction of a temporal defect following pediatric oncologic surgery: Case report + literature review.

INTRODUCTION: Rhabdomyosarcoma (RMS) is the most common soft-tissue sarcoma in children and adolescents. Around 35 % of pediatric sarcomas occur in the head and neck region. Consequently, RMS is considered the most common type of childhood malignancy diagnosed in this region. OBSERVATION: We report the clinical case of a 6 years old patient, who presented a large temporal hollowing following oncological excision surgery for temporal rhabdomyosarcoma. He underwent surgical reconstruction to fill the right temporalis fossa using a latissimus dorsi muscle free flap micro-anastomosed to the lingual vessels. DISCUSSION: This clinical case highlights the value of plastic surgery in oncological reconstruction, which, combined with a multidisciplinary and collective approach, enables a holistic approach and facilitates socio-psychological integration after oncological surgery in the pediatric population.

Outcomes of mandibular reconstruction using three-dimensional custom-made porous titanium prostheses.

BACKGROUND: Our aim was to report the long-term outcomes of mandibular reconstruction using CAD-CAM-designed 3D-printed porous titanium implants in patients not amenable to a free vascularized fibula flap reconstruction. METHODS: The implants were designed with ProPlan CMF® 2.2 software and manufactured with a Selective Laser Melting (SLM) "layer-by-layer" 3D-printing of pure porous titanium powder beds. Primary endpoints were implant exposure and implant removal calculated using Gray's tests. Secondary endpoints were predictive factors of implant exposure and implant removal, and rates of dental rehabilitation. RESULTS: Thirty-six patients were operated between 2015 and 2017 and were included in this study. Reconstruction using a porous titanium 3D-printed implant was proposed due to medical contraindication for a fibula free flap (n = 13), due to the failure of a previous fibula free flap reconstruction (n = 7), or due to refusal of a fibula free flap reconstruction by the patient (n = 16). The medical indications for mandibular reconstruction were a primary tumor requiring mandibulectomy in nine patients, mandibular osteoradionecrosis requiring mandibulectomy in nineteen patients, and secondary reconstruction in eight patients. The 2-year rates of implant exposure and implant removal were 69.4% and 52.8%. Reconstruction of the symphysis was a high-risk exposure variable (OR 30; p = 0.0003). Only one patient underwent a successful dental rehabilitation. CONCLUSION: The use of a porous titanium 3D- implant for mandibular reconstruction in head and neck cancer patients resulted in high rates of implant exposure and of implant removal, notably when symphysis involvement.

Challenging a classic myth: pneumoperitoneum associated with acute diverticulitis is not an indication for open or laparoscopic emergency surgery in hemodynamically stable patients. A 10-year experience with a nonoperative treatment.

BACKGROUND: In patients presenting with acute diverticulitis (AD) and signs of acute peritonitis, the presence of extradigestive air (EDA) on a computer tomography (CT) scan is often considered to indicate the need for emergency surgery. Although the traditional management of "perforated" AD is open sigmoidectomy, more recently, laparoscopic drainage/lavage (usually followed by delayed elective sigmoidectomy) has been reported. The aim of this retrospective study is to evaluate the results of nonoperative management of emergency patients presenting with AD and EDA. METHODS: The outcomes of 39 consecutive hemodynamically stable patients (23 men, mean age = 54.7 years) who were admitted with AD and EDA and were managed nonoperatively (antibiotic and supportive treatment) at a tertiary-care university hospital between January 2001 and June 2010 were retrospectively collected and analyzed. These included morbidity (Clavien-Dindo) and treatment failure (need for emergency surgery or death). A univariate analysis of clinical, radiological, and laboratory criteria with respect to treatment failure was performed. Results of delayed elective laparoscopic sigmoidectomy were also analyzed. RESULTS: There was no mortality. Thirty-six of the 39 patients (92.3%) did not need surgery (7 patients required CT-guided abscess drainage). Mean hospital stay was 8.1 days. Duration of symptoms, previous antibiotic administration, severe sepsis, PCR level, WBC concentration, and the presence of abdominal collection were associated with treatment failure, whereas "distant" location of EDA and free abdominal fluid were not. Five patients had recurrence of AD and were treated medically. Seventeen patients (47.2%) underwent elective laparoscopic sigmoidectomy for which mean operative time was 246 min (range = 100-450) and the conversion rate was 11.8%. Mortality was nil and the morbidity rate was 41.2%. Mean postoperative stay was 7.1 days (range = 4-23). CONCLUSIONS: Nonoperative management is a viable option in most emergency patients presenting with AD and EDA, even in the presence of symptoms of peritonitis or altered laboratory tests. Delayed laparoscopic sigmoidectomy may be useless in certain cases and its results poorer than expected.

A twostep supraclavicular flap method in head and neck reconstruction for refractory osteoradionecrosis.

Techniques of reconstructive surgery of the head and neck region have existed since Antiquity, with the pedicled forehead flap of Susruta as a reference. These methods are constantly evolving, with the introduction of free flaps in the 1980s, and more recently new technologies such as CAD-CAM. However, the surgical management of patients treated by radiotherapy for upper airway cancers remains a challenge in terms of functional and aesthetic results. Indeed, cervical irradiation, which alters the quality of skin and vascular tissue, jeopardizes good healing after head and neck reconstructive surgery. In this article, the authors proposed to revisit the standard technique of the pedicled supraclavicular flap. Flap design inspired from the known and described technique of the two-stage forehead flap, for the management of a fragile patient with refractory mandibular osteoradionecrosis.

Delto-acromial artery perforator flap combined with a radial forearm free flap as a "vascular bridge" for nasal reconstruction.

Nasal reconstruction for total rhinectomy is challenging, especially if locoregional flaps are unavailable. Herein, we report the case of a nasal reconstruction combining a forearm free flap as "vascular bridge" and a Delto-Acromial Artery Perforator (DAAP) flap in its free form. The forearm free flap was used to restore missing elements of the nasal lining while the distal part of the radial pedicle has served as a donor vessel for the DAAP free flap which restores the nasal covering. A chondrocostal graft was used as a nasal framework. The nasal aspect at 24 months postop support the patient's satisfaction. The main advantages of the DAAP Flap are the pliability, relative hairless nature, skin thinness and its geographical proximity with the nose avoiding major dyschromia. Moreover, the anatomy consistency makes it easier to harvest, the underlying muscles are respected, and it allows for tension free primary closure without shoulder movement limitation.

Vestibuloplasty for immediate dental implantation in fibular free flap for oral cancer patients undergoing mandibulectomy reconstruction: A technical note.

Vestibuloplasty is fundamental to restore an oral vestibule for immediate dental implantation in fibular free flap (FFF) for oral cancer patients undergoing mandibulectomy reconstruction. Double surgical team including reconstructive head and neck surgeon and a dental surgeon is fundamental. The first step of the vestibuloplasty is to identify the skin perforator. The second step is to thin the FFF skin island as much as necessary to facilitate: i-the reinset into the gingivobuccal sulcus while creating enough space in the oral vestibule for the future dental prosthesis and ii-the exposition of dental implants. The third step is to create a percutaneous access to the implants through the FFF skin paddle using a dermatologic punch while preserving a large oral vestibule. The fourth step is the skin reinsertion into the gingivobuccal sulcus and closure. Realizing vestibuloplasty before radiotherapy allows prevention of soft tissue contraction and osteoradionecrosis while reducing the necessary time for a complete dental rehabilitation and improving patient quality of life.

Indications and Clinical Outcomes of Transoral Robotic Surgery and Free Flap Reconstruction.

We reviewed the indications, peroperative feasibility, and postoperative clinical outcomes of our first 50 consecutive patients who underwent free flap reconstruction after TORS for complex pharyngeal defects at our institution. We analyzed indications according to previous radiotherapy, the size of the resection, and the transoral exposure of critical structures. We reviewed surgical data, postoperative complications, and functional outcomes comprising tracheostomy and alimentation management. Indications were upfront surgery (34%), a second primary surgery after radiotherapy (28%), or salvage surgery after chemoradiotherapy failure (38%). Localizations were the tongue base (44%), tonsillar fossa (28%), pharyngeal wall (22%), and soft palate (6%). T-classifications were T1 (6%), T2 (52%), T3 (20%), and T4 (22%). The mean length of the surgery was 574 min. Two patients were intraoperatively converted to a conventional approach at the beginning of the learning curve. In conclusion, TORS and free flap reconstruction in complex situations were associated with low rates of postoperative complications and satisfactory functional outcomes. They were, however, associated with a renewed learning curve.

Thoracodorsal artery perforator free flap with vascularized thoracodorsal nerve for head and neck reconstruction following radical parotidectomy with facial nerve sacrifice: Step-by-step surgical technique video.

Oncological surgery of the parotid region sometimes requires the sacrifice of the facial nerve (parotid cancers, extensive skin cancers of the face, soft tissue sarcomas). The sacrificed portion of nerve can be reconstructed by a vascularized nerve graft, especially if the patient must undergo radiotherapy after surgery. In those cases, the facial nerve sacrifice is associated to an important loss of substance from the parotid region (skin, masseter, parotid, and sometimes jaw). Chimeric flap permit the reconstruction at the same time of the external skin, soft tissues for the volume (fat or muscle), nerve, and bone (ramus and angular part of the mandible). An other option was to raise two flaps but it increased the risk of failure (time of surgery, number of anastomosis, etc.). Reconstruction with a chimeric flap appears to be an ideal choice. Based on these observations, we offer our patients at the Gustave Roussy Institute (Villejuif, France) a thoracodorsal artery perforator (TDAP) free flap including the motor nerve of the latissimus dorsi and vascularized by the thoraco-dorsal pedicle, thus allowing reconstruction in a single surgery. The surgical technique is explained with a step-by-step video. Functional outcomes are also shown in the video. The TDAP or chimeric scapulo-dorsal flap with vascularized nerve has many advantages in the facial reanimation of patients suffering from parotid region cancers. This video article explains surgical steps for other teams.

Locoregional Control and Survival in Children, Adolescents, and Young Adults With Localized Head and Neck Alveolar Rhabdomyosarcoma-The French Experience.

INTRODUCTION: The head and neck (HN) are the most frequent sites of pediatric rhabdomyosarcoma (RMS). Alveolar RMS (ARMS) represents ~20% of all RMS cases and frequently spread to lymph nodes (LNs). The aim was to report locoregional control, event-free survival (EFS), and overall survival (OS), according to clinical and pathological features, LN staging, and treatment modalities. METHODS: The study included all patients prospectively enrolled in EpSSG RMS 2005 study under 21 years of age with localized HN ARMS and diagnosed between 2005 and 2016 in France. Medical data including imaging, surgical report, and radiation therapy planes were analyzed. RESULTS: Forty-eight patients (median age 6 years; range 4 months-21 years), corresponding to 30 parameningeal and 18 non-parameningeal ARMS, were included. There were 33 boys (69%). Tumor locations included the following: orbit (n = 7) among which four cases had bone erosion, paranasal sinuses and nasal cavity (n = 16), deep facial spaces (n = 10), nasolabial fold (n = 8), and other non-parameningeal HN sites (n = 7). A fusion transcript of PAX3-FOXO1 or PAX7-FOXO1 was expressed in 33 of the 45 cases (73%) with molecular analysis. At diagnosis, 10 patients had primary resection of the primary tumor (PRPT) (none with microscopic complete resection) and 9 had LN staging. After induction chemotherapy, 26 patients (54%) had secondary resection of the primary tumor (SRPT) and 13 patients (27%) had cervical LN dissection. A total of 43 patients (90%) were treated with radiation therapy.With a median follow-up of 7 years (range 2-13 years), 5-year OS and EFS were 78% (95% CI, 63-88%) and 66% (95% CI, 51-78%), respectively. We observed 16 events (10 deaths): 4 local, 4 regional, 1 local and regional, and 7 metastatic. In univariate analysis, OS was only superior for patients under 10 years of age (p = 0.002), while FOXO1-negative ARMS, SRPT for parameningeal ARMS, and LN surgery were associated with significantly better EFS. CONCLUSION: Our study confirms a better outcome for fusion-negative ARMS and ARMS in children under 10 years. Moreover, LN surgery and SRPT of parameningeal tumor may improve EFS of ARMS. Larger studies are needed to confirm our findings.

Robotic Nipple-Sparing Mastectomy with Immediate Prosthetic Breast Reconstruction: Surgical Technique.

Robotic nipple-sparing mastectomy could be a significant advancement in the treatment and prophylaxis of selected breast cancers. Motion-scaling, high-resolution, three-dimensional optics; tremor elimination; and instruments with enhanced precision with 7 degrees of freedom have allowed surgeons to overcome the limitations experienced with the endoscopic approach in breast surgery. Advantages of this procedure, in comparison with the open technique, are a shorter and more acceptable scar located in the lateral thoracic region, and greater respect for the vascularization of the mastectomy skin flap, because there is no incision on the breast and no retractors are used. The authors recently received approval from both the French health authorities and the ethics committee to carry out a clinical trial in their institution to assess feasibility, reproducibility, and safety of robotic nipple-sparing mastectomy with immediate prosthetic breast reconstruction. The aims of this article are to describe the surgical technique they have developed, and to share, through a video, the clinical experience gained from over 60 procedures performed so far.

Revisiting vascular contraindications for transoral robotic surgery for oropharyngeal cancer.

OBJECTIVE: We analyzed the outcomes for patients with a retropharyngeal internal carotid artery (ICA) who underwent a transoral robotic surgery (TORS) procedure involving a cervical-transoral robotic oropharyngectomy course with free flap reconstruction. METHODS: Patients were included in the prospective multicentric trial NCT02517125. These patients were scheduled to undergo surgery for an oropharyngeal localization. By pre-operative CT scan and MRI it was determined that they had a retropharyngeal internal carotid artery. RESULTS: Three patients had a retropharyngeal ICA: a patient with a 35 mm synovial sarcoma of the tonsillar fossa, a patient with a T2N2b squamous-cell carcinoma (SCC) of the glossotonsillar sulcus, and a patient with a T3N0 SCC of the tonsillar fossa in a previously irradiated field. These patients encountered neither preoperative nor postoperative complications. CONCLUSIONS: In our experience, TORS for oropharyngeal cancers appears to be feasible in patients with a retropharyngeal ICA, provided that the procedure has been adapted for complex situations. LEVEL OF EVIDENCE: 4.