Sphincter-saving surgery after neoadjuvant therapy for ultra-low rectal cancer where abdominoperineal resection was indicated: 10-year results of the GRECCAR 1 trial

This phase III trial included patients with ultra-low rectal adenocarcinoma that initially required abdominoperineal resection. The surgical decision was based on clinical tumour status after preoperative treatment. The overall sphincter-saving resection rate was 85 per cent, with 72 per cent rate of intersphincteric resection. Long-term results showed that changing the initial abdominoperineal resection indication into a sphincter-saving resection according to tumoral response is oncologically safe.

Saving the sphincter

Abstract P4-13-02: Exclusive fat grafting breast reconstruction after mastectomy: Aesthetic results, satisfaction and quality of life evaluation on 38 patients

Background: Autologous fat grafting has become a frequent, simply reproducible and low-risk technique in breast reconstruction. The potential risk of fat tissue transfer to the breast for oncologic patients remains to be discussed, but one must clearly distinguish the situation where there is a breast parenchyma left and where the whole gland has been removed, like in our study. Although lipotransfer has become very popular, only a limited number of case series have been reported up to date. The presented study evaluates aesthetic results and quality of life after exclusive fat grafting breast reconstruction.

Patients and methods: A retrospective study was performed in two French centers with five surgeons between February 2011 and June 2015. We included patients with prior breast cancer, treated by mastectomy and with a finished breast reconstruction with exclusive fat grafting. We excluded patients with implant or flap. For each patient, the aesthetic evaluation was threefold, performed by the patient, the surgeon and an extra person, using the same questionnaire. For the analysis of the cosmetic results, the patients, surgeons and the other person were asked to grade the result on a 0 to 10 scale, ranging from "very bad" to "very good". They were questioned about the global esthetic result, symmetry between the two breasts and reconstructed breast texture. Satisfaction was evaluated using a Breast-Q adapted questionnaire, elaborated by psycho-oncologists and surgeons. Quality of life was evaluated using WHOQOL-BREF 26. Statistical analysis was performed using stata 13.1 SE.

Results: We sent a questionnaire to 48 patients and we obtained 38 responses. The mean age of the patients was 52 years, 31 patients (81,6%) lived in couple and 29 patients (76,3%) were employed. We performed 190 fat grafting procedures with an average of 4,2 per patient. The mean total quantity of fat injected was 904 ml per patient with a mean quantity per procedure of 219 ml. The mean time between two procedures was 4,3 months. The average grade obtained for the global esthetic result was 7,3 +/- 1,8 out of 10 for patients, 7,6 +/-2 for the extra person and 7,9 +/- 1,4 for surgeons. For symmetry between the two breasts, the result was 7,1 +/- 1,9 and for the texture, it was 6,8 +/- 2,6. To the question "did the final result meet your expectations?” 81,5% (31/38) of the patients and 79% (30/38) of the surgeons said yes. Among the 29 patients having a professional activity, 86% (25/29) of patients were able to work between each fat grafting session. The handicap evaluation in the professional life for these patients from 0 "no handicap "to 10 " important handicap” showed a score of 2,24 +/-2,7. As for global quality of life evaluation, to the question: "how would you grade your quality of life?" 92,3 % (35/38) of the patients answered "good" or "very good" (vs. 72,0 % in the general population - p = 0.004).

Conclusion: Autologous fat grafting can be offered as a good alternative for total reconstruction after mastectomy with good aesthetic results and no deleterious impact on quality of life.

Citation Format: Bordes V, Simorre M, Campion L, Lejeune F, Loirat Y, Dravet F, Bouffaut A-L. Exclusive fat grafting breast reconstruction after mastectomy: Aesthetic results, satisfaction and quality of life evaluation on 38 patients [abstract]. In: Proceedings of the 2017 San Antonio Breast Cancer Symposium; 2017 Dec 5-9; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2018;78(4 Suppl):Abstract nr P4-13-02.

Abstract P2-01-33: Non-sentinel lymph nodes involvement in early breast cancer patients: Performance of two predictive nomograms integrating the analysis of sentinel nodes by one step nucleic acid amplification in a cohort of 299 patients

Backgrounds: Sentinel lymph node (SLN) biopsy is a highly accurate predictor of axillary status and has become the surgical axillary standard in breast cancer patients. About 50–70 % of patients with involved SLN have no additional non sentinel node (NSN) involved, suggesting that it be possible to avoid ALND in selected patients. Many tools have been developed to help surgeons in NSLN evaluation but they all need pathological data from tumor and SLN and can't be used during surgery. Developed for intraoperative detection of SLN macro or micrometastasis involvement, the semi-automated molecular one step nucleic acid amplification (OSNA), as accurate as pathology, is available. Two simple nomograms have been developed to predict NSN involvement based on the number of CK19 mRNA copy determined by OSNA:

· Nomogram developed by Peg V (Eur J Surg Oncol 2013): based on total tumoral load (TTL). TTL is defined as the addition of CK19 mRNA copies of each positive SLN (copies/μL). A TTL≥1.2 × 10(5) copies/ml (specificity=85.3%, negative predictive value (NPV) = 80%) can predict NSN involvement.

· Nomogram developed by Di Filippo F (Journal of Experimental & Clinical Cancer Research 2015): based on the number of CK19 mRNA copies and ultrasound tumor size. These two variables are categorized using quartiles with a score for each and the addition of both corresponds to a probability of NSN involvement (sensitivity = 98.1%, NPV = 92.5 %).

Patients and Methods: this is a retrospective study of 299 patients. Each patient had SLN involvement (macro or micrometastasis) and underwent a complementary ALND. The main objective was to evaluate the performance of each nomogram using a discrimination ability model, assessed by ROC analysis. Predictive accuracy was measured by the area under ROC curves (AUC) reported with its 95 % confidence interval. The second objective was to compare the two nomograms using Hanley & McNeil method, to test the statistical significance of the difference between the AUC. Analysis was performed using stata 13.1 SE.

Results: The mean age was 59, 1 year. Most patients were treated for an infiltrating ductal carcinoma (80.3%, 240/299). The mean ultrasound tumor size was 13 mm and the mean pathological tumor size was 15 mm. The median number of examined SLN was 2 with a macro-metastasis in 67, 6%, 202/299). 70 patients had involved nodes in ALND (23%).

The discrimination of N Peg, quantified with AUC was 0.685 (p<0, 00001). The discrimination of N Di Filippo, quantified with AUC was 0.72 (p<0, 00001).

Hanley & McNeil method shows that Di Filippo nomogram is significantly superior to Peg nomogram (p=0,048).

Conclusion: The current study shows that these two nomograms are reliable and can be used to predict NSLN involvement. The combination of molecular data and ultrasound tumor size seems to be more efficient than molecular data alone. These results are similar to results of nomogram studies based on pathological analysis but only these nomograms integrating molecular data can be used during the surgery.

Citation Format: Bordes V, Campion L, Jezequel P, Lefrancois A, Boiffard F, Brillaud-Meflah V, Dravet F, Jaffre I, Classe J-M. Non-sentinel lymph nodes involvement in early breast cancer patients: Performance of two predictive nomograms integrating the analysis of sentinel nodes by one step nucleic acid amplification in a cohort of 299 patients [abstract]. In: Proceedings of the 2016 San Antonio Breast Cancer Symposium; 2016 Dec 6-10; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2017;77(4 Suppl):Abstract nr P2-01-33.

Abstract P3-14-04: Exclusive fat grafting breast reconstruction after mastectomy: Feasibility and complications on 54 patients

Backgrounds: Autologous fat grafting has become a frequent, simply reproducible and low-risk technique in breast reconstruction. The potential risk of fat tissue transfer to the breast in oncologic patients remains to be discussed, but one must clearly distinguish the situation where there is a breast parenchyma left and where the whole gland has been removed, like in our study. Although lipotransfer has become very popular, only a limited number of case series have been reported up to date. The presented study describes an optimized treatment and complications for breast reconstruction after total mastectomy by lipotransfer alone.

Patients and methods: A retrospective study was performed in two French centers with five surgeons between February 2011 and June 2015, including 54 patients. Inclusion criteria were patients with prior breast cancer, treated by mastectomy and with a finished breast reconstruction with exclusive fat grafting. Exclusion criteria were prior reconstruction with implant or flap. We used two technics for liposuction: manual aspiration with syringes (pouret kit®) or waterjet assisted liposuction (body-jet®). The BRAVA® could be combined with the reconstruction. Our study had 2 main objectives: evaluate the factors influencing the number of surgical procedures and study the complications and carcinologic evolution. Statistical analysis was performed using stata 13.1 SE.

Results: We included 54 patients, 49 delayed reconstructions including two bilateral reconstructions and 5 immediate reconstructions. The morphologic data showed: a normal BMI for 70,3 % (38/54) patients and a bra cup A or B for 72,2 % (39/54). 39 patients had radiotherapy during the cancer treatment and the mean time between radiotherapy and reconstruction was 19 months. For the patients without radiotherapy, the mean time between mastectomy and reconstruction was 22 months. 6 patients (11%) were smoker or diabetic. We used manual aspiration in 37 patients (68,5 %) and hydro dissection in 17 patients (31,5%). 10 patients received BRAVA system in complement. We performed 231 fat grafting procedures with an average of 4,2 per patient. The mean total quantity of fat injected was 904 ml per patient with a mean quantity per procedure of 219 ml. The mean time between two procedures was 4,3 months. Only the prior radiotherapy treatment increases the number of fat grafting procedures significantly (p=0,02) and the use of hydro dissection with bodyjet decreases the number of fat grafting procedures significantly (p=0,04). We observed one failure of procedure requiring an implant and three patients with metastatic disease without local recurrence with a mean follow of 5, 2 years. We also observed 3% of infectious complications (7/231) and 19 patients presented fat necrosis (34%). Of these 19 cases of fat necrosis, 6 (11 %) required a surgery.

Conclusion: Autologous fat grafting can be proposed as an alternative for total reconstruction after mastectomy with a low level of complications and no local recurrence in our study. Only anterior radiotherapy increases the number of procedures probably due to fibrosis and lack of cutaneous flexibility.

Citation Format: Bordes V, Campion L, Lejeune F, Loirat Y, Boiffard F, Brillaud-Meflah V, Dravet F, Bouffaut A-L. Exclusive fat grafting breast reconstruction after mastectomy: Feasibility and complications on 54 patients [abstract]. In: Proceedings of the 2016 San Antonio Breast Cancer Symposium; 2016 Dec 6-10; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2017;77(4 Suppl):Abstract nr P3-14-04.

Changes in quality of life after a diagnosis of cancer: a 2-year study comparing breast cancer and melanoma patients

PURPOSE

Longitudinal studies addressing change in health-related quality of life (HRQoL) following a diagnosis of cancer have mainly focused on a single cancer type, and little is known about the differences in HRQoL over time according to the type of tumor. The current study aims to compare the change in HRQoL over 2 years following breast cancer or melanoma diagnosis and socio-demographic variables associated with HRQoL over time.

METHODS

Patients recently diagnosed with breast cancer (n = 215) or melanoma (n = 78) completed surveys within 1 month of diagnosis and 6, 12, and 24 months later. Multilevel modeling analyses were used to compare the evolution over time of HRQoL dimensions, as measured by the EORTC QLQ-C30, in both cancers. Longitudinal effect of socio-demographic variables on HRQoL was also assessed.

RESULTS

Consistent with the literature, both cancer patients experienced decreased HRQoL scores following the diagnosis before improving over time. However, our analyses revealed that this rebound effect may occur at diverse times over the course of the illness according to the type of cancer. In addition, HRQoL over time was positively associated with age and negatively related to living with a partner regardless of the type of cancer.

CONCLUSIONS

The results of the present study suggest that support in hospital units should be specific and depend on the cancer type.

Characteristics and clinical outcome of T1 breast cancer: a multicenter retrospective cohort study

BACKGROUND

A subgroup of T1N0M0 breast cancer (BC) carries a high potential of relapse, and thus may require adjuvant systemic therapy (AST).

PATIENTS AND METHODS

Retrospective analysis of all patients with T1 BC, who underwent surgery from January 1999 to December 2009 at 13 French sites. AST was not standardized.

RESULTS

Among 8100 women operated, 5423 had T1 tumors (708 T1a, 2208 T1b and 2508 T1c 11-15 mm). T1a differed significantly from T1b tumors with respect to several parameters (lower age, more frequent negative hormonal status and positive HER2 status, less frequent lymphovascular invasion), exhibiting a mix of favorable and poor prognosis factors. Overall survival was not different between T1a, b or c tumors but recurrence-free survival was significantly higher in T1b than in T1a tumors (P = 0.001). In multivariate analysis, tumor grade, hormone therapy and lymphovascular invasion were independent prognostic factors.

CONCLUSION

Relatively poor outcome of patients with T1a tumors might be explained by a high frequency of risk factors in this subgroup (frequent negative hormone receptors and HER2 overexpression) and by a less frequent administration of AST (endocrine treatment and chemotherapy). Tumor size might not be the main determinant of prognosis in T1 BC.

[Diagnostic laparoscopy in gynecological cancer, prophylactic oophorectomy: feasibility study on 22 cases]

OBJECTIVES

The purpose of our study was to assess the feasibility of outpatient laparoscopy in a cohort of 22 patients admitted for bilateral oophorectomy (n=11) and preoperative diagnostic laparoscopy (n=11).

PATIENTS AND METHODS

Between December 2012 and May 2013, we included 22 patients in our study. All selected patients received a questionnaire the day before surgery. The questionnaire consisted of chapters on intraoperatively, and the postoperative assessments of patients regarding a possible return home on the evening of surgery. The ability to output was measured with the score of Chung at the evening of surgery and in the morning before leaving.

RESULTS

The mean age of patients was 60 years. The average length of stay was 1.2 days. Postoperative pain tends to be higher in the morning in the bilateral oophorectomy group (P=0.06), nausea and vomiting are the same in both groups. In the bilateral oophorectomy group, six patients were able to go out and five wished it; in the diagnostic laparoscopy group nine patients were able to go out and two wished it, this difference was significant (P=0.041).

DISCUSSION

The outpatient hospital is the norm for many surgeries. In our study, 47% of patients able to go out wishing that output. This difference is important when comparing the two groups. There are more patients wishing an output in the oophorectomy group. This reduction in length of stay must be compensated by a medical and paramedical supervision at home.

CONCLUSION

A large number of surgical procedure are performed on an outpatient basis. Patients who underwent diagnostic laparoscopy are more fragile, they should receive active postoperative support to enable an outpatient hospital.

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.

[Oncologic, functional, and aesthetics results; evaluation of the quality of life after latissimus dorsi flap breast reconstruction. About a retrospective series of 450 patients]

Retrospective assesssment from 1998 to 2005 from women who have a breast reconstruction by autologus latissimus flap or by latissimus flap and silicone breast implant for differed breast reconstruction (DBR) or mastectomy and immediate breast reconstruction (MIBR).

PATIENTS AND METHOD

Analysis of oncologic results on 450 patients. Analysis of aesthetic, functional results and of quality of life by an anonymous questionnaire in the non progressive patients (407): 263 appraisable answers (13 DBR, 127 MIBR). Middle age: 49.8 years.

RESULTS ONCOLOGIC

Forty-three patients (9.5%) had a relapse of their disease, 33 patients died (7.2%). The relapse of the disease was done in the form of metastasis alone: 29 (67.4%), metastasis and local recurrence: three (7%), local recurrence only: four (9.3%), not specified: seven (16.3%). The average time between the breast reconstruction and the relapse was 18.25±15.4 months.

AESTHETIC RESULTS

The overall assessment is of 7.68/10. There is no statistical difference between immediate reconstruction and delayed reconstruction. A total of 11.2% patients considered it to be bad (<5/10). The symmetry between the two breasts in time is of 6.6/10 and 19.9% patients considered it to be bad (<5/10). The scar ransom, considered to be most important, is mostly in the back (4.1/10) then on the controlateral breast and then the breast reconstruction. This ransom is not easily acceptable in 15 to 20% of the patients.

FUNCTIONAL RESULTS

The discomfort and the pain prevail above all in the back (3.56 and 2.59/10). Weaker symptoms in the event of immediate reconstruction than delayed reconstruction. We noted that 77.2% had kinesitherapy after surgery and 18.9% continues to have kinesitherapy, long time after surgery, mainly for massages of the back. The handicap is considered to be overall low 2.5/10 but 10% of the patients keep a feeling of important handicap (>7.5/10).

QUALITY OF LIFE RESULTS

Seventy-one of the patients are serene. The discomfort to wear a bathing suit or to look at bare-chested is low (2.59 and 2.44/10). However 8.9% are in a very discomfort to see themselves bare-chested and 17.6% to show themselves to their spouse, with an impact on their emotional and sexual life in 36.4% of the cases. There is no significant difference between MIBR and DBR but on the other hand according to the judgement of the woman of her aesthetic result. A total of 95.7% do not regret having made this breast reconstruction.

CONCLUSION

This study makes it possible to concentrate on the group of non satisfied patient for better determining the causes and the improvements of the surgical techniques to bring but also the overall surgical management of the patient even if most of the patients were mainly satisfied with their breast reconstruction.

[Patient follow-up after treatment for breast cancer]

Patient follow-up after treatment for a breast cancer is based on the local recurrence risk. Annual mammography remains the main point of this follow-up and tumor markers detection has still no interest. Absence of benefit of an intensive clinical, biological and radiological surveillance has been proved for a long time but expert recommendations still are a subject of discussion although they knew no evolution for more than 10 years. Evolution of those follow-up modalities will depend on the future indications of MRI and PET. About distant recurrence, a better knowledge of the risk is now possible thanks to the tumor biological profile study. Nevertheless, intensification of follow-up for some kind of high-risk tumors will have interest only if we can propose a therapeutic alternative in metastatic situation.

[Uterine abnormalities in non menopausal women who received tamoxifen for breast cancer adjuvant therapy]

OBJECTIVE

To elaborate a strategy of endometrial follow-up for premenopausal women treated with Tamoxifen as adjuvant hormonal treatment of breast cancer.

PATIENTS AND METHODS

Retrospective study of 152 premenopausal patients treated with Tamoxifen in Nantes Comprehensive Cancer Center for a breast cancer from January 2003 to December 2005. Vaginal sonography was used in the follow-up of 70 of them.

RESULTS

Endometrial hypertrophy was found in 26 patients. Sonohysterography and hysteroscopy allowed to find 11 polyps and three hyperplasias in the 19 women who were investigated. In our study, endometrial pathology was found in 20% of premenopausal women treated with Tamoxifen (polyps or hyperplasia). Uterine bleeding was found in half patient of this group.

DISCUSSION AND CONCLUSION

Vaginal sonography monitoring could be proposed to premenopausal women treated with Tamoxifen among whom endometrial pathology is usual.

[Sentinel node detection applied to breast cancer: 2007 update]

The technique of detection and resection of the sentinel lymph node applied to early breast cancer management aims to spare the patient with a low risk of lymph node involvement an unnecessary axillary lymphadenectomy. This innovating technique lies on the double hypothesis of an accuracy to predict non sentinel lymph node status and to induce a lower morbidity when compared with axillary lymphadenectomy. This multidisciplinary technique depends on surgeons, nuclear physicians and pathologists. In practice sentinel lymph nodes are detected thanks to two types of tracers, the Blue and the colloids marked with technetium, harvested by the surgeon guided by the blue lymphatic channel and the use of a gamma probe detection, analyzed by the pathologist according to a particular procedure with the concept of serial slices, and possibly immuno histo chemistry. The objectives of this review are to specify the state of knowledge concerning the different steps: detection, surgical resection and the pathological analysis of the sentinels lymph nodes and to focus on validated and controversial indications, and on the main ongoing trials.

Sphincter preserving surgery after preoperative treatment for ultra-low rectal carcinoma. A French multicenter prospective trial: GRECCAR 1

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Background: GRECCAR 1 is a phase III randomised multicenter trial which compared two preoperative treatments for low rectal carcinoma which should be classicaly treated by abdominoperineal resection (Eligibility: distance between the tumor [T] and the levator ani [LA] less than 2 cm). Methods: Between 2001 and 2005, 207 patients with rectal adenocarcinomas were included in 13 French centers. The average distance between the tumor and the levator ani was 0.8 cm. 72% of the tumors were classified T3 with 60% of N1 on pre treatment endorectal ultrasonography. The mean lenght of the tumors was 5 cm on colonoscopy. Preoperative treatment randomisation was made between high dose radiation (HDR: 45 + 18 Gy: 106 patients) and radio-chemotherapy (RTCT: 45 Gy + 5FU continuous infusion: 101 patients). All surgeons performed homogeous technique for intersphincteric resection. Results: Conservative rate was 83% (HDR) and 86% (RTCT) (p: 0.64) with 84% (140/168) of intersphincteric resection. Conservative rate did not differ according to the distance T-LA: 0 cm: 84% / 1–2 cm: 84% and 3 cm: 91%. No post operative mortality was noticed with a 15% post operative morbidity rate, same in the two arms. Sterilized specimen rate was respectively 7% and 12.5% (p: 0.29), the mean inferior safety margin and radial margin was 1 cm and 4 mm, same in the two groups as the 90% R0 resection rate. On specimen, nodal involvement rate was 5.6% for pT0–1, 29% for pT2 and 56% for pT3–4. No difference was seen for down-staging between the two groups (p: 0.59). With a 22 months follow up, we noticed 92% rate of stoma closure in the conservative group. Seven patients had a local recurrence and 25 metastases with 12 patient’s death. Conclusions: GRECCAR 1 is the first prospective randomized trial which shows an 85% rate of sphincter conservative surgery due to down staging induced by preoperative tretament. No significant difference was seen between HDR and RTCT with a trend for more morbidity in the first group. Intersphincteric resection is a safe technical procedure in order to preserv the striated sphincter with sufficient lateral and inferior margins.

No significant financial relationships to disclose.

Randomized clinical trial comparing axillary padding with closed suction drainage for the axillary wound after lymphadenectomy for breast cancer

Background

After axillary lymphadenectomy for breast cancer, a suction drain is routinely inserted into the axilla to prevent seroma formation. This drain is an obstacle to reducing hospital stay after breast-conserving surgery. This was a prospective randomized clinical trial to assess the safety and results of axillary padding without the use of a drain.

Methods

Between May 2001 and August 2003, 100 women were randomly allocated axillary padding without a drain or with the use of an axillary suction drain. Prospective assessments were made of morbidity, pain, shoulder mobility, quality of life and medical costs including length of hospital stay.

Results

Using axillary padding significantly reduced the mean (s.d.) length of hospital stay (1·8(1) versus 4·5(2) days, P &lt; 0·001). Postoperative complications, pain, shoulder mobility and quality of life were similar in the two groups. There was no difference in the duration of the two procedures.

Conclusion

Axillary padding after axillary lymphadenectomy was feasible and safe, without a drain, and shortened hospital stay.

Negative influence of delayed surgery on survival after preoperative radiotherapy in rectal cancer

OBJECTIVE

In Europe, until recently the standard treatment for locally advanced rectal cancer was preoperative radiotherapy (RT). The objective of this study was to evaluate the influence on survival of intervals between diagnosis and treatment.

PATIENTS AND METHODS

The influence on survival of intervals between diagnosis and surgery (Dg-Surg), diagnosis and initiation of RT (Dg-Rad), and completion of RT and surgery (Rad-Surg) was evaluated in a retrospective series of patients treated with preoperative RT. Between 1991 and 1998, 102 patients received treatment with preoperative RT without concomitant chemotherapy at the René Gauducheau Cancer Center. Patients generally received 45 Gy (80%) in 25 fractions over 35 days for T2-T3-T4 N0-N1 M0 rectal adenocarcinoma located mainly (62.7%) in the lower third of the rectum (< or = 5 cm from anal margin). Thirty-five pN1 patients were treated with postoperative chemotherapy. Differences between survival were assessed by the log-rank test, and prognostic factors by the Cox test.

RESULTS

Median time was 14.7 weeks for Dg-Surg, 4.6 weeks for Dg-Rad and 5.1 weeks for Rad-Surg. Median follow-up from diagnosis was 57.4 months. Five-year local relapse-free survival was 83.9%, metastasis-free survival 64% and overall survival 60.8%. No factor was predictive of tumour response to RT. Log-rank and multivariate analysis showed that overall survival was significantly influenced by lower-third tumours, pT, pN and Dg-Surg (poorer survival when > or = 16 weeks: OR = 2.59, P = 0.005). Metastasis-free survival correlated significantly with Dg-Surg (> or = 16 weeks: OR = 2.05, P = 0.05).

CONCLUSION

An interval of more than 16 weeks between diagnosis and surgery may reduce overall survival of patients treated with preoperative RT for locally advanced rectal cancer. Surgery should be performed shortly after completion of RT for patients with no possibility of sphincter preservation, or a minimal risk of morbidity from an abdominoperineal excision.

Post-operative care and patient satisfaction after ambulatory surgery for breast cancer patients

AIM

This study aimed to evaluate patient information provided, the management of post-operative symptoms and post-operative care, and patient satisfaction with ambulatory breast surgery over a 1-year period.

METHODS

From January to December 2000, all breast cancer patients undergoing conservative breast surgery were offered surgery as an outpatient procedure at the Ambulatory Surgery Unit.

RESULTS

Two hundred and thirty six patients underwent outpatient surgery. None were readmitted during the first night or the first week. Two hundred and nineteen patients completed a questionnaire. One hundred and sixty nine patients (group 1) underwent wide local excision (WLE) and 50 (group 2), WLE and axillary lymphadenectomy. Patients in group 2 experienced more pain at discharge from the hospital (p < or = 0.01) and during the first week after discharge (p < or = 0.00001) than patients in group 1. The mean overall satisfaction score was 8.97 on a scale of 1-10. Post-operative information provided by the surgeon before discharge from the hospital was rated 8.90 on a scale of 1-10 while information provided by the nurse was rated 9.33 (p < 0.0001).

CONCLUSION

Ambulatory surgery for breast cancer patients is safe and popular with patients, however, post-operative pain presents problem.

The Impact of Nonvisualization of Sentinel Nodes on Lymphoscintigraphy in Breast Cancer

BACKGROUND

This study aimed at evaluating the relationship between the nonvisualization of sentinel nodes (SNs) at lymphoscintigraphy and the intraoperative detection rate, radioactive counts in vivo, and histological status of SNs.

METHODS

Two hundred eighty patients with infiltrating breast carcinoma (T0, T(1)/T(2)) underwent preoperative lymphoscintigraphy before gamma probe-guided SN biopsy.

RESULTS

The surgical identification rate with a gamma probe was 84.6% (56 of 280) in lymphoscintigraphy-negative patients and 93.2% (224 of 280) in lymphoscintigraphy-positive patients (P < .05) after two subdermal periareolar injections. The average number of SNs per patient was 1.7 in lymphoscintigraphy-negative patients and 2.2 in lymphoscintigraphy-positive patients (P < .01), as assessed by gamma detection. The mean age of lymphoscintigraphy-negative patients was 62 +/- 10 years, versus 55 +/- 13 years for lymphoscintigraphy-positive patients (P < .001). The median radioactive count in dissected SNs identified by gamma detection was 204 cps (range, 4-618 cps) in lymphoscintigraphy-negative patients, versus 606 cps (range, 43-16,928 cps) in lymphoscintigraphy-positive patients (P < .001). The rate of macrometastatic SNs was 40% in lymphoscintigraphy-negative patients, versus 30% in lymphoscintigraphy-positive patients (not significant), whereas the size of involved SNs was 16.6 mm in lymphoscintigraphy-negative patients, versus 13.1 in lymphoscintigraphy-positive patients (P < .05). The micrometastasis detection rate in SNs from lymphoscintigraphy-negative patients was 6.25%, versus 23.3% in lymphoscintigraphy-positive patients (P < .01).

CONCLUSIONS

Negative lymphoscintigraphy was observed in 20% of patients and was more frequent in elderly patients. Negative lymphoscintigraphy was predictive of a lower surgical identification rate and fewer detected SNs. These SNs had fewer micrometastases, were fairly large, and tended to harbor metastases.

G388R mutation of the FGFR4 gene is not relevant to breast cancer prognosis

This study screened large cohorts of node-positive and node-negative breast cancer patients to determine whether the G388R mutation of the FGFR4 gene is a useful prognostic marker for breast cancer as reported by Bange et al in 2002. Node-positive (n=139) and node-negative (n=95) breast cancer cohorts selected for mutation screening were followed up for median periods of 89 and 87 months, respectively. PCR – RFLP analysis was modified to facilitate molecular screening. Curves for disease-free survival were plotted according to the Kaplan – Meier method, and a log-rank test was used for comparisons between groups. Three other nonparametric linear rank-tests particularly suitable for investigating possible relations between G388R mutation and early cancer progression were also used. Kaplan – Meier analysis based on any of the four nonparametric linear rank tests performed for node-positive and node-negative patients was not indicative of disease-free survival time. G388R mutation of the FGFR4 gene is not relevant for breast cancer prognosis.

[Accuracy of conservative treatment for infiltrating lobular breast cancer: a retrospective study of 217 infiltrating lobular carcinomas and 2155 infiltrating ductal carcinomas]

OBJECTIVES

Prognosis factors used for the management of infiltrative lobular carcinoma (ILC) are not different from those for infiltrative cuctal carcinoma (IDC). The aim of our work was to evaluate indications for conservative treatment for patients with ILC and to compare the results to those of patients with IDC. MATERIAL AND METHODS. Between 1985 and 1999 we retrospectively compared cases of 217 ILC with cases of 2155 IDC treated in Centre Rene Gauducheau, Nantes.

RESULTS

Clinical size of tumors was not different between ILC and IDC but pathological size>30 mm was more frequent for IDC. Good prognosis factors as pathological SBR classification I or II, positive hormone receptor, and the lack of axillary lymph node involvement, were more frequent for ILC. Clinical examination underestimated tumor size more frequently of ILC than IDC (p=0.02). Secondary mastectomy for involved margin was more frequent for ILC than IDC (p=0.001). For tumor with good prognosis factors, such as T<20mm, lack of lymph node involvement and SBR I or II with conservative treatment, 5 years local relapse were less frequent for ILC than IDC (p=0.025).

CONCLUSION

Parameters to validate conservative or radical treatment are the same for ILC and IDC. Diagnosis of ILC should not influence decisions regarding surgical treatment.

Learning curve for the detection of axillary sentinel lymph node in breast cancer

AIM

Sentinel axillary lymph node (SALN) detection is a new technique. Surgeons must progress up a learning curve in order to guarantee quality and safety equivalent to axillary lymphadenectomy. To ensure accurate staging of patients this learning curve must include SALN detection and an axillary lymphadenectomy. The aim of our work was to validate the principles and evaluate the consequences of learning curve for SALN detection from a prospective series of 200 consecutive patients.

METHOD

Prospective assessment was made of the detection and false negative rates, post operative morbidity as abcess and seroma, and length of hospital stay.

RESULTS

We evaluated the performance from the first to the hundredth case for each surgeon. Detection rate improved to 85% after patient number 10. False negative rate was less than 6%. Post operative axillary morbidity included 11% of seromas and 2% of abcess. Mean hospital stay was 2.8 days.

CONCLUSION

Multidisciplinary validation of the learning period contributes to an accurate and safe SALN.

Lymphoscintigraphy in the sentinel lymph node technique for breast tumor: value of early and late images for the learning curve

As the performance of early (H+1 to H+4) and late (D1) lymphoscintigraphic images raises organizational problems in outpatient surgery for breast cancer, only early images are generally obtained. The present study evaluated whether two series of images are better than one and defined the advantages of both methodologies. One hundred and eighteen patients with infiltrating breast carcinoma (T(0), T(1) and T(2)) were included in the study: 87 in group A (early and late images) and 31 in group B (only early images). All patients received two peritumoral injections of (99m)Tc-sulfur colloid, 15-18 MBq (group A) and <15 MBq (group B). During the operation, the patent blue bye technique was associated with radioactivity detection. The two groups were comparable for histological type and tumor size and localization. Successful localization of sentinel nodes on early lymphoscintigraphic images was significantly greater for group B. The identification of a sentinel node focus on early lymphoscintigraphy increased by 10% during the study. Sentinel node detection by the isotopic method alone, or the two methods combined, was comparable for both groups. In radioactivity detection, the count rate for sentinel nodes versus background (contralateral breast) was similar for the two groups. During the learning phase, two series of images gave a definite advantage. Subsequently, lymphoscintigraphy performed at +2 h was sufficient (the results for the two groups became indistinguishable).

[Primary angioplasty associated with systemic coronary stenting in acute myocardial infarction. Results at the end of the hospitalization period and at 24 months]

A series of 149 consecutive patients admitted for myocardial infarction (excluding cardiogenic shock), dilated and systematically stented in the acute phase before the 12th hour and followed up for a period from 30 days to 2 years, was studied. The criteria of follow-up were: number of asymptomatic patients, deaths, reinfarction, residual ischaemia, cardiac failure, angioplasty or bypass surgery. On admission, 40.9% of the infarcts were anterior, 44.3% inferior and 14.8% lateral. One hundred and eighty-three stents with a diameter of over 3 mm were inserted. The angioplasty success rate was 98.6%. During the hospital period, 90.6% of patients were asymptomatic. 4.7% had recurrent infarction, 4% had cardiac failure, 0.7% had residual ischaemia, and there were 0.7% of cardiac deaths. The survival rate was 97.2% at 2 years: 69.8% of patients were totally asymptomatic: the cumulative major cardiac event rate (death, reinfarction, angioplasties or bypass graft) was 25.9% and the reoperation rate on the culprit vessel was 20.1%. These results show the short and long-term value of angioplasty associated with coronary stenting over other techniques in the acute phase of infarction based on the criteria studied. The long-term results of larger randomised studies using glycoprotein inhibitors (Gp IIb IIIa) associated with angioplasty and stenting are expected for validating the use of these products.

Gene amplifications detected by fluorescence in situ hybridization in pure intraductal breast carcinomas: relation to morphology, cell proliferation and expression of breast cancer-related genes

Investigation of early breast carcinogenesis is limited by the difficulty in obtaining cell cultures or adequate fresh frozen material and by the fact that available data from in situ techniques are interpreted in terms of various classification systems. Our studies in a series of pure ductal carcinomas in situ (DCIS) were conducted in accordance with the recommendations of the international Consensus Conference (Hum. Pathol., 28, 122-125, 1997) relative to processing, determination of lesion extent, and histological stratification primarily on nuclear grade (NG). A multifactorial study performed in 15 low- and 16 high-NG DCIS (68% detected by mammography) included the following: (1) morphological analysis of NG, necrosis, and architectural pattern; (2) detection of numerical genomic abnormalities at ERBB2, MYC, CCND1, Xq1.2 and 20q13 loci by fluorescence in situ hybridization on interphase nuclei; and (3) immunohistochemical determination of cell proliferation, p53 accumulation, hormonal receptors and bcl-2 expression on serial sections of formalin-fixed, paraffin-embedded specimens. High NG, comedo/solid pattern and necrosis were significantly associated with amplification at one or more loci, the number of amplified loci, amplification at the ERBB2 locus, absence of bcl-2 and hormonal receptor expression and high cell proliferation (p < 0.05). High NG and comedo/solid pattern were significantly associated with MYC amplification and p53 accumulation, and necrosis with CCND1 amplification (the only gene amplification detected in low NG DCIS). These data provide additional information on the early steps of breast carcinogenesis, in accordance with currently recognized criteria of histological classification.

[Role of outpatient surgery in breast surgery. Prospective feasibility study]

STUDY AIM

The objective of this prospective study was to assess the feasibility of outpatient breast surgery, the reasons for inpatient procedures (IPP), the reasons for conversion and the conversion rate, and the postoperative morbidity after outpatient procedures (OPP).

PATIENTS AND METHODS

In 1999, among 625 patients eligible for OPP (diagnostic surgery or conservative curative surgery), OPP was performed in 418 patients (67%) and IPP was performed in 207 patients (33%). The reasons for IPP rather than OPP were environmental (64%) rather than medical (16%).

RESULTS

The conversion rate to conventional surgery was 12.4% and the definitive OPP rate was 58.6%. The reasons for conversion were more often medical (50%) and environmental (21%) than surgical (23%). The morbidity, except for axillary seroma, was similar for OPP and IPP. The axillary seroma rate after axillary lymph node dissection was higher with OPP (27.4 vs 16.1%).

CONCLUSION

OPP is a good alternative to IPP in breast surgery, especially for diagnostic purposes. OPP is also feasible for partial mastectomy with axillary lymph node dissection, but patients must be clearly informed about the risks of axillary morbidity. The patients' quality of life and satisfaction index should also be evaluated.

Genetic alterations in early-onset invasive breast carcinomas: correlation of c-erbB-2 amplification detected by fluorescence in situ hybridization with p53 accumulation and tumor phenotype

p53 tumor-suppressor gene mutation and p53 protein over-expression have been reported with higher frequency in early-onset breast carcinomas (EOBC). Given the role attributed to normal p53 protein in DNA-repair mechanisms, other somatic genomic alterations would be expected to be associated with this abnormality. Amplification of the c-erbB-2 (HER-2/neu) oncogene and over-expression of the corresponding p185erbB-2 protein have been linked to prognosis and response to therapy in breast cancer. In a retrospective study of 62 formalin-fixed paraffin-embedded invasive EOBC (diagnosed at 35 years or less), the amplification status of the c-erbB-2 gene detected by fluorescence in situ hybridization (FISH) using a unique sequence probe was compared with p53 protein accumulation measured by immunohistochemistry (IHC) and phenotypic features. p185erbB2-protein expression was also detected by immunohistochemistry, together with estrogen-receptor (ER) and progesterone-receptor (PR) expression. The data for a sub-set of 33 node-negative EOBC cases were compared with 70 node-negative tumors diagnosed in women above 36 years of age. Compared with node-negative BC in older women, node-negative EOBC was significantly more likely to feature high grade, high proliferation rate, negative ER and/or PR and p53 over-expression (p < 0.05). A trend toward a higher incidence of c-erbB-2 amplification in EOBC (21% vs. 9%) reached near-significance (p = 0.07). In EOBC, c-erbB-2 amplification and p53 over-expression were not associated with high tumor grade or high cell-proliferation rate, in contrast to the significant associations of these markers in tumors in older women. Abnormalities in tumor markers, including c-erbB-2 gene amplification and p53-protein over-expression, occur at different rates in women with EOBC as compared with BC developing in older women. This finding may reflect a different pathogenesis for EOBC, and warrants further investigation.

[Surgical management of non-palpable breast lesions in ambulatory care]

OBJECTIVE

The aim of our study was to assess if surgery for non-palpable breast lesions could be compatible with a walk-in case hospitalization setting.

METHOD

We retrospectively compared 75 patients with a traditional hospital stay to 68 patients with a walking case hospitalization. Overall 143 patients were treated during 1997. Studied parameters were: the quality of the surgical results, the duration of the hospital stay and the post operatives complications. Statistical analysis was realized using the chi 2 test.

RESULTS

There was no difference between the studied populations according to the quality of surgical results either the post operatives complications.

CONCLUSION

Surgery for non palpable breast lesions can be performed during a one day surgery. The reduction of the duration of the hospital stay decrease the cost of health care system. We should follow the evaluation of the walking case hospitalization for the breast cancer surgery especially when an axillary lymphadenectomy have to be performed.

Conservative surgery for low rectal carcinoma after high-dose radiation. Functional and oncologic results

OBJECTIVE

Using a prospective, nonrandomized study, the authors evaluated the morbidity and functional and oncologic results of conservative surgery for cancer of the lower third of the rectum after high-dose radiation.

SUMMARY BACKGROUND DATA

Colo-anal anastomosis has made sphincter conservation for low rectal carcinoma technically feasible. The limits to conservative surgery currently are oncologic rather than technical. Adjuvant radiotherapy has proven its benefit in terms of regional control, with a dose relationship.

METHODS

Since June 1990, 27 patients with distal rectal adenocarcinoma were treated by preoperative radiotherapy (40 + 20 Gy delivered with three fields) and curative surgery. The mean distance from the anal verge was 47 mm (27-57 mm), and none of the tumors were fixed (15 T2, 12 T3).

RESULTS

Mortality and morbidity were not increased by high-dose preoperative radiation. Twenty-one patients underwent conservative surgery (78%-17 total proctectomies and colo-anal anastomoses, 4 trans-anal resections). After colo-anal anastomosis, all patients with colonic pouch had good results; two patients had moderate results and one patient had poor results after straight colo-anal anastomosis. With a mean follow-up of 24 months, the authors noted 1 postoperative death, 2 disease-linked deaths, 1 controlled regional recurrence, 2 evolutive patients with pulmonary metastases, and 21 disease-free patients.

CONCLUSIONS

These first results confirm the possibility of conservative surgery for low rectal carcinoma after high-dose radiation. A prospective, randomized trial could be induced to determine the real role of the 20 Gy boost on the sphincter-saving decision.

[Effect of chronic electric stimulation on colonic motricity. An experimental model. Results]

The study of direct electrical stimulation of the colon in 10 dogs allowed establishing a significant decrease in motor activity at the level of the stimulated segment, a nonsignificant decrease upstream and a significant increase downstream. The mechanism of intestinal response to stimulation remains hypothetic: there probably is a local release of neuromediators.

[Monitoring after total hip prosthesis. Value of semi-quantitative D-dimer assay]

Criteria for positive assay of the D-dimer were defined in order to establish its diagnostic value for phlebitis in the post-operative period. A retrospective study was carried out on the files of 94 patients who had received a total hip prosthesis in 1990. A semi-quantitative assay technique was used to measure the D-dimer because it is the only method giving immediate results. Three criteria were used to classify the results: criterium A: D-dimer greater than or equal to 2 micrograms/ml; criterium B: D-dimer greater than or equal to 4 times the preceding test; absence of both of these criteria. The results were compared to echo-doppler results and confirmed by phlebography when necessary. The incidence of proximal phlebitis was low (2 percent); criterium B showed a 100 percent negative predictability and a 29 percent positive predictability. None of the cases of phlebitis diagnosed with this test had been suspected clinically. This test provides a means of patient screening and spares the need for other explorations.