Lymphovascular invasion has a significant prognostic impact in patients with early breast cancer, results from a large, national, multicenter, retrospective cohort study

Background

We determined the prognostic impact of lymphovascular invasion (LVI) in a large, national, multicenter, retrospective cohort of patients with early breast cancer (BC) according to numerous factors.

Patients and methods

We collected data on 17 322 early BC patients treated in 13 French cancer centers from 1991 to 2013. Survival functions were calculated using the Kaplan–Meier method and multivariate survival analyses were carried out using the Cox proportional hazards regression model adjusted for significant variables associated with LVI or not. Two propensity score-based matching approaches were used to balance differences in known prognostic variables associated with LVI status and to assess the impact of adjuvant chemotherapy (AC) in LVI-positive luminal A-like patients.

Results

LVI was present in 24.3% (4205) of patients. LVI was significantly and independently associated with all clinical and pathological characteristics analyzed in the entire population and according to endocrine receptor (ER) status except for the time period in binary logistic regression. According to multivariate analyses including ER status, AC, grade, and tumor subtypes, the presence of LVI was significantly associated with a negative prognostic impact on overall (OS), disease-free (DFS), and metastasis-free survival (MFS) in all patients [hazard ratio (HR) = 1.345, HR = 1.312, and HR = 1.415, respectively; P < 0.0001], which was also observed in the propensity score-based analysis in addition to the association of AC with a significant increase in both OS and DFS in LVI-positive luminal A-like patients. LVI did not have a significant impact in either patients with ER-positive grade 3 tumors or those with AC-treated luminal A-like tumors.

Conclusion

The presence of LVI has an independent negative prognostic impact on OS, DFS, and MFS in early BC patients, except in ER-positive grade 3 tumors and in those with luminal A-like tumors treated with AC. Therefore, LVI may indicate the existence of a subset of luminal A-like patients who may still benefit from adjuvant therapy.

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In a study of 17 322 early BC patients, LVI had a significant independent negative prognostic impact on survival.

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LVI negatively impacted survival in almost every patient category and cancer subtype, with and without AC.

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LVI did not have a negative survival impact in patients with ER+ grade 3 or with luminal A-like tumors with chemotherapy.

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Results suggest a possible benefit of AC in LVI-positive luminal A-like patients.

Abstract P1-13-04: Impact of hormone receptor status in HER2-Positive early breast cancer in the trastuzumab era: Results of a National multi-institutional study

Background: Recent updated analysis of the HERA (HERceptin Adjuvant) trial indicate that tumor hormone receptor status (HR)remains a major determinant of outcome in HER2-positive (HER2+) early breast cancer (BC) patients, with higher rates of recurrence and death in women with HR-negative (HR-) disease, even after 11 years' median follow-up. Furthermore, data reported from the HERA trial suggest that the timing of recurrences is different, with an initial higher frequency of disease-free survival (DFS) events in patients with HR- disease than those with HR-positive disease (HR+). No evidence of a different trastuzumab efficacy according to the HR of the primary tumor was found. In this study, we examined the impact of HR on outcome in a large, multicenter, “real-world”, retrospective cohort of HER2+ early breast cancer patients

Methods: HER2+ BC were retrospectively identified from a large cohort of 23,375 consecutive patients who underwent primary surgery at 17 French centers between Dec 1987 and Jan 2014. A multivariate Cox model was built including age, tumor size, SBR grade, lymphovascular invasion, lymph node involvement, hormonal receptors status, adjuvant chemotherapy, adjuvant hormone therapy, trastuzumab, radiotherapy and type of surgery.

Results: A total of 1308 cases were identified, including 829 (63%) HR+ and 479 (47%) HR- patients. Median follow-up was 52 months (range 0 to 201). Compared with HR+, HR- patients had significantly smaller tumors (37 vs. 31% ≤ 10mm, p=0.027; information for multifocal tumors was not available), with higher SBR grade (58 vs. 40% grade 3, p&lt;0.001) and had more lymph nodes involvement (41 vs. 32% pN+, p=0.001). HR- patients were more frequently treated by mastectomy (41 vs. 31%, p&lt;0.001), received more trastuzumab (63 vs. 53%, p&lt;0.001) and less radiotherapy (85 vs. 89%, p=0.020). Endocrine therapy was administered in 90% (744) of HR+ patients. No other significant difference in patient, tumor or treatment characteristics was found. HR status impacted DFS, metastasis free-survival (MFS) and BC-Specific survival (BC-SS) (hazard ratios: 0.46 [0.32-0.66]; p&lt;0.001, 0.52 [0.33-0.82]; p=0.004 and 0.56 [0.34-0.90]; p=0.017, respectively), log-rank test) in overall population with higher rates of recurrence and death in women with HR- disease. In multivariate analysis, lymph node involvement and use of trastuzumab but not HR status impacted significantly DFS, MFS and BC-SS. Considering patients by treatment groups (with or without trastuzumab), HR status was not predictive of survival outcomes in the trastuzumab group, as opposed to the group without trastuzumab. Regarding the timing of recurrences, we observed an increased tendency for later relapse in patients with HR+ disease compared with HR- disease, for both DFS and MFS events.

Conclusions: Our results suggest that HR status remains a major determinant of outcome in HER2+ BC, including the timing of recurrence. Yet, this prognostic impact appears to be mitigated by trastuzumab-based adjuvant treatment.

Citation Format: de Nonneville A, Gonçalves A, Cohen M, Reyal F, Classe JM, Giard S, Colombo PE, Muracciole X, Chopin N, Lambaudie E, Houvenaeghel G. Impact of hormone receptor status in HER2-Positive early breast cancer in the trastuzumab era: Results of a National multi-institutional study [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 P1-13-04.

Prospective Assessment of First-Year Quality of Life After Pelvic Exenteration for Gynecologic Malignancy: A French Multicentric Study

BACKGROUND

Pelvic exenteration remains one of the most mutilating procedures, with important postoperative morbidity, an altered body image, and long-term physical and psychosocial concerns. This study aimed to assess quality of life (QOL) during the first year after pelvic exenteration for gynecologic malignancy performed with curative intent.

METHODS

A French multicentric prospective study was performed by including patients who underwent pelvic exenteration. Quality of life by measurement of functional and symptom scales was assessed using the European Organisation for Research and Treatment of Cancer (EORTC) QLQ-C30 (version 3.0) and the EORTC QLQ-OV28 questionnaires before surgery, at baseline, and 1, 3, 6, and 12 months after the procedure.

RESULTS

The study enrolled 97 patients. Quality of life including physical, personal, fatigue, and anorexia reported in the QLQ-C30 was significantly reduced 1 month postoperatively and improved at least to baseline level 1 year after the procedure. Body image also was significantly reduced 1 month postoperatively. Global health, emotional, dyspnea, and anorexia items were significantly improved 1 year after surgery compared with baseline values. Unlike younger patients, elderly patients did not regain physical and social activities after pelvic exenteration.

CONCLUSIONS

Therapeutic decision on performing a pelvic exenteration can have a severe and permanent impact on all aspects of patients' QOL. Deterioration of QOL was most significant during the first 3 months after surgery. Elderly patients were the only group of patients with permanent decreased physical and social function. Preoperative evaluation and postoperative follow-up evaluation should include health-related QOL instruments, counseling by a multidisciplinary team to cover all aspects concerning stoma care, sexual function, and long-term concerns after surgery.

Adjuvant chemotherapy in pT1ab node-negative triple-negative breast carcinomas: Results of a national multi-institutional retrospective study

BACKGROUND

Triple-negative breast cancers (TNBCs) are considered as associated with poor outcome, but prognosis of subcentimetric, node-negative disease remains controversial and evidence that adjuvant chemotherapy (CT) is effective in these small tumours remains limited.

PATIENTS AND METHODS

Our objective was to investigate the impact of CT on survival in pT1abN0M0 TNBC. Patients were retrospectively identified from a cohort of 22,475 patients who underwent primary surgery in 15 French centres between 1987 and 2013. As rare pathological types may display very particular prognoses in these tumours, we retained only the invasive ductal carcinomas of no special type according to the last World Health Organisation (WHO) classification which is the most common TNBC histological type. End-points were disease-free survival (DFS) and metastasis-free survival (MFS). A propensity score for receiving CT was estimated using a logistic regression including age, tumour size, Scarff Bloom and Richardson (SBR) grade and lymphovascular invasion.

RESULTS

Of a total of 284 patients with pT1abN0M0 ductal TNBC, 144 (51%) received CT and 140 (49%) did not. Patients receiving CT had more adverse prognostic features, such as tumour size, high grade, young age, and lymphovascular invasion. CT was not associated with a significant benefit for DFS (Hazard ratio, HR = 0.77 [0.40-1.46]; p = 0.419, log-rank test) or MFS (HR = 1.00 [0.46-2.19]; p = 0.997), with 5-year DFS and MFS in the group with CT versus without of 90% [81-94%] versus 84% [74-90%], and 90% [81-95%] versus 90% [83%-95%], respectively. Results were consistent in all supportive analyses including multivariate Cox model and the use of the propensity score for adjustment and as a matching factor for case-control analyses.

CONCLUSIONS

This study did not identify a significant DFS or MFS advantage for CT in subcentimetric, node-negative ductal TNBC. Although current consensus guidelines recommend consideration of CT in all TNBC larger than 5 mm, clinicians should carefully discuss benefit/risk ratio with patients, given the unproven benefits.

Axillary lymph node micrometastases decrease triple-negative early breast cancer survival

BACKGROUND

Triple-negative breast cancers (TNBCs) are the most deadly form of breast cancer (BC) subtypes. Axillary lymph node involvement (ALNI) has been described to be prognostic in BC taken as a whole, but its prognostic value in each subtype is unclear. We explored the prognostic impact of ALNI and especially of small size axillary metastases in early TNBCs.

METHODS

We analysed in this multicentre study all patients treated for early TNBC in 12 French cancer centres. We explored the correlation between clinicopathological data and ALNI, with a specific focus on the dichotomisation between macrometastases and occult metastases, which is defined as the presence of isolated tumour cells or micrometastases. The prognostic value of ALNI both in terms of disease-free survival (DFS) and overall survival (OS) was also explored.

RESULTS

We included 1237 TNBC patients. Five-year DFS and OS were 83.7% and 88.5%, respectively. The identified independent prognostic features for DFS were tumour size >20 mm (hazard ratio (HR)=1.86; 95% CI: 1.11-3.10, P=0.018), lymphovascular invasion (HR=1.69; 95% CI: 1.21-2.34, P=0.002) and ALNI both in case of macrometastases (HR=1.97; 95% CI: 1.38-2.81, P<0.0001) and occult metastases (HR=1.72; 95% CI: 1.1-2.71, P=0.019). DFS and OS were similar between tumours with occult metastases and macrometastases. Tumours presenting at least two pejorative features (out of ALNI, lymphovascular invasion and large tumour size) displayed a significantly poorer DFS in both the training set and validation set, independently of chemotherapy administration. Tumours with no more than one of the above-cited pejorative features had a 5-year OS of ⩾90% vs 70% for other cases (P<0.0001).

CONCLUSIONS

Axillary lymph node involvement is a key prognostic feature for early TNBC when isolated tumour cells were identified in lymph nodes. This impact is independent of chemotherapy use.

Impact of completion axillary lymph node dissection in patients with breast cancer and isolated tumour cells or micrometastases in sentinel nodes

BACKGROUND

Omission of completion axillary lymph node dissection (ALND) is a standard practice in patients with breast cancer (BC) and negative sentinel nodes (SNs) but has shown insufficient evidence to be recommended in those with SN invasion.

METHODS

A retrospective analysis of a cohort of patients with BC and micrometastases (Mic) or isolated tumour cells (ITCs) in SN. Factors associated with ALND were identified, and patients with ALND were matched to patients without ALND. Overall survival (OS) and recurrence-free survival (RFS) were estimated in the overall population, in Mic and in ITC cohorts.

FINDINGS

Among 2009 patients analysed, 1390 and 619 had Mic and ITC in SN, respectively. Factors significantly associated with ALND were SN status, histological type, age, number of SN harvested and absence of adjuvant chemotherapy. After a median follow-up of 60.4 months, ALND omission was independently associated with reduced OS (hazard ratio [HR] 2.41, 90 confidence interval [CI] 1.36-4.27, p = 0.0102), but not with increased RFS (HR 1.21, 90 CI 0.74-2.0, p = 0.52) in the overall population. In matched patients, the increased risk of death in case of ALND omission was found only in the Mic cohort (HR 2.88, 90 CI 1.46-5.69), not in the ITC cohort. The risk of recurrence was also significantly increased in the subgroup of matched Mic patients (HR 1.56, 90 CI 0.90-2.73).

INTERPRETATION

A separate analysis of Mic and ITC groups, matched for the determinants of ALND, suggested that patients with Mic had increased recurrence rates and shorter OS when ALND was not performed. Our results are consistent with those of previous studies for patients with ITC but not for those with Mic. Randomised controlled clinical trials are still warranted to show with a high level of evidence if ALND can be safely omitted in patients with micrometastatic disease in SN.

Diffuse malignant peritoneal mesothelioma: Evaluation of systemic chemotherapy with comprehensive treatment through the RENAPE Database: Multi-Institutional Retrospective Study

PURPOSE

Diffuse malignant peritoneal mesothelioma (DMPM) is a severe disease with mainly locoregional evolution. Cytoreductive surgery and hyperthermic intraperitoneal chemotherapy (CRS-HIPEC) is the reported treatment with the longest survival. The aim of this study was to evaluate the impact of perioperative systemic chemotherapy strategies on survival and postoperative outcomes in patients with DMPM treated with curative intent with CRS-HIPEC, using a multi-institutional database: the French RENAPE network.

PATIENTS AND METHODS

From 1991 to 2014, 126 DMPM patients underwent CRS-HIPEC at 20 tertiary centres. The population was divided into four groups according to perioperative treatment: only neoadjuvant chemotherapy (NA), only adjuvant chemotherapy (ADJ), perioperative chemotherapy (PO) and no chemotherapy before or after CRS-HIPEC (NoC).

RESULTS

All groups (NA: n = 42; ADJ: n = 16; PO: n = 16; NoC: n = 48) were comparable regarding clinicopathological data and main DMPM prognostic factors. After a median follow-up of 61 months, the 5-year overall survival (OS) was 40%, 67%, 62% and 56% in NA, ADJ, PO and NoC groups, respectively (P = 0.049). Major complications occurred for 41%, 45%, 35% and 41% of patients from NA, ADJ, PO and NoC groups, respectively (P = 0.299). In multivariate analysis, NA was independently associated with worse OS (hazard ratio, 2.30; 95% confidence interval, 1.07-4.94; P = 0.033).

CONCLUSION

This retrospective study suggests that adjuvant chemotherapy may delay recurrence and improve survival and that NA may impact negatively the survival for patients with DMPM who underwent CRS-HIPEC with curative intent. Upfront CRS and HIPEC should be considered when achievable, waiting for stronger level of scientific evidence.

Professional risks when carrying out cytoreductive surgery for peritoneal malignancy with hyperthermic intraperitoneal chemotherapy (HIPEC): A French multicentric survey

BACKGROUND

Over the last two decades, many surgical teams have developed programs to treat peritoneal carcinomatosis with extensive cytoreductive surgery and hyperthermic intraperitoneal chemotherapy (HIPEC). Currently, there are no specific recommendations for HIPEC procedures concerning environmental contamination risk management, personal protective equipment (PPE), or occupational health supervision.

METHODS

A survey of the institutional practices among all French teams currently performing HIPEC procedures was carried out via the French network for the treatment of rare peritoneal malignancies (RENAPE).

RESULTS

Thirty three surgical teams responded, 14 (42.4%) which reported more than 10 years of HIPEC experience. Some practices were widespread, such as using HIPEC machine approved by the European Community (100%), individualized or centralized smoke evacuation (81.8%), "open" abdominal coverage during perfusion (75.8%), and maintaining the same surgeon throughout the procedure (69.7%). Others were more heterogeneous, including laminar flow air circulation (54.5%) and the provision of safety protocols in the event of perfusate spills (51.5%). The use of specialized personal protective equipment is ubiquitous (93.9%) but widely variable between programs.

CONCLUSION

Protocols regarding cytoreductive surgery/HIPEC and the associated professional risks in France lack standardization and should be established.

[Prophylactic surgery in patients mutated BRCA or high risk: retrospective study of 61 patients in the ICO]

BACKGROUND

Genetic predisposition is involved in only 10% of patients with breast cancer. This study was to evaluate the impact of prophylactic surgery.

PATIENTS AND METHODS

This is a retrospective study of 61 patients who received prophylactic breast surgery. Data collection was carried out through the computer file of the ICO. The inclusion criteria were: patients who benefited from a bilateral prophylactic mastectomy. There were no exclusion criteria. Patients received a satisfaction questionnaire to complete.

RESULTS

Our study included 61 patients, 67% had a history of breast cancer. Bilateral prophylactic surgery was performed in 40 patients. It was made an average of two interventions, 44.3% of them presented postoperative complications, 18% recovery. Forty-three patients were satisfied with the medical information before surgery. The end result matched the expectations of 54.4% and 67.4% of patients would be ready to start. It was found pain associated with breast surgery in 56.5% of patients and almost half reported a change in their sexual life.

DISCUSSION AND CONCLUSION

Prophylactic mastectomy is the most effective technique to prevent the risk of breast cancer. The consequences of such an action are important. It is necessary to better select patients who would benefit most from this type of surgery.

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.

Peritoneal carcinomatosis treated with cytoreductive surgery and Hyperthermic Intraperitoneal Chemotherapy (HIPEC) for advanced ovarian carcinoma: a French multicentre retrospective cohort study of 566 patients

BACKGROUND

Despite a high response rate to front-line therapy, prognosis of epithelial ovarian carcinoma (EOC) remains poor. Approaches that combine Cytoreductive Surgery (CRS) and Hyperthermic Intraperitoneal Chemotherapy (HIPEC) have been developed recently. The purpose of this study was to assess early and long-term survival in patients treated with this strategy.

PATIENTS AND METHODS

A retrospective cohort multicentric study from French centres was performed. All consecutive patients with advanced and recurrent EOC treated with CRS and HIPEC were included.

RESULTS

The study included 566 patients from 13 centres who underwent 607 procedures between 1991 and 2010. There were 92 patients with advanced EOC (first-line treatment), and 474 patients with recurrent EOC. A complete cytoreductive surgery was performed in 74.9% of patients. Mortality and grades 3 to 4 morbidity rates were 0.8% and 31.3%, respectively. The median overall survivals were 35.4 months and 45.7 months for advanced and recurrent EOC, respectively. There was no significant difference in overall survival between patients with chemosensitive and with chemoresistant recurrence. Peritoneal Cancer Index (PCI) that evaluated disease extent was the strongest independent prognostic factor for overall and disease-free survival in all groups.

CONCLUSION

For advanced and recurrent EOC, curative therapeutic approach combining optimal CRS and HIPEC should be considered as it may achieve long-term survival in patients with a severe prognosis disease, even in patients with chemoresistant disease. PCI should be used for patient's selection.

[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.

Quality indicators in ovarian cancer surgery: report from the French Society of Gynecologic Oncology (Societe Francaise d'Oncologie Gynecologique, SFOG)

BACKGROUND

Based on registries, the European experience has been that <50% of patients are treated according to protocols and/or benefit from the minimum required surgery for ovarian cancer. The French Cancer Plan 2009-2013 considers the definition of qualitative indicators in ovarian cancer surgery in France. This endeavour was undertaken by the French Society of Gynaecologic Oncology (SFOG) in partnership with the French National College of Obstetricians and Gynecologists and all concerned learned societies in a multidisciplinary mindset.

METHODS

The quality indicators for the initial management of patients with ovarian cancer were based on the standards of practice determined from scientific evidence or expert consensus.

RESULTS

The indicators were divided into structural indicators, including material (equipment), human (number and qualification of staff), and organizational resources, process indicators, and outcome indicators.

CONCLUSIONS

The enforcement of a quality assurance programme in any country would undoubtedly promote improvement in the quality of care for ovarian cancer patients and would result in a dramatic positive impact on their survival. Such a policy is not only beneficial to the patient, but is also profitable for the healthcare system.

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.

Phase III randomized equivalence trial of early breast cancer treatments with or without axillary clearance in post-menopausal patients results after 5 years of follow-up

BACKGROUND

Axillary lymph node clearance (ALNC) improves locoregional control and provides prognostic information for early breast cancer treatment, but effects on survival are controversial. This multicentre, randomized pragmatic equivalence trial compares outcomes for post-menopausal early invasive breast cancer patients after locoregional treatment with ALNC and adjuvant therapies to outcomes after locoregional treatment without ALNC and adjuvant therapies.

METHODS

From 1995-2005, women aged ≥ 50 years with early breast cancer (tumor ≤ 10 mm) and clinically-negative axillary nodes were randomized to receive treatment with ALNC (Ax) or without (no-Ax). Adjuvant therapies were prescribed according to hormonal receptor status and individual histological results. The primary endpoint was overall survival (OS); secondary endpoints were event-free survival (EFS) and functional outcomes. The trial was terminated due to lack of equivalence and low accrual after first interim analyses.

TRIAL REGISTRATION

NCT00210236.

RESULTS

Of 625 patients, 297 no-Ax and 310 Ax patients were maintained for final per-protocol analyses. OS and EFS at five years were not equivalent (Ax vs. no-Ax: 98% vs. 94% and 96% vs. 90% respectively). Recurrence was higher for no-Ax, particularly in the first five years after surgery. Axillary nodes were positive for 14% Ax patients but only 2% no-Ax patients experienced axillary node recurrence. Functional impairments were greater after ALNC.

CONCLUSION

Our results fail to demonstrate equivalence of outcomes when ALNC is omitted from post-menopausal early breast cancer patient treatment. However the low locoregional recurrence rates warrant further examination over a longer duration, in particular to consider whether these would impact on survival.

Surgery after concurrent chemoradiotherapy and brachytherapy for the treatment of advanced cervical cancer: morbidity and outcome: results of a multicenter study of the GCCLCC (Groupe des Chirurgiens de Centre de Lutte Contre le Cancer)

OBJECTIVES

To evaluate the morbidity and therapeutic value of surgery after concurrent chemoradiotherapy and brachytherapy in a multicentric series of patients with advanced cervical cancer.

METHODS

Patients with stage IB2 to IVA cervical cancer treated with concurrent chemoradiotherapy and pelvic radiotherapy followed by brachytherapy and surgery from seven participating French comprehensive cancer centers were enrolled. The surgical treatment consisted of a hysterectomy, which ranged from radical hysterectomy to anterior pelvic exenteration, and lymph node resection. Acute toxicity, pathological response, overall, and disease-free survival were assessed for each pathological response to therapy.

RESULTS

One hundred seventy-five patients were enrolled from September 1987 to June 2002. The median age was 44 years [27;75]. Patients distribution according to clinical classification was as follows: 41 stage IB2, 18 IIA, 77 IIB, 12 IIIA, 14 IIIB, and 13 IVA. Forty-six patients experienced 51 postoperative complications. Thirty-three patients experienced grade 2 morbidity (18.9%, 33/175), among whom 19 experienced urinary complications (57.5%, 19/175). No post treatment mortality was observed. Grade 3 toxicity rate was 6.9% (12/175). Pathological complete response rate was 38% (67/175). After a median follow-up of 36 months, overall survival and disease-free survival were significantly better in patients who had a pathological complete response to therapy than those who achieved a partial pathological response (P < 0.0001).

CONCLUSION

Surgery after concurrent chemoradiotherapy and brachytherapy for advanced cervical cancer leads to an acceptable morbidity. Furthermore, surgery allows evaluation of the pathological response to therapy and improves local control in the case of partial pathological response.

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.

Ovarian cancer management. Practice guidelines for nuclear physicians

Ovarian cancer is a frequent and severe malignancy. Over 75% of cases are diagnosed at an advanced stage with disease spread beyond the ovaries. Despite the high response rates of initial treatments (i.e.,70-80%), the median progression-free survival of advanced ovarian cancer is 16-22 months, and the 5-year overall survival, 20-30%. The majority of these patients relapse, with metastatic peritoneal spread, unresectable, or drug resistant disease. Our goal was to outline current knowledge about diagnosis, prognostic factors, and treatments, and to dwell on non-nuclear medicine and nuclear-medicine diagnostic procedures.

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).

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.

A phase II study of intraperitoneal radioimmunotherapy with iodine-131-labeled monoclonal antibody OC-125 in patients with residual ovarian carcinoma

Standard treatment of advanced ovarian cancer is a combination of surgery and chemotherapy. Additional therapies using the i.p. route are considered as a potential means of improving the locoregional control rate. This Phase II study evaluated the efficacy of i.p. radioimmunotherapy (RIT) in patients with minimal residual ovarian adenocarcinoma after primary treatment with surgery and chemotherapy. Between February 1995 and March 1996, six patients with residual macroscopic (<5 mm) or microscopic disease as demonstrated by laparotomy and multiple biopsies received i.p. RIT. All had initial stage III epithelial carcinoma and were treated with debulking surgery and one line (four patients) or two lines (two patients) of chemotherapy. RIT was performed with 60 mg of OC 125 F(ab')2 monoclonal antibody labeled with 4.44 GBq (120 mCi) of 131I injected 5-10 days after the surgical procedure. Systematic laparoscopy or laparotomy with multiple biopsies performed 3 months after RIT in five patients (clinical progression was seen in one patient) showed no change in three patients and progression in two patients. Toxicity was mainly hematological, with grade III neutropenia and thrombocytopenia in two patients. Human antimouse antibody production was demonstrated in all six patients. This study showed little therapeutic benefit from i.p. RIT in patients with residual ovarian carcinoma.

[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.

Ovarian transposition by laparoscopy before radiotherapy in the treatment of Hodgkin's disease

BACKGROUND

The use of inverted Y irradiation in the treatment of Hodgkin's disease with pelvic lymph node involvement can cause iatrogenic early menopause in young women as a result of ovarian exposure to radiation. Ovarian transposition protects the ovaries by removing them from the irradiation field. This surgical procedure, initially performed by laparotomy, can now be done by laparoscopy.

METHODS

During the period July 1994 to April 1996, laparoscopic ovarian transposition was performed on 4 young women with Hodgkin's disease 1 week before inverted Y radiotherapy. The surgical procedure, complications, length of hospitalization, and hormonal, clinical, and biologic results were evaluated.

RESULTS

The mean duration of hospitalization was 4 days, and there were no postoperative complications. Iatrogenic menopause did not occur in any of the patients during the mean follow-up period of 20.75 months (range, 6-35 months; median, 20 months).

CONCLUSIONS

Laparoscopy offers many advantages over laparotomy for ovarian transposition. This procedure, which can be performed without opening the abdominal wall, is highly efficient, requires only a short period of hospitalization, and leads to few postoperative complications. Laparoscopy is an attractive alternative to laparotomy for ovarian transposition in young women with advanced Hodgkin's disease who require pelvic radiotherapy.

[Breast metastasis from a "tall cell variant" of papillary thyroid carcinoma]

The authors report a case of breast metastasis from a "tall cell" variant of papillary thyroid carcinoma in a 59-year-old woman. This metastasis was discovered two months after the diagnosis of an inextirpable thyroid tumor. Tall cell variant of papillary thyroid carcinoma is a sub-type of papillary carcinoma with an aggressive course and frequent metastases (in patients over 50 years of age). No mammary metastasis of this tumor type has been reported so far.