A computer synoptic operative report versus a report dictated by a surgeon in advanced ovarian cancer

OBJECTIVE

To evaluate the role of a computer synoptic operative report in enhancing the quality and completeness of surgical reporting for advanced ovarian cancer surgeries.

METHODS

The study was conducted at a tertiary cancer center between January 2016 and September 2021, and the computer synoptic operative report was implemented in May 2019. The study compared two cohorts: the first consisted of the 'before computer synoptic operative report (P1)' period, during which the operative reports were dictated freely by the surgeons, and the second consisted of the 'after computer synoptic operative report (P2)' period, during which all surgeons used the computer synoptic operative report.

RESULTS

The study analyzed 227 operative reports, with 104 during period 1 (P1) and 123 during period 2 (P2). In the P1 group, more than half of the patients (54 out of 104, 52%) underwent interval surgery after completing six cycles of chemotherapy; In contrast, in the P2 group, all interval debulking surgeries were performed after fewer than six chemotherapy cycles (p<0.001). Although interval debulking surgery after fewer than six chemotherapy cycles was more frequent in P2, the rate of primary debulking surgery was similar between the groups. The median intra-operative peritoneal carcinomatosis index was higher in P2 (2 in P1 vs 4 in P2, p<0.001), and mean blood loss was higher in P1 (308 mL vs 151 mL, p<0.001). The rate of complete cytoreduction was similar between P1 and P2 (97% vs 87%, respectively, p=0.6). The median length of hospital stay was 12 days in the P1 group and 16 days in the P2 group (p=0.5). Compliance with all eight significant items was higher in the P2 group, with all items present in 66% of the operative reports in the P2 group compared with none of the reports in the P1 group. Compliance for the following items was: International Federation of Obstetrics and Gynecology stage (24% vs 100%), histology (76% vs 97%), CA125 (63% vs 89%), type of surgery (38% vs 100%), peritoneal carcinomatosis index (21% vs 100%), complete cytoreduction score 36% vs 99%), Aletti score (0% vs 89%), and blood loss (32% vs 98%) for P1 and P2; respectively.

CONCLUSION

The use of the computer synoptic operative report improved the completeness and quality of the surgical information documented in advanced ovarian cancer surgeries.

[RECOMA study: Evaluation of quality of life and satisfaction after immediate or delayed breast reconstruction]

OBJECTIVE

Breast reconstruction after mastectomy, whether immediate or delayed, is an integral part of the overall management of breast cancer. However, up to 40 % of reconstructed patients are not satisfied with the aesthetic result. The primary objective of the study was to evaluate satisfaction and quality of life according to the reconstruction techniques used in our center. The secondary objectives were to identify the parameters that could influence satisfaction and quality of life after surgery, to list the main complications, and the number of operations required to consider the reconstruction process as completed.

METHOD

A retrospective monocentric study, RECOMA, was carried out at the CHRU Minjoz in Besançon. All patients who underwent immediate or delayed breast reconstruction between 2010 and 2021 were contacted by post or e-mail and asked to complete the standardized BREAST-Q postoperative module.

RESULTS

Of 508 patients contacted, 149 were included. Reconstructed patients reported satisfaction, but also "average" quality of physical and psychological sexual life. Only the surgeon's assessment was rated as "good". There was no significant difference in satisfaction and quality of life depending on the reconstruction method chosen. On the other hand, patients who underwent nipple areolar complex (NAC) reconstruction had a significantly higher psychic quality of life score (P=0.02). In addition, a significant decrease in physical satisfaction was observed over time(P=0.049). An average of 2.4 operations was required to consider breast reconstruction complete.

CONCLUSION

In our opinion, breast reconstruction is an essential procedure to be considered as soon as the indication for mastectomy is given, but it is a process that requires the patient to be prepared for a result that may be weaker than expected, may require several operations, and may be complicated.

Is minimally invasive surgical approach a reasonable option in apparent early stage epithelial ovarian cancer restaging? Results from a multicentric retrospective study

INTRODUCTION

To perform surgical staging of early stage ovarian cancer (EOC), conventional laparoscopy (LS) and robot-assisted laparoscopy (RLS) appear to be reliable procedures compared to open surgery. But oncologicals results with long-term follow up are limited in the literature. The objective of this study is to evaluate the surgical and long-term survival for patients managed by minimally invasive surgery (MIS).

MATERIALS AND METHODS

We conducted a multicentric retrospective study in 6 institutions. All patients referred for epithelial EOC (apparent stage I-IIa) managed with LS and RLS were involved.

RESULTS

From December 2008 to December 2017, 140 patients were included (109 in LS group and 31 in RLS group). A total of 27 (19.2 %) patients were upstaged to an advanced ovarian cancer (FIGO stage > IIA), and 73 % of patients received chemotherapy. Mean operative time was 265,8 ± 88,4 min and significantly longer in RLS group (LS = 254,5 ± 86,8; RLS = 305,6 ± 85,5; p = 0,008). Rate of severe post-operative complications (grade 3) was 5,7 %. Thirteen conversion to laparotomy occurred, including one per-operative hemorrhaege. After a mean follow-up of 60,7 months, 29 (20.7 %) patients recurred, with a time to recurrence was >24 months in 51,7 % of cases. Overall survival (OS) was 88.6 % and disease-free survival (DFS) was 79.3 %. Oncologic outcomes were similar between LS and RLS group (OS: p = 0,504 and DFS: p = 0,213).

CONCLUSION

Surgical staging of EOC by LS or RLS approach has long-term equivalent surgical and oncological approach. These results seem to be equivalent to open surgery according to literature review.

Neoadjuvant chemotherapy for breast cancer: Pathologic response rates but not tumor size, has an independent prognostic impact on survival

AIM

We investigated the pathologic complete response rates (pCR) and survival outcomes of early breast cancer patients who underwent neoadjuvant chemotherapy (NAC) over 14 years at a French comprehensive cancer center and reported pCR and survival outcomes by tumor subtypes and size.

METHODS

From January 2005 to December 2018, 1150 patients receiving NAC were identified. Correlations between cT stage, breast tumor response, axillary lymph node response, pCR, surgery, and outcomes were assessed. pCR was defined as (ypT0/ypTis) and (ypN0/pN0sn).

RESULTS

A pCR was reached in 31.7% (365/1150) of patients and was strongly associated with tumor subtypes, but not with tumor size (pretreatment cT category). Luminal-B Her2-negative and triple-negative (TN) subtypes, cN1 status, older age, and no-pCR had an independent negative prognostic value. Overall survival (OS), relapse-free survival (RFS), and metastasis-free survival (MFS) were not significantly different for cT0-1 compared to cT2 stages. In Cox-model adjusted on in-breast pCR and pN status, ypN1 had a strong negative impact (OS, RFS, and MFS: HR = 3.153, 4.677, and 6.133, respectively), higher than no in-breast pCR (HR = 2.369, 2.252, and 2.323). A negative impact of no pCR on OS was observed for cN0 patients and TN tumors (HR = 4.972) or HER2-positive tumors (HR = 11.706), as well as in Luminal-B Her2-negative tumors on MFS (HR = 2.223) and for Luminal-A on RFS (HR = 4.465) and MFS (HR = 4.185).

CONCLUSION

Achievement of pCR, but not tumor size (pretreatment cT category), has an independent prognostic impact on survival. These results suggest potential NAC benefits in patients with small tumors (<2 cm), even in absence of clinically suspicious lymph nodes. Residual lymph node disease after NAC is the most powerful adverse prognostic factor.

Triple-negative and Her2-positive breast cancer in women aged 70 and over: prognostic impact of age according to treatment

Background

Elderly breast cancer (BC) patients have been underrepresented in clinical trials whereas ~60% of deaths from BC occur in women aged 70 years and older. Only limited data are available on the prognostic impact of age according to treatment, especially in the triple-negative (TN) and Her2-positive because of the lower frequency of these subtypes in elderly patients. We report herein the results of a multicenter retrospective study analyzing the prognostic impact of age according to treatment delivered in TN and Her2-positive BC patients of 70 years or older, including comparison by age groups.

Methods

The medical records of 31,473 patients treated from January 1991 to December 2018 were retrieved from 13 French cancer centers for retrospective analysis. Our study population included all ≥70 patients with TN or Her2-positive BC treated by upfront surgery. Three age categories were determined: 70-74, 75-80, and > 80 years.

Results

Of 528 patients included, 243 patients were 70-74 years old (46%), 172 were 75-80 years (32.6%) and 113 were >80 years (21.4%). Half the population (51.9%, 274 patients) were TN, 30.1% (159) Her2-positive/hormone receptors (HR)-positive, and, 18% (95) Her2-positive/endocrine receptors (ER)-negative BC. Advanced tumor stage was associated with older age but no other prognostic factors (tumor subtype, tumor grade, LVI). Adjuvant chemotherapy delivery was inversely proportional to age. With 49 months median follow-up, all patient outcomes (overall survival (OS), disease-free survival (DFS), breast cancer-specific survival (BCSS), and recurrence-free survival (RFS)) significantly decreased as age increased. In multivariate analysis, age >80, pT2-3 sizes, axillary macrometastases, lymphovascular involvement, and HR-negativity tumor negatively affected DFS and OS. Comparison between age >80 and <=80 years old showed worse RFS in patients aged > 80 (HR=1.771, p=0.031).

Conclusion

TN and Her2-positive subtypes occur at similar frequency in elderly patients. Older age is associated with more advanced tumor stage presentation. Chemotherapy use decreases with older age without worse other pejorative prognostic factors. Age >80, but not ≤80, independently affected DFS and OS.

CD25high Effector Regulatory T Cells Hamper Responses to PD-1 Blockade in Triple-Negative Breast Cancer

Regulatory T cells (Treg) impede effective antitumor immunity. However, the role of Tregs in the clinical outcomes of patients with triple-negative breast cancer (TNBC) remains controversial. Here, we found that an immunosuppressive TNBC microenvironment is marked by an imbalance between effector αβCD8+ T cells and Tregs harboring hallmarks of highly suppressive effector Tregs (eTreg). Intratumoral eTregs strongly expressed PD-1 and persisted in patients with TNBC resistant to PD-1 blockade. Importantly, CD25 was the most selective surface marker of eTregs in primary TNBC and metastases compared with other candidate targets for eTreg depletion currently being evaluated in trials for patients with advanced TNBC. In a syngeneic TNBC model, the use of Fc-optimized, IL2 sparing, anti-CD25 antibodies synergized with PD-1 blockade to promote systemic antitumor immunity and durable tumor growth control by increasing effector αβCD8+ T-cell/Treg ratios in tumors and in the periphery. Together, this study provides the rationale for the clinical translation of anti-CD25 therapy to improve PD-1 blockade responses in patients with TNBC.

SIGNIFICANCE

An imbalance between effector CD8+ T cells and CD25high effector Tregs marks immunosuppressive microenvironments in αPD-1-resistant TNBC and can be reversed through effector Treg depletion to increase αPD-1 efficacy.

Negative Survival Impact of Occult Lymph Node Involvement in Small HER2-Positive Early Breast Cancer Treated by Up-Front Surgery

(1) Background: The independent negative prognostic value of isolated tumor cells or micro-metastases in axillary lymph nodes has been established in triple-negative breast cancers (BC). However, the prognostic significance of pN0(i+) or pN1mi in HER2-positive BCs treated by primary surgery remains unexplored. Therefore, our objective was to investigate the impact of pN0(i+) or pN1mi in HER2-positive BC patients undergoing up-front surgery on their outcomes. (2) Methods: We retrospectively analyzed 23,650 patients treated in 13 French cancer centers from 1991 to 2013. pN status was categorized as pN0, pN0(i+), pN1mi, and pNmacro. The effect of pN0(i+) or pN1mi on outcomes was investigated both in the entire cohort of patients and in pT1a-b tumors. (3) Results: Of 1771 HER2-positive BC patients included, pN status distributed as follows: 1047 pN0 (59.1%), 60 pN0(i+) (3.4%), 118 pN1mi (6.7%), and 546 pN1 macro-metastases (30.8%). pN status was significantly associated with sentinel lymph node biopsy, axillary lymph node dissection, age, ER status, tumor grade, and size, lymphovascular invasion, adjuvant systemic therapy (ACt), and radiation therapy. With 61 months median follow-up (mean 63.2; CI 95% 61.5-64.9), only pN1 with macro-metastases was independently associated with a negative impact on overall, disease-free, recurrence-free, and metastasis-free survivals in multivariate analysis. In the pT1a-b subgroup including 474 patients, RFS was significantly decreased in multivariate analysis for pT1b BC without ACt (HR 2.365, 1.04-5.36, p = 0.039) and for pN0(i+)/pN1mi patients (HR 2.518, 1.03-6.14, p = 0.042). (4) Conclusions: Survival outcomes were not adversely affected by pN0(i+) and pN1mi in patients with HER2-positive BC. However, in the case of pT1a-b HER2-positive BC, a negative impact on RFS was observed specifically for patients with pN0(i+) and pN1mi diseases, particularly among those with pT1b tumors without ACt. Our findings highlight the importance of considering the pN0(i+) and pN1mi status in the decision-making process when discussing trastuzumab-based ACt for these patients.

Enhanced Recovery after Surgery and Endometrial Cancers: Results from an Initial Experience Focused on Elderly Patients

Endometrial cancer is the fifth most common cancer among French women and occurs most frequently in the over-70-year-old population. Recent years have seen a significant shift towards minimally invasive surgery and Enhanced Recovery After Surgery (ERAS) protocols in endometrial cancer management. However, the impact of ERAS on endometrial cancer has not been well-established. We conducted a prospective observational study in a comprehensive cancer center, comparing the outcomes between endometrial cancer patients who received care in an ERAS pathway (261) and those who did not (166) between 2006 and 2020. We performed univariate and multivariate analysis. Our primary objective was to evaluate the impact of ERAS on length of hospital stay (LOS), with the secondary objectives being the determination of the rates of early discharge, post-operative morbidity, and rehospitalization. We found that patients in the ERAS group had a significantly shorter length of stay, with an average of 3.18 days compared to 4.87 days for the non-ERAS group (estimated decrease -1.69, p < 0.0001). This effect was particularly pronounced among patients over 70 years old (estimated decrease -2.06, p < 0.0001). The patients in the ERAS group also had a higher chance of early discharge (47.5% vs. 14.5% in the non-ERAS group, p < 0.0001), for which there was not a significant increase in post-operative complications. Our study suggests that ERAS protocols are beneficial for the management of endometrial cancer, particularly for older patients, and could lead to the development of ambulatory pathways.

Early breast cancer in women aged 35 years or younger: A large national multicenter French population-based case control-matched analysis

BACKGROUND

There is a scarcity of data exploring early breast cancer (eBC) in very young patients. We assessed shared and intrinsic prognostic factors in a large cohort of patients aged ≤35, compared to a control group aged 36 to 50.

METHODS

Patients ≤50 were retrospectively identified from a multicentric cohort of 23,134 eBC patients who underwent primary surgery between 1990 and 2014. Multivariate Cox analyses for DFS and OS were built. To assess the independent impact of age, 1 to 3 case-control analysis was performed by matching ≤35 and 36-50 years patients.

RESULTS

Of 6481 patients, 556 were aged ≤35, and 5925 from 36 to 50. Age ≤35 was associated with larger tumors, higher grade, ER-negativity, macroscopic lymph node involvement (pN + macro), lymphovascular invasion (LVI), mastectomy, and chemotherapy (CT) use. In multivariate analysis, age ≤35 was associated with worse DFS [HR 1.56, 95% CI 1.32-1.84; p < 0.001], and OS [HR 1.29, 95% CI 1.03-1.60; p = 0.025], as were high grade, large tumor, LVI, pN + macro, ER-negativity, period of diagnostic, and absence of ET or CT (for DFS). Adverse prognostic impact of age ≤35 was maintained in the case control-matched analysis for DFS [HR 1.56, 95%CI 1.28-1.91, p < 0.001], and OS [HR 1.33, 95%CI 1.02-1.73, p = 0.032]. When only considering patients ≤35, ER, tumor size, nodal status, and LVI were independently associated with survival in this subgroup.

CONCLUSIONS

Age ≤35 is associated with less favorable presentation and more aggressive treatment strategies. Our results support the poor prognosis value of young age, which independently persisted when adjusting for other prognostic factors and treatments.

The need to tailor the omission of axillary lymph node dissection to patients with good prognosis and sentinel node micro-metastases

BACKGROUND

Results of IBCSG-23-01-trial which included breast cancer patients with involved sentinel nodes (SN) by isolated-tumor-cells or micro-metastases supported the non-inferiority of completion axillary-lymph-node-dissection (cALND) omission. However, current data are considered insufficient to avoid cALND for all patients with SN-micro-metastases.

METHODS

To investigate the impact of cALND omission on disease-free-survival (DFS) and overall survival (OS), we analyzed a cohort of 1421 patients <75 years old with SN-micro-metastases who underwent breast conservative surgery (BCS). We used inverse probability of treatment weighting (IPTW) to obtain adjusted Kaplan-Meier estimators representing the experience in the analysis cohort, based on whether all or none had been subject to cALND omission.

RESULTS

Weighted log-rank tests comparing adjusted Kaplan-Meier survival curves showed significant differences in OS (p-value = 0.002) and borderline significant differences in DFS (p-value = 0.090) between cALND omission versus cALND. Cox's regression using stabilized IPTW evidenced an average increase in the risk of death associated with cALND omission (HR = 2.77, CI95% = 1.36-5.66). Subgroup analyses suggest that the rates of recurrence and death associated with cALND omission increase substantially after a large period of time in the half sample of women less likely to miss cALND.

CONCLUSIONS

Using IPTW to estimate the causal treatment effect of cALND in a large retrospective cohort, we concluded cALND omission is associated with an increased risk of recurrence and death in women of <75 years old treated by BCS in the absence of a large consensus in favor of omitting cALND. These results are particularly contributive for patients treated by BCS where cALND omission rates increase over time.

Contribution of endocrine therapy in oestrogen receptor-positive pT1a-b breast cancer: Results of a retrospective study

INTRODUCTION

Few data have been reported regarding endocrine therapy (ET) in patients with small pT1a-b ER-postive breast cancer (BC). Thus, we conducted a study to detect possible survival improvements due to ET in such patients.

METHODS

Our retrospective observational study included 5545 patients with pT1a-b ER-positive BC treated in 15 French centres, excluding patients with HER2-positive status, neoadjuvant chemotherapy, ER-negative status, unknown pN status or in situ BC. We estimated disease-free survival (DFS), recurrence-free survival (RFS) and overall survival (OS) via univariate analysis and multivariate Cox regression.

RESULTS

Most patients (80.3%: 4453) received ET and-when compared to those without ET-experienced increases of 2.5% and 3.3% in DFS and 1.9% and 4.3% in RFS after 5 and 7 years of follow-up, respectively, with little difference in OS. In Cox regression analysis, no ET was significantly associated with decreased DFS (hazard ratio, HR = 1.275, p = 0.047, 95% CI[1.003-1.620]) but not OS or RFS in all patients, while in 2363 patients with pT1a-b ER-positive grade 2-3 BC, no ET was significantly associated with decreased DFS (HR = 1.502, p = 0.049, 95% CI[1.001-2.252]), but not OS (HR = 1.361, p = 0.272). ET omission was not significantly associated with decreased survival in 3047 patients with pT1a-b ER-positive grade 1 BC.

CONCLUSION

Our results indicate that while ET provided a beneficial impact on survival to patients with pT1a-bN0 ER-positive BC-and especially in those with grade 2-3 tumours-no such impact was observed in grade 1 tumours. Consequently, ET should be discussed with these patients, particularly in those with pT1a grade 1 tumours.

Mastectomy and Immediate Breast Reconstruction with Pre-Pectoral or Sub-Pectoral Implant: Assessing Clinical Practice, Post-Surgical Outcomes, Patient's Satisfaction and Cost

Immediate breast reconstruction (IBR) rates increase during last years and implant-based reconstruction was the most commonly performed procedure. We examined data collected over 25 months to assess complication rate, duration of surgery, patient's satisfaction and cost, according to pre-pectoral or sub-pectoral implant-IBR. All patients who received an implant-IBR, from January 2020 to January 2022, were included. Results were compared between pre-pectoral and sub-pectoral implant-IBR in univariate and multivariate analysis. We performed 316 implant-IBR, 218 sub-pectoral and 98 (31%) pre-pectoral. Pre-pectoral implant-IBR was significantly associated with the year (2021: OR=12.08 and 2022: OR=76.6), the surgeons and type of mastectomy (SSM vs NSM: OR=0.377). Complications and complications Grade 2-3 rates were 12.9% and 10.1% for sub-pectoral implant-IBR respectively, without significant difference with pre-pectoral implant-IBR: 17.3% and 13.2%. Complications Grade 2-3 were significantly associated with age <50-years (OR=2.27), ASA-2 status (OR=3.63) and cup-size >C (OR=3.08), without difference between pre and sub-pectoral implant-IBR. Durations of surgery were significantly associated with cup-size C and >C (OR=1.72 and 2.80), with sentinel lymph-node biopsy and axillary dissection (OR=3.66 and 9.59) and with sub-pectoral implant-IBR (OR=2.088). Median hospitalization stay was 1 day, without difference between pre and sub-pectoral implant-IBR. Cost of surgery was significantly associated with cup-size > C (OR=2.216) and pre-pectoral implant-IBR (OR=8.02). Bad-medium satisfaction and IBR-failure were significantly associated with local recurrence (OR=8.820), post-mastectomy radiotherapy (OR=1.904) and sub-pectoral implant-IBR (OR=2.098).

Conclusion

Complications were not different between pre and sub-pectoral implant-IBR. Pre-pectoral implant-IBR seems a reliable and faster technique with better patient satisfaction but with higher cost.

Posterior pelvic exenteration for ovarian cancer: surgical and oncological outcomes

Objective

Posterior pelvic exenteration (PPE) can be required to achieve complete resection in ovarian cancer (OC) patients with large pelvic disease. This study aimed to analyze morbidity, complete resection rate, and survival of PPE.

Methods

Ninety patients who underwent PPE in our Comprehensive Cancer Center between January 2010 and February 2021 were retrospectively identified. To analyze practice evolution, 2 periods were determined: P1 from 2010 to 2017 and P2 from 2018 to 2021.

Results

A 82.2% complete resection rate after PPE was obtained, with rectal anastomosis in 96.7% of patients. Complication rate was at 30% (grade 3 in 9 patients), without significant difference according to periods or quality of resection. In a binary logistic regression adjusted on age and stoma, only age of 51–74 years old was associated with a lower rate of complication (odds ratio=0.223; p=0.026). Median overall and disease-free survivals (OS and DFS) from initial diagnosis were 75.21 and 29.84 months, respectively. A negative impact on OS and DFS was observed in case of incomplete resection, and on DFS in case of final cytoreductive surgery (FCS: after ≥6 chemotherapy cycles). Age ≥75-years had a negative impact on DFS for new OC surgery. For patients with complete resection, OS and DFS were decreased in case of interval cytoreductive surgery and FCS in comparison with primary cytoreductive surgery.

Conclusion

PPE is an effective surgical measure to achieve complete resection for a majority of patients. High rate of colorectal anastomosis was achieved without any mortality, with acceptable morbidity and high protective stoma rate.

Posterior-pelvic-exenteration (PPE) can be required to achieve complete cyto-reductive-surgery (CS) in ovarian cancer (OC) patients. A 82.2% complete-CS rate was obtained for PPE, with rectal anastomosis in 96.7%. Complication rate was 30%. Negative impact on DFS for patients with incomplete-CS or final-CS or age ≥75-years for new OC and PPE.

Neoadjuvant Chemotherapy for Breast Cancer: Evolution of Clinical Practice in a French Cancer Center Over 16 Years and Pathologic Response Rates According to Tumor Subtypes and Clinical Tumor Size: Retrospective Cohort Study

We examined characteristics trends in early breast cancer patients receiving neoadjuvant chemotherapy (NAC) over a 16-year period. Our primary objective was to analyze variations in tumor stage and subtype over time. Secondary objectives included analyses of type of surgery and pathological response, from January 2005 to May 2021, 1623 patients receiving NAC were identified. Three periods were determined: 2005-2009 (P1), 2010-2014 (P2), 2015-2021 (P3). Correlations between periods and patient features with cT stage, pathological breast and axillary node response, pathological complete response (pCR), and type of surgery were assessed in univariate and multivariate analyses. We observed a significant increase in cT0-1 and N0 stages with periods (from 6.8% at P1 to 21.2% at P3, and from 43.2% at P1 to 55.9% at P3, respectively) and in the proportion of HER2+ and triple negative (TN) subtypes. In a multivariate analysis, a decrease of cT2-3-4 tumors during P3 was observed for HER2+ (OR:0.174; p=0.004) and TN tumors (OR:0.287; p=0.042). In-breast pCR and pCR were observed in 40.8% and 34.4% of all patients, respectively, with strong association with tumor subtypes, but not with tumor size in multivariate analysis (37.0% pCR for cT0-1 tumors, 36.4% for cT2 tumors, 29.1% for cT3 tumors (cT0-1 versus cT≥2; p=0.222)). pCR was negatively associated with cN1 stage (OR:1.499; p<0.001 for cN1 patients compared to cN0). We observed an increase in the proportion of small cT0-1 and N0 stages treated with NAC, especially in HER2+ and TN subtypes. No significant impact of tumor size on pCR rates was found.

The Management of a Comprehensive Cancer Center during the First Six Months of the COVID-19 Pandemic in the South of France: Lessons from the Paoli-Calmettes Institute's Experience

During the COVID-19 pandemic, it was rapidly established that cancer patients have an increased risk of developing severe forms of the 2019 coronavirus disease (COVID-19) due to a backlog of cancer diagnostics and immunosuppressive treatments. Cancer centers had to quickly adapt to continue cancer therapies despite the high infection risks and major disruptions in the French healthcare system. We described and analyzed the impact of the pandemic in our institution: management adjustments, COVID-19 infection rates in patients and staff, and impacts on clinical activities and finances during the first wave of the pandemic from March to September 2020. We also compared the results to the clinical activity data from preceding periods. A crisis unit was rapidly created that met 27 times over 66 days, generating numerous changes in hospital protocol. While our area was devastated by the pandemic, the infection rate of our staff and patients remained low (less than 1.5% of all employees). However, the lockdown period was accompanied with a reduction of most clinical activities, leading to decreases of 43%, 36%, 36%, 1%, and 10% in surgery, endoscopy, radiotherapy, and in- and out-patient chemotherapy sessions, respectively, with substantial financial loss. Our report highlights the need for the rapid creation, implementation, and adaptation of new protocols during a pandemic’s evolution to prevent disease transmission. Lessons from this situation should provide motivation to better prepare for/limit the dismantling of cancer therapies that can dramatically impact patient care and have deleterious consequences on an institution’s financial situation.

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.

•

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

•

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

•

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

•

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

Prophylactic nipple-sparing mastectomy with immediate breast reconstruction: results of a French prospective trial

BACKGROUND

Nipple-sparing mastectomy (NSM) with immediate breast reconstruction (IBR) is used increasingly when performing a prophylactic mastectomy. Few prospective studies have reported on complication rates. This complementary trial to the French prospective multicentre MAPAM trial aimed to evaluate the nipple-areola complex (NAC) necrosis rate in prophylactic NSM with IBR.

METHODS

Patient characteristics and surgical data were recorded. Morbidity after prophylactic NSM with a focus on NAC necrosis was analysed.

RESULTS

Among 59 women undergoing prophylactic NSM, 19 (32 per cent) of the incisions were partly on the NAC. Reconstructions were performed with 46 definitive implants and 13 expanders. The crude rate of postoperative complications was 25 per cent (15 patients). Complete NAC necrosis was reported in two women (3 per cent) and partial or total necrosis in nine (15 per cent). No NAC resection was necessary. Median BMI was lower in women with total or partial NAC necrosis compared with the others (20.0 versus 21.3 kg/m2 respectively; P = 0.034).

CONCLUSION

Results of this prospective study confirm that prophylactic NSM with IBR is associated with a low risk of total NAC necrosis.

Adjuvant chemotherapy for small, lymph node-negative, triple-negative breast cancer: A single-center study and a meta-analysis of the published literature

BACKGROUND

Current guidelines recommend adjuvant chemotherapy for patients with small, lymph node-negative, triple-negative breast cancer (TNBC) measuring >5 mm (T1b disease), but clinical evidence to support this recommendation is lacking. Thus, the current study aimed to evaluate the survival benefit of adjuvant chemotherapy in patients with T1N0M0 (measuring ≤2 cm) TNBC with different tumor sizes.

METHODS

The authors retrospectively evaluated consecutive patients with pT1N0M0 TNBC who were diagnosed between 2000 and 2016 at Sun Yat-Sen University Cancer Center. For the meta-analysis, electronic medical databases were searched for all relevant studies regarding the effect of adjuvant chemotherapy on the target population.

RESULTS

Of the 351 enrolled patients, 309 (88%) received adjuvant chemotherapy and 42 patients (12%) did not. The distribution by T classification was T1a in 19 patients (5.4%), T1b in 67 patients (19.1%), and T1c in 265 patients (75.5%). Adjuvant chemotherapy significantly improved recurrence-free survival (RFS) in the patients with T1c disease, but not those with T1b and T1a disease. Meanwhile, there was no difference in RFS noted according to the chemotherapy regimen among patients with T1c disease. Seven eligible studies comprising 1525 patients with T1N0M0 (941 with T1a/bN0M0) were included in the meta-analysis. The meta-analysis demonstrated that adjuvant chemotherapy significantly reduced the rate of disease recurrence for patients with T1a/b disease as a group, but the population driving that was only patients with T1b disease, not those with T1a disease.

CONCLUSIONS

Although the retrospective analysis demonstrated a survival benefit of adjuvant chemotherapy only for patients with T1cN0 TNBC, the meta-analysis showed it also is beneficial for individuals with T1bN0 TNBC. For patients with T1cN0M0 TNBC, less intensive chemotherapy regimens achieve an excellent survival outcome similar to that of intensive anthracycline and taxane combination chemotherapy.

Lack of prognostic impact of sentinel node micro-metastases in endocrine receptor-positive early breast cancer: results from a large multicenter cohort☆

Background

Prognostic impact of lymph node micro-metastases (pN1mi) has been discordantly reported in the literature. The need to clarify this point for decision-making regarding adjuvant therapy, particularly for patients with endocrine receptor (ER)-positive status and HER2-negative tumors, is further reinforced by the generalization of gene expression signatures using pN status in their recommendation algorithm.

Patients and methods

We retrospectively analyzed 13 773 patients treated for ER-positive breast cancer in 13 French cancer centers from 1999 to 2014. Five categories of axillary lymph node (LN) status were defined: negative LN (pN0i−), isolated tumor cells [pN0(i+)], pN1mi, and pN1 divided into single (pN1 = 1) and multiple (pN1 > 1) macro-metastases (>2 mm). The effect of LN micro-metastases on outcomes was investigated both in the entire cohort of patients and in clinically relevant subgroups according to tumor subtypes. Propensity-score-based matching was used to balance differences in known prognostic variables associated with pN status.

Results

As determined by sentinel LN biopsy, 9427 patients were pN0 (68.4%), 546 pN0(i+) (4.0%), 1446 pN1mi (10.5%) and 2354 pN1 with macro-metastases (17.1%). With a median follow-up of 61.25 months, pN1 status, but not pN1mi, significantly impacted overall survival (OS), disease-free survival (DFS), metastasis-free survival (MFS), and breast-cancer-specific survival. In the subgroup of patients with known tumor subtype, pN1 = 1, as pN1 > 1, but not pN1mi, had a significant prognostic impact on OS. DFS and MFS were only impacted by pN1 > 1. Similar results were observed in the subgroup of patients with luminal A-like tumors (n = 7101). In the matched population analysis, pN1macro, but not pN1mi, had a statistically significant negative impact on MFS and OS.

Conclusion

LN micro-metastases have no detectable prognostic impact and should not be considered as a determining factor in indicating adjuvant chemotherapy. The evaluation of the risk of recurrence using second-generation signatures should be calculated considering micro-metastases as pN0.

•

LN micro-metastases have no detectable prognostic impact.

•

pN1 status, but not pN1mi, significantly impacted overall survival, disease-free survival, metastasis-free survival.

•

In the subgroup of patients with known tumor subtype, pN1=1, as pN1>1, but not pN1mi, had a significant prognostic impact on OS.

•

LN micro-metastases should not be considered as a determining factor in indicating adjuvant chemotherapy.

Care as Usual: An Acceptable Strategy to Apply During the COVID-19 Pandemic in a French Tertiary Gynecologic Oncology Department

We describe and analyze a “care as usual” strategy of a French Comprehensive Cancer Center during the COVID-19 pandemic to manage surgical patients with gynecological cancer. We conducted a retrospective analysis evaluating the surgical activity in our gynecologic oncology department between January 21 and May 12, 2020. We compared the surgical activity and surgical and oncologic outcomes during the pre-lockdown period and the pandemic period. The main objective was to evaluate the impact of the COVID-19 pandemic on surgical activity. The secondary objectives were to analyze the surgical and the oncologic outcomes. We compared the surgical activity during the 8 weeks after the national lockdown (85 procedures) to the surgical activity in the 8 weeks preceding the lockdown (127 procedures). We observed a 33% decrease in activity between the two periods. The clinical and epidemiologic characteristics were similar between the two periods. There were no differences between the surgical approaches (p = 0.592), the surgical complexity (p = 0.323), the length of stay (p = 0.85), and even for the complex procedure (p = 0.96) and the perioperative (p = 0.791) and postoperative complication rates (p = 0.102). We observed a significant decrease in the time of return to intended oncological treatment (RIOT) during the lockdown period with an average of 31.9 days compared to 46.9 days in the pre-lockdown period (p = 0.003). During the COVID-19 pandemic, “care as usual” represents an acceptable strategy without impairing the oncologic outcome in a Comprehensive Cancer Center with a patient-centered clinical pathway for gynecologic oncologic surgical patients.

Robotic Versus Conventional Nipple-Sparing Mastectomy With Immediate Breast Reconstruction

Background

Several studies reported the feasibility and safety of robotic-NSM (R-NSM). The aim of our prospective study was to compare R-NSM and conventional-NSM (C-NSM).

Methods

We analyzed patients who were operated on with and without robotic assistance (R-NSM or C-NSM) and who received immediate breast reconstruction (IBR) with implant or latissimus dorsi-flap (LDF). The main objective was complication rate and secondary aims were post-operative length of hospitalization (POLH), duration of surgery, and cost.

Results

We analyzed 87 R-NSM and 142 C-NSM with implant-IBR in 50 and 135 patients, with LDF-IBR in 37 and 7 patients, respectively. Higher durations of surgery and costs were observed for R-NSM, without a difference in POLH and interval time to adjuvant therapy between R-NSM and C-NSM. In the multivariate analysis, R-NSM was not associated with a higher breast complication rate (OR=0.608) and significant factors were breast cup-size, LDF combined with implant-IBR, tobacco and inversed-T incision. Grade 2-3 breast complications rate were 13% for R-NSM and 17.3% for C-NSM, significantly higher for LDF combined with implant-IBR, areolar/radial incisions and BMI>=30. A predictive score was calculated (AUC=0.754). In logistic regression, patient's satisfaction between C-NSM and R-NSM were not significantly different, with unfavorable results for BMI >=25 (OR=2.139), NSM for recurrence (OR=5.371) and primary breast cancer with radiotherapy (OR=4.533). A predictive score was calculated. In conclusion, our study confirms the comparable clinical outcome between C- NSM and R-NSM, in the price of longer surgery and higher cost for R-NSM. Predictive scores of breast complications and satisfaction were significantly associated with factors known in the pre-operative period.

The impact of modern preoperative high-dose-rate brachytherapy in early-stage cervical cancer

PURPOSE

To analyze the clinical outcomes and the safety of preoperative high-dose-rate (HDR) image-guided adaptive brachytherapy (IGABT) followed by minimally invasive surgery (MIS) in the multidisciplinary management of early-stage cervical cancer.

METHODS AND MATERIALS

Medical records of all consecutive patients with early-stage cervical cancer treated at our institution between 2012 and 2018 with preoperative IGABT in a multidisciplinary approach were reviewed. Treatment schedule was pelvic node dissection, preoperative IGABT followed 6-8 week later by MIS hysterectomy.

RESULTS

Seventy patients with cervical cancer FIGO stages (IB1 18.6%, IB2 75.7% and IIA1 5.7%) were treated by preoperative HDR brachytherapy. With a median follow-up of 37.4 months [95% confidence interval, 32.1-39.7 months] isolated vaginal vault recurrence was not observed, 3 pelvic relapses were reported (4.3%). None of patients received postoperative radiotherapy (EBRT) or radiochemotherapy. The estimated 3-year local and pelvis relapse free survival for the entire population were respectively 98% [95% confidence interval, 89%-100%] and 90% [80%-96%]. The estimated 3-year disease-free survival (DFS) for the entire population was 88% [77-94%]. The 3-year overall survival (OS) rate was 97% [88%-99%]. Microscopic vaginal resection margin (R1) was observed in one patient ([1].4%). Lymph-vascular space invasion (LVSI) was found found in 6 (8.6%) patients. Forty-eight late complications in 36 patients (51.4%) were observed. Five (7.1%) grade 3 vaginal wound dehiscence toxicities were observed. Urinary and gastrointestinal toxicities were grade 1-2. No grade 4-5 complications were observed.

CONCLUSIONS

Preoperative image-guided adaptive brachytherapy followed by minimally invasive surgery allows high local control, reduces positive surgical margins and rates of lymph-vascular space invasion avoiding adjuvants treatments. Surgical approaches must be discussed with patients including preoperative brachytherapy as a down-staging treatment.

Development of a mucinous adenocarcinoma on a sigmoid colpoplasty for vaginal agenesis: About a case report and review of the literature

•

Our article lists all cases in the neovaginal cancer literature since 1929.

•

We propose an explanation of the pathophysiology of the development of neovaginal cancer.

•

We propose a classification of neovaginal cancers.

We report a case of mucinous adenocarcinoma developed on sigmoid colpoplasty, performed for a congenital agenesis vaginal. The cancer development of neovagina remains exceptional. Its management consists, in the majority of cases, in surgery for a complete excision. Adjuvant treatments are associated according to the pathological results and the neovagina reconstruction technique performed.

Quantification of Immune Variables from Liquid Biopsy in Breast Cancer Patients Links Vδ2+ γδ T Cell Alterations with Lymph Node Invasion

The rationale for therapeutic targeting of Vδ2+ γδ T cells in breast cancer is strongly supported by in vitro and murine preclinical investigations, characterizing them as potent breast tumor cell killers and source of Th1-related cytokines, backing cytotoxic αβ T cells. Nonetheless, insights regarding Vδ2+ γδ T cell phenotypic alterations in human breast cancers are still lacking. This paucity of information is partly due to the challenging scarcity of these cells in surgical specimens. αβ T cell phenotypic alterations occurring in the tumor bed are detectable in the periphery and correlate with adverse clinical outcomes. Thus, we sought to determine through an exploratory study whether Vδ2+ γδ T cells phenotypic changes can be detected within breast cancer patients' peripheral blood, along with association with tumor progression. By using mass cytometry, we quantified 130 immune variables from untreated breast cancer patients' peripheral blood. Supervised analyses and dimensionality reduction algorithms evidenced circulating Vδ2+ γδ T cell phenotypic alterations already established at diagnosis. Foremost, terminally differentiated Vδ2+ γδ T cells displaying phenotypes of exhausted senescent T cells associated with lymph node involvement. Thereby, our results support Vδ2+ γδ T cells implication in breast cancer pathogenesis and progression, besides shedding light on liquid biopsies to monitor surrogate markers of tumor-infiltrating Vδ2+ γδ T cell antitumor activity.

Mastectomy with immediate breast reconstruction: Results of a mono-centric 4-years cohort

Introduction

Oncological safety, quality of life and cosmetic outcomes seems to be similar between breast conserving surgery (BCS) and mastectomy with immediate breast reconstruction (IBR). We report our experience of IBR for consecutive mastectomies realized in a recent period of four years in order to determined immediate surgical results according to type of mastectomy and type of reconstruction, as mains objectives.

Methods

All mastectomies with IBR during years 2016–2019 were included. A retrospective analysis with prospective data collection was performed.

Results

We analyzed 748 IBR: 353 nipple-sparing mastectomies (NSM), 391 skin-sparing mastectomies (SSM) and 4 standard mastectomies, 551 with definitive implant or expanders and 196 with latissimus dorsi-flap (LDF). More NSM were performed during the 2 last years and more LDF were performed for high BMI, high breast cup-size, neo-adjuvant chemotherapy and radiotherapy and local recurrence. We realized 111 robotic NSM and 125 robotic LDF. Longer duration of surgery was significantly associated with the robotic procedures.

The overall complications crude rate was 31.4% with 9.9% of re-operations and 5.8% of implant loss. Grade 2–3 complications were significantly associated with smoking. Breast complications occurred in 32.9% of mastectomies with principally skin or nipple-areola-complex suffering or necrosis, hematomas and infections. A predictive score was determined to evaluate risk of complications before surgery.

Conclusion

Mastectomy with IBR seems to be a safe technique with an acceptable complication rate which is increased by tobacco use, high breast cup-size and IBR-type.

•

Mastectomy with immediate breast to determined immediate surgical results.

•

More Nipple Sparing Mastectomy performed during the 2 last years.

•

More Latissimus dorsi-flap performed for high BMI, high breast cup-size, after radiotherapy.

Salvage Mastectomy Versus Second Conservative Treatment for Second Ipsilateral Breast Tumor Event: A Propensity Score-Matched Cohort Analysis of the GEC-ESTRO Breast Cancer Working Group Database

PURPOSE

Second conservative treatment has emerged as an option for patients with a second ipsilateral breast tumor event after conserving surgery and breast irradiation. We aimed to address the lack of evidence regarding second breast event treatment by comparing oncologic outcomes after conservative treatment or mastectomy.

METHODS AND MATERIALS

Oncologic outcomes were analyzed using a propensity score-matched cohort analysis study on patients who received a diagnosis of a second breast event between January 1995 and June 2017. Patient data were collected from 15 hospitals/cancer centers in 7 European countries. Patients were offered mastectomy or lumpectomy plus brachytherapy. Propensity scores were calculated with logistic regression and multiple imputations. Matching (1:1) was achieved using the nearest neighbor method, including 10 clinical/pathologic data related to the second breast event. The primary endpoint was 5-year overall survival from the salvage surgery date. Secondary endpoints were 5-year cumulative incidence of third breast event, regional relapse and distant metastasis, and disease-free and specific survival. Complications and 5-year incidence of mastectomy were investigated in the conservative treatment cohort.

RESULTS

Among the 1327 analyzed patients (mastectomy, 945; conservative treatment, 382), 754 were matched by propensity score (mastectomy, 377; conservative treatment, 377). The median follow-up was 75.4 months (95% confidence interval [CI], 65.4-83.3) and 73.8 months (95% CI, 67.5-80.8) for mastectomy and conservative treatment, respectively (P = .9). In the matched analyses, no differences in 5-year overall survival and cumulative incidence of third breast event were noted between mastectomy and conservative treatment (88% [95% CI, 83.0-90.8] vs 87% [95% CI, 82.1-90.2], P = .6 and 2.3% [95% CI, 0.7-3.9] vs 2.8% [95% CI, 0.8-4.7], P = .4, respectively). Similarly, no differences were observed for all secondary endpoints. Five-year cumulative incidence of mastectomy was 3.1% (95% CI, 1.0-5.1).

CONCLUSIONS

To our knowledge, this is the largest matched analysis of mastectomy and conservative treatment combining lumpectomy with brachytherapy for second breast events. Compared with mastectomy, conservative treatment does not appear to be associated with any differences in terms of oncologic outcome. Consequently, conservative treatment could be considered a viable option for salvage treatment.

Types of Mastectomies and Immediate Reconstructions for Ipsilateral Breast Local Recurrences

Purpose: Ipsilateral-breast-local-recurrence (ILBLR) is a rare event with little data on immediate-breast-reconstruction (IBR). We report post-operative results of different types of mastectomy for ILBLR with or without IBR performed during a period of 40 months in order to analyze post-operative complications as main objective. Methods: We analyzed mastectomies performed for ILBLR after initial breast conservative treatment from January 2016 to April 2019. The characteristics of patients, surgery, complication rate, postoperative hospitalization have been determined. Results: Of the 207 mastectomies, 32.8% had an IBR: 31 nipple-sparing-mastectomy (NSM) and 37 skin-sparing-mastectomy (SSM) with 37 latissimus-dorsi-flap (LDF) IBR and 31 implant-IBR. Few reconstruction was performed for patients with body-mass-index ≥30 (OR = 0.214), infiltrating ductal carcinomas (OR = 0.272) and ASA-3 patients (OR = 0.254). In multivariate analysis, LDF-IBR was more often realized for NSM and for patients with BMI ≥25. The overall complication rate was 37.4%: 45.6 and 33.1% with and without IBR, respectively (p = 0.056). In multivariate analysis, BMI ≥25 (OR 2.02, p = 0.023), IBR (OR 1.9, p = 0.046) and tobacco (OR 2.17, p = 0.055) were correlated with higher risk of complications. There was no difference for Grade 2-3 complications rates for IBR and no IBR, respectively (14.7%: 10/68 and 9.3%: 13/139). In multivariate analysis, overall survival from date of mastectomy for local recurrence was significantly associated with interval time to local recurrence (OR 6.981). Conclusion: Salvage mastectomy and IBR is a good choice for ILBLR, particularly using flap reconstruction. NSM can be considered as a good option in selected patients for ILBLR for NSM and/or LDFR.

EVAN-G score in patients undergoing minimally invasive gynecology oncologic surgery in an Enhanced Recovery After Surgery (ERAS) program

INTRODUCTION

Enhanced Recovery After Surgery (ERAS) has been proven to decrease the length of hospital stay without increasing re-admission rates or complications. There are limited data on the satisfaction of patients undergoing minimally invasive surgery for gynecologic malignancy within ERAS programs. The aim of this study was to evaluate patient satisfaction after minimally invasive surgery for gynecologic malignancy within the ERAS program using the 'Evaluation du Vécu de l'Anésthésie Génerale (EVAN-G)' questionnaire.

METHODS

This observational retrospective study was conducted at the Paoli-Calmettes Institute between June 2016 and December 2018. All the included patients underwent minimally invasive surgery for a gynecologic malignancy. EVAN-G, a validated questionnaire, was used to measure peri-operative patient satisfaction. This questionnaire consists of 26 items assessing six elements: attention, privacy, information, pain, discomfort, and waiting time. Each element is assessed via a 5-step numerical scale and then transformed to a 0-100 scale according to the degree of satisfaction. The EVAN-G questionnaire was given to patients before surgery and collected during the post-operative consultation (2-3 weeks after surgery).

RESULTS

A total of 175 patients underwent minimally invasive surgery for gynecologic malignancy within the ERAS program. Of these, 92 patients were included in the study and 83 patients were excluded. The overall patient compliance rate with our ERAS program was 90%. The analysis of the EVAN-G score of all participants showed an overall high level of satisfaction with a mean score of 81.9 (range 41.6-100). Patients with peri-operative complications or having prolonged hospitalization also showed high levels of satisfaction with a mean score of 80.5 (41.6-100) and 83.2(55-100), respectively.

CONCLUSION

In this study we showed a high patient satisfaction with the ERAS program. When comparing length of stay and complications, neither extended length of stay nor development of complications after minimally invasive surgery impacted patient satisfaction.

How to manage BRCA mutation carriers?

Inherited mutations in BRCA1 and BRCA2 genes increase the risk of development of cancer in organs especially in breast and ovary. Prevention and screening in BRCA mutation carriers are of high importance. Prophylactic surgeries are possible but are still insufficiently performed because they require surgical procedures in healthy patients. Guidelines for the management of BRCA mutations carriers must absolutely be part of the standard practice of all those involved in the management of these patients to increase the impact of the implementation of these preventive measures. There is no screening recommended for ovarian cancer. A risk-reducing bilateral salpingo-oophorectomy should be performed from age 35 to 40 years for BRCA1 mutation carriers and 40 to 45 years for BRCA2 mutation carriers. A screening for breast cancer should be performed annually from 30 years old by breast MRI and mammography. A risk-reducing bilateral mastectomy is recommended with nipple sparing mastectomy and immediate breast reconstruction from 30 years and before 40 years. A multidisciplinary care must be implemented for these patients with an important psychological support.

Results of a prospective phase II national study: Prophylactic radical fimbriectomy (NCT01608074), in women with a documented high risk of breast/ovarian cancer—Final pathological results and outcomes

1594

Background: Risk-reducing salpingo-oophorectomy (RRSO) is the gold standard in surgical prophylaxis of pelvic high-grade serous carcinoma (HGSC) for women at risk of breast/ovarian cancer. Due to significant adverse effects of early oophorectomy, 20-30% of women delay or deny performing this operation. Recent data highlight the fallopian origin of most pelvic HGSC, especially its fimbrial part. Thus, we suggested a new two-step risk-reducing procedure: the radical fimbriectomy (RF) with delayed oophorectomy (DO) (Leblanc et al Gyn Oncol 2011), leading to the current RF/DO Phase 2 study. We present the definitive results on primary and secondary objectives of this trial. Methods: BRCA1/2 carriers or any women with a documented familial risk of breast/ovarian cancer were first counseled to perform a classical laparoscopic RRSO. If they denied, they were offered to enter the RF/DO study. All specimens were submitted to the SEE-FIM pathological protocol. Pathological data along with all intra- and 30-day and beyond post-operative adverse events were prospectively recorded. Follow-up consisted in an annual clinical breast and gynecological examination, with tumor markers and hormonal status assessment. Primary endpoint was the rate of pelvic serous carcinoma. Secondary endpoints were procedure morbidity, rates of tubal abnormalities, breast cancer, secondary oophorectomy. Results: From January 2012 to October 2014, 121 RF were performed: 120 by laparoscopy, 1 laparotomy (concurrent myomectomy). An occult neoplasia was found in 3 cases with 1 invasive HGSC. Intraoperative complications were two grade1 bleedings without transfusion with no grade ≥3 early post-operative or delayed complication. With a median follow-up of 5.3 years (0.2 -7.6), no patient developed any pelvic HGSC, 21 patients developed a breast cancer (3 de novo, 18 recurrences/contralateral.). 1 cancer-free BRCA1-mutated lady delivered safe twins, after an uneventful post-RF pregnancy obtained with assisted reproductive technology (ART). Overall, 29 women underwent DO (by choice: 12 or menopause: 17) resulting in grade 3b complication in 1 case, but no pathological abnormality. Conclusions: RF/DO appears as a safe, well tolerated and effective procedure in terms of occult neoplasia detection. A successful pregnancy with ART was possible after radical fimbriectomy. Longer follow-up and larger cohort are necessary to confirm its efficacy in terms of ovarian cancer prophylaxis. Clinical trial information: NCT01608074.

Robotic Nipple-Sparing Mastectomy and Immediate Breast Reconstruction With Robotic Latissimus Dorsi Flap Harvest: Technique and Results

Introduction. Only few cases of robotic latissimus dorsi flap reconstruction (RLDFR) have been reported in indication of reconstruction for breast cancer (BC). We report our experience of combined robotic nipple-sparing mastectomy (R-NSM) and RLDFR, and analyze technique, indications, and reproducibility. Methods. All patients with R-NSM and RLDFR from November 2016 to August 2, 2018, were analyzed, and technics have been described. Complication rate with Clavien-Dindo grading and postoperative hospitalization length (days) are reported. Results. Thirty-five R-NSM with RLDFR were performed in 22 cases for primitive BC and 13 for local recurrence. In 12 patients, another surgical procedure was performed during the same time (axillary lymph node dissection or contralateral breast surgery). R-NSM was realized through a short axillar incision, with inside-only installation for 12 patients (34.3%): 18 nonautologous and 17 autologous RLDFR associated with implant in 9 patients. In logistic regression, mastectomy weight >330 g was significantly associated with the use of implant (odds ratio [OR] = 17, P = .015), and significant factor of the time of anesthesia ≥380 minutes was 2 installations (OR = 10.4, P = .049). The median duration of hospitalization stay was 4 days. Complications rates were 51.4% (18/35; 9 grade-1, 2 grade-2, and 7 grade-3). In logistic regression, associated other surgical procedure was predictive of grade-3 complications (OR = 6.87, P = .053). Conclusion. We confirmed the reproducibility and safety of R-NSM and RLDFR with a decreased complication rate. NSM was performed in 42.8% of our patients after previous radiotherapy. We observed an increase of grade-3 complications when R-NSM and RLDFR was combined to another surgical procedure.

Choosing the most appropriate minimally invasive approach to treat gynecologic cancers in the context of an enhanced recovery program: Insights from a comprehensive cancer center

Objective

The aim of the study was to compare the characteristics of procedures for gynecologic cancers conducted with conventional laparoscopy (CL) or robotically assisted laparoscopy (RAL) in the context of an enhanced recovery program (ERP).

Methods

This is a secondary analysis of prospectively collected data from a cohort study conducted between 2016 (when the ERP was first implemented at the Institut Paoli-Calmettes, a comprehensive cancer center in France) and 2018. We included patients who had undergone minimally invasive surgery for gynecological cancers and followed our ERP. The endpoints were the analysis of postoperative complications, the length of postoperative hospitalization (LPO), and the proportion of combined procedures depending on the approach (RAL or CL). Combined procedures were defined by the association of at least two of the following operative items: hysterectomy, pelvic lymphadenectomy, and para-aortic lymphadenectomy.

Results

A total of 362 women underwent either CL (n = 187) or RAL (n = 175) for gynecologic cancers and followed our ERP. The proportion of combined procedures performed by RAL was significantly higher (85/175 [48.6%]) than that performed by CL (23/187 [12.3%]; p < 0.001). The proportions of postoperative complications were similar between the two groups (19.4% versus 17.1%; p = 0.59). Logistic regression analysis revealed a statistically insignificant trend in the association of RAL with a reduced likelihood of an LPO > 3 days after adjusting for predictors of prolonged hospitalization (adjusted OR = 0.573 [0.236–1.388]; p = 0.217).

Conclusion

Experts from our cancer center preferentially choose RAL to perform gynecologic oncological procedures that present elements of complexity. More studies are needed to determine whether this strategy is efficient in managing complex procedures in the framework of an ERP.

When to do surgical resection for atypical breast lesions: Results of a prospective cohort of 518 lesions

AIM

There is no consensual indication for surgical resection after diagnosis on per-cutaneous biopsy of borderline breast lesions (B3). We evaluate under-evaluation rate of per-cutaneous biopsy and predictive factors of under-evaluation. We analyze accuracy of reported decision-making tools.

METHODS

We conduct a prospective multicentric study including, atypic-ductal hyperplasia (ADH), atypic-lobular hyperplasia (ALH), atypic-cylindro-cubic metaplasia (FEA), papilloma, radial scars (RS) and phyllod tumors. When several B3 lesions were associated, the more severe lesion was used to classify the lesion. We determined breast cancers (BC) rate and histologic type. Among 478 patients, 518 B3 lesions were studied: 15.1% (78) FEA, 48.6% (252) ADH, 16.8% (n = 87) ALH, 5.4% (n = 28) RS, 12% (n = 62) papilloma, 0.8% (n = 4) phyllod tumors and 0,8% (n = 4) with a suspicious low grade DCIS. More than 1 lesion was identified in 31.9% (165) of cases. A surgical resection was performed for 86.3% (447/518) lesions. Significant factors of surgical resection were: residual micro-calcification after biopsy (OR: 2.7) and type of B3 lesion.

RESULTS

Overall BC rate was 15.3% (68/445) with 79.4% (54) in-situ carcinomas. According to B3 lesions, BC rates were 12.9% for FEA, 20% for ADH, 11.6% for ALH, 3.7% for RS, 8.8% for papilloma and 25% for suspicious in-situ carcinoma. A score has been calculated and patients were distributed in 3 groups. Patient's rates without BC were respectively: 100%, 80.4% and 80.6% (p = 0.029).

CONCLUSION

In conclusion, it could be suggested to avoided complementary surgical resection in case of good radio-pathologic concordance and low probability of BC.

The actual benefit of intraoperative radiation therapy using 50 kV x-rays in early breast cancer: A retrospective study of 676 patients

This French study reports the 5-year results of partial-breast irradiation using intraoperative radiation therapy (IORT) with 50 kV x-rays, in select early breast cancer patients. We report a retrospective analysis of 676 consecutive early breast cancer patients treated between November 2011 and December 2015 by partial-breast irradiation using the INTRABEAM^® system. Patients were highly selected based on the ASTRO and GEC-ESTRO criteria and underwent breast-conservative surgery and IORT, completed with additional whole-breast irradiation (WBI) when unexpected unfavorable prognostic factors were found at the final pathology report. Patients' outcomes relative to local and distant control, overall and breast cancer-specific survival, and toxicity are presented, as well as rates of additional WBI. Additional WBI was mandatory in one third of patients (31%), mainly due to lymph node involvement and extensive intraductal component. With a median follow-up time of 54 months, the 5-year local recurrence rate was 1.7% [95%CI: 0.9-3.3]; the median time to local recurrence was 23 months; ipsilateral breast recurrences mainly occurred in the same quadrant (7/11); in the restricted population, meeting all predefined criteria and treated with IORT alone (406 patients), the local recurrence rate was 1.5% [95%CI: 0.6-3.6]. Five-year distant tumor control was 98.6% [95%CI: 97.2-99.3], and the median time to distant recurrence was 22 months. Five-year overall survival was 96.5% [95%CI: 94.2-97.8], and 5-year breast cancer-specific survival was 98.9% [95%CI: 97.6-99.7]. In patients treated with IORT alone, there was no grade 3 toxicity, only four grade 3 (mainly fibrosis) affected patients treated with IORT and WBI. Grade 1-2 toxicity rates were 14% and 34.4% in patients treated with IORT alone and IORT plus WBI, respectively. Partial-breast irradiation using IORT by a 50 kV photon device is safe and well-tolerated in select patients with early breast cancer and is a valuable option in patients reluctant for adjuvant WBI.

30 Years of Experience in the Management of Stage III and IV Epithelial Ovarian Cancer: Impact of Surgical Strategies on Survival

Objective: to analyze the evolution of surgical techniques and strategies, and to determine their influence on the survival of patients with stage III or IV epithelial ovarian cancer (EOC). Methods: a retrospective data analysis was performed in two French tertiary cancer institutes. The analysis included clinical information, cytoreductive outcome (complete, optimal and suboptimal), definitive pathology, Overall Survival (OS), and Progression-Free Survival (PFS). Three surgical strategies were compared: Primary Cytoreductive Surgery (PCS), Interval Cytoreductive Surgery (ICS) after three cycles of Neo-Adjuvant Chemotherapy (NAC), and Final Cytoreductive Surgery (FCS) after at least six cycles of NAC. We analyzed four distinct time intervals: prior to 2000, between 2000 and 2004, between 2005 and 2009, and after 2009. Results: data from 1474 patients managed for International Federation of Gynecology and Obstetrics (FIGO) stages III (80%) or IV (20%) EOC were analyzed. Throughout the four time intervals, the rate of patients who were treated only medically increased significantly (10.1% vs. 22.6% p < 0.001). NAC treatment increased from 20.1% to 52.2% (p < 0.001). Complete resection rate increased from 37% to 66.2% (p < 0.001). Of our study population, 1260 patients (85.5%) underwent surgery. OS was longer in cases of complete cytoreduction (Hazard Ratio (HR) = 2.123 CI 95% [1.816–2.481] p < 0.001) but the surgical strategy itself did not affect median OS. OS was 44.9 months, 50.3 months, and 42 months for PCS, ICS, and FCS, respectively (p = 0.410). After adjusting for surgical strategies (PCS, ICS, and FCS), all patients with complete cytoreduction presented similar OS with no significant difference. However, PFS was three months shorter when FCS was compared to PCS (p < 0.001). Conclusion: In our 30 years’ experience of EOC management, complete resection rate was the only independent factor that significantly improved OS and PFS, regardless of the surgical strategy.

Lessons from radiochemotherapy and modern image-guided adaptive brachytherapy followed by hysterectomy

PURPOSE

To analyze the clinical outcomes and the safety of radiochemotherapy (RCT) and image-guided adaptive brachytherapy (IGABT) and to evaluate the impact of hysterectomy (HT) as completion of treatment for cervical cancer.

METHODS AND MATERIALS

145 patients with locally advanced cervical cancer were treated at our institution. Patients underwent RCT and IGABT, then hysterectomy (HT) as completion of treatment was performed, with the exception of patients with surgical contraindications, para aortic metastatic disease or patients who refused surgery. Clinical outcomes and morbidity were retrospectively reviewed in both groups. Local relapse free survival (LRFS), pelvic relapse free survival (PRFS) and overall survival (OS) were analyzed.

RESULTS

Completion HT was performed in 90 (62.1%) patients. Complete histological response and microscopic disease were found in 77 patients (85.6%). Local relapse was observed in 14 patients (9.6%) without differences between completion HT group and the definitive RCT and IGABT group (Odds Ratio OR = 1.73 [0.57-5.23], p = 0.33). The estimated 3-year LRFS and PRFS for the entire population were respectively 90% [84%-94%] and 93% [87%-96%], with no significant differences between them (respectively Hazard Ratio HR = 0.57 [0.20-1.64], p = 0.30 and HR = 0.37 [0.10-1.31], p = 0.12). The estimated 3-year OS rate for the whole population was 84% [75%-91%] with no significant differences between groups (HR = 0.81 [0.32-2.06], p = 0.65). Regarding morbidity, grade ≥ 2 vaginal toxicity was more frequent in the definitive RCT and IGABT group (43.6% vs 26.7%, p = 0.04). All grade 4 toxicity events were reported in the completion HT group.

CONCLUSIONS

Due to high severe toxicity, RCT and IGABT with dose escalation followed by completion hysterectomy don't seem compatible. No benefit and increased severe late morbidity were observed. Combined intracavitary/interstitial technique is mandatory in large target volume at brachytherapy.

Skin sparing mastectomy and robotic latissimus dorsi-flap reconstruction through a single incision

Background

Robotic latissimus dorsi-flap reconstruction (RLDFR) after skin-sparing mastectomy (SSM) for breast cancer (BC) has been performed through a single nipple incision. We report results of SSM with RLDFR, mainly with analysis of feasibility, morbidity, indications, and technique standardization.

Methods

We determined characteristics of patients, previous treatment of BC, and type of reconstruction. Surgical technique, duration of surgery, and complication rate were reported according to three successive periods: P1–3.

Results

Forty RLDFR, with breast implant for 16 patients, with previous breast radiotherapy in 30% had been performed. In logistic regression, factors significantly associated with duration of surgery ≥ 300 min were P2 (OR 0.024, p = 0.004) and P3 (OR 0.012, p = 0.004) versus P1. The median mastectomy weight was 330 g and 460 g for BMI < and ≥ 23.5 (p = 0.025). Length of hospitalization was 4 days. Total complication rate was 20% (8/40): seven breast complications (four re-operations) and one RLDF complication with re-operation. Periods were significantly predictive of complications (p = 0.045).

Conclusion

SSM with RLDFR is feasible, safe, and reproducible. We reported a decrease of duration of surgery, length of post-operative hospitalization, and complication rate.

Transperitoneal para-aortic lymphadenectomy by robot assisted laparoscopy in 10 steps

Objective

Para-aortic lymphadenectomy was the cornerstone of gynecologic oncology surgery. In endometrial cancer, the quality of para-aortic lymphadenectomy had direct impact on survival of patient. The launch of robot assisted laparoscopy started in 2005 in France, and in 2008 a transperitoneal para-aortic lymphadenectomy was described [1]. With the increase of robots, the robot assisted laparoscopy became more and more popular, hence the need of video tutorial to help less experienced surgeon in this surgical procedure [2].

Methods

We proposed a description in 10 key steps, of a transperitoneal para-aortic lymphadenectomy by robot assisted laparoscopy (Da Vinci® Si or Xi Robot Surgical System; Intuitive Surgical Inc., Sunnyvale, CA, USA), without other surgical procedure.

Results

The 10 steps are:

Conclusion

A standardization of transperitoneal para-aortic lymphadenectomy by robot-assisted laparoscopy is the basis of teaching and learning process. Also it increases the quality of surgery, and consequently decreases the risk of complications.

Prediction of early discharge after gynaecological oncology surgery within ERAS

OBJECTIVES

Enhanced recovery after surgery programs (ERAS) have been proven to decrease the length of hospital stay without increasing readmission rates or complications. However, the patient and operative characteristics that improve the chance of a successful early hospital discharge are not well established. The aim of this study was to design a nomogram which could be used before surgery, using the characteristics of patients, to establish who could benefit from early discharge (POD ≤ 2 days).

METHODS

This observational study has been prospectively conducted. All the included patients were referred for surgical treatment of gynecologic cancer. We defined two sub-groups of patients on surgical procedure characteristics: isolated procedures (hysterectomy or lymphadenectomy) and combined procedures (at least the association of two procedures).

RESULTS

230 patients were enrolled during the study protocol. 83.9% of patients were treated with a minimally invasive surgery (MIS). 159 patients (69.1%) were discharged on or before POD 2. On multivariate analysis, the surgical approach (open surgery vs. laparoscopy, OR  0.02 (95% CI [0-0.07]), p < 0.001) and the type of surgery (combined procedure versus isolated procedure, OR  0.41 (95% CI [0.18-0.91]), p = 0.028) were found to be significant predictors of increased hospital stay. A nomogram has been built for the purpose of predicting eligible patients for early post-operative discharge based on the multivariate analysis results (AUC = 0.86, 95% CI [0.81-0.92]).

CONCLUSION

The use of MIS for isolated procedures in oncologic indications constitutes an independent factor of early discharge in a setting of ERAS. These promising preliminary results still require to be validated on a prospective cohort.

Preoperative Breast Magnetic Resonance Imaging in Women With Local Ductal Carcinoma in Situ to Optimize Surgical Outcomes: Results From the Randomized Phase III Trial IRCIS

PURPOSE

We evaluated the addition of breast magnetic resonance imaging (MRI) to standard radiologic evaluation on the re-intervention rate in women with ductal carcinoma in situ (DCIS) undergoing breast-conserving surgery.

PATIENTS AND METHODS

Women with biopsy-proven DCIS corresponding to a unifocal microcalcification cluster or a mass less than 30 mm were randomly assigned to undergo MRI or standard evaluation. The primary end point was the re-intervention rate for positive or close margins (< 2 mm) in the 6 months after randomization ( ClinicalTrials.gov identifier: NCT01112254).

RESULTS

A total of 360 patients from 10 hospitals in France were included in the study. Of the 352 analyzable patients, 178 were randomly assigned to the MRI arm, and 174 were assigned to the control arm. In the intent-to-treat analysis, 82 of 345 patients with the assessable end point were reoperated for positive or close margins within 6 months, resulting in a re-intervention rate of 20% (35 of 173) in the MRI arm and 27% (47 of 172) in the control arm. The absolute difference of 7% (95% CI, −2% to 16%) corresponded to a relative reduction of 26% (stratified odds ratio, 0.68; 95% CI, 0.41 to 1.1; P = .13). When considering only the per-protocol population with an assessable end point, the difference was 9% (stratified odds ratio, 0.59; 95% CI, 0.35 to 1.0; P = .05). Total mastectomy rates were 18% (31 of 176) in the MRI arm and 17% (30 of 173) in the control arm (stratified P = .93). For 100 lesions seen on MRI, nonmass-like enhancement was more predominant (82%) than mass enhancement (20%). Nevertheless, no specific morphologic and kinetic parameters for DCIS were identified.

CONCLUSION

The study did not show sufficient surgical improvement with the use of preoperative MRI to be clinically relevant in DCIS staging. However, this could be reconsidered with the improvement of new MRI sequences and new modalities in magnetic resonance techniques.