Observation of oxygen inhibited layer of organic dental resin by confocal Raman-microscopy

This study investigated degrees of conversion of oxygen inhibited layer (OIL) of organic dental resins for restoration using Confocal-Raman spectroscopy. The aim was to determine which laser is adapted to determine the degrees of conversion of OIL and to measure variations of thickness and degrees of conversion in OIL with respect to monomers proportions. Bis-GMA (bis-phenol A glycidyl dimethacrylate) and TEGDMA (triethylene glycol dimethacrylate) based resins with various ratio of an equimolecular mixture of camphorquinone/EDMAB (ethyl (4-dimethyl amino) benzoate) were studied with different lasers by confocal- Raman spectroscopy. Results show that this technique is adapted for the non destructive measurement of OIL. The Thickness of OIL is not correlated with the proportions of Bis-GMA and TEGDMA in the resin and was close to 3-4μm. Thickness of OIL is very thin without inorganic fillers (3 or 4 μm). Inorganic fillers might be responsible of greater OIL in composite resins.

[Relevance of combined radiation and surgical treatment of early invasive carcinoma of the cervix]

The aim of this study was to assess the result and the postherapeutic complications rates of preoperative radiation therapy and radical surgery in association, for stage IB to IIB cervical carcinoma. For 1983 to 1990, 314 patients were treated at the Institut Curie for stage IB to IIB cervical carcinoma. For small lesions, less than 4 cm, preoperative uterovaginal brachytherapy was performed (60 to 65 Gy), followed, 6 weeks later, by a modified radical hysterectomy (Piver type 2) with pelvic lymphadenectomy. Larger tumors were treated with pelvic radiotherapy (36 Gy), then by brachytherapy (30 Gy), followed, 6 weeks later, by the same surgical procedure. 82% of the tumors were 4 cm or smaller. 64% of tumors were completely sterilised by the preoperative radiation. 5 and 10-year actuarial survival rates were respectively 81% and 70 %. 5-year actuarial survival rate was 87.5% for stage I and 63% for stage II patients. 5-year local disease free survival rate was 88% for stage I and 73% for stage II patients. All complications were prospectively recorded. The early post operative complication rate was 6.3%, with no urinary complications. The late complication rate was 3.3%, mainly grade 2 sequelae. No ureteral fistulas were observed. By combined preoperative radiotherapy and surgery, adapting the dosimetry and the radicality of the procedure, we obtained cure rates and recurrence rates identical to those obtained with exclusive surgery or radiotherapy alone. However, the complication rate of the association of both adapted treatments, has considerably reduced the early and late complication rate.

Remote tumor cells in the case of breast cancers: significance of their presence for prognosis [corrected]

Through two clinical studies, tumor cells were searched for in the bone biopsies and cytapherisis of patients suffering from inflammatory tumors and who had undergone intensive therapy and autografts (Pegase 2 program). In these studies we used immunocytochemical test with two monoclonal antibodies. The results have shown the presence of tumor cells in 14% of the patients (respectively 18%), with no correlation to the appearance of metastases after 4 years in the first study. Nevertheless, the presence of these tumor cells seems to be an important factor in the number of relapses. It seems important to develop research into tumor contamination especially in the selection of grafts over the next few years.

Second look for ovarian cancer: laparoscopy or Laparotomy? A prospective comparative study

OBJECTIVE

The objective of this study was to evaluate, for patients with ovarian cancer, the feasibility, reliability, and complications of a laparoscopic second look and to compare them with those of a second look by laparotomy.

METHODS

Twenty patients treated by initial surgery and adjuvant chemotherapy for ovarian carcinoma underwent a laparoscopic second look, immediately followed by a comparative laparotomy. All were in complete remission after chemotherapy. Both operations were performed according to a predefined checklist, identical for both surgical techniques and for each patient: after liberation of adhesions, an exhaustive intraperitoneal inspection was performed, with systematic peritoneal cytology and biopsies. Each patient therefore was her own control for the two techniques.

RESULTS

The positive predictive value of laparoscopy for the diagnosis of residual disease was 100% (6 of 6 cases), while the negative predictive value was 86% (2 false-negative cases out of 14). Because of the presence of postoperative adhesions, the rate of complete intraperitoneal investigation was 95% for laparotomy versus 41% for laparoscopy. The complication rate of laparoscopy requiring laparotomy was 5.3%.

CONCLUSIONS

After treatment of ovarian cancer, a laparoscopic second look appears to be less reliable than one performed by laparotomy. The presence of severe postoperative adhesions is the main obstacle to an exhaustive, reliable, and safe laparoscopic second look.

[Conservative treatment of multifocal breast cancer: a comparative study]

Conservative treatment of multifocal breast cancer is still very controversial. This retrospective study concerns 56 patients with stage I or II multifocal breast cancer who underwent conservative treatment at the Institut Curie from January 1983 to December 1989. These patients (group 1) were matched with 132 patients with multifocal lesions treated by mastectomy (group 2). Surgical treatment consisted of a single wide lumpectomy followed by external radiotherapy. Adjuvant systemic therapy and regional nodal irradiation were administered as indicated by current protocols. The actuarial 5-year overall survival rate was 94% 6 in group 1, and 90% 6 in group 2 (NS). The actuarial 5-year ipsilateral breast recurrence rate was 11% 8 in group 1, and 11% 5 in group 2 (NS). In group 1 patients, the ipsilateral breast recurrence rate was related neither to type of multifocality nor to presence of intra ductal breast carcinoma, nodal status, tumor margins, radiotherapy boost, or distance between tumors. Consequently, conservative treatment of multifocal breast cancers which can be completely removed by a single lumpectomy seems, when technically feasible, an alternative to mastectomy.

Increased expression of prolactin receptor gene assessed by quantitative polymerase chain reaction in human breast tumors versus normal breast tissues

The role of PRL in human breast tumorigenesis is not well understood. One of the limitations is the difficulty of accurately measuring PRL receptors (PRLR) in human tissues. We established a quantitative PCR method (Q-PCR) in T-47D human breast cancer cells and applied it to 29 patients, 25 of whom presented with either cancer or fibroadenoma. Four patients underwent a mammoplasty, and normal epithelial cells were cultured before Q-PCR. In T-47D cells, 31 x 10(6) messenger RNA molecules were detected per microgram of total RNA. In all patients, expression of the PRLR gene was detected, varying from 1500 to 1 x 10(6) molecules/microgram of RNA in normal tissues and from 4500 to 34.7 x 10(6) molecules/microgram of RNA in tumors. PRLR expression was always greater in tumor than in normal contiguous tissue and similar in cultured mammary epithelial cells and normal breast tissues. Estradiol and progesterone receptor-negative tumors expressed low levels of PRLR transcripts, similar to normal breast tissue from menopausal women. Immunocytochemical analysis of PRLR confirmed stronger staining in almost all tumor samples compared with normal tissues. A messenger RNA encoding locally produced human PRL was also identified by RT-PCR in every sample tested. Our results confirm PRLR gene expression in all tissues studied, and moreover, indicate that this expression is increased in human breast tumors vs. normal contiguous tissues.

[Breast cancers with central localization: conservative treatment by tumorectomy with ablation of the areolar plaque]

OBJECTIVES

In breast cancer, retroareolar tumors are observed in 5 to 20% of cases; mammectomy is the conventional treatment. Conservative surgery was used in this series of 36 patients with retroareolar cancer situated less than 2 cm from the areola.

PATIENTS AND METHODS

Tumorectomy with resection of the areolar plaque was followed by radiotherapy. Six patients had Paget's disease of the nipple, 64% were in classes T0 or T1 and 36% in T2. Chemotherapy or radiotherapy was given for tumor reduction prior to surgery in 8 patients. Wide tumorectomy with resection of the areolar plaque and gland remodeling was performed in all patients. Three plastic surgery techniques were used. Mean tumor size was 17.3 mm (8 to 33 mm). The areola was invaded in 16 patients (44%) and the derma or retroareolar ducts in 26 (72%).

RESULTS

The mean distance between the tumor and skin surface was 3.8 mm. The section surface was in healthy tissue in 31 patients and 2 patients underwent subsequent surgery for mammectomy. All patients had either pre-operative (n = 4) or post-operative (n = 32) radio-therapy. Secondary reconstruction of the nipple was performed in 14 patients.

CONCLUSION

Histology findings and esthetic results suggested that this conservative approach can be proposed when the tumor is located close to the areola, as confirmed by our series and results from other teams using the same technique.

S-phase fractions of breast cancer predict overall and post-relapse survival

We studied the correlation of S-phase fraction (SPF) with clinical outcome in 127 pre- or perimenopausal patients with breast cancers treated by neoadjuvant chemotherapy from October 1986 to June 1990. When the patients were analysed using the median value of the SPF as a threshold, there was a small but non-significant difference in favour of low SPF tumours for metastasis-free survival. SPF was the only parameter predicting overall survival in multivariate analysis (P < 0.002) which included T, N, histopathological grade and steroid hormone receptors. The results of metastasis-free survival contrasted with previous analyses with shorter follow-up, so we tested the time-dependent influence of SPF on prognosis. It was thus shown that SPF significantly predicts metastasis-free survival only during the first 30 months, whereas the relative risk of cancer-related death according to SPF remains significant for 56 months. In order to find an explanation for the difference in predictivity between metastasis-free survival and overall survival, we studied the post-relapse survival. Significantly shorter survival (median 12 months) was associated with tumours presenting pre-treatment high SPF values, compared to the low SPF group for which 60% of the patients were still alive after 30 months of metastasis phase (P = 0.002). Our current results, in a homogeneous series with a median follow-up of over 5 years, emphasise the importance of proliferation-related parameters for breast cancer management.

[Contralateral breast cancer: metastasis or second primary cancer?]

Metachronous contralateral breast cancer (CBC) is defined as a tumour in the opposite breast which was diagnosed more than 6 months following the detection of the first cancer. We screened, for factors that might predict the risk of developing CBC, a cohort series of 4748 women who had invasive unilateral breast cancer, clinical stage I-IIIa and had been treated at Institut Curie (Paris) between 1981 and 1987. Two hundred and eighty two CBC had been diagnosed with a median follow-up of 80 months. The cumulative rate of CBC was 4.1% at 5 years. We studied relationships between CBC and family history of breast cancer, age at diagnosis of first cancer, menopausal status, tumour size, node involvement, histological type, Scarff Bloom Richardson grade, estrogen and progesterone receptor measurements, as well as the type of primary treatment. Due to competing risks between the occurrence of CBC, local recurrence and metastasis, several options for multivariate analysis were considered. In model I, we focused on the occurrence of CBC, and ignored others events. In model II, only CBC, if first site of failure was taken into account, and in model III we considered others events as time-dependant covariates. Whichever the model we chose, age less than 55 years (RR = 1.40) as well as the presence of lobular type carcinoma (RR = 1.50), were associated with an increased risk of developing a tumour in the contralateral breast. In contrast, the risk of CBC was significantly decreased by adjuvant chemotherapy (RR = 0.54). Neither tumor stage or lymph node involvement influence the risk of CBC. These results suggested that CBC is a second primary breast cancer.

Decreased frequency of HLA-DRB1 13 alleles in Frenchwomen with HPV-positive carcinoma of the cervix

Specific types of human papillomaviruses (HPV) are associated with most cases of pre-invasive and invasive neoplasia of the uterine cervix. HLA phenotype influences susceptibility and resistance to viral infections and may therefore influence the course of HPV-associated tumors. Some data suggest that specific HLA class-II alleles may be associated with protection from or susceptibility to papillomavirus-associated lesions, but these results are still controversial. Using molecular probes, we looked for associations between specific DQA1, DQB1, DRB1 HLA class-II alleles, HPV types and cervical cancer. The analysis was performed on a population of 126 patients with invasive cervical cancer. For HLA typing, 165 healthy individuals were taken as controls. The DRB1 1301/02 allele frequency significantly decreased in patients (11%) as compared to controls (29%). This difference in frequency was dependent on the HPV-positive status of tumors and was no longer significant in the group of HPV-negative lesions. The same trends were observed with the DRB1 1301/02-DQA1 0103-DQB1 0603 haplotype frequency. An increase in the frequency of the DRB1 1401/07 and DRB1 03 alleles was observed in patients under 40. Contrary to what has been reported in the literature, no increase in the DRB1 15 allele frequency was observed in our series and only a slight increase in the DQB1 03 frequency was found in patients (70%) compared to controls (58%). In our study, no positive correlations between cervical cancer in Frenchwomen and specific HLA DR-DQ haplotypes has been found. In contrast, a negative correlation between DRB1 1301/ 02 alleles and HPV-positive tumors has been observed. This may suggest a protective effect of DR13 against HPV-associated lesions of the cervix.

Laparoscopic unilateral ovarian transposition prior to irradiation: prospective study of 20 cases

BACKGROUND

The objective of this study was to evaluate the feasibility, morbidity, and efficacy of unilateral laparoscopic ovarian transposition on the preservation of hormonal function in premenopausal patients requiring pelvic irradiation (external and/or intracavity by brachytherapy).

METHODS

This prospective study was based on 20 patients: 17 presenting with cervical cancer, 2 with Hodgkin's disease, and 1 with ependymoma of the cauda equina. The operative technique consisted of releasing the right ovary from its pelvic attachments, and placing it as high and as laterally as possible in the right paracolic gutter, after creating a pedicle on the infundibulopelvic ligament. The follow-up of ovarian function was more than 1 year for 14 patients.

RESULTS

The therapeutic protocol was not modified as a result of ovarian transposition. No intraoperative or postoperative complications were observed. The mean dose of irradiation received by the transposed ovary was 1.75 gray (Gy) (range 0.4-3.7). Mean follow-up was 2 years. Two cases of menopause (14.7%), in the only 2 patients older than 40 years, were observed among the 14 patients followed for more than 1 year. The success rate was 100% for patients younger than age 40 years.

CONCLUSIONS

Laparoscopic ovarian transposition is a simple and reliable method, which does not complicate subsequent therapeutic protocol. Its short term efficiency is comparable to results obtained by laparotomy, with a lesser morbidity. Although long term evaluation is necessary, laparoscopic surgery should be considered as an alternative to laparotomy for ovarian transposition.

[Intraductal cancer of the breast in women under age 35 years]

The incidence of intraductal carcinomas (IDC) of the breast is increasing. However, few cases have been reported in young women. Based on a series of 13,168 women treated for breast cancer at the Institut Curie over a 12-year period, this article analyses the prevalence, clinical presentation, prognosis and treatment of IDC in patients younger than 35 years. Of this series of 13,168 cancers, 882 occurred in women under the age of 35 years (6.7%). Sixteen of these cases (2%) were strictly intraductal lesions and therefore constituted the study population. The frequency of IDC in women under the age of 35 years was identical to that of IDC in the general population of this study. The circumstances of discovery were: palpable tumour in seven cases (44%), mammographic discovery in four cases (25%), nipple discharge in five cases (31%). Histological examination revealed a well-differentiated IDC in two cases, moderately differentiated in seven cases and poorly differentiated in five cases (two cases not specified). Conservative treatment by lumpectomy and irradiation was performed in nine patients, and another seven patients were treated by mastectomy and low axillary lymph node dissection. The mean follow-up was 83 months (range: 5 to 156 months). A single patient has relapsed: an isolated invasive mammary recurrence, 6 years after conservative treatment. This patient in now in complete remission after mastectomy. All patients are therefore alive, with no evidence of disease, at 83 months. In the group of women younger than 35, the frequency of IDC appeared to be identical to that observed in the general population. Their prognosis after treatment is excellent, and identical to that of IDC in older women. Conservative treatment is justified in localized forms, but mastectomy with immediate reconstruction must be performed in the presence of extensive disease.

Isolated axillary recurrences after conservative treatment of breast cancer

This retrospective study presents the diagnostic, prognostic and therapeutic problems raised by axillary recurrences (AR). 1589 cases of breast cancer measuring less than 3 cm, treated at the Institut Curie between 1981 and 1987, were studied by a combination of surgery and radiotherapy. Treatment of the breast always included wide local excision associated with irradiation. The axilla was treated either by dissection (865 cases) or by irradiation (724 cases) and 159 patients received chemotherapy. 26 patients (2%) developed AR, confirmed by fine needle aspiration cytology in 92% of cases. None of these 26 patients had initially received chemotherapy. The treatment of the AR was variable, adapted to the initial treatment. 22 patients retained their breast during treatment of the AR and none subsequently developed a local recurrence. 4 mastectomies were performed and histological examination revealed a subclinical local recurrence in 2 cases. The TNM classification, menopausal status, size of the tumour and hormonal receptor status were not risk factors for AR. Young age (P = 0.01) and high histological grade (P = 0.03) were significant risk factors for AR. The AR rate was similar whether axillary dissection or axillary irradiation had been performed. The overall 5-year survival after initial treatment was 85% for AR and 95% for the reference population. The overall 4-year survival after recurrence was 69% and the incidence of metastasis was markedly increased (P = 0.002). 2 of the 26 patients developed lymphoedema of the arm after treatment of AR. We confirm that AR worsens the prognosis, but not significantly more than local recurrence. Young age and the modified histological grading of Scarff Bloom and Richardson were risk factors for AR. Although excision of the AR is necessary to ensure local control, mastectomy is unnecessary when clinical examination and mammography are normal.

Immediate breast reconstruction by prosthesis: a safe technique for extensive intraductal and microinvasive carcinomas

BACKGROUND

Immediate breast reconstruction (IBR) by prosthesis is frequently proposed after mastectomy. However, due to the morbidity of this operation, especially the early implant removal rate, its indications remain controversial.

METHODS

We have performed 141 IBR by prosthesis (saline or gel-filled implant, tissue expander) in a homogeneous population of patients with extensive intraductal or microinvasive carcinoma, diagnosed after an initial local excision. This prospective study was designed to assess the feasibility and morbidity of IBR for an "ideal" population, allowing wide cutaneous preservation, without preoperative or postoperative treatment.

RESULTS

The early prosthesis removal rate (< 2 months) was 0.7%, with only 2.1% of early surgical revisions and 3% of lymphoceles. Cutaneous complications (5%) were significantly correlated with the type of incision. Cosmetic results at 1 year were good or very good in 66% of cases, similar to the percentage observed after delayed reconstruction by prosthesis.

CONCLUSIONS

In this selected population, IBR by prosthesis did not induce any additional morbidity compared with mastectomy without reconstruction. IBR by prosthesis can be systematically proposed in cases of extensive intraductal or microinvasive carcinoma.

Infiltrating lobular carcinoma of the breast. Clinicopathologic analysis of 975 cases with reference to data on conservative therapy and metastatic patterns

BACKGROUND

The clinicopathologic features of infiltrating lobular carcinoma (ILC), which represents 5% to 15% of all breast cancers, are still controversial. In particular, the high frequency of multicentric lesions has led to questioning of the effectiveness of conservative treatment for this type of cancer. By studying a large number of cases, we aimed to compare the clinicopathological features of ILC with those of nonlobular infiltrating carcinoma (NLIC) and to assess the advisability of conservative therapy in the management of ILC.

METHODS

The population analyzed included 726 cases of ILC, 249 cases of mixed ILC/invasive ductal carcinoma (ILC/IDC), and 10,061 cases of NLIC. The age of patients, TNM status, estrogen- and progesterone-receptor status (ER, PR), and histologic grades of the 3 groups were compared. The follow-up was carried out on a subgroup of 5846 cases.

RESULTS

At diagnosis, ILC tumors were found to be larger on average and were detected in patients older than those with NLIC, but the degree of lymph node involvement was lower in patients with ILC than in NLIC. In ILC, tumors are more frequently grade I and ER-positive than in NLIC. Multicentric lesions were not significantly more frequent in ILC than in NLIC. The overall survival, locoregional control, disease free interval, and metastatic spread rates were not different among the three groups neither by univariate nor multivariate analysis, but the pattern of metastatic dissemination was different. In 480 cases of ILC considered for conservation therapy, the local recurrence and overall survival rates were similar to those observed for IDC.

CONCLUSIONS

Our analysis specifies the clinicopathological features of ILC and confirms that conservation therapy may be an appropriate treatment for this type of cancer.

Breast tumour response to primary chemotherapy predicts local and distant control as well as survival

The purpose of the present paper was to evaluate correlations between clinical response to chemotherapy and outcome in a subgroup analysis of premenopausal patients with tumours considered too large for breast conserving surgery, treated with primary chemotherapy (n = 200) from a previously published trial (Scholl S.M., Fourquet A., Asselain B, et al. Eur J Cancer 1994, 30A, 645-652). Objective response rates amounted to 65% following four courses. In a multivariate Cox regression analysis, comparing seven parameters, the following variables were associated with poor survival: clinically involved nodes [N1b:RR: 2.7 (95% CI 1.3-5.3)], the failure to respond to chemotherapy [D:RR: 2.62 (95% CI 1.3-5)] and a raised S phase fraction [SPF > 5%: RR: 2.4 (95% CI 1.2-5)]. Parameters associated with increased metastatic recurrence rates, by order of entry in the model, were: young age [< 35: RR: 2.46 (95% CI 1.2-5)], large clinical tumour size [T3: RR: 2.02 (95% CI 1.2-3.4)], poor histological grade (SBR III: RR: 1.93 (95% CI 1.1-3.3)] and the failure to respond to chemotherapy [D: RR: 1.91 (95% CI 1-3.4)]. The assessment of both tumour cell proliferation rates as well as possibly drug resistance markers (although not available in the present study) should be helpful in selecting patients likely to benefit from intensified chemotherapy regimens. The most accurate predictor of response in the present study appeared to be the response to chemotherapy treatment itself.

[Breast cancer without palpable tumor revealed by microcalcifications. Prognosis and treatment]

OBJECTIVES

Routine screening mammography has greatly increased the number of breast cancers detected in the form of clumped microcalcifications without a palpable tumour.

METHODS

From 1964 to 1989, 315 breast cancers revealed by microcalcifications without contralateral cancer, treated at the Institut Curie. Cancers were observed in 40% of the microcalcifications excised. Treatment was conservative in 57.5% of cases and mutilating in 42.5% of cases; these rates have changed only very slightly with time. Histologically, 50% of the tumours were intraductal cancers, 25% were microinvasive, 24% were infiltrating and 1% were lobular in situ carcinomas. The therapeutic indication can be defined on the basis of the histological result of the initial tumour excision, as the initial examination underestimated the lesions in only 5.6% of cases. Lymph node invasion was observed in 1.8% of intraductal cancers, 5.3% of microinvasive cancers and 14.8% of invasive cancers.

RESULTS

The overall survival was 99% at 5 years and 89.9% at 10 years. The prognosis of invasive cancer was less favourable than that of intraductal and microinvasive cancers (p = 0.03). Survival was not influenced by the radical or conservative nature of treatment. The presence of lymph node invasion severely worsened the prognosis. The 5 year recurrence rate was 4.2% for intraductal, 4.6% for microinvasive and 6.1% for invasive. The incomplete nature of the resection increased the local recurrence rate: 11.9% at 5 years instead of 5%.

CONCLUSION

Conservative treatment of cancers revealed by microcalcifications without a palpable tumour therefore appears to be justified provided the lesion is radiologically localized, with a histologically satisfactory resection and in the absence of residual microcalcifications on postoperative mammography.

[Prognostic factors in endometrial cancer: apropos of 206 cases treated at the Curie Institute]

From January 1, 1983 to December 31, 1990 two hundred and six patients with an invasive, non metastatic endometrial carcinoma were first treated at Institut Curie. Initial tumoral staging (TNM) was as follows: stage Ia: 48%, stage Ib: 31%, stage II: 15% and stage III-IV: 6%. Total hysterectomy or colpohysterectomy was performed in 186 cases, with a bilateral oophorectomy in 180 cases. Bilateral limited pelvic lymphadenectomy was performed in 116 cases. Brachytherapy was performed in the pre-operative setting in 25 cases, in the post-operative setting in 134 cases. Only five patients had brachytherapy alone, because of poor medical condition. External irradiation was exclusive in 15 cases and added to surgery for 68 patients. Median follow-up is 61 months (8-122 months). Five-year survival rate is 77% (71-83%); 5-year specific survival rate is 81% (75-87%). Independent prognostic factors for survival in multivariate analysis (Cox regression model) are tumoral stage (p < 0.0001), ovarian involvement (p < 0.0001), histologic node involvement (p = 0.005) and grade (p = 0.01). For local relapse, independent risk factors in the same analysis are ovarian involvement (p = 0.0004), tumoral stage (p = 0.01), age (p = 0.02) and histologic involvement of cervix (p = 0.04). For distant failure, independent risk factors are histologic node involvement (p = 0.0001), tumoral stage (p = 0.002) and grade (p = 0.003).

Conservative treatment of breast cancers by mammaplasty and irradiation: a new approach to lower quadrant tumors

Conservative treatment of breast cancers confined to the lower quadrants often leaves a residual deformity. In order to prevent these poor cosmetic results, 20 patients with lower quadrant cancers have been treated since 1986 at the Institut Curie by wide lumpectomy combined with immediate remodeling of the gland by nipple-bearing superior pedicle mammaplasty and preoperative (9 cases) or postoperative (11 cases) irradiation. The contralateral breast was always rendered symmetrical at the same time. The mean weight of resection was 248 gm, and the resection margins were always free of tumor. The treatment protocols were not modified by the addition of mammaplasty to lumpectomy, and this combination did not induce any significant complications. The mean follow-up was 4.5 years (range 1 to 7.5 years). There was one case of local recurrence; there were four cases of metastases. In this series, the oncologic results were identical to those of conventional treatment by lumpectomy and irradiation. The cosmetic result was good or very good in 75 percent of patients and 91 percent of patients in the group in which mammaplasty was performed prior to irradiation. Treatment of breast cancers by superior pedicle reduction mammaplasty and irradiation is indicated in tumors located in the lower quadrants, whose size in relation to the breast volume is such that conventional conservative treatment by lumpectomy and irradiation would achieve a poor cosmetic result.

Contralateral breast cancer: annual incidence and risk parameters

PURPOSE

To screen for factors that might predict the risk of developing metachronous contralateral breast cancer (CBC), taking into account the influence of local or distant recurrence, and to assess the annual incidence of CBC.

PATIENTS AND METHODS

Of 4,748 women with invasive unilateral breast cancer, clinical stage I to IIIa, treated between 1981 and 1987, 282 metachronous CBCs were diagnosed. Due to competing risks between the occurrence of CBC and other events, several options for multivariate analysis were considered.

RESULTS

The median follow-up time was 80 months (range, 1 to 158). The cumulative rate of CBC was 4.1% +/- 0.3% at 5 years, and the annual incidence rate of CBC increased slowly, while the risk of local recurrence and metastases decreased after the fourth year. Whichever model we chose, age less than 55 years (relative risk [RR] = 1.40) at the time of diagnosis of the first breast cancer, as well as the presence of lobular type carcinoma (RR = 1.50), was associated with an increased risk of developing a tumor in the contralateral breast. Adjuvant chemotherapy significantly decreased (RR = 0.54) the risk of CBC.

CONCLUSION

Lobular histology and age less than 55 years are found to increase the risk of CBC, while adjuvant chemotherapy significantly decreased the risk of CBC. The progressive rise in the annual incidence rates of CBC, together with the absence of a link between clinical prognostic factors of the first cancer and CBC, suggested that CBC can be considered as a second primary breast cancer.

[Diagnosis of non-palpable breast lesions: contribution of cytological punctures after stereotaxic localization]

The authors reviewed the accuracy of stereotaxic fine-needle aspiration cytology. Two hundred-twenty-eight lesions were studied: 103 benign lesions, 125 cancers. Inadequate sample was obtained in 26% of cases. None of the cytology reports were false-positive, whereas 77% of the suspect cytologic reports were malignant on histology. In strongly suspicious lesions at mammography, the decision to perform surgical biopsy should not be postponed as false negative cytologic findings (7 cases) are possible. In patients with a low suspicious lesion, cytology found six cancers. The benign-to-malignant ratio of excisional biopsies of non palpables lesions should be reduced by stereotaxic fine-needle aspiration cytology.

[Recurrences after conservative radiosurgical treatment of breast cancer]

From 1960 to 1989, 154 cases of recurrent breast cancer after conservative radiosurgery were treated at the Curie Institute. Relapse was discovered at clinical examination in 88% of the cases and mammography was only useful in 45%. In 18 cases (12%) an unpalpable tumour was discovered at mammography, especially for intragalactophoric tumors. Cytopuncture yielded a precise diagnosis in 83% of the cases. Overall survival rate after recurrence was 72% at 5 years (62% without metastasis). Survival rate was better for late recurrence, and poorer in cases with subclinical axillary invasion. Neither age nor type of treatment had any effect on survival. Indications for general associated treatment are based on: the invasive character of the recurrent tumour, axillary invasion, tumour size and delay to recurrence after initial surgery.

Simultaneous bilateral breast carcinomas: a retrospective review of 149 cases

PURPOSE

To evaluate clinical and biological characteristics as well as treatment outcome in simultaneous bilateral breast carcinomas.

METHODS AND MATERIALS

Between 1981 and 1990, 149 patients were diagnosed to have simultaneous bilateral breast carcinoma, defined as tumor arising in both breasts within a maximum of a 6-month interval, in the absence of distant metastases. The median age was 58. Out of a total of 298 tumors, the clinical tumor size was T0-T1 in 40%, T2 in 45%, and T3-T4 in 15% of tumors. The majority of patients (83%) were clinically node negative. Seventy-eight percent of all tumors were classified ductal invasive; 6% were invasive lobular carcinomas; in situ tumors were present in 9%. More than two-thirds of all tumors were well or moderately well differentiated. Tumors were estrogen positive in 86% and progesterone positive in 69% of 62% of patients for whom this information was available in both tumors. Treatment had been by bilateral mastectomy in 43%, by exclusive irradiation in 16%, and by combined surgery and radiation in 41%.

RESULTS

Median follow-up was 68 months (11-141). A number of positive correlations existed between the tumors in both breasts more often than by chance alone: These were the presence of lobular carcinomas in both breasts (p = 0.06), the same histological grade (p = 0.002), similar ER (p = 0.03) and PR (p = 0.01) status. Five-year rates for survival and disease-free interval were 86% (80-92) and 70% (62-78), respectively. For each patient the stage of the largest tumor at diagnosis was defined as maximum stage. When survival figures were compared between each maximum stage and matched stages of a group of unilateral breast cancer patients treated during the same time interval in our institute, bilateral breast cancer fared not worse than unilateral breast tumors. Treatment related complications occurred in eight patients (5%).

CONCLUSION

Simultaneous bilateral breast carcinomas have similar biological, but not clinical, features more frequently than would be predicted by chance alone. So far, the number of patients is too small, and the follow-up is too short to determine whether or not the prognosis is equivalent to that of unilateral breast cancer patients of equal stage. Bilateral conservative treatment is feasible with acceptable cosmetic results and toxicity by using carefully designed radiotherapy techniques.

Neoadjuvant versus adjuvant chemotherapy in premenopausal patients with tumours considered too large for breast conserving surgery: preliminary results of a randomised trial: S6

The aim of this study was to assess a potential advantage in survival by neoadjuvant as compared to adjuvant chemotherapy. 414 premenopausal patients with T2-T3 N0-N1 M0 breast cancer were randomised to receive either four cycles of neoadjuvant chemotherapy (cyclophosphamide, doxorubicin, 5-fluorouracil), followed by local-regional treatment (group I) or four cycles of adjuvant chemotherapy after primary irradiation +/- surgery (group II). Surgery was limited to those patients with a persisting mass after irradiation, and aimed to be as conservative as possible. 390 patients were evaluable. With a median follow-up of 54 months, we observed a statistically significant difference (P = 0.039) in survival in favour of the neoadjuvant chemotherapy group. A similar trend was seen when the time to metastatic recurrence was evaluated (P = 0.09). At this stage, no difference in disease-free interval or local recurrence between these two groups could be observed. The mean total dose of chemotherapy administered was similar in both groups. On average, group I had more intensive chemotherapy regimes (doxorubicin P = 0.02) but fewer treatment courses (P = 0.008) as compared to the treated patients in group II. Haematological tolerance was reduced when chemotherapy succeeded to exclusive irradiation. Breast conservation was identical for both groups at the end of primary treatment (82 and 77% for groups I and II, respectively). Of the 191 evaluable patients in the neoadjuvant treatment arm, 65% had an objective response (> 50% regression) following four cycles of chemotherapy. The objective response rate to primary irradiation (55 Gy) was 85%. Improved survival figures in the neoadjuvant treatment arm could be the result of the early initiation of chemotherapy, but we cannot exclude that this difference might be attributable to a slightly more aggressive treatment. So far, the trend in favour of decreased metastases was not statistically significant. The local control appeared similar in both subgroups.

Prognostic value of the S-phase fraction of breast cancers treated by primary radiotherapy or neoadjuvant chemotherapy

Neoadjuvant chemotherapy for large operable breast cancers is being increasingly used for the purpose of "downstaging," so that the lesions become accessible to conservative treatment. Since tumor proliferative activity has been shown to be a major prognostic factor for breast cancers, we have studied the value of S-phase fractions established by flow cytometry on cytological samples at diagnosis, in 184 stage II or IIIa patients entered in a randomized trial comparing neoadjuvant to adjuvant chemotherapy. All patients were pre- or perimenopausal, and the median follow-up was for 43 months (24-64). Using the median value (5%) as cutoff, a high SPF was found to be associated with relapse (p < 0.0008), locoregional recurrence (p < 0.02), or metastasis (p < 0.003). However, when the patients were analyzed according to the type of treatment, significance was maintained for the patients in the primary radiotherapy arm (p < 0.003) but not for those in the neoadjuvant chemotherapy arm (p < 0.06). The overall rate of response to neoadjuvant chemotherapy was significantly lower for tumors with low SPF (56.5%), compared to tumors with high SPF (85.6%). Thus, SPF was no longer predictive of outcome when the tumors regressed by more than 50% after chemotherapy (p = 0.66), whereas it was highly predictive in the nonresponding patients (p < 0.0001). Our study has revealed that patients with low-SPF tumors, irrespective of response or treatment schedule, had similar prognosis (around 70% free of disease at 45 months), while the high-SPF nonresponders had a dismal prognosis, with less than 25% free of disease at 24 months. If our results are confirmed with a longer follow-up, proliferative activity of breast cancers should prove to be instrumental for the initial therapeutic decision of stage II or IIIa patients.

Age as prognostic factor in premenopausal breast carcinoma

Whether or not young age at diagnosis is an adverse prognostic factor in breast cancer has long been controversial, in part because much previous work has not taken due account of menopausal status and confounding factors. We have analysed the influence of age on prognosis in a consecutive series of 1703 patients with stage I-III breast cancer. All were premenopausal and all were treated in one centre (Institut Curie, Paris) between 1981 and 1985. Mean age was 44 years (range 23-55) and median follow-up was 82 months. Younger patients had significantly lower survival rates and higher local and distant relapse rates than older patients. The hazard rate of relapse decreased over time in the youngest age group (< or = 33) to reach that of older patients after 5 years. The relation between the hazard of recurrence and age was a continuous one, best fitted by a log-linear function and indicating a 4% decrease in recurrence for every year of age. Multivariate analysis of both survival and disease-free interval demonstrated that the worse prognosis of young age was independent of other factors such as clinical tumour size, clinical node status, histological grade, hormone receptor status, locoregional treatment procedure, and adjuvant systemic therapy. This difference in outlook has yet to be explained biologically but it does suggest the need for a closer look at the natural history of breast cancer in young women.

Value of axillary dissection in addition to lumpectomy and radiotherapy in early breast cancer. The Breast Carcinoma Collaborative Group of the Institut Curie

Axillary dissection in early breast cancer remains controversial because of its substantial side-effects and because its value with respect to recurrence or survival has not been unequivocally proven. Between 1982 and 1987, 658 patients were included in a prospective randomised comparison of lumpectomy alone with lumpectomy plus axillary dissection. All patients had a unilateral breast tumour not exceeding 3 cm in diameter and lymph-node involvement or metastases. Radiation therapy was given to both groups. The two groups of patients were similar with respect to mean age, TNM stage, and presence of hormonal receptors. Median follow-up was 54 months. 5-year survival of the patients was 94.2% (95% Cl: 92.1-96.4). There was a significant advantage in survival in the axillary dissection group (p = 0.014). Recurrence of tumour in the breast was similar in the two groups but visceral metastases, supraclavicular metastases, and lymph-node recurrences were less frequent in the axillary dissection group. Survival was related to the age of the patients (p = 0.005), the presence of positive nodes (p = 0.006), the histological grading (p less than 0.0001), and the presence of hormonal receptors (progesterone p = 0.0008, oestrogen p less than 0.0001). Treatment-adjusted relative risk was 2.4 (95% Cl: 1.3-4.2). The findings show that axillary dissection is justified for treatment of small breast cancers, although whether the better survival is due to axillary clearance itself or to adjuvant treatment for lymph-node involvement is unclear.

[Value an immediate histological study of the lymph nodes at the time of surgical treatment of cancer of the uterine cervix]

From 1978 to 1989, 500 external iliac lymph node dissections were carried out at the Institut Curie during surgery for cancers of the uterine cervix. The percentage of error of the histological study of the lymph node was 2.8%, including 13 false-negative findings and 1 false-positive. In 1.8% of cases (9), there were doubts as to lymph node invasion, and no confirmation was possible. The most frequent cause of error was the failure to recognize partial invasion of a lymph node. Fibrosis and necrosis secondary to preoperative radiation therapy make the intraoperative histological study more difficult.

[Conservative surgery after radiotherapy with preoperative doses in the treatment of breast cancer]

Radiotherapy as primary treatment is one of the means of increasing the rate of conservative treatment in patients with a breast tumour more than 3 cm in diameter. Between 1980 and 1986, 232 patients were treated in the Curie Institute by irradiation followed by conservative surgery for T2NO or T2N1a tumours wider than 3 cm, which accounted for 66 percent of the cases; 126 of these 232 tumours were located in the upper and outer quadrant. Axillary dissection was combined with tumoral excision in 63 percent of the cases. Conservative surgery was performed in patients who, after preoperative irradiation (50 Gy), had a persistent tumour less than 3 cm in diameter. Tumorectomy was complete in 96 percent of the cases, and the operative specimen was sterilized in 20 percent. The mean follow-up period was 46 months. The overall survival rate was 83 percent at 5 years (91 percent for T2NON1a). No local recurrence was observed in 92 percent of the patients at 3 years and 87 percent at 5 years. Nine percent of these women developed lymphoedema of the upper limb. The cosmetic result was good in 70 percent of the cases, fair in 25 percent and poor in 5 percent. The survival rate being the same with this treatment as with mastectomy, and the local recurrence rate being relatively low (13 percent at 5 years), we feel authorized to suggest that this post-radiotherapy conservative surgery should be used, at least in women with T2NON1a breast cancer.

Neoadjuvant chemotherapy in operable breast cancer

Primary chemotherapy in localised breast cancer may prevent tumour spread during surgical treatment and reduce proliferation of micrometastases. A randomised clinical trial, in 196 premenopausal and postmenopausal patients with operable (T2-3, N0-1b) breast cancer, was started in November 1983 at the Institut Curie to compare neoadjuvant and adjuvant regimens of chemotherapy with radiotherapy with or without surgery. The patients have been followed up for 35-70 months (median 54). A neoadjuvant group received two monthly cycles of intravenous doxorubicin/cyclophosphamide/5-fluorouracil before locoregional therapy and four cycles subsequently. Six monthly cycles following locoregional therapy were administered to the adjuvant group. Because of inclusion of postmenopausal and/or node-negative patients, compliance was less than optimal in 39 patients who were analysed separately according to actual dose received. Tumour response, evaluated after two cycles of neoadjuvant chemotherapy, was significantly associated with dose (P = 0.003). Survival showed a slight non-significant advantage for the neoadjuvant group. Survival plotted by actual dose was also similar. Neoadjuvant chemotherapy was safe and at least as effective as the adjuvant regimen. Patients have been accrued to a subsequent larger trial of chemotherapy as first-line treatment.

[Treatment of cancer of the endometrium]

Basically, endometrial carcinomas are treated by surgery. The standard operation consists of total hysterectomy with ablation of the adnexae and bilateral dissection of the external iliac lymph nodes. Invasion of the parametrium is extremely rare, and colpohysterectomy is justified only when the cervix is involved. Improvements in anaesthesia and intensive care have limited the contra-indications of surgery. As a rule, hysterectomy is combined with vaginal curietherapy which has reduced recurrences at the vaginal fornices from 12 p. 100 to 3 p. 100. Uterovaginal curietherapy is necessary only in cases where the endometrium and cervix are involved. Invasion of the myometrium in depth and a histological diagnosis of undifferentiated epithelioma are predictive of a poor prognosis and may justify a complementary treatment. Post-operative external radiotherapy of the pelvis is indicated when the lymph nodes and adnexae are involved and the deep myometrium is invaded. It reduces the local recurrence rate but its influence on survival has not yet been formally demonstrated. Local and regional recurrences are treated by radiotherapy if the initial treatment was surgical and by surgery if radiotherapy was part of the initial treatment. Chemotherapy and hormonotherapy are effective against advanced, recurrent or metastatic carcinomas. Chemotherapy is used in undifferentiated types and hormonotherapy in differentiated types. However, when used as adjuvants in early endometrial carcinoma their beneficial effect on survival has not been established.

Conventional megavoltage radiotherapy in the management of malignant epithelial tumours of the parotid gland

This is an evaluation of definitive conventional megavoltage radiotherapy in a consecutive series of 35 patients presenting malignant epithelial tumours of the parotid gland. In this series, the 5-year actuarial locoregional control rate was 41% with a 5-year crude survival rate of 36%. The results are analyzed according to tumour presentation and tumour doses. Six of 15 patients with tumours larger than 6 cm have had a lasting locoregional control. During the same period 43 other patients received radiotherapy as a post-operative modality. Results obtained in this group confirm the previously published data. While recent studies tend to demonstrate the specific efficacy of high LET radiation in the management of locally advanced salivary gland tumours, radical conventional radiotherapy can still be employed with a curative intent when neutron facilities are not available.

Conservative treatment of early breast cancer: prognostic value of the ductal in situ component and other pathological variables on local control and survival. Long-term results

Four hundred and thirty-four patients with infiltrative ductal carcinoma were treated by limited surgery and irradiation between January 1960 and December 1980. The median follow-up was 103 months. Retrospective pathological analysis of the primary tumor identified a subset of pathological parameters which were predictors of local breast failure and survival. Pathological predictors of local breast recurrence were: incomplete surgical excision (P less than 0.0001), lymphatic invasion (P less than 0.02) and presence of an extensive in situ component (EDISC) (P less than 0.03). Pathological predictors of survival were: incomplete surgery (P less than 0.007), size of the primary tumour (P less than 0.03), high histologic grade (P less than 0.005), lymphatic invasion (P less than 0.0001) and absence of associated in situ component (P less than 0.008). This study emphasizes the role of the in situ component in the prognosis of breast carcinoma treated with conservative management.

Prognostic factors of breast recurrence in the conservative management of early breast cancer: a 25-year follow-up

Between 1960 and 1980, 518 patients with T1, T2, N0, N1a, invasive breast cancer were treated by limited surgery at Institute Curie with (183 patients) or without (335 patients) axillary node dissection, followed by radiation therapy to breast and nodes. Median follow-up was 8.6 years (1.3 to 25 years). Fifty-six breast recurrences occurred, including 49 breast recurrences alone, 3 simultaneous breast and node recurrences, and 4 simultaneous breast recurrences and metastasis. Five-year, 10-year, and 15-year actuarial risks of breast recurrences were 7 +/- 1%, 11 +/- 1.5%, and 18 +/- 3%, respectively. Univariate analysis of 14 clinical and pathological prognostic factors revealed that local control in breast was significantly impaired by young age, premenopausal status, inadequate gross surgical excision, extensive ductal in situ component, and endolymphatic extension. On multivariate analysis with a Cox regression model, the most important contributors to local breast control in order of importance were age (p less than 10(-4), relative risk = 2.44), adequacy of surgery (p = 0.003, relative risk = 2.78), and endolymphatic extension (p = 0.03, relative risk = 2.98). The 5-year actuarial survival rate following breast recurrence was 73%, and was significantly worse when breast recurrence occurred in the first 3 years after treatment: 44% versus 87%, respectively (p less than 0.01). This study confirms the relationship between young age and low breast control rates, and demonstrates the importance of adequate initial surgical procedures. It emphasizes the adverse prognosis of early breast recurrences as compared to the relatively favorable outcome of late recurrences.

[Nipple discharge without palpable tumor. Experience of the Institut Curie from 1970 to 1984]

Four hundred and ten women with serous or bleeding nipple discharge without palpable mass were treated by surgery in the Curie Institute between 1970 and 1984. The cancer rate in this group was 12.2 per cent. Galactography was of anatomical interest as it showed the canal at the origin of the discharge. Malignant cells were observed at cytological examination in only 17 per cent of intragalactophoric cancers. Surgical excision is necessary if the nipple discharge is uniporous and easily reproducible by areolar pressure, particularly in the post-menopausal period when the frequency of cancer is highest (17.7 per cent).

[Prognostic value of the Lauren and Ming classifications in gastric adenocarcinoma. Multidimensional analysis]

Of the various pathology classifications for gastric carcinoma, those of Lauren and of Ming have been claimed to be of prognostic value. We therefore reviewed the charts of 101 patients (mean age 64 +/- 11 years) treated for gastric carcinoma between 1960 and 1983 at the Institut Curie. We excluded the following patients: 1) those with distant metastases; 2) those who were not operated on; 3) those who underwent laparotomy only, and 4) those who had a palliative procedure. The type of surgery performed was partial gastrectomy in 73 cases and total gastrectomy in 28. Pathology was reviewed according to the WHO, Lauren, and Ming classifications. Were taken into consideration: 1) whether the surgeon believed that removal of tumor was grossly complete or not, 2) the degree of parietal involvement according the pTNM classification system, and 3) the number of positive lymph nodes. Survival was analyzed by the Kaplan Meier method after exclusion of all postoperative deaths. Mean overall survival was 30 months, while that for patients undergoing grossly complete removal of tumor was 34 months. In univariate analysis, no correlation was found between survival and pathology according to Lauren's or Ming's classifications, sex, parietal involvement, or age. Survival was statistically correlated with the size of the tumor (p = 0.015), the gross completeness of surgery (p = 0.008), the type of surgery performed (prognosis was better after partial gastrectomy than after total gastrectomy) and the number of positive lymph nodes (p = 0.0001).(ABSTRACT TRUNCATED AT 250 WORDS)

Thin stage I primary cutaneous malignant melanoma. Comparison of excision with margins of 1 or 3 cm

Although wide surgical excision is the accepted treatment for thin malignant melanomas, there is reason to believe that narrower margins may be adequate. We conducted a randomized prospective study to assess the efficacy of narrow excision (excision with 1-cm margins) for primary melanomas no thicker than 2 mm. Narrow excision was performed in 305 patients, and wide excision (margins of 3 cm or more) was performed in 307 patients. The major prognostic criteria were well balanced in the two groups. The mean thickness of melanomas was 0.99 mm in the narrow-excision group and 1.02 mm in the wide-excision group. The subsequent development of metastatic disease involving regional nodes and distant organs was not different in the two groups (4.6 and 2.3 percent, respectively, in the narrow-excision group, as compared with 6.5 and 2.6 percent in the wide-excision group). Disease-free survival rates and overall survival rates (mean follow-up period, 55 months) were also similar in the two groups. Only three patients had a local recurrence as a first relapse. All had undergone narrow excision, and each had a primary melanoma with a thickness of 1 mm or more. The absence of local recurrence in the group of patients with a primary melanoma thinner than 1 mm and the very low rate of local recurrences indicate that narrow excision is a safe and effective procedure for such patients.

[Cancer of the anal canal. Results of the treatment of a series of 195 cases]

Between 1968 and 1982, 195 patients with invasive anal canal carcinoma were treated at Institut Curie (Paris, France). There were 168 females and 27 males --sex-ratio: 5.7/1, mean age: 67 +/- 11 yrs. (range: 38-85 yrs.). The initial size of the tumors was analyzed according to the circumferential invasion of the anal canal. The tumor involved 1/4 of the circumference in 49 cases, 1/2 of the circumference in 108 cases, 3/4 of the circumference in 22 cases and the whole circumference in 16 cases. Pathological examination revealed 20 cloacogenic carcinomas and 175 squamous carcinomas. All patients received radiotherapy as initial treatment and none received chemotherapy as a curative procedure. Eight patients received only palliative treatment. Twenty-seven patients were operated on because the response of the tumor to irradiation was partial or incomplete. One hundred and sixty patients received the full course of irradiation with a complete response. Among the latter, 100 patients were alive NED with a normal anal function with at least a 2-year follow-up. Local recurrences (n = 42) underwent salvage surgery in 50 p. 100 of the cases with a 3-year survival over 50 p. 100. Actuarial survival of the 195 patients was 68.5 p. 100 at 3 years and 58 p. 100 at 5 years. Survival was highly related to the initial size of the tumor and to the presence of positive inguinal nodes (p less than 0.0002). The histologic type was not related to the response to radiotherapy, nor to local recurrence or to survival.(ABSTRACT TRUNCATED AT 250 WORDS)

[Evaluation of 17-beta-hydroxysteroid dehydrogenase activity as a marker of the hormone dependence of breast cancers]

Intratumoral activity of the enzyme 17 beta-hydroxysteroid dehydrogenase (17 beta-HSD) was measured in 55 patients with breast cancer (17 pre- and 38 post-menopausal) before and/or after 8 days of a progestin treatment (lynestrenol 10 mg/day). In 12 patients the 17 beta-HSD ability to be stimulated was compared to estradiol and progesterone receptor (ER and PR) levels. In premenopausal patients 17 beta-HSD was higher when tumorectomy was performed in the luteal phase than in the follicular phase. In post-menopausal patients, 17 beta-HSD is higher after progestin treatment. However 17 beta-HSD stimulation by lynestrenol depends on receptor levels. It is most after markedly stimulated in ER+ PR+ tumors. It remains low in ER- PR- tumors. In conclusion, intratumoral measurement of the progesterone dependent enzyme (17 beta-HSD) in breast cancer after progestin treatment provides a fine and reliable index of the presence and functional character of PR and hormone dependence of the tumor.

Estradiol 17 beta-hydroxysteroid dehydrogenase, a marker of breast cancer hormone dependency

Intratumoral activity of the progesterone-dependent enzyme 17 beta-hydroxysteroid dehydrogenase (E2DH) was measured in 114 patients with breast cancer (33 pre- and 81 postmenopausal) before and/or after 8 days of a progestin treatment (lynestrenol, 10 mg/day). In 12 postmenopausal patients, the ability of E2DH to be stimulated by lynestrenol was compared to estradiol receptor (ER) and progesterone receptor (PR) levels. In premenopausal patients, E2DH was higher when tumors were excised in the luteal phase than when excised in the follicular phase. In postmenopausal patients, E2DH was higher after progestin treatment. However, E2DH stimulation by lynestrenol depended on receptor levels. It was most often markedly stimulated in ER-positive, PR-positive tumors. It remained low in ER-negative, PR-negative tumors. Intratumoral measurement of the progesterone-dependent enzyme E2DH in breast cancer after progestin treatment could therefore provide a fine and reliable index of the presence and functional character of PR and hormone dependency of the tumor.

[Prevention of postoperative lymphocele after breast amputation]

Closed suction drainage is widely used after modified radical mastectomy to prevent accumulation of serum or lymph and to promote adherence of the skin flaps to the chest wall. However, between 5 and 35% of the patients develop seroma, which may prolong their stay in hospital and require more frequent post-operative outpatient visits. The prospective study reported demonstrate a significant correlation between the incidence of post-operative seromas, the duration of suction drainage and the amounts of fluid drained. The incidence of seroma also correlated significantly with the patient's age, the size of the breast removed, the presence of arterial hypertension and the post-operative use of heparin. Pre-operative radiotherapy and the TNM type of the tumour had no effect on the duration and volume of drainage nor on the occurrence of seromas. A drainage of short duration and a short stay in hospital are advocated for most mastectomy patients. Delayed mobilization of the shoulder should decrease the volume of accumulated fluid and the incidence of seromas.

Wide excision of the tumor, axillary dissection, and postoperative radiotherapy as treatment of small breast cancers

A retrospective study was carried out on 265 patients with small cancers of the breast who were subjected to wide excision of the tumor, axillary dissection, and postoperative radiotherapy. In the group of patients with T1, T2 less than 3 cm, N0, N1a (which represents 90% of all patients in the study), axillary lymph node involvement was found in 27% of cases, and in 11% three nodes or more were affected. Only five cases of recurrences occurred during the follow-up, and 19 patients presented distant metastases. The survival for all patients T1, T2 less than 3 cm, N0, N1a in the study was of 93% at 3 years and 93% at 5 years. Morbidity was minimal and the cosmetic results were generally good.