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

Background

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

Patients and methods

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

Results

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

Conclusion

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

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

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

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

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

Development of a noninvasive HIFU treatment for breast adenocarcinomas using a toroidal transducer based on preliminary attenuation measurements

Breast cancer is the most commonly diagnosed type of cancer among women. For the last fifteen years, treatments that are less invasive than lumpectomy, such as high-intensity focused ultrasound (HIFU) therapy, have been developed, with encouraging results. In this study, a toroidal HIFU transducer was used to create lesions of at least 2 cm in diameter within less than one minute of treatment. The toroidal HIFU transducer created two focal zones that led to large, fast and homogeneous ablations (10.5 cc/min). The experiments were conducted in 30 human samples of normal breast tissues recovered from mastectomies to measure acoustic attenuation (N = 30), and then, HIFU lesions were created (N = 15). Eight HIFU ablations were performed to evaluate the reproducibility of the lesions. HIFU lesions were created in 45 s with a toroidal HIFU transducer working at 2.5 MHz. The longest and shortest axes of the HIFU lesions were 21.7 ± 3.1 mm and 23.5 ± 3.3 mm respectively, corresponding to an average volume of 7.3 ± 1.4 cm³. These HIFU lesions were performed at an average depth of 19.0 ± 1.5 mm, while the integrity of the skin was preserved. The HIFU-treated breast tissues had a higher level of attenuation (0.57 ± 0.11 Np.cm^-1.MHz^-1) when compared to the untreated tissues (0.21 ± 0.04 Np.cm^-1.MHz^-1). This study shows the feasibility of a fast and fully noninvasive treatment using a toroidal transducer for breast tumors measuring up to 15 mm in diameter.

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.

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LN micro-metastases have no detectable prognostic impact.

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

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

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

[Borderline Ovarian Tumours: CNGOFS Guidelines for Clinical Practice - Hormonal Contraception and MHT/HRT after Borderline Ovarian Tumour]

Contraceptive options and menopause management are frequent clinical issues among women previously treated for a borderline ovarian tumour (BOT).

OBJECTIVES

To synthesize knowledge on BOT and risk related to hormonal contraception and to menopausal hormone therapy (MHT), and to propose recommendations on contraception and MHT after BOT treatment.

METHODS

Systematic review of the literature about hormonal contraception and BOT and on MHT and BOT was conducted on PubMed/Medline and the Cochrane Library.

RESULTS

There are no data concerning hormonal contraception after BOT. Current or previous oral contraception is associated with a trend towards decreased risk of serous BOT. Mucinous BOT risk is not or slightly decreased by oral contraception. Hormonal contraception is thus not contraindicated in women previously treated for a BOT (grade C). MHT is associated with a trend towards increased risk of serous BOT. No relation was found between MHT and risk of mucinous BOT. Serous BOTs with high-risk histological criteria (micropapillary pattern, stromal microinvasion or peritoneal implants) are at high-risk of invasive potentially hormone-sensitive recurrence. Hence, caution is needed in the decisions of using MHT after serous BOT with one of these high-risk histological criteria, and MHT should be discussed on a case to case basis. MHT can be prescribed without restriction in women previously treated for mucinous and serous BOT without high-risk histological criteria (grade C).

CONCLUSION

Hormonal contraception can be used after BOT. The histological characteristics of the tumour must be taken into account when deciding on the use of HRT/THM.

Abstract P2-08-08: Isolated ipsilateral local recurrence of breast cancer: Predictive factors and prognostic impact

Background

Tumour features associated with isolated invasive breast cancer ipsilateral local recurrence (ILR) after breast conservative treatment (BCT) and consequences on overall survival (OS) are still debated. The aim of our study was to examine predictive factors of isolated ILR after BCT with in sano resection and whole breast irradiation as well as the impact of such an ILR on overall survival in a large multi-institutional cohort.

Methods

Patients were retrospectively identified from a large cohort of 23,375 consecutive patients who underwent BCT for invasive breast cancer in 16 cancer centres. End-points were ILR rate and OS. The impact of ILR on OS was assessed through multivariate analysis by logistic regression and Cox model, adjusted on ERs/Grade status (ERs+/Grade 1, ERs+/Grade 2, ERs+/Grade 3 and ERs-) and then on tumour subtypes.

Results

Of 15,570 patients, ILR rate was 3.1%. Cumulative ILR rates differed according to ERs/grade (ERs+/Grade2: HR=1.42, p=0.010; ERs+/Grade3: HR=1.41, p=0.067; ERs-: HR=2.14, p&lt;0.0001), endocrine therapy (HR=2.05, p&lt;0.0001) and age&lt;40-years old (HR=2.28, p=0.005) in multivariate analysis. When multivariate analysis was adjusted on tumour subtype, the latter was the only independent factor. OS-after-ILR was significantly different according to ILR-free intervals (HR=4.96 for ILR-free interval between 2-5-years and HR=9.00 when &lt;2-years, in comparison with ≥5-years).

Impact of free interval time on OS among patients with ILR and among all patients  p-valueHRInfSupILRno ILR 1   &lt;2 years0.0172.2551.1594.388 2-5 years0.0012.451.423.89 ≥5 years0.1030.5550.2741.126Tumor subtypesLuminal A G1 1   Luminal A G20.0031.4311.1321.810 Triple negative&lt;0.00012.6992.0553.544 Luminal B ER-&lt;0.00013.1952.4144.229 Luminal B ER+0.021.6081.0762.401 HER2+&lt;0.00012.2791.4523.579

Conclusion

ERs/Grade status, lack of endocrine therapy and tumour subtypes predict isolated ILR risk in patients treated with BCT. Short ILR-free-intervals represent a strong pejorative factor for OS. These results may help selecting initial treatment as well as tailoring ILR systemic chemotherapy.

Citation Format: Houvenaeghel G, de Nonneville A, Cohen M, Classe J-M, Reyal F, Mazouni C, Chopin N, Martinez A, Daraï E, Coutant C, Colombo P-E, Gimbergues P, Chauvet M-P, Azuar A-S, Rouzier R, Tunon de Lara C, Murraciole X, Agostini A, Gonçalves A, Lambaudie E. Isolated ipsilateral local recurrence of breast cancer: Predictive factors and prognostic impact [abstract]. In: Proceedings of the 2018 San Antonio Breast Cancer Symposium; 2018 Dec 4-8; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2019;79(4 Suppl):Abstract nr P2-08-08.

Abstract P2-11-17: Is post mastectomy radiotherapy contributive in pN0-1mi breast cancers patients? Results of a French multi-centric cohort

Aim: To assess the value of Post-mastectomy radiation therapy (PMRT) in breast cancer patients with no or minimal lymph nodes involvement.

Materials and methods: We retrospectively analyzed a French multi-centric cohort of 4283 patients treated between 1980 and 2013, by mastectomy and axillary dissection with or without PMRT. Practices were analyzed according 3 treatment periods (1980-1999, 2000-2005; 2006-2013). The value of PMRT on loco-regional recurrence, disease-free survival, breast cancer specific survival and overall survival was assessed in pN0-1mi patients, using multivariate analyses (logistic regression and Cox model). It was subsequently assessed according to the number of clinicopathologic recurrence-risk factors, generating a prognostic index (f-PMRT index), in an attempt to isolate a pN0-1mi patients subgroup deriving benefit from PMRT. We tested the accuracy of the Cambridge-PMRT (c-PMRT) index in the discrimination of patients with significantly different outcomes, as well as the value of PMRT in each c-PMRT prognostic group.

Results: PMRT was considered in more than half pN0-1mi patients of our cohort. Whereas matching pN0-1mi patients according to the number of clinicopathologic recurrence-risk factors led to isolate a higher-risk subpopulation (≥ 3 RR factors), PMRT had no significant impact on patients' outcomes, on multivariate analysis. Whereas the Cambridge-PMRT index had the potential to discriminate 3 patient populations with significantly different outcomes, its use did not help to the decision making for PMRT.

Conclusion: Despite a large cohort, we failed to isolate a subgroup of early breast cancer patients suitable for PMRT, in the absence of lymph node involvement.

Citation Format: Forissier V, Tallet A, Cohen M, Classe J-M, Reyal F, Chopin N, Mazouni C, Gimbergues P, Daraï E, Colombo PE, Azuar P, Lambaudie E, Houvenaeghel G. Is post mastectomy radiotherapy contributive in pN0-1mi breast cancers patients? Results of a French multi-centric cohort [abstract]. In: Proceedings of the 2017 San Antonio Breast Cancer Symposium; 2017 Dec 5-9; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2018;78(4 Suppl):Abstract nr P2-11-17.

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

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

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

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

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

Citation Format: de Nonneville A, Gonçalves A, Cohen M, Reyal F, Classe JM, Giard S, Colombo PE, Muracciole X, Chopin N, Lambaudie E, Houvenaeghel G. Impact of hormone receptor status in HER2-Positive early breast cancer in the trastuzumab era: Results of a National multi-institutional study [abstract]. In: Proceedings of the 2017 San Antonio Breast Cancer Symposium; 2017 Dec 5-9; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2018;78(4 Suppl):Abstract nr P1-13-04.

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Genomic alterations and radioresistance in breast cancer: an analysis of the ProfiLER protocol

BACKGROUND

Breast cancer (BC) patients with comparable prognostic features have heterogeneous outcomes, party related to a possible radiotherapy resistance leading to local-regional recurrences (LRR). The objective of the present study was to identify predictive molecular biomarkers of LRR of BC.

PATIENTS AND METHODS

Genetic profile of 146 BC patients' tumours included in the ProfiLER clinical trial (NC01774409) between 2013 and 2016 were analysed using next-generation-sequencing and comparative-genomic-hybridization tests. Patients and tumour characteristics were retrospectively collected and analysed for association with genomic rearrangements (mutations, amplification, deletions). Only gene alterations observed in >3% of the tumours were selected.

RESULTS

A total of 193 genomic rearrangements were identified, and 16 were observed in >3% of tumours. One was statistically correlated to the risk of local relapse. A median loco-regional progression-free survival (LRPFS) of 23.6 years was reported for PIK3CA mutation carriers (n = 31, 21.2%) versus 9.9 years for PIK3CA wild-type patients (HR 0.27, 95% CI 0.12-0.65, P = 0.002 in univariate analysis). PIK3CA mutation was identified as an independent protective factor on LRR using multivariate analysis (HR 0.29, 95% CI 0.09-0.99, P = 0.047). All other mutations, amplifications or deletions were not found associated with LRPFS.

CONCLUSION

PIK3CA mutation was associated with a lower risk of local relapse in this population of BCs. This is consistent with recent studies suggesting PIK3CA to be part of biological pathways impacting the radiosensitivity.

Abstract P3-13-08: Preclinical validation of a new tumor imaging agent targeting αvβ3 to detect breast tumor using NIR-light imaging

Surgery is still a essential step for breast cancer treatment. Complete tumor removal during surgery rely on surgeon's ability to differentiate tumor from normal tissue. To date, no intra operative method is available and reliable enough to help the surgeon delineate precisely tumor extension in the adjacent normal tissue. Thus, surgeons rely solely on pre operative imaging techniques to delineate tumor margins. Recent advances made in the field of non-invasive imaging and vectorized nano-size particles have revealed a remarkable potential for improved tumor-margin detection. AngiostampTM is a new fluorescent agent for intra operative imaging. This system provides strong binding on αvβ3 integrin-rich tumor neoangiogenesis. Our general hypothesis is that targeting αvβ3 integrin-rich breast carcinoma neoangiogenesis should provide improved delivery of diagnostic compounds and assist surgeons intra operatively using near-infrared imaging techniques.

We conducted preclinical studies to evaluate the distribution of angiostampTM in vivo in murine breast tumor model and to determine the expression of αvβ3 integrin on human breast specimens.

The capacity of AngiostampTM to target αvβ3 integrin was assessed in 4T1 breast tumor model. After tumor implantation, mices were injected with AngiostampTM or a saline solution. Detection of the tumors was performed at different timepoints (early, progressive and established tumors, N= 24 mices/timepoint) using near infrared (NIR) imaging system (FluobeamTM) to detect fluorescence in tumor tissue.

In parallel, the expression of αvβ3 integrins in normal breast tissue, benign lesions (N=20) and various tumors subtypes (N=120) was assessed by immunohistochemistry.

In mice injected with AngiostampTM, fluorescence was observed only within the tumors with low background. AngiostampTM labeled tumors at all timepoint. No false negative fluorescence was found as confirmed by histopathological analyses.

In humans, the αvβ3 integrin are expressed in normal breast epithelial cells and benign metaplastic or proliferative epithelial lesions. However, due to the density of carcinomatous cells, the level of expression was much higher in breast cancer: 94% of invasive ductal carcinomas and 100% of invasive lobular carcinomas had a membranous staining (moderate to high intensity). Expression in breast cancer was not restricted to tumor subtypes neither hormone receptor expression nor SBR grade.

Based on this preclinical demonstration, AngiostampTM could allow a better intra-operative detection of tumor bed in breast cancer, increasing the efficiency of surgical procedure especially for infraclinic disease and decreasing the rate of second surgery. Preclinical development is ongoing and the first clinical trial is expected in 2017.

Citation Format: Beurrier F, Dutour A, Chen Y, Froc E, Gayet P, Guillermet S, Rizo P, Chopin N, Faure C, Dammaco MA, Klinger S, Ferraioli D, Garin G, Treilleux I. Preclinical validation of a new tumor imaging agent targeting αvβ3 to detect breast tumor using NIR-light imaging [abstract]. In: Proceedings of the 2016 San Antonio Breast Cancer Symposium; 2016 Dec 6-10; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2017;77(4 Suppl):Abstract nr P3-13-08.

[Axillary lymph node dissection after breast reconstruction by pedicled Latissimus dorsi: Operative steps and outcomes]

OBJECTIVES

We retrospectively reviewed all the cases of axillary lymph node dissection (ALND) performed within a year after an immediate breast reconstruction procedure by a pedicled Latissimus dorsi, which is transferred to the anterior thoracic wall through an axillary funnel. Operative technical steps are described taking account of the new anatomical relationship of the axilla.

METHODS

We assessed postoperative immediate complications and late sequelaes.

RESULTS

From 1999 to 2013, 21 ALND were performed. Immediate postoperative period was free of complication in 85% of cases when following the operative steps described in this work. Partial or total necrosis of the reconstructed breast did not occur. With a median follow-up of 64 months, 6 patients (28% of the whole population) presented at least one sequelae like a feeling of heavy arm (n=2, 9%) or a lymphedema (n=3, 14%), a chronic neuropathic pain (n=4, 19%) or a limitation in the arm range of motion (n=2, 9%).

CONCLUSION

ALND after immediate breast reconstruction by a pedicled Latissimus dorsi is feasible and safe, without any additional postoperative complication in comparison with a classic ALND.

[Axillary lymph node metastases with an occult breast: About 16 cases from a cohort of 7770 patients]

OBJECTIVES

Isolated axillary lymph node metastases is an unusual clinical presentation of breast carcinoma. We studied its different issues.

METHODS

This study is a follow-up study of 16patients, treated between 1996 and 2012, presenting with axillary metastases with an occult breast carcinoma, which could not be identified by physical examination nor by a conventional imaging or a breast MRI. Clinical characteristics, histological analysis, treatment, monitoring and five-year survival rate were studied.

RESULTS

The incidence of this kind of breast cancer was 0.20%. A breast MRI was performed in 75% of the patients. The histology of these tumors showed a rate of hormono-sensibility of 50% and an HER2 overexpression of 44%. Sixty-nine percent of the patients had no breast surgery or radiotherapy; global five-year survival rate for these women was 77.4%±11.5.

CONCLUSION

The survival rates of this study should lead the practitioner to choose a less aggressive breast therapy. Moreover, the histological characteristics explain the high metastatic potential of these tumors, and relate them to the HER2+ subclass of gene expression patterns of breast carcinomas.

[Spontaneous regression of breast cancer after biopsy. About two cases]

We report two cases of spontaneous regression of breast cancer occurred in our institution. It was about a 34- and an 82-year-old patient. The examination revealed a palpable nodule. In both cases, biopsy revealed a negative immunohistochemical staining for estrogen and progesterone receptors, and HER-2 negative. Histological analysis of the surgical specimen found fibrous tissue rearrangement without carcinoma. In the first case, a sarcoidosis was diagnosed at the same time, the mediastinal nodes mimicked a metastatic cancer. These cases illustrate a rare phenomenon. The main hypothesis is a carcinoma- directed immune response triggered by the biopsy.

Treatment of FIGO stage IV ovarian carcinoma: results of primary surgery or interval surgery after neoadjuvant chemotherapy: a retrospective study

The objective of the study is to determine whether surgery influences the outcome of stage IV ovarian cancer. The study design is as follows: From May 1995 to December 2000, 129 patients with FIGO stage IV ovarian cancer, recruited in 42 centers, were prospectively included in GINECO first-line randomized studies of platinum-based regimens with paclitaxel administered simultaneously or sequentially. In all, 109 were eligible for this study. Standard peritoneal cytoreductive surgery was defined as a procedure including at least total hysterectomy, bilateral salpingo-oophorectomy, omentectomy, and peritoneal debulking. Surgery was considered optimal if residual lesions were smaller than 1 cm. The Kaplan-Meier method was used to compare survival. Initial abdominopelvic cytoreductive surgery was considered standard in 55 (54%) patients. Abdominopelvic surgery was optimal in 29 patients and nonoptimal in 26. Twenty-two (22%) patients had a simple biopsy, and 25 (24%) patients underwent substandard surgery. Twenty-two of these 47 patients without initial standard surgery underwent a second surgical procedure, and 17 of the 22 patients completed standard surgery. The median overall survival time in the entire population was 24.3 months (95% confidence interval [CI], 19.5-29.1 months). Patients treated without a cytoreductive surgical procedure had significantly worse median survival (15.1 months; 95% CI, 5.4-24.9 months) than patients who had optimal primary surgery (22.9 months; 95% CI, 15.6-30.1 months), nonoptimal primary surgery (27.1 months; 95% CI, 21.2-32.9 months), or neoadjuvant chemotherapy followed by surgery (45.5 months; 95% CI, 23.5-67.5 months) (P= .001). In conclusion, this study shows a significant benefit of debulking surgery in stage IV ovarian cancer patients who responded to neoadjuvant chemotherapy. Neoadjuvant chemotherapy can help to select patients for surgery.

[The abnormal activated partial thromboplastin time biphasic waveform: a red flag in the sepsis? Technique and interest as marker of the sepsis]

The biphasic waveform (BPW) is an abnormality of the optical transmission waveform obtained during measurement of the activated partial thromboplastin time on a specific photometric haemostasis autoanalyzer. This abnormality is related to calcium-dependent formation of complexes between C reactive protein and very low density lipoprotein. Biphasic waveform had a high sensitivity and negative predictive value for the identification of patients with severe sepsis and septic shock. On day 3, the time course of the biphasic waveform is a marker for the prognosis of sepsis-related mortality. The BPW is not a surrogate marker for C-reactive protein or procalcitonin and provides additional information. Further trials should be necessary using BPW for diagnostic and management procedures. Compared with other laboratory markers such as C reactive protein or procalcitonin, activated partial thromboplastin time waveform analysis is a tool that is rapid, inexpensive, effective and available 24 hours a day. When the analyzer is locally available, waveform analysis of this routine coagulation test provides information for the diagnosis of severe sepsis and the prognosis of septic patients.

[Laparoscopy-assisted vaginal pelvic exenteration]

OBJECTIVE

The aim of the study was to evaluate the feasibility, morbidity and survival outcome of laparoscopy-assisted vaginal pelvic exenteration.

PATIENTS AND METHODS

Since 2000, 7 en-bloc pelvic exenteration combining a vaginal or perineal approach and laparoscopic approach have been performed in our cancer center associated with complex laparoscopic reconstruction. All patients but one received previous irradiation. Two patients underwent a total pelvic exenteration; three patients an anterior and middle exenteration; two patients a middle and posterior exenteration. Urinary system was reconstructed with an ileal loop in one case, with a hand-assisted laparoscopic Miami pouch in four cases. Reconstruction of the vagina was performed with an omental cylinder in three cases, with a gluteal thigh flap in one case. A colorectal anastomosis was performed in three patients, one patient had an end colostomy. A mini-laparotomy conversion was necessary in one case because of a pelvic side involvement to perform an intraoperative irradiation.

RESULTS

Mean time of the procedure was 6.5 hours with peroperative bleeding less than 500 cm3. Four patients presented minor complications. No revision of the Miami pouch was necessary. Mean length of hospital stay was 27 days. The four patients with a Miami pouch were able to self catheterize at the time of discharge. Mean follow-up was 14 months. Four patients died of the disease (three were metastatic). One patient presented a local recurrence. Two patients are free of disease.

DISCUSSION AND CONCLUSION

Laparoscopic or laparoscopy-assisted vaginal pelvic exenteration followed by reconstruction is feasible with curative intent in selected patients.

Monarc transobturator sling system for the treatment of female urinary stress incontinence: results of a post-operative transvaginal ultrasonography

The aim of the study was to determine Monarc (American Medical Systems) sling position after surgical treatment of stress urinary incontinence (SUI) through the transobturator approach. A total of 54 consecutive women with SUI were evaluated post-operatively with transvaginal ultrasound. A concomitant hysterectomy was performed in ten cases and a concomitant prolapse surgery in six cases. Ultrasound measurements include urethral length, the distance between the upper edge of the sling and the bladder neck (BN-S) and the BN-S/U ratio. The mean distance between the transobturator tape and the bladder neck was found to be 12.6 +/- 3.2 mm in the group of patients who underwent the transobturator procedure alone, 13 +/- 3.1 mm in the transobturator plus hysterectomy group and 12 +/- 2.8 mm in the transobturator plus prolapse group. The superior tape margin was at the mid-urethra in 81.5% of patients and always at a distance greater than 7 mm from the bladder neck. Eight patients did not have satisfactory results after the surgery. Only in one out of these eight patients was the transobturator sling not found to be at the mid-urethra. The superior tape margin of the Monarc sling remained at the level of mid-urethra in the majority of cases. It was never located too proximally beneath the bladder neck.

Accuracy of rectal endoscopic ultrasonography and magnetic resonance imaging in the diagnosis of rectal involvement for patients presenting with deeply infiltrating endometriosis

OBJECTIVE

To compare the accuracy of rectal endoscopic ultrasonography (REU) and magnetic resonance imaging (MRI) for predicting rectal wall involvement in patients presenting histologically proven deeply infiltrating endometriosis (DIE).

METHODS

This was a retrospective study of a continuous series of 81 patients presenting histologically proven DIE who underwent preoperative investigations using both REU and MRI. The sonographer and the radiologist, who were unaware of the clinical findings and patient history, but knew that DIE was suspected, were asked whether there was involvement of the digestive wall.

RESULTS

Rectal DIE was confirmed histologically in 34 of the 81 (42%) patients. For the diagnosis of rectal involvement, sensitivity, specificity and positive and negative predictive value for REU were 97.1%, 89.4%, 86.8% and 97.7% and for MRI they were 76.5%, 97.9%, 96.3% and 85.2%.

CONCLUSION

The sensitivity and negative predictive value of REU were higher than those of MRI suggesting that REU performs better than MRI in the diagnosis of rectal involvement for patients presenting with DIE. Prospective studies with a large number of patients are needed in order to validate these preliminary results.

Abdominal wall and surgical scar endometriosis: results of magnetic resonance imaging

Scar endometriosis is a rare disease which is difficult to diagnose. The symptoms are nonspecific, typically involving abdominal wall pain at the time of menstruation. Clinical examination may reveal a painful nodule, if the scar involved is located on the abdominal wall, but is normal, when the lesion is located on the uterine scar. Other means of investigation (transvaginal ultrasonography, computed tomography) may be useful in case of lesions on the abdominal wall, or if the nodule is large, but give no specific results. The diagnosis is frequently made only after excision of the lesion. We report here 4 patients operated for scar endometriosis (two abdominal and two uterine scars) for whom MRI had suggested the diagnosis. Thanks to its very high spatial resolution, MRI enables very small lesions to be detected and can distinguish the hemorrhagic signal of endometriotic lesions. Furthermore, it performs better than the CT scan in detecting the limits between muscles and abdominal subcutaneous tissues.

Complications during set-up procedures for laparoscopy in gynecology: open laparoscopy does not reduce the risk of major complications

OBJECTIVE

To compare the risk of major complications during the set-up procedures for laparoscopy according to whether the classic technique (creation of the pneumoperitoneum followed by introduction of the optics trocar) or open laparoscopy is used.

METHODS

Comparison was made of two retrospective series each carried out in a department promoting one of the two techniques. The setting was a university-affiliated hospital. Two groups of patients were compared: group A, classic laparoscopy, n = 8324; group B, open laparoscopy, n = 1562. We investigated the set-up procedures of operative laparoscopy according to the rules of classic or open laparoscopy.

RESULTS

The risk of failure requiring conversion to laparotomy is significantly higher in the group of patients who underwent open laparoscopy [three cases (0.19%) vs. 0 case (0.0%); p = 0.004]. The risk of major complications is comparable in the two groups [group A, four cases (0.05%) vs. group B, three cases (0.19%); p = 0.08]. In the classic laparoscopy group there were four major complications: one injury to the aorta and three bowel injuries. In the open laparoscopy group there were three major complications: two bowel injuries and one postoperative occlusion.

CONCLUSIONS

Open laparoscopy does not reduce the risk of major complications during the set-up procedures for laparoscopy. Randomized prospective trials are indispensable for comparing the risks involved with the classic technique and those of open laparoscopy.

[Verrucous carcinoma of the vulva: a tailored treatment]

OBJECTIVE

Verrucous carcinoma is a rare form of vulvar squamous carcinoma, with particular clinical presentation and histological description. We analyze the specificity of the treatment of this form.

MATERIALS AND METHODS

We analyzed the records of 8 patients treated in our hospital between 1995 and 2001. In the absence of an associated lesion, the treatment was partial vulvectomy without lymph node dissection. A close follow-up was then organized.

RESULTS

Mean age was 76 years (range 54 to 92). In 7 out of the 8 cases we found an associated lesion: invasive squamous carcinoma, VIN III or lichen. Two patients later developed a squamous carcinoma. Two others died because of intercurrent diseases. The last four patients are doing well.

CONCLUSION

We confirm the efficacy of the treatment generally proposed: partial vulvectomy, without lymph node dissection and without complementary treatment but with a close follow-up. The coexistence of other vulvar lesions such as lichen is remarkable in our series.

[Deep pelvic endometriosis: management and proposal for a "surgical classification"]

Deep pelvic endometriosis presents essentially in the form of a painful syndrome dominated by deep dyspareunia and painful functional symptoms that recur according to the menstrual cycle, with the semiology directly correlated with the location of the lesions (bladder, rectum). It is essential to investigate these deep endometriosis lesions and draw up a precise map, which is the only way to be sure that exeresis will be complete. The treatment of first intention remains surgery, and medical treatment is only palliative in the majority of cases. Success of treatment depends on how radical surgical exeresis is. Based on analysis of the anatomical distribution of deep pelvic endometriosis lesions, a "surgical classification" is proposed with the aim of establishing standard modes for surgical treatment. Further studies are required to clarify the place and modes for pre- and postoperative medical treatment.

[Validation of the French version of a pleasure scale for children (The Pleasure Scale for Children, PSC, Kazdin, 1989) in 214 hospitalized children in pediatrics]

The aim of this study was to determine the metrological parameters of a french version of the Pleasure Scale for Children (PSC): 214 (121 males and 93 females) with a mean age of 8.69 years (sd: 1.95) ranging from 6 years to 12 years were included in the study. The children were inpatients presenting various somatic disorders.

STATISTICAL ANALYSIS

First a principal component analysis was done on the 39 items of the correlation matrix. Several guidelines were used to limit the number of factors (Kaiser criteria, Cattell scree test, Horn parallel analysis). Secondly the construct validity was studied using the alpha Cronbach coefficient and by calculing the Pearson correlation coefficient between each item and the total score. Thirdly the concurrent validity was determinated using two items of the Children Depression Rating Scale--Revised (CDRS-R) measuring pleasure (social withdrawal and enjoyment capacity). Fourthly the discriminant validity of the PSC was studied by comparing non depressive children (score lower than 30 to the CDRS-R) and depressive children (score higher than 30 to the CDRS-R).

RESULTS

The principal component analysis showed a one factor solution with 33 items among the 39 having a higher than 0.3 saturation. The Cronbach alpha coefficient was 0.84. All the items correlated with the total score. The mean value was 0.37. The correlations between the total score of the scale and the CDRS-R enjoyment capacity and social withdrawal items were respectively -0.37 (p < 0.01) and -0.38 (p < 0.01). PSC score were significantly lower in depressive children (m = 86.96; sd = 8.33) than in non depressive children (m = 94.67; sd = 10) (t = 5.32; df = 212; p < 0.001).