[Anatomoclinical study of ovarian cancers in patients with history of hysterectomy for benign pathology]

OBJECTIVE

To establish the various anatomoclinical characteristics of ovarian cancer in patients with a history of hysterectomy for benign disease.

METHODS

This is a comparative, retrospective, monocentric and descriptive study, carried out at the Centre of Jean-Perrin in patients with ovarian cancer between 2005 and 2014 and with a history of hysterectomy for benign disease. Each patient was paired with a non-hysterectomy patient with ovarian cancer. The two populations were matched 1 to 5, based on their age at diagnosis and their FIGO stage.

RESULTS

During the period of the study, 249 patients were operated for de novo ovarian neoplasia, 43 patients had a history of hysterectomy (group 1) and 206 remaining patients represented the control group (group 2). There was no difference in overall survival and disease-free survival between the two subpopulations of patients (P=0.59 and P=0.38). On CT-scan assessment, the lymph node involvement risk was greater than 2.6 in the group of patients with hysterectomy (P=0.00038). Peritoneal Cancer Index scores of the two subgroups of populations were comparable, there were an average of 13.65 for group 1 versus 12.31 for group 2 (P=0.28). The rate of rectosigmoid resection was higher in group 1: 48.6% versus 32.9% in group 2 without any significant difference (P=0.07). Hundred and thirty-three patients undergone lumbar aortic lymphadenectomy, with node involvement found in 83% of patients in the hysterectomy group and 51% of patients in the control group (P=0.0053).

CONCLUSION

Indication of lumbar aortic lymphadenectomy should be taken in better consideration in patients with history of inter-adnexial hysterectomy. These data must be thoroughly assessed with a prospective multicenter comparative study.

Cost comparison of axillary sentinel lymph node detection and axillary lymphadenectomy in early breast cancer. A national study based on a prospective multi-institutional series of 985 patients 'on behalf of the Group of Surgeons from the French Unicancer Federation'

BACKGROUND

Our objective was to assess the global cost of the sentinel lymph node detection [axillary sentinel lymph node detection (ASLND)] compared with standard axillary lymphadenectomy [axillary lymph node dissection (ALND)] for early breast cancer patients.

PATIENTS AND METHODS

We conducted a prospective, multi-institutional, observational, cost comparative analysis. Cost calculations were realized with the micro-costing method from the diagnosis until 1 month after the last surgery.

RESULTS

Eight hundred and thirty nine patients were included in the ASLND group and 146 in the ALND group. The cost generated for a patient with an ASLND, with one preoperative scintigraphy, a combined method for sentinel node detection, an intraoperative pathological analysis without lymphadenectomy, was lower than the cost generated for a patient with lymphadenectomy [€ 2947 (σ = 580) versus € 3331 (σ = 902); P = 0.0001].

CONCLUSION

ASLND, involving expensive techniques, was finally less expensive than ALND. The length of hospital stay was the cost driver of these procedures. The current observational study points the heterogeneous practices for this validated and largely diffused technique. Several technical choices have an impact on the cost of ASLND, as intraoperative analysis allowing to reduce rehospitalization rate for secondary lymphadenectomy or preoperative scintigraphy, suggesting possible savings on hospital resources.

Abstract P1-01-15: Intraoperative Imprint Cytology Examination of Sentinel Lymph Nodes after Neoadjuvant Chemotherapy in Breast Cancer Patients

Background: Intraoperative imprint cytology (IC) is one of several accurate, proved methods to detect tumor cells in sentinel lymph nodes (SLN) from patients with operable breast cancer. In patients treated by neoadjuvant chemotherapy (NAC), studies have demonstrated the feasibility and accuracy of SLN biopsy procedure. The aim of this study was to evaluate the validity of tumor cell detection using IC in SLN from patients who underwent NAC.

Material and methods: Patients with infiltrating breast carcinoma receiving NAC (n= 132) were studied prospectively. At surgery, SLN biopsy followed by axillary lymph node dissection was performed. Intraoperative SLN evaluation using IC was performed in 80 out of 132 patients (60%). In the same period, IC has been evaluated at random for 100 chemonaïve patients in the same institution.

Results: Sentinel lymph node metastases were correctly identified using IC in 58 of 80 (72%) patients. False negative results were observed in 21 patients. The overall sensitivity and specificity of IC for the identification of lymph node metastases was respectively 38.2% and 97.8%. The positive predictive value was 92.9% and the negative predictive value was 68.2%. In univariate analysis and multivariate logistic regression analysis, patients with micrometastases or ITC in SLN have 2.3 times higher risk of a false negative IC result than patients with macrometastases of the SLN (P= 2.1.10-4; RR= 2.3; 95% confidence interval [1.37-3.85]). For chemonaïve patient, sensitivity, specificity, PPV and NPV were respectively 47.4%, 98.8%, 90% and 88.9%.

Conclusion: The accuracy of intraoperative IC observed in our study is similar to that reported previously in patients without NAC, indicating that IC is a clinically acceptable method for intraoperative pathological examination of SLN for patients after NAC. Variations in sensitivity are related to the proportion of cases with micrometastases and ITC, as it was also shown in chemonaive patients.

Citation Information: Cancer Res 2010;70(24 Suppl):Abstract nr P1-01-15.

Intraoperative imprint cytology examination of sentinel lymph nodes after neoadjuvant chemotherapy in breast cancer patients

BACKGROUND

Intraoperative imprint cytology (IC) is one of several accurate, proven methods to detect tumor cells in sentinel lymph nodes (SLN) from patients with operable breast cancer. In patients treated with neoadjuvant chemotherapy (NAC), studies have demonstrated the feasibility and accuracy of SLN biopsy procedure. We evaluated the validity of IC for SLN testing in patients after NAC.

MATERIAL AND METHODS

Patients with infiltrating breast carcinoma receiving NAC (n = 132) were studied prospectively. At surgery, SLN biopsy followed by axillary lymph node dissection was performed. SLN were evaluated using IC in 80 of 132 patients (60%). The results of IC in the adjuvant setting (100 patients) were used for comparison.

RESULTS

SLN metastases were correctly identified using IC in 58 of 80 (72%) patients. False negative results were observed in 21 patients. The sensitivity of IC testing was 38.2% and specificity 97.8%. The positive and negative predictive values (PPV and NPV) were 92.9% and 68.2%, respectively. In univariate analysis and multivariate logistic regression analysis, patients with micrometastases or isolated tumor cells in SLN have 2.3 times higher risk of a false negative IC result than patients with macrometastases in SLN (P = .00021; relative risk [RR] = 2.3; 95% confidence interval, 1.37-3.85). The non-NAC group, which contained fewer micrometastatic cases, showed better sensitivity (47.4%) and NPV (88.9%).

CONCLUSION

NAC does not seem to influence the accuracy and sensitivity of IC. Variations in sensitivity are related to the proportion of cases with micrometastases and ITC, as it was also shown in chemonaive patients.

Six versus nine cycles of paclitaxel-carboplatin as first-line chemotherapy in patients with newly diagnosed epithelial advanced ovarian cancer

e16535

Background: A multimodality approach with cytoreductive surgery and six courses of paclitaxel-platinum-based chemotherapy is actually the mainstay of treatment of Advanced Ovarian Cancer (AOC). This study was performed to determine retrospectively the efficacy of three additional cycles of paclitaxel-carboplatin (PC) in patients with AOC who had previously demonstrated chemosensitivity to six courses of this regimen. Methods: From January 2000 to August 2008, 125 epithelial AOC (FIGO stages IIIC and IV) were diagnosed in a single institution. After a cytoreductive surgery, 51 patients received six cycles of PC (PC 6 group), 57 received 9 (PC 9 group), and 17 experienced progressive disease during treatment. The chemotherapeutic regimen consisted of intravenous paclitaxel 175 mg/m2 for a 3-hour infusion period and intravenous carboplatin AUC 5 every 3 weeks. Results: Median age was 62 years in PC6 group and 59.7 years in PC9. According to the FIGO criteria, 72.6% patients were in stage IIIC in group PC6 and 75.4% in group PC9. Except the patients who experienced refractory disease, complete clinical response at the end of chemotherapy was assessed in 71.4% patients in group PC6 and 71.9% in PC9 (p = 0.13). The median time to progression (TTP) was 26.2 months in PC6 and 29 months in PC9 (p = 0.5). The median overall survival (OS) was 106 months and 97 months respectively (p = 0.16). Conclusions: This retrospective study suggests that three cycles of consolidation chemotherapy with paclitaxel and carboplatin might not prolong duration of TTP or OS in AOC patients.

No significant financial relationships to disclose.

Clinicopathological factors and nomograms predicting nonsentinel lymph node metastases after neoadjuvant chemotherapy in breast cancer patients

BACKGROUND

Studies have demonstrated the feasibility and accuracy of sentinel lymph node (SLN) biopsy after neoadjuvant chemotherapy (NAC) in breast cancer. Some SLN-positive patients have low risk of nonsentinel lymph node (non-SLN) involvement. Our goal was to determine clinicopathological factors correlating with the presence of non-SLN metastases in patients after NAC and to assess the validity of nomograms predicting additional axillary metastases.

METHODS

Patients with infiltrating breast carcinoma (n = 132) were studied prospectively. All patients received NAC. At surgery, SLN biopsy followed by axillary lymph node dissection was performed. Lymphatic mapping was done using the isotope method. Fifty-one patients were SLN positive.

RESULTS

In univariate analysis, tumor size (P = 0.016) and the size of SLN metastases (P = 0.0055) were significantly correlated with the presence of non-SLN metastases. In multivariate analysis, SLN macrometastases (P = 0.047) conferred significantly increased risk of non-SLN metastases. The Memorial Sloan-Kettering Cancer Center nomogram was not reliably predictive for non-SLN metastases (area under the receiver operating characteristic curve, AUC, of 0.542), whereas the MD Anderson (AUC 0.716) and Tenon scoring systems (AUC 0.778) were validated.

CONCLUSION

Our results suggest that clinicopathological factors predicting non-SLN involvement in SLN-positive patients with and without NAC are essentially the same. The risk of involvement may be assessed using existing nomograms, but additional large prospective studies are needed to determine their accuracy in patients after NAC.

Sentinel lymph node biopsy after neoadjuvant chemotherapy is accurate in breast cancer patients with a clinically negative axillary nodal status at presentation

Abstract #1020

Background: In breast cancer, neoadjuvant chemotherapy (NAC) is widely used in order to enable a conservative surgery. In patients treated with NAC, the use of sentinel lymph node (SLN) biopsy, which is a good predictor of the axillary nodal status in previously untreated patients, is still discussed. The aim of our study was to determine clinicopathological factors that may influence the accuracy of SLN biopsy after NAC.
 Patients and methods : Between March 2001 and December 2006, 129 patients with infiltrating breast carcinoma were studied prospectively. Preoperatively, all of them underwent NAC. At surgery, SLN biopsy followed by axillary lymph node (ALN) dissection was performed. Lymphatic mapping was done using the isotope method.
 Results : The SLN identification rate was 93.8% (121/129). Fifty-six out of the 121 sucessfully mapped patients had positive ALN. Eight out of these 56 patients had tumor-free SLN (false-negative rate of 14.3%). The false-negative rate was correlated with larger tumor size (T1-T2 versus T3; p=0.045) and positive clinical nodal status (N0 versus N1-N2; p=0.003) before NAC. In particular, the false-negative rate was 0% (0/29) in N0 patients and 29.6% (8/27) in N1-N2 patients. Clinical and pathological responses to NAC did not influence the accuracy of SLN biopsy.
 Conclusion : Our results show that clinical nodal status is the main clinicopathological factor influencing the false-negative rate of SLN biopsy after NAC for breast cancer. SLN biopsy after NAC can predict the ALN status with a high accuracy in patients who are clinically lymph node negative at presentation.

Citation Information: Cancer Res 2009;69(2 Suppl):Abstract nr 1020.

Correlation between molecular metastases in sentinel lymph nodes of breast cancer patients and St Gallen risk category

AIMS

To evaluate the clinical significance of tumour metastases detected using real-time reverse transcription-PCR (RT-PCR) in sentinel lymph nodes (SLN) of breast cancer patients.

METHODS

Sixty-seven patients with T1-T2 primary breast cancer were included in a prospective study. SLN were analysed for the presence of metastatic tumour cells using standard histopathology staining, immunochemistry (IHC) and multimarker real-time RT-PCR assay for mammaglobin (MMG), carcinoembryonic antigen (CEA) and cytokeratin-19 (CK19) mRNA expression. Correlations between molecular metastases and traditional clinicopathological prognostic factors, including St Gallen risk categories were studied.

RESULTS

Of the 67 patients, 15 (22.3%) had one or more pathology-positive SLN. Five (9.6%) pathology-negative SLN were positive by IHC and 19 (36.5%) by RT-PCR. Of note, RT-PCR analysis was also positive in all cases with pathology- or IHC-positive SLN. MMG was the most informative tumour marker in the panel. Molecularly detected metastases were significantly associated with intermediate St Gallen risk category (p=0.023).

CONCLUSION

Molecular staging of SLN using real-time RT-PCR for early breast cancer could serve as a useful complement to standard clinicopathological risk factors. Studies with long-term follow-up are necessary to define the impact of molecular metastases on disease free survival and overall survival.

Prognostic significance of a complete pathological response after induction chemotherapy in operable breast cancer

Only a few papers have been published concerning the incidence and outcome of patients with a pathological complete response after cytotoxic treatment in breast cancer. The purpose of this retrospective study was to assess the outcome of patients found to have a pathological complete response in both the breast and axillary lymph nodes after neoadjuvant chemotherapy for operable breast cancer. Our goal was also to determine whether the residual pathological size of the tumour in breast could be correlated with pathological node status. Between 1982 and 2000, 451 consecutive patients were registered into five prospective phase II trials. After six cycles, 396 patients underwent surgery with axillary dissection for 277 patients (69.9%). Pathological response was evaluated according to the Chevallier's classification. At a median follow-up of 8 years, survival was analysed as a function of pathological response. A pathological complete response rate was obtained in 60 patients (15.2%) after induction chemotherapy. Breast tumour persistence was significantly related to positive axillary nodes (P=5.10(-6)). At 15 years, overall survival and disease-free survival rates were significantly higher in the group who had a pathological complete response than in the group who had less than a pathological complete response (P=0.047 and P=0.024, respectively). In the absence of pathological complete response and furthermore when there is a notable remaining pathological disease, axillary dissection is still important to determine a major prognostic factor and subsequently, a second non cross resistant adjuvant regimen or high dose chemotherapy could lead to a survival benefit.

Endometrial histopathology in 700 patients treated with tamoxifen for breast cancer

OBJECTIVE

The aim of this study was the evaluation of endometrial histopathologic findings from 700 patients treated with tamoxifen (Tx) for breast cancer from two medical centers (United States and France).

METHODS

A retrospective review of data including histologic slides from 134 hysterectomies and 566 endometrial biopsies from Tx-treated patients who presented with abnormal vaginal bleeding and/or abnormal sonograms was performed. Analysis of histologic characteristics included inactive/atrophic and functional endometria, endometrial polyps, hyperplasia and metaplasia, and endometrial cancer. Duration of Tx therapy was recorded when available, and its correlation with endometrial pathology was assessed.

RESULTS

The only statistically significant difference between the data from the United States and France was the number of hysterectomies, which was almost double in France (27% vs 13.7%). Nonpathologic endometria made up 61.14% (inactive/atrophic 46%, functional 15.14%). Pathologic changes were found in 39.86% cases, of which polyps were 23.14%, glandular hyperplasia 8%, and metaplasia 3%; endometrial cancer made up 4.71% (33 cases). Nine cancers were well-differentiated endometrioid adenocarcinomas, and 24 were moderately or poorly differentiated, of which 13 had nonendometrioid components (serous, clear cell, MMMT). Fifteen cancers were found in endometrial polyps; 12 were invasive to the myometrium and 4 to blood vessels. The weight of the uteri exceeded 300 g in 15 cases, with 4 exceeding 900 g. The average age of all patients was 60.91 years and of the cancer patients alone it was 69.26 years. The shortest average duration of Tx therapy (2.5 years) was found in patients with inactive/atrophic endometria and the longest (6.8 years) in patients with endometrial cancer. Patients with endometrial polyps and cancer presented more often with abnormal vaginal bleeding than those with inactive/atrophic endometrium.

CONCLUSIONS

Most Tx-treated patients had no pathologic endometrial changes. Endometrial polyps, hyperplasia, and metaplasia, consistent with an estrogen-agonist effect of Tx, were found in roughly one-third of all patients. The endometrial cancers were often high-grade and invasive tumors. Patients with endometrial pathology were more often symptomatic than patients with inactive/atrophic endometria.

[Parathyroidectomy by elective route with perioperative measurement of parathyroid hormone. Report of 80 cases]

STUDY AIM

The aim of this study was to report a series of 80 patients treated by unilateral neck exploration for a sporadic primary hyperparathyroidism.

PATIENTS AND METHOD

Between April 1992 and November 1998, 80 patients (65 women and 15 men, mean age: 63.5 years) with a single gland enlargement localized by ultrasonography, were operated on through a short unilateral neck incision, under general anesthesia in 72 cases and local in eight cases. The enlarged gland was removed with intraoperative pathological examination and intraoperative monitoring of parathyroid hormone.

RESULTS

Mean duration of surgery was 25 minutes. There was no postoperative mortality or morbidity. Mean duration of hospital stay was two days. The enlarged gland was an adenoma in 75 cases and an hyperplasia in five. Adequate intraoperative parathyroid hormone decrease was observed. Postoperative calcemia was normal in 78 patients (97.5%). Among 76 surviving patients, with a 31-month follow-up, there was only a suspicion of persistent hyperparathyroidism in two patients.

CONCLUSIONS

Minimal invasive approach by unilateral neck exploration may be performed with safety and efficiency in patients with a single gland enlargement under intraoperative monitoring of parathyroid hormone.

[Surgery for subclinical breast lesions]

Subclinical mammographic abnormalities discovered through screening are subjected to excisional surgical biopsy in order to prove or rule out malignant disease of the breast by histological examination. Close attention should be paid by the surgeon to avoid cosmetically disfiguring scar and failure in excision removal exhibited on postoperative mammogram. Indications for surgical assessment are selected upon suspicious patterns of opacities, clusters of microcalcifications or architectural distortions. Good communication between the radiologist, the surgeon and the pathologist is required for proper management of non palpable lesion. The most adequate lumpectomy technique should be performed with regard to the oncologic risk and cosmetic outcome.

Technetium-99m-sestamibi uptake in breast tumor and associated lymph nodes

The aim of this study was to measure the accumulation of 99mTc-sestamibi in breast tumors and their axillary lymph nodes in patients undergoing scintimammography.

METHODS

Eighteen patients who were scheduled for breast surgery underwent scintimammography with 740 MBq of 99mTc-sestamibi on the day before the operation. The next morning, reinjection with 370 MBq was performed. Immediately after the surgical procedure, the 99mTc activity of the tumor samples and, when available, the related lymph nodes was measured in a gamma counter. The samples were weighed and prepared for histological analysis. The activity of each sample was normalized to the mean activity of normal tissue samples obtained from the same patient.

RESULTS

Among the 198 samples analyzed, the relative uptake of sestamibi was increased in 111 containing normal lymph nodes (1.80+/-0.79 vs 1.00+/-0.22, p<0.05), as well as in the seven containing invaded lymph nodes (2.01+/-0.83, p<0.01) and more dramatically, in the 22 with a carcinoma (5.64+/-3.06, p<0.001). In two patients with a benign lesion, both scintigraphy and counting demonstrated increased activity in the tumor. Four patients had negative scan results despite the presence of malignant tumor and a more than fourfold increase of sestamibi concentration in two of them.

CONCLUSION

Technetium-99m-sestamibi concentrates strongly in breast carcinoma, sometimes even when the scan results appear normal, and mildly in lymph nodes, especially when invaded; it also concentrates in some benign tumors, possibly in relation to the presence of epithelial hyperplasia.

Laparoscopic staging of early ovarian cancer

The relevance of staging in early ovarian carcinoma is reviewed in light of the advances in surgical laparoscopy. Data from the literature suggest that a lymphadenectomy should be performed instead of a sampling. We have realized the former through laparoscopy. In this paper we propose a detailed surgical technique, similar to the laparotomy approach, that ensures an adequate nodal evaluation. Ten patients underwent a completion of staging by laparoscopy, including peritoneal washings for cytology, peritoneal and ovarian biopsies, an infracolic omentectomy, and a lymph node dissection. The use of laparoscopy for staging of early ovarian carcinoma appears to be a valuable alternative to traditional surgical staging.

[Superinfection of ovarian dermoid cyst. Apropos of a case]

One case of a rare complication of dermoid ovarian cyst is reported: infection. Sonographic examination was not helpful, mainly due to a great quantity of gas within the mass. However radiography of the abdomen with the patient upright and CT showed a gas-fluid level, teeth and presence of fat. These findings permitted diagnosis of a complicated ovarian dermoid cyst before surgery.

[The axillopectoral muscle]

Extending between the pectoralis major and latissimus dorsi muscles, the "pectoro-axillary" muscle, the principal anatomic variation of the axillary wall, forms and ectopic muscle band that can complicate axillary dissection. The origin and features of this supernumerary muscle related to Langer's arch are described with emphasis on its surgical applications.

[Intestinal metastases from breast cancer. Apropos of 8 cases]

Eight patients with intestinal metastases from breast cancer are described. The different clinical presentations and pathological types are studied. The difficulty in distinguishing such uncommon secondary sites of breast cancer from primary intestinal cancer is emphasized. Attention should be paid to intestinal symptoms in women with a history of infiltrating lobular breast cancer: in agreement with recent literature data the lobular type seems mainly responsible for gastrointestinal and peritoneal involvement originating from breast cancer (7 cases out of 8 in our series). Prolonged survival could be obtained if no metastases elsewhere were found with appropriate treatment including ablative surgery, chemotherapy and hormonotherapy.

Intracholedocal metastatic thrombus of renal adenocarcinoma

The authors report about the intraoperative discovery of a metastatic thrombus in the common bile duct, produced by a right renal adenocarcinoma metastasized in the Vth segment of the liver. As far as the treatment is concerned, in addition to nephrectomy, the use of a simple device allowed intraluminal irradiation with radioiridium. Although this approach is palliative, it resulted from the desire to maintain the patency of the common bile duct by controlling tumor proliferation within the duct. The pathogenesis of this proliferation is discussed. In our opinion, the favorable outcome after 18 months confirms the merits of this therapeutic attitude, which can be used for such tumoral extensions.

Prevention of radiation enteritis by an absorbable polyglycolic acid mesh sling. A 60-case multicentric study

Radiation-induced small bowel injury is a limiting factor to postoperative tumoricidal pelvic doses exceeding 4500 to 5000 cGy. Data from a review of the literature showed the inadequacy of medical measures and the bad reproducibility of radiation therapeutic attempts to decrease small intestine damage. Recent studies cited the benefit of a polyglycolic acid mesh to create an absorbable intestinal sling and suspend the loops above the pelvic radiation field. In 60 cases of gynecologic and rectal malignancies with a surgical intestinal morbidity of 8.3% (5 cases), the rate of radiation enteritis was 7% (4 cases) with an average follow-up of 17.8 months (range, 1 to 57 months). The quality of small intestinal elevation and the absence of loop herniation were demonstrated by the barium index. Magnetic resonance imaging was used for checking the polymer polyglycolic acid mesh position and its complete resorption at the third to fifth postoperative month. The authors conclude that this new procedure is safe in selected patients with high pelvic recurrence risk after optimal surgery, in residual disease after debulking surgery, or at the time of exploration for unresectable pelvic tumors. Clinical studies are ongoing to evaluate the long-term efficacy of this surgical technique to prevent chronic radiation enteropathy and improve locoregional control in advanced pelvic carcinomas.

Prevention of radiation enteritis by an absorbable polyglycolic acid mesh sling. A 60-case multicentric study

Radiation-induced small bowel injury is a limiting factor to postoperative tumoricidal pelvic doses exceeding 4500 to 5000 cGy. Data from a review of the literature showed the inadequacy of medical measures and the bad reproducibility of radiation therapeutic attempts to decrease small intestine damage. Recent studies cited the benefit of a polyglycolic acid mesh to create an absorbable intestinal sling and suspend the loops above the pelvic radiation field. In 60 cases of gynecologic and rectal malignancies with a surgical intestinal morbidity of 8.3% (5 cases), the rate of radiation enteritis was 7% (4 cases) with an average follow-up of 17.8 months (range, 1 to 57 months). The quality of small intestinal elevation and the absence of loop herniation were demonstrated by the barium index. Magnetic resonance imaging was used for checking the polymer polyglycolic acid mesh position and its complete resorption at the third to fifth postoperative month. The authors conclude that this new procedure is safe in selected patients with high pelvic recurrence risk after optimal surgery, in residual disease after debulking surgery, or at the time of exploration for unresectable pelvic tumors. Clinical studies are ongoing to evaluate the long-term efficacy of this surgical technique to prevent chronic radiation enteropathy and improve locoregional control in advanced pelvic carcinomas.

The lymphatic drainage of the human ovary in vivo investigated by isotopic lymphography before and after the menopause

The authors report 14 lymphoscintigraphies of the ovary, 8 before and 6 after the menopause. Injection of colloid labeled with technetium 99 m with elective lymphatic absorption was made into the mesovarium under laparoscopic control. Frontal and lateral images of the lymphatic drainage were made with a gamma camera 4-6 h after injection. Even in this short preliminary series, the premenopausal women showed major local and regional lymphatic circulation with drainage to the lumbo-aortic and pelvic nodes. After the menopause the lymphatic flow decreased and drainage was essentially by the aorto-lumbar nodes.

[Stage III and IV epithelial cancer of the ovary. Prognostic role of surgical tumor reduction]

We report the results of surgical excision prior to chemotherapy in 180 cases of advanced epithelial ovarian carcinoma. In this retrospective study, the mean survival rate at 5 years was 22 percent. It was 40 percent in patient with stage III carcinoma, divided into 60 percent for micronodular carcinomas (stages IIIa + b) and 30 percent for macronodular carcinomas (stage IIIc). However, in cases with optimal initial excision the overall survival rate was the same in patients with macronodular carcinoma as in those with micronodular carcinoma. This finding suggests that surgical excision itself has a favourable effect on the prognosis of this disease.

[Surgical technic for the excision of subclinical radiologic anomalies of the breast]

Routine mammography screening can detect radiologically evident but subclinical breast anomalies. Insofar as these anomalies can correspond to carcinoma, either in situ or invasive, surgeons are increasingly forced to operate on non-palpable breast lesions. A regulated and strict surgical technic is necessary to ensure exeresis of a radiologically detected focus, while avoiding sufficient adjacent healthy parenchyma and thus reducing the esthetic prejudice to a minimum. Technical artifices are described to assist compliance with these imperatives. First, the periareolar incision is chosen, as a principle, for its cosmetic qualities. Insofar as it provides an often limited approach it can be extended radially. The latter is concealed during closure without major alteration to the areola. Second, the radiating exeresis assists detection and is safer. It also provides glandular reconstruction of good esthetic quality and facilitates follow up surveillance.