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.

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.

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.

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

BACKGROUND

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

PATIENTS AND METHODS

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

RESULTS

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

CONCLUSIONS

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

Abstract S2-07: Sentinel node detection after neoadjuvant chemotherapy in patient without previous axillary node involvement (GANEA 2 trial): Follow-up of a prospective multi-institutional cohort

Background

Half of the patient treated with neoadjuvant chemotherapy (NAC) for a large operable breast cancer has no axillary lymph node involvement at the time of surgery. Sentinel lymph node detection (SLND), after NAC, is aimed to select patient who should be safely spared of an axillary lymphadenectomy (ALND).GANEA 2 is a French prospective multi institutional trial, aimed to assess SLND after NAC.

Objective

To assess the risk of relapse for patients without previous axillary node involvement treated with NAC followed with a SLND without a systematic lymphadenectomy.

Patients and Method

Inclusion: FIGO stage T1-T3 infiltrating breast carcinoma, indication of NAC.

Exclusion: inflammatory cancer, local relapse, contra-indication to NAC, NAC interrupted due to progressive disease.

Design: indication to plan a NAC, axillary sonography with fine needle cytology before NAC to select patients without lymph node involvement, SLND after NAC. ALND was mandatory in case of SLN involvement (macro or micro-metastasis) or SLND failure. Follow-up was scheduled with a medical visit / 6 months with axillary assessment and a mammography each year. Follow-up results are updated every 6 months.

Pathological analysis were carried out according to standard methods and classified according to the last American Joint Committee staging system.

Studied parameters were SLND detection rate, pathological results on breast specimen and nodes, rate of relapse (axilla, breast, metastasis), and survival.

Results

From July 2010 to February 2014, 587 patients were enrolled, from 17 institutions, and experienced breast tumor surgery and a SLND after NAC.

Each patient experienced breast surgery. A breast tumour pathological complete response was found in 21.3% (125/587).

SLND rate was 97% (570/587), with a median number of 2 sentinel nodes (1-9).

Patients with a sentinel detection failure (n=17) experienced a systematic lymphadenectomy, without any involvement (n=13), a micro-metastasis (n=2) and a macro-metastasis (n=2).

A total of 140 patients had at least one sentinel node involved: macro-metastasis (n=86), micro-metastasis (n=54). A lymphadenectomy was performed in 128 cases: metastasis free (n=100), macro-metastasis (n=17), micro-metastasis (n=11).

A total of 430 patients had a SLN metastasis free (75% ;430/570). A not mandatory lymphadenectomy was performed (n=14): metastasis free (n=11), macro-metastasis (n=2) and micro-metastasis (n=1). 17 patients were lost to follow-up.

A total of 399 patients without sentinel node involvement were followed 2.3 years (from 0.5 to 5.6 yrs). At 3 years overall survival was 97.8% [94.9-99.1], disease free survival was 94.8% [91.0-97.1%]. Six patients died. Fifteen patients experienced a relapse: 8 metastasis, 4 homolateral breast, 2 controlateral breast, 1 homolateral axillary relapse.

Conclusion

This is the most important series of patients followed 2.3 years after SLND without axillary lymphadenectomy after NAC for an advanced breast cancer, showing acceptable results. The current series validate the safety of this conservative strategies avoiding systematic lymphadenectomy to patients without initially involved axillary node treated with NAC.

Citation Format: Classe J-M, Loaec C, Alran S, Paillocher N, Tunon-Lara C, Gimbergues P, Faure-Virelizier C, Chauvet M-P, Lasry S, Dupre P-F, Verhaeghe J-L, De Blaye P, Gutowski M, Barranger E, Lecuru F, Lefevre Lacoeuille C, Loussert L, Lambaudie E, Ferron G, Campion L. Sentinel node detection after neoadjuvant chemotherapy in patient without previous axillary node involvement (GANEA 2 trial): Follow-up of a prospective multi-institutional cohort [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 S2-07.

Abstract P2-01-33: Non-sentinel lymph nodes involvement in early breast cancer patients: Performance of two predictive nomograms integrating the analysis of sentinel nodes by one step nucleic acid amplification in a cohort of 299 patients

Backgrounds: Sentinel lymph node (SLN) biopsy is a highly accurate predictor of axillary status and has become the surgical axillary standard in breast cancer patients. About 50–70 % of patients with involved SLN have no additional non sentinel node (NSN) involved, suggesting that it be possible to avoid ALND in selected patients. Many tools have been developed to help surgeons in NSLN evaluation but they all need pathological data from tumor and SLN and can't be used during surgery. Developed for intraoperative detection of SLN macro or micrometastasis involvement, the semi-automated molecular one step nucleic acid amplification (OSNA), as accurate as pathology, is available. Two simple nomograms have been developed to predict NSN involvement based on the number of CK19 mRNA copy determined by OSNA:

· Nomogram developed by Peg V (Eur J Surg Oncol 2013): based on total tumoral load (TTL). TTL is defined as the addition of CK19 mRNA copies of each positive SLN (copies/μL). A TTL≥1.2 × 10(5) copies/ml (specificity=85.3%, negative predictive value (NPV) = 80%) can predict NSN involvement.

· Nomogram developed by Di Filippo F (Journal of Experimental & Clinical Cancer Research 2015): based on the number of CK19 mRNA copies and ultrasound tumor size. These two variables are categorized using quartiles with a score for each and the addition of both corresponds to a probability of NSN involvement (sensitivity = 98.1%, NPV = 92.5 %).

Patients and Methods: this is a retrospective study of 299 patients. Each patient had SLN involvement (macro or micrometastasis) and underwent a complementary ALND. The main objective was to evaluate the performance of each nomogram using a discrimination ability model, assessed by ROC analysis. Predictive accuracy was measured by the area under ROC curves (AUC) reported with its 95 % confidence interval. The second objective was to compare the two nomograms using Hanley & McNeil method, to test the statistical significance of the difference between the AUC. Analysis was performed using stata 13.1 SE.

Results: The mean age was 59, 1 year. Most patients were treated for an infiltrating ductal carcinoma (80.3%, 240/299). The mean ultrasound tumor size was 13 mm and the mean pathological tumor size was 15 mm. The median number of examined SLN was 2 with a macro-metastasis in 67, 6%, 202/299). 70 patients had involved nodes in ALND (23%).

The discrimination of N Peg, quantified with AUC was 0.685 (p&lt;0, 00001). The discrimination of N Di Filippo, quantified with AUC was 0.72 (p&lt;0, 00001).

Hanley & McNeil method shows that Di Filippo nomogram is significantly superior to Peg nomogram (p=0,048).

Conclusion: The current study shows that these two nomograms are reliable and can be used to predict NSLN involvement. The combination of molecular data and ultrasound tumor size seems to be more efficient than molecular data alone. These results are similar to results of nomogram studies based on pathological analysis but only these nomograms integrating molecular data can be used during the surgery.

Citation Format: Bordes V, Campion L, Jezequel P, Lefrancois A, Boiffard F, Brillaud-Meflah V, Dravet F, Jaffre I, Classe J-M. Non-sentinel lymph nodes involvement in early breast cancer patients: Performance of two predictive nomograms integrating the analysis of sentinel nodes by one step nucleic acid amplification in a cohort of 299 patients [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 P2-01-33.

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

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

BACKGROUND

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

METHODS

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

FINDINGS

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

INTERPRETATION

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

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

PURPOSE

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

PATIENTS AND METHODS

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

RESULTS

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

CONCLUSION

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

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSION

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

[Male breast cancer: prognostic factors, diagnosis and treatment: a multi-institutional survey of 95 cases]

OBJECTIVES

The optimal treatment for male breast cancer is not known because male breast cancer is a rare disease. It represents as little as 0.6% of all breast cancers and less than 1% of human cancers. The aim was to analyze the clinical, histological and therapeutic characteristics of 95 men cared for breast cancer between 2000 and 2010 in four hospitals, and determine predictors of poor prognosis to improve care of male breast cancer.

METHODS

This study is a multi-institutional survey, retrospective, involving four French institutions: Cancer Institute of the West (ICO), Reunion Island South hospital group, the hospital group of Dax, and the Bergonié Institute. All carcinomas in situ or invasive breast occurred in male patients were included. An analysis of clinical, histological and therapeutic features was performed. Statistical analysis of our study focused on the overall survival of patients and specific method of Kaplan-Meier, enabling search for predictors of poor prognosis.

RESULTS

The mean age was 65 years. Thirty-seven percent of patients were overweight or obese. It was in 88% of cases of palpable tumor whose average size was 26.29mm. Ninety patients, none had a lesion palpable T0, 44% T1 tumors, 38% T2 tumors, 3% had a T3 tumors, and finally 10% T4 tumors. The histological type was the most common invasive ductal carcinoma (87%). He found a similar proportion of patients with or without lymph node involvement. N+ patients, capsular rupture was observed in 29% of cases. Receptor positivity was found, estrogen in 95% of cases and progesterone in 83% of cases. Additional irradiation was performed in 75% of patients and chemotherapy in 37% of patients. Overall survival was 79.2% at five years and 70.8% at ten years. Age, tumor size and histological capsular rupture are factors that significantly influence the overall survival and specific.

CONCLUSION

Male breast cancer is a different pathology of breast cancer in women. The majority of recommendations suggest treating men who are diagnosed with breast cancer, using the guidelines applied to postmenopausal women treatments. There is no study based on male population that has evaluated these treatment modalities in terms of impact on survival. The diagnosis is usually made at later stages, and tumor size is often greater. Histological characteristics also differ. However, the treatment is almost identical.

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

BACKGROUND

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

PATIENTS AND METHODS

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

RESULTS

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

DISCUSSION AND CONCLUSION

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

Characteristics and clinical outcome of T1 breast cancer: a multicenter retrospective cohort study

BACKGROUND

A subgroup of T1N0M0 breast cancer (BC) carries a high potential of relapse, and thus may require adjuvant systemic therapy (AST).

PATIENTS AND METHODS

Retrospective analysis of all patients with T1 BC, who underwent surgery from January 1999 to December 2009 at 13 French sites. AST was not standardized.

RESULTS

Among 8100 women operated, 5423 had T1 tumors (708 T1a, 2208 T1b and 2508 T1c 11-15 mm). T1a differed significantly from T1b tumors with respect to several parameters (lower age, more frequent negative hormonal status and positive HER2 status, less frequent lymphovascular invasion), exhibiting a mix of favorable and poor prognosis factors. Overall survival was not different between T1a, b or c tumors but recurrence-free survival was significantly higher in T1b than in T1a tumors (P = 0.001). In multivariate analysis, tumor grade, hormone therapy and lymphovascular invasion were independent prognostic factors.

CONCLUSION

Relatively poor outcome of patients with T1a tumors might be explained by a high frequency of risk factors in this subgroup (frequent negative hormone receptors and HER2 overexpression) and by a less frequent administration of AST (endocrine treatment and chemotherapy). Tumor size might not be the main determinant of prognosis in T1 BC.

Incidence of occult contralateral carcinomas of the breast following mastoplasty aimed at symmetrization

INTRODUCTION

Breast carcinomas are the most frequent form of cancer in French women. Following a total mastectomy, only an estimated 25% of patients wish to undergo breast reconstruction. After mammary volume reconstitution, the plastic surgeon often attempts to harmonize the two breasts by carrying out contralateral reduction mammaplasty (CRM). In the literature, the incidence of occult contralateral carcinomas incidentally discovered in surgical specimens ranges from 1.12 to 4.5%. The main objective of this study was to evaluate occurrence of carcinoma in the CRM specimens in the framework of a breast reconstruction operation. The secondary objective was to determine the consequences of the incidentally discovered carcinoma in the contralateral breast.

MATERIAL AND METHODS

This was a 6-year, bicentric, retrospective study involving women having undergone breast cancer surgery who later underwent contralateral reduction mammaplasty (CRM), that is to say reconstruction aimed at harmonization of the two breasts.

RESULTS

Three hundred and nineteen patients were included in the study. Mean age during the CRM was 55years (29-79). Mean weight of the surgical specimens was 323grams (12-2500). Incidence of occult carcinomas found in the specimens was 0.94% (3 patients). The mean age for these 3 cases was 58years (47-64). All 3 patients had superior pedicle mammaplasty. One of the patients benefited from monobloc resection with orientation of the surgical specimen. In the other 2 cases, there existed 3 surgical resection specimens; in one case, they were oriented; in the other, they were not. In all 3 cases, the histological findings were unifocal ductal carcinomas in situ (DCIS). Mean tumor size was 5.7mm (3-9). Only the patient having had monobloc resection with orientation of the specimen underwent salvage surgery, which consisted in partial mastectomy, otherwise known as secondary lumpectomy. Adjuvant radiotherapy was administered to all of the patients. After 17months of mean follow-up (12-22), no recurrence was found in any of the three cases.

CONCLUSION

Incidence of occult contralateral breast carcinomas after symmetrization CRM approximates 1%. Our observations are in agreement with the data in the literature. Incidence is greater than in mammaplasty carried out for esthetic or functional reasons; this is probably due to the higher age and the previous breast cancer history of the breast reconstruction population. Monobloc resection and orientation of the surgical specimens with surgeon's knots facilitate precise pinpointing of the occult carcinoma. A secondary lumpectomy may take place when margins of excision are invaded or inadequate.

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

BACKGROUND

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

PATIENTS AND METHODS

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

RESULTS

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

CONCLUSION

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

[Diagnostic laparoscopy in gynecological cancer, prophylactic oophorectomy: feasibility study on 22 cases]

OBJECTIVES

The purpose of our study was to assess the feasibility of outpatient laparoscopy in a cohort of 22 patients admitted for bilateral oophorectomy (n=11) and preoperative diagnostic laparoscopy (n=11).

PATIENTS AND METHODS

Between December 2012 and May 2013, we included 22 patients in our study. All selected patients received a questionnaire the day before surgery. The questionnaire consisted of chapters on intraoperatively, and the postoperative assessments of patients regarding a possible return home on the evening of surgery. The ability to output was measured with the score of Chung at the evening of surgery and in the morning before leaving.

RESULTS

The mean age of patients was 60 years. The average length of stay was 1.2 days. Postoperative pain tends to be higher in the morning in the bilateral oophorectomy group (P=0.06), nausea and vomiting are the same in both groups. In the bilateral oophorectomy group, six patients were able to go out and five wished it; in the diagnostic laparoscopy group nine patients were able to go out and two wished it, this difference was significant (P=0.041).

DISCUSSION

The outpatient hospital is the norm for many surgeries. In our study, 47% of patients able to go out wishing that output. This difference is important when comparing the two groups. There are more patients wishing an output in the oophorectomy group. This reduction in length of stay must be compensated by a medical and paramedical supervision at home.

CONCLUSION

A large number of surgical procedure are performed on an outpatient basis. Patients who underwent diagnostic laparoscopy are more fragile, they should receive active postoperative support to enable an outpatient hospital.

[Axillary support in breast cancer: survey practice in France]

OBJECTIVE

To establish an inventory concerning the consistency of current medical practices in the management of axillary support for non-metastatic breast cancer since the publication of the ACOSOG-Z0011 randomized trial.

PATIENTS AND METHODS

A descriptive survey practice using a questionnaire sent by email was conducted in medical care teams for breast cancer.

RESULTS

Forty-eight medical teams across the French territory answered to the questionnaire. It has been noted that 72.9% of medical teams have said to consistently achieve an additional axillary lymph node dissection (ALND) in case of macrometastatic sentinel node (SN), 12.5% in case of micrometastatic SN and only 2.1% in isolated tumor cells SN. The majority of medical teams (61.9%) claimed they did not perform the procedure GS before or after neoadjuvant chemotherapy (NAC). The SN biopsy was performed in only 29.1% of teams before and 9% after NAC, outside study. Axillary irradiation was performed in case of macrometastatic SN without complementary by 27.1% of interviewed medical teams and by 4.1% in the case of micrometastic SN.

DISCUSSION AND CONCLUSION

This survey of practice in patients with breast cancer highlights the evolution of medical practice for the axillary management in France. It also illustrates the diversity of practices in medical teams and the significant compensatory increase in the expansion of radiation fields in patients with metastatic SN without additional ALND.

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Abstract P1-01-21: Sentinel Lymph Node detection after previous breast tumour surgical resection: identification rate and false negative rate through a prospective multi institutional study

Background: Large multi institutional studies have pointed that previous surgical resection of breast tumours before axillary sentinel node detection (ASLND) was the main criteria of failure of this technique. Screening campaigns provide small tumours and despite efforts to obtain a diagnosis of early breast cancer, this is not always obtained, due to small tumours or false negative results of micro biopsies. The aim of our series was to assess identification rates and false negative rates of ASLND after previous surgical resection of breast tumours.

Material and Methods: In a prospective multi institutional setting (14 multidisciplinary teams), we have included patients with a previous breast tumour surgical resection for the diagnosis of infiltrative breast adenocarcinoma. Patients with only a core biopsy and no surgical removal of the tumor before axillary surgery were not included. Each patient underwent a secondary surgical procedure for ASLND and axillary lymphadenectomy, and sometimes a breast secondary surgical procedure for margins. ASLND was performed with the combined method, with blue dye and technetium. Pathology was performed with serial sectioning, eosin safron and immune histo chemistry (IHC).

Results: From July 2006 to November 2011, 138 patients where included. The median tumor size was 9mm. Identification rate was 86% (118/138). A macrometastasis was found in 11 cases, in a sentinel node (9), or in a non sentinel node(2). False negative rate was 9% (1 false negative sentinel node with macrometastasis in non sentinel node from lymphadenectomy/11 cases with a macrometastasis in either a sentinel node or a non sentinel node). In 1 case a micrometastasis was found in a sentinel node through IHC, with a macrometastasis in a non sentinel node from lymphadenectomy. Without IHC or without the decision of performing a complementary lymphadenectomy in the case of micrometastasis, the false negative rate would have been 18%.

Conclusions: After previous surgical resection of early breast cancer, ASLND remains feasible with a low identification rate of 86%, despite the use of the combined method. The False negative rate is acceptable with the use of IHC.

Citation Information: Cancer Res 2012;72(24 Suppl):Abstract nr P1-01-21.

Abstract OT2-1-01: Feasibility of sentinel node detection after neoadjuvant chemotherapy for patient with proved axillary lymph node involvement: the French prospective multiinstitutional GANEA 2 ongoing trial

Background: Half of the patient treated with neoadjuvant chemotherapy (NAC) for a large operable breast cancer have no axillary lymph node involvement at the time of surgery. Sentinel lymph node detection (SLND), performed after NAC, would select patient who might be spared of an axillary lymphadenectomy (AL). In a previous study, we assessed the feasibility of SLND after NAC in the case of patients without axillary involvement1. Previous published series have shown that, for patients with an axillary lymph node involvement before treatment, SLND after NAC bring a low detection rate and a high false negative rate (FNR), making this technique contra indicated in this situation.

The aim of GAEA 2 study is to assess the FNR of SLND after NAC in the particular case of patients with a proven axillary lymph node involvement before NAC.

Patients and Method: Prospective study validated by scientific and ethical National boards.

Inclusion criteria: FIGO stage T2-T3 infiltrating breast carcinoma, indication of NAC, surgery (radical or conservative) after NAC and signature of the consent form,

Exclusion criteria: locally advanced, inflammatory breast cancer, local relapse, previous surgical removal of the tumour, mental disorder, pregnancy or no contraceptive method, contra-indication to NAC, NAC interrupted due to progressive disease.

Design of the study: Indication to plan a NAC, control of inclusion and exclusion criteria, consent form signature, axillary sonography before NAC to select the patient in group 1 (patient with a proven lymph node involvement treated with SLND and complementary AL) or 2 (no involvement proven treated with SLND + AL only if detection failure or involvement). Surgery, breast and axilla, performed 4 to 6 weeks after NAC.

Pathological procedure: No intraoperative histopathological examination. Pathological analysis, of sentinel and non sentinel nodes, carried out according to standard methods and classified according the last American Joint Committee staging system and Sataloff classification.

FNR is defined as the ratio of patients with a false negative case of SLNB to the patients with at least one involved node, SLN or not, among patients with SLN detected.

The hypothesis: Taking into account results of lymph node involvement rate found in GANEA 1, to estimate our hypothesis of a FNR between 10 and 15% with a 95% confidence interval will require to include 858 patients in order to obtain 260 patient with a proven axillary lymph node involvement (group 1).

A standard follow up is planned for each patient, with a clinical breast and axillary examination two times/ year and an annual mammography, for five years. In case of clinical axillary relapse a fine needle aspiration must be performed guided with sonography.

Results: On May 31, 2012, 341 patients were included from 16 French institutions; 130 patients with a proven SLN involvement before NAC and 211 with SLN free of metastasis.

1Classe JM, Bordes V, et al. Sentinel lymph node biopsy after neoadjuvant chemotherapy for advanced breast cancer: results of Ganglion Sentinelle et Chimiotherapie Neoadjuvante, a French prospective multicentric study. J Clin Oncol. 2009 Feb.

Citation Information: Cancer Res 2012;72(24 Suppl):Abstract nr OT2-1-01.

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

BACKGROUND

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

PATIENTS AND METHODS

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

RESULTS

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

CONCLUSION

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

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

BACKGROUND

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

METHODS

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

TRIAL REGISTRATION

NCT00210236.

RESULTS

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

CONCLUSION

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

[Retroperitoneal lymphadenectomy and survival of patients treated for an advanced ovarian cancer: the CARACO trial]

The standard management for advanced-stage epithelial ovarian cancer is optimum cytoreductive surgery followed by platinum based chemotherapy. However, retroperitoneal lymph node resection remains controversial. The multiple directions of the lymph drainage pathway in ovarian cancer have been recognized. The incidence and pattern of lymph node involvement depends on the extent of the disease and the histological type. Several published cohorts suggest the survival benefit of pelvic and para-aortic lymphadenectomy. A recent large randomized trial have demonstrated the potential benefit for surgical removal of bulky lymph nodes in term of progression-free survival but failed to show any overall survival benefit because of a critical methodology. Further randomised trials are needed to balance risks and benefits of systematic lymphadenectomy in advanced-stage disease. CARACO is a French ongoing trial, built to bring a reply to this important question. A huge effort for inclusion of the patients, and involving new teams, are mandatory.

[Oncologic, functional, and aesthetics results; evaluation of the quality of life after latissimus dorsi flap breast reconstruction. About a retrospective series of 450 patients]

Retrospective assesssment from 1998 to 2005 from women who have a breast reconstruction by autologus latissimus flap or by latissimus flap and silicone breast implant for differed breast reconstruction (DBR) or mastectomy and immediate breast reconstruction (MIBR).

PATIENTS AND METHOD

Analysis of oncologic results on 450 patients. Analysis of aesthetic, functional results and of quality of life by an anonymous questionnaire in the non progressive patients (407): 263 appraisable answers (13 DBR, 127 MIBR). Middle age: 49.8 years.

RESULTS ONCOLOGIC

Forty-three patients (9.5%) had a relapse of their disease, 33 patients died (7.2%). The relapse of the disease was done in the form of metastasis alone: 29 (67.4%), metastasis and local recurrence: three (7%), local recurrence only: four (9.3%), not specified: seven (16.3%). The average time between the breast reconstruction and the relapse was 18.25±15.4 months.

AESTHETIC RESULTS

The overall assessment is of 7.68/10. There is no statistical difference between immediate reconstruction and delayed reconstruction. A total of 11.2% patients considered it to be bad (<5/10). The symmetry between the two breasts in time is of 6.6/10 and 19.9% patients considered it to be bad (<5/10). The scar ransom, considered to be most important, is mostly in the back (4.1/10) then on the controlateral breast and then the breast reconstruction. This ransom is not easily acceptable in 15 to 20% of the patients.

FUNCTIONAL RESULTS

The discomfort and the pain prevail above all in the back (3.56 and 2.59/10). Weaker symptoms in the event of immediate reconstruction than delayed reconstruction. We noted that 77.2% had kinesitherapy after surgery and 18.9% continues to have kinesitherapy, long time after surgery, mainly for massages of the back. The handicap is considered to be overall low 2.5/10 but 10% of the patients keep a feeling of important handicap (>7.5/10).

QUALITY OF LIFE RESULTS

Seventy-one of the patients are serene. The discomfort to wear a bathing suit or to look at bare-chested is low (2.59 and 2.44/10). However 8.9% are in a very discomfort to see themselves bare-chested and 17.6% to show themselves to their spouse, with an impact on their emotional and sexual life in 36.4% of the cases. There is no significant difference between MIBR and DBR but on the other hand according to the judgement of the woman of her aesthetic result. A total of 95.7% do not regret having made this breast reconstruction.

CONCLUSION

This study makes it possible to concentrate on the group of non satisfied patient for better determining the causes and the improvements of the surgical techniques to bring but also the overall surgical management of the patient even if most of the patients were mainly satisfied with their breast reconstruction.

[Patient follow-up after treatment for breast cancer]

Patient follow-up after treatment for a breast cancer is based on the local recurrence risk. Annual mammography remains the main point of this follow-up and tumor markers detection has still no interest. Absence of benefit of an intensive clinical, biological and radiological surveillance has been proved for a long time but expert recommendations still are a subject of discussion although they knew no evolution for more than 10 years. Evolution of those follow-up modalities will depend on the future indications of MRI and PET. About distant recurrence, a better knowledge of the risk is now possible thanks to the tumor biological profile study. Nevertheless, intensification of follow-up for some kind of high-risk tumors will have interest only if we can propose a therapeutic alternative in metastatic situation.

[Intraperitoneal chemotherapy in the treatment of advanced ovarian cancer]

The standard treatment for advanced ovarian cancer consist in complete surgical debulking and intravenous platin and taxane based chemotherapy. Despite research efforts, a lot of patients still die from peritoneal carcinomatosis. The aim of our work was to present the state of art about intraperitoneal chemotherapy. Intraperitoneal chemotherapy (IPC): three multi-institutional randomised trials showed that platin based IPC gave better results in term of overall and disease free survival when compared to standard intravenous treatment. Even so, IPC is not yet becoming a new international standard of treatment because a high rate of morbidity. Hyperthermic Intraperitoneal chemotherapy (HIPEC) represents an innovative alternative to IPC. HIPEC is based on a complete surgical debulking without any visible mass and an intraperitoneal chemotherapy with synergy of hyperthermia. Phase II trails have shown its feasibility. Randomised trials are needed to assess its efficiency in improving survival.

A nomogram predictive of non-sentinel lymph node involvement in breast cancer patients with a sentinel lymph node micrometastasis

PURPOSE

Predictive factors of non-sentinel lymph node (NSN) involvement at axillary lymph node dissection (ALND) have been studied in the case of sentinel node (SN) involvement, with validation of a nomogram. This nomogram is not accurate for SN micrometastasis. The purpose of our study was to determine a nomogram for predicting the likelihood of NSN involvement in breast cancer patients with a SN micrometastasis.

METHODS

We collated 909 observations of SN micrometastases with additional ALND. Characteristics of the patients, tumours and SN were analysed.

RESULTS

Involvement of SN was diagnosed 490 times (53.9%) with standard staining (HES) and 419 times solely on immunohistochemical analysis (IHC) (46.1%). NSN invasion was observed in 114 patients (12.5%), whereas 62.3% (71) had only one NSN involved and 37.7% (43) two or more NSN involved. In multivariate analysis, significant predictive factors were: tumour size (pT stage < or = 10 mm or >11 and < or = 20 or >20 mm [odds ratio (OR) 2.1 and 3.43], micrometastases detected by HES or IHC [OR 1.64], presence or absence of lymphovascular invasion (LVI) [OR 1.76], tumour histological type mixed or not [OR 2.64]. The rate and probability of NSN involvement with the model are given for 24 groups, with a representation by a nomogram.

CONCLUSION

One group, corresponding to 10.1% of the patients, was associated with a risk of NSN involvement of less than 5%, and five groups, corresponding to 29.8% of the patients, were associated with a risk < or = 10%. Omission of ALND could be proposed with minimal risk for a low probability of NSN involvement.

[Uterine abnormalities in non menopausal women who received tamoxifen for breast cancer adjuvant therapy]

OBJECTIVE

To elaborate a strategy of endometrial follow-up for premenopausal women treated with Tamoxifen as adjuvant hormonal treatment of breast cancer.

PATIENTS AND METHODS

Retrospective study of 152 premenopausal patients treated with Tamoxifen in Nantes Comprehensive Cancer Center for a breast cancer from January 2003 to December 2005. Vaginal sonography was used in the follow-up of 70 of them.

RESULTS

Endometrial hypertrophy was found in 26 patients. Sonohysterography and hysteroscopy allowed to find 11 polyps and three hyperplasias in the 19 women who were investigated. In our study, endometrial pathology was found in 20% of premenopausal women treated with Tamoxifen (polyps or hyperplasia). Uterine bleeding was found in half patient of this group.

DISCUSSION AND CONCLUSION

Vaginal sonography monitoring could be proposed to premenopausal women treated with Tamoxifen among whom endometrial pathology is usual.

[Sentinel node detection applied to breast cancer: 2007 update]

The technique of detection and resection of the sentinel lymph node applied to early breast cancer management aims to spare the patient with a low risk of lymph node involvement an unnecessary axillary lymphadenectomy. This innovating technique lies on the double hypothesis of an accuracy to predict non sentinel lymph node status and to induce a lower morbidity when compared with axillary lymphadenectomy. This multidisciplinary technique depends on surgeons, nuclear physicians and pathologists. In practice sentinel lymph nodes are detected thanks to two types of tracers, the Blue and the colloids marked with technetium, harvested by the surgeon guided by the blue lymphatic channel and the use of a gamma probe detection, analyzed by the pathologist according to a particular procedure with the concept of serial slices, and possibly immuno histo chemistry. The objectives of this review are to specify the state of knowledge concerning the different steps: detection, surgical resection and the pathological analysis of the sentinels lymph nodes and to focus on validated and controversial indications, and on the main ongoing trials.

Randomized clinical trial comparing axillary padding with closed suction drainage for the axillary wound after lymphadenectomy for breast cancer

Background

After axillary lymphadenectomy for breast cancer, a suction drain is routinely inserted into the axilla to prevent seroma formation. This drain is an obstacle to reducing hospital stay after breast-conserving surgery. This was a prospective randomized clinical trial to assess the safety and results of axillary padding without the use of a drain.

Methods

Between May 2001 and August 2003, 100 women were randomly allocated axillary padding without a drain or with the use of an axillary suction drain. Prospective assessments were made of morbidity, pain, shoulder mobility, quality of life and medical costs including length of hospital stay.

Results

Using axillary padding significantly reduced the mean (s.d.) length of hospital stay (1·8(1) versus 4·5(2) days, P &lt; 0·001). Postoperative complications, pain, shoulder mobility and quality of life were similar in the two groups. There was no difference in the duration of the two procedures.

Conclusion

Axillary padding after axillary lymphadenectomy was feasible and safe, without a drain, and shortened hospital stay.

Lésions cervicales utérines pendant la grossesse : diagnostic et prise en charge

OBJECTIVES

To define a practical attitude for the management of pregnant women with cervical intraepithelial neoplasia (CIN) and cervical cancer.

MATERIALS AND METHODS

Review of the literature indexed in Medline.

RESULTS

The prevalence of the HPV infections is unchanged among pregnant women with infection by low risk viruses. The viral load increases at the time of the pregnancy, and decreases in the post-partum period. Cervical cytology is easily to perform with reliable results: among the 5% of pathological cervical smears, low grade lesions predominate. The high grade smears require colposcopic exploration, usefully completed by directed biopsies to rule out invasive lesions. Surveillance of high grade CIN is required during pregnancy with post-partum control; most regress. In France during the year 2000, 189 cancers of the uterine cervix were detected during 774.782 pregnancies. Clinical diagnosis is delayed by the non specific clinical signs and the histological aspects of the lesions which are identical with those observed in young woman. The intrinsic outcome of cancer is not modified by pregnancy, and the cesarean section is often preferred (vaginal delivery likely facilitates vascular dissemination). For fetal reasons, a therapeutic delay can be proposed for small sized lesions with a favourable histological subtype and no progression after 20 weeks of gestation.

CONCLUSION

Pregnancy offers the opportunity to perform cervical smears in women not regularly followed. A conservative attitude with a revaluation in postpartum can be proposed in the event of diagnosis of CIN during pregnancy. Pregnancy has little influence on invasive cervical cancers. Management decisions must be made on a case-by-case basis.

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

OBJECTIVES

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

METHODS

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

RESULTS

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

CONCLUSION

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

[Contribution of viral typing in cytological anomalies of the cervix]

Management practices for low-grade cervical lesions identified on screening swabs have been modified by research on the HPV. The appropriate approach for low-grade lesions is particularly difficult to determine due to the potential risk of malignant transformation coupled with the cost implications of treating lesions which will heal spontaneously in the majority of patients. The diagnosis of these low-grade lesions can be improved by thin layer swabs which have a greater sensitivity than conventional swabs. The current consensus is that swab results should be expressed according to the Bethesda classification. Routine tests for HPV (Hybrid Capture II) should be reserved for patients with an ASC-US swab. Colposcopy is indicated if the swab is positive for a low-grade lesion followed by cytology if the colposcopy is normal. If there is no evidence of HPV, search for oncogenes can lighten the treatment regimen due to the high specificity of the test. If a low-grade histological lesion (CIN1) is proven, cytocolposcopic surveillance should be proposed, surgical resection being undertaken in colposcopy cannot be performed. Here again search for HPV oncogenes at one year is an interesting alternative if the examination is negative. These practices are applicable in adolescents and HIV- positive patients who are particularly exposed to HPV.

Post-operative care and patient satisfaction after ambulatory surgery for breast cancer patients

AIM

This study aimed to evaluate patient information provided, the management of post-operative symptoms and post-operative care, and patient satisfaction with ambulatory breast surgery over a 1-year period.

METHODS

From January to December 2000, all breast cancer patients undergoing conservative breast surgery were offered surgery as an outpatient procedure at the Ambulatory Surgery Unit.

RESULTS

Two hundred and thirty six patients underwent outpatient surgery. None were readmitted during the first night or the first week. Two hundred and nineteen patients completed a questionnaire. One hundred and sixty nine patients (group 1) underwent wide local excision (WLE) and 50 (group 2), WLE and axillary lymphadenectomy. Patients in group 2 experienced more pain at discharge from the hospital (p < or = 0.01) and during the first week after discharge (p < or = 0.00001) than patients in group 1. The mean overall satisfaction score was 8.97 on a scale of 1-10. Post-operative information provided by the surgeon before discharge from the hospital was rated 8.90 on a scale of 1-10 while information provided by the nurse was rated 9.33 (p < 0.0001).

CONCLUSION

Ambulatory surgery for breast cancer patients is safe and popular with patients, however, post-operative pain presents problem.

The Impact of Nonvisualization of Sentinel Nodes on Lymphoscintigraphy in Breast Cancer

BACKGROUND

This study aimed at evaluating the relationship between the nonvisualization of sentinel nodes (SNs) at lymphoscintigraphy and the intraoperative detection rate, radioactive counts in vivo, and histological status of SNs.

METHODS

Two hundred eighty patients with infiltrating breast carcinoma (T0, T(1)/T(2)) underwent preoperative lymphoscintigraphy before gamma probe-guided SN biopsy.

RESULTS

The surgical identification rate with a gamma probe was 84.6% (56 of 280) in lymphoscintigraphy-negative patients and 93.2% (224 of 280) in lymphoscintigraphy-positive patients (P < .05) after two subdermal periareolar injections. The average number of SNs per patient was 1.7 in lymphoscintigraphy-negative patients and 2.2 in lymphoscintigraphy-positive patients (P < .01), as assessed by gamma detection. The mean age of lymphoscintigraphy-negative patients was 62 +/- 10 years, versus 55 +/- 13 years for lymphoscintigraphy-positive patients (P < .001). The median radioactive count in dissected SNs identified by gamma detection was 204 cps (range, 4-618 cps) in lymphoscintigraphy-negative patients, versus 606 cps (range, 43-16,928 cps) in lymphoscintigraphy-positive patients (P < .001). The rate of macrometastatic SNs was 40% in lymphoscintigraphy-negative patients, versus 30% in lymphoscintigraphy-positive patients (not significant), whereas the size of involved SNs was 16.6 mm in lymphoscintigraphy-negative patients, versus 13.1 in lymphoscintigraphy-positive patients (P < .05). The micrometastasis detection rate in SNs from lymphoscintigraphy-negative patients was 6.25%, versus 23.3% in lymphoscintigraphy-positive patients (P < .01).

CONCLUSIONS

Negative lymphoscintigraphy was observed in 20% of patients and was more frequent in elderly patients. Negative lymphoscintigraphy was predictive of a lower surgical identification rate and fewer detected SNs. These SNs had fewer micrometastases, were fairly large, and tended to harbor metastases.

Ovarian cancer management. Practice guidelines for nuclear physicians

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

G388R mutation of the FGFR4 gene is not relevant to breast cancer prognosis

This study screened large cohorts of node-positive and node-negative breast cancer patients to determine whether the G388R mutation of the FGFR4 gene is a useful prognostic marker for breast cancer as reported by Bange et al in 2002. Node-positive (n=139) and node-negative (n=95) breast cancer cohorts selected for mutation screening were followed up for median periods of 89 and 87 months, respectively. PCR – RFLP analysis was modified to facilitate molecular screening. Curves for disease-free survival were plotted according to the Kaplan – Meier method, and a log-rank test was used for comparisons between groups. Three other nonparametric linear rank-tests particularly suitable for investigating possible relations between G388R mutation and early cancer progression were also used. Kaplan – Meier analysis based on any of the four nonparametric linear rank tests performed for node-positive and node-negative patients was not indicative of disease-free survival time. G388R mutation of the FGFR4 gene is not relevant for breast cancer prognosis.

[Accuracy of conservative treatment for infiltrating lobular breast cancer: a retrospective study of 217 infiltrating lobular carcinomas and 2155 infiltrating ductal carcinomas]

OBJECTIVES

Prognosis factors used for the management of infiltrative lobular carcinoma (ILC) are not different from those for infiltrative cuctal carcinoma (IDC). The aim of our work was to evaluate indications for conservative treatment for patients with ILC and to compare the results to those of patients with IDC. MATERIAL AND METHODS. Between 1985 and 1999 we retrospectively compared cases of 217 ILC with cases of 2155 IDC treated in Centre Rene Gauducheau, Nantes.

RESULTS

Clinical size of tumors was not different between ILC and IDC but pathological size>30 mm was more frequent for IDC. Good prognosis factors as pathological SBR classification I or II, positive hormone receptor, and the lack of axillary lymph node involvement, were more frequent for ILC. Clinical examination underestimated tumor size more frequently of ILC than IDC (p=0.02). Secondary mastectomy for involved margin was more frequent for ILC than IDC (p=0.001). For tumor with good prognosis factors, such as T<20mm, lack of lymph node involvement and SBR I or II with conservative treatment, 5 years local relapse were less frequent for ILC than IDC (p=0.025).

CONCLUSION

Parameters to validate conservative or radical treatment are the same for ILC and IDC. Diagnosis of ILC should not influence decisions regarding surgical treatment.

Learning curve for the detection of axillary sentinel lymph node in breast cancer

AIM

Sentinel axillary lymph node (SALN) detection is a new technique. Surgeons must progress up a learning curve in order to guarantee quality and safety equivalent to axillary lymphadenectomy. To ensure accurate staging of patients this learning curve must include SALN detection and an axillary lymphadenectomy. The aim of our work was to validate the principles and evaluate the consequences of learning curve for SALN detection from a prospective series of 200 consecutive patients.

METHOD

Prospective assessment was made of the detection and false negative rates, post operative morbidity as abcess and seroma, and length of hospital stay.

RESULTS

We evaluated the performance from the first to the hundredth case for each surgeon. Detection rate improved to 85% after patient number 10. False negative rate was less than 6%. Post operative axillary morbidity included 11% of seromas and 2% of abcess. Mean hospital stay was 2.8 days.

CONCLUSION

Multidisciplinary validation of the learning period contributes to an accurate and safe SALN.

Lymphoscintigraphy in the sentinel lymph node technique for breast tumor: value of early and late images for the learning curve

As the performance of early (H+1 to H+4) and late (D1) lymphoscintigraphic images raises organizational problems in outpatient surgery for breast cancer, only early images are generally obtained. The present study evaluated whether two series of images are better than one and defined the advantages of both methodologies. One hundred and eighteen patients with infiltrating breast carcinoma (T(0), T(1) and T(2)) were included in the study: 87 in group A (early and late images) and 31 in group B (only early images). All patients received two peritumoral injections of (99m)Tc-sulfur colloid, 15-18 MBq (group A) and <15 MBq (group B). During the operation, the patent blue bye technique was associated with radioactivity detection. The two groups were comparable for histological type and tumor size and localization. Successful localization of sentinel nodes on early lymphoscintigraphic images was significantly greater for group B. The identification of a sentinel node focus on early lymphoscintigraphy increased by 10% during the study. Sentinel node detection by the isotopic method alone, or the two methods combined, was comparable for both groups. In radioactivity detection, the count rate for sentinel nodes versus background (contralateral breast) was similar for the two groups. During the learning phase, two series of images gave a definite advantage. Subsequently, lymphoscintigraphy performed at +2 h was sufficient (the results for the two groups became indistinguishable).

Gene amplifications detected by fluorescence in situ hybridization in pure intraductal breast carcinomas: relation to morphology, cell proliferation and expression of breast cancer-related genes

Investigation of early breast carcinogenesis is limited by the difficulty in obtaining cell cultures or adequate fresh frozen material and by the fact that available data from in situ techniques are interpreted in terms of various classification systems. Our studies in a series of pure ductal carcinomas in situ (DCIS) were conducted in accordance with the recommendations of the international Consensus Conference (Hum. Pathol., 28, 122-125, 1997) relative to processing, determination of lesion extent, and histological stratification primarily on nuclear grade (NG). A multifactorial study performed in 15 low- and 16 high-NG DCIS (68% detected by mammography) included the following: (1) morphological analysis of NG, necrosis, and architectural pattern; (2) detection of numerical genomic abnormalities at ERBB2, MYC, CCND1, Xq1.2 and 20q13 loci by fluorescence in situ hybridization on interphase nuclei; and (3) immunohistochemical determination of cell proliferation, p53 accumulation, hormonal receptors and bcl-2 expression on serial sections of formalin-fixed, paraffin-embedded specimens. High NG, comedo/solid pattern and necrosis were significantly associated with amplification at one or more loci, the number of amplified loci, amplification at the ERBB2 locus, absence of bcl-2 and hormonal receptor expression and high cell proliferation (p < 0.05). High NG and comedo/solid pattern were significantly associated with MYC amplification and p53 accumulation, and necrosis with CCND1 amplification (the only gene amplification detected in low NG DCIS). These data provide additional information on the early steps of breast carcinogenesis, in accordance with currently recognized criteria of histological classification.

[Role of outpatient surgery in breast surgery. Prospective feasibility study]

STUDY AIM

The objective of this prospective study was to assess the feasibility of outpatient breast surgery, the reasons for inpatient procedures (IPP), the reasons for conversion and the conversion rate, and the postoperative morbidity after outpatient procedures (OPP).

PATIENTS AND METHODS

In 1999, among 625 patients eligible for OPP (diagnostic surgery or conservative curative surgery), OPP was performed in 418 patients (67%) and IPP was performed in 207 patients (33%). The reasons for IPP rather than OPP were environmental (64%) rather than medical (16%).

RESULTS

The conversion rate to conventional surgery was 12.4% and the definitive OPP rate was 58.6%. The reasons for conversion were more often medical (50%) and environmental (21%) than surgical (23%). The morbidity, except for axillary seroma, was similar for OPP and IPP. The axillary seroma rate after axillary lymph node dissection was higher with OPP (27.4 vs 16.1%).

CONCLUSION

OPP is a good alternative to IPP in breast surgery, especially for diagnostic purposes. OPP is also feasible for partial mastectomy with axillary lymph node dissection, but patients must be clearly informed about the risks of axillary morbidity. The patients' quality of life and satisfaction index should also be evaluated.

Genetic alterations in early-onset invasive breast carcinomas: correlation of c-erbB-2 amplification detected by fluorescence in situ hybridization with p53 accumulation and tumor phenotype

p53 tumor-suppressor gene mutation and p53 protein over-expression have been reported with higher frequency in early-onset breast carcinomas (EOBC). Given the role attributed to normal p53 protein in DNA-repair mechanisms, other somatic genomic alterations would be expected to be associated with this abnormality. Amplification of the c-erbB-2 (HER-2/neu) oncogene and over-expression of the corresponding p185erbB-2 protein have been linked to prognosis and response to therapy in breast cancer. In a retrospective study of 62 formalin-fixed paraffin-embedded invasive EOBC (diagnosed at 35 years or less), the amplification status of the c-erbB-2 gene detected by fluorescence in situ hybridization (FISH) using a unique sequence probe was compared with p53 protein accumulation measured by immunohistochemistry (IHC) and phenotypic features. p185erbB2-protein expression was also detected by immunohistochemistry, together with estrogen-receptor (ER) and progesterone-receptor (PR) expression. The data for a sub-set of 33 node-negative EOBC cases were compared with 70 node-negative tumors diagnosed in women above 36 years of age. Compared with node-negative BC in older women, node-negative EOBC was significantly more likely to feature high grade, high proliferation rate, negative ER and/or PR and p53 over-expression (p < 0.05). A trend toward a higher incidence of c-erbB-2 amplification in EOBC (21% vs. 9%) reached near-significance (p = 0.07). In EOBC, c-erbB-2 amplification and p53 over-expression were not associated with high tumor grade or high cell-proliferation rate, in contrast to the significant associations of these markers in tumors in older women. Abnormalities in tumor markers, including c-erbB-2 gene amplification and p53-protein over-expression, occur at different rates in women with EOBC as compared with BC developing in older women. This finding may reflect a different pathogenesis for EOBC, and warrants further investigation.

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

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