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 P5-16-04: Evaluation of autologous fat grafting local morbidity (fat necrosis and biopsy rates) in breast reconstruction after breast cancer: A retrospective study on 257 patients in Oscar Lambret Center

Background.Autologous fat grafting (AFG) is a widely used procedure in breast reconstruction after breast cancer. Indications are in constant increase but there is a lack of dataabout global morbidity, especially fat necrosis and management of local complications. The purpose of this study was to evaluate the complications rate in term of abnormal clinical examination or imaging and the proportion of additional explorations.

Methods. We retrospectively reviewed the computerized files of consecutive patients who underwent AFG for breast reconstruction after breast cancer or for preventive surgery and aesthetic sequelae after lumpectomy in the Oscar Lambret center between January 2013 and December 2016. Fat grafts were harvested with a fat trap then processed and injected according the Coleman technique. We collected demographics, operative details, local complications, incidence of palpable masses and/or suspicious breast imaging findings leading to additional explorations (breast imaging or biopsy), and locoregional cancer recurrence. Descriptive statistics were generated.

Results. Over a 4-year period, 257 women underwent autologous fat grafting for breast reconstruction and aesthetic sequelae after lumpectomy. Their mean age was 50 years [range 28-75], the mean BMI was 25 [range 18-44], 26% (n=66) were smoking and 74% (n=190) underwent radiotherapy. A total of 303 breasts were operated by 270 mastectomies (89%) or33 lumpectomies (11%). The reconstruction was delayed in 63% (n=171) and the main techniques used were breast implant (44%, n=119) and autologous latissimus dorsi (31%, n=84). The mean number of fat grafting procedures was 1,9 per patient [range 1-7] with a mean volume of 181 mL [range 30-535]. The mean time interval between cancer diagnosis and first fat graft session was 56 months [range 3-285], and the follow-up ranged from 0 to 51 months (mean=16). The prevalence of donor site complications was 6% (n=16) and infections was 2% (n=5). Sixty six (25,6%) patients had a clinically palpable lesion and 54 (21%) underwent additional imagings, mostly by ultrasounds (53 patients, 98%) except the usual follow-up. Twenty one biopsies (8%) were performed and showed 16 benign results (76,2%) and 5 malignant results (23,8%) leading to 6,2% of fat necrosis and 1,9% of locoregional recurrence after AFG in our study.Tobacco (p=0.45), BMI (p=0.95), radiotherapy (p=0.56) and amount of fat grafted ( p=0.09) didn't appear to be risk factors for fat necrosis.

Conclusions. A good knowledge of local complications by surgeons and radiologists enables to avoid systematic and repeated further imaging explorations. Multicentric, prospective studies with long term follow up and evaluation of patients reported outcomes are needed to evaluate anxiety generated by biopsies and costs generated by repeated imagings.

Key words: autologous fat grafting, breast cancer, local morbidity, fat necrosis.

Citation Format: Hannebicque K, Renaudeau C, Giard S, Regis C, Boulanger L, Bogart E, Le Deley M-C, Ceugnart L, Chauvet M-P. Evaluation of autologous fat grafting local morbidity (fat necrosis and biopsy rates) in breast reconstruction after breast cancer: A retrospective study on 257 patients in Oscar Lambret Center [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 P5-16-04.

Abstract GS4-01: Radiotherapy or surgery of the axilla after a positive sentinel node in breast cancer patients: 10 year follow up results of the EORTC AMAROS trial (EORTC 10981/22023)

Background: Sentinel node biopsy (SNB) is standard in assessing axillary lymph node status in patients with clinically node-negative breast cancer. The 5-year analysis of AMAROS trial showed that if locoregional treatment is advised after a tumor-positive axillary SNB, axillary radiotherapy (ART) is a reasonable alternative for an axillary lymph node dissection (ALND) with less side effects, though follow up was relatively short. Here we present the 10-year follow up data.

Methods: From February 2001 to April 2010, patients with primary breast cancer stage cT1-2N0M0 were enrolled in the EORTC phase III non-inferiority AMAROS trial by 34 European sites. Patients were randomized between ALND and ART in case of a tumor-positive SNB. The primary endpoint, axillary recurrence rate (AxR) is now assessed at 10 years in the ITT population using Fine and Gray cumulative incidence method with deaths as competing risks, as well as secondary endpoints: overall survival (OS), distant metastasis free survival (DMFS), second primaries (including cancers other than breast cancers and contralateral DCIS) and locoregional recurrences (LRR). Little extra information beyond 5 years was available concerning Quality of Life and morbidity. Data collection is still ongoing and will be presented later.

Results:Of the 4806 patients entered, 1425 patients had a tumor-positive SNB: 744 in the ALND-arm and 681 in the ART-arm, 60% with a macrometastasis. Both treatment-arms achieved a median 10-year follow-up and were comparable regarding age, tumor size, grade, tumor type and adjuvant systemic treatment. In the group who had ALND, the 5-year AxR was 0.41% (95%CI: 0.00;0.88) (4/744) and the 10-year AxR was 0.93% (95%CI:0.18;1.68) (7/744). In the group who had ART, the 5-year AxR was 1.04% (95%CI: 0.27;1.81) (7/681) and the 10-year AxR was 1.82% (95%CI: 0.74;2.94) (11/681) (HR 1.71, 95%CI: 0.67;4.39, p = 0.37). Sensitivity analysis, considering deaths and distant recurrences as competing risks, revealed consistent results. There were no significant differences between treatment arms regarding OS (ALND: 84.6% (95%CI: 81.5;87.1), ART: 81.4% (95%CI: 77.9;84.4), HR 1.17, 95%CI: 0.89;1.52, p= 0.26) and DMFS (ALND: 81.7% (95%CI: 78.5;84.4), ART: 78.2% (95%CI: 74.6;81.3), HR 1.18, 95%CI: 0.92;1.50, p=0.19). Cumulative incidence estimates of 10-year LRR are 3.59% (95%CI: 2.12;5.06) (ALND) versus 4.07% (95%CI: 2.49;5.65) (ART) (p= 0.69). More second primaries were observed after ART: 75/681 (21 contralateral breast) as compared to ALND: 57/744 (11 contralateral breast) (p = 0.035). All results are consistent in the per protocol analysis of patients with a tumor-positive SNB.

Conclusion: Axillary recurrence after 10 years in patients with a tumor-positive SNB who were treated with ART is extremely rare and not significantly different from patients who were treated with ALND. OS, DMFS and locoregional control are also comparable. Second primaries including contralateral breast cancers are more frequently encountered after ART, but the difference is still low in absolute numbers. Thus, ART is a safe treatment for breast cancer patients with a tumor-positive SNB.

Citation Format: Rutgers EJ, Donker M, Poncet C, Straver ME, Meijnen P, van de Velde CJ, Mansel RE, Blanken C, Orzalesi L, Klinkenbijl JH, van der Mijle HC, Veltkamp SC, van 't Riet M, Albregts M, Marinelli A, Rijna H, Tobon Morales R, Snoj M, Bundred N, Chauvet MP, Merkus JW, Petignat P, Schinagl DA, Coens C, Peric A, Bogaerts J, van Tienhoven G. Radiotherapy or surgery of the axilla after a positive sentinel node in breast cancer patients: 10 year follow up results of the EORTC AMAROS trial (EORTC 10981/22023) [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 GS4-01.

Sentinel lymph node biopsy without axillary lymphadenectomy after neoadjuvant chemotherapy is accurate and safe for selected patients: the GANEA 2 study

PURPOSE

GANEA2 study was designed to assess accuracy and safety of sentinel lymph node (SLN) after neo-adjuvant chemotherapy (NAC) in breast cancer patients.

METHODS

Early breast cancer patients treated with NAC were included. Before NAC, patients with cytologically proven node involvement were allocated into the pN1 group, other patient were allocated into the cN0 group. After NAC, pN1 group patients underwent SLN and axillary lymph node dissection (ALND); cN0 group patients underwent SLN and ALND only in case of mapping failure or SLN involvement. The main endpoint was SLN false negative rate (FNR). Secondary endpoints were predictive factors for remaining positive ALND and survival of patients treated with SLN alone.

RESULTS

From 2010 to 2014, 957 patients were included. Among the 419 patients from the cN0 group treated with SLN alone, one axillary relapse occurred during the follow-up. Among pN1 group patients, with successful mapping, 103 had a negative SLN. The FNR was 11.9% (95% CI 7.3-17.9%). Multivariate analysis showed that residual breast tumor size after NAC ≥ 5 mm and lympho-vascular invasion remained independent predictors for involved ALND. For patients with initially involved node, with negative SLN after NAC, no lympho-vascular invasion and a remaining breast tumor size 5 mm, the risk of a positive ALND is 3.7% regardless the number of SLN removed.

CONCLUSION

In patients with no initial node involvement, negative SLN after NAC allows to safely avoid an ALND. Residual breast tumor and lympho-vascular invasion after NAC allow identifying patients with initially involved node with a low risk of ALND involvement.

Abstract P4-13-07: Determinants in decision-making process of breast reconstruction in women over 65 years old

Background: Breast cancer is the most common cancer among European women with 54,000 new cases in France in 2015. Nearly 47% of these cancers are diagnosed in women aged 65 and over. Mastectomy is still needed in 30% of cases, resulting in significant physical and psychological consequences. Breast reconstruction (BR) can reduce the effects of surgical treatment and improve quality of life. However, less than 20% of women choose BR in France. This number drops to 6% for patients over 65 years old. The objective of the study was to find the factors influencing the decision-making process for attempting breast reconstruction in women who are over 65.

Methods: We included retrospectively all patients over 65 years old who had an immediate or delayed breast reconstruction in our Cancer Center from January 2006 to July 2016. We set up a control group matching them with patients treated by mastectomy during the same period who did not choose BR. The matched-pair criteria were age, TNM stage and performans status, obtained from multidisciplinary consultation meeting database. We mailed to all patients a specially-designed questionnaire inspired by the BREAST-Q aimed at assessing the medical information that was delivered to them about BR and the reasons to choose or not choose reconstruction. The qualitative and quantitative results were analyzed. The two groups were compared using Chi-square, Fisher's exact, Mann-Whitney, and Student t test.

Results: Among 134 patients, 103 (77%) completed the questionnaire. Dedicated information on BR before the mastectomy was provided more frequently to patients who had BR (91.7% vs 66.7% p=0.008). Forty-one percent of patients sought out sources of information other than their surgeon (other physicians, friends, other patients, the internet – no significant differences between the two groups, p=0.1). The three most important persons influencing the decision-making process were first the patient's surgeon, second the patient's husband, and third her general practitioner (GP). These people were more often in favor of reconstruction in the BR group than in the mastectomy group (respectively, 94.5% vs 22.9% p&lt;0.001; 65.4% vs 7.1 % p&lt;0.001; and 64.2% vs 19.4%, p&lt;0.001). Women judged that their age was an obstacle to reconstruction at the rate of 66.7% for the mastectomy group and at the rate of 3.8% in the BR group (p= 0.001). None of the women reported that her surgeon considered her age to be an obstacle for breast reconstruction. Women in the mastectomy group reported more fears about reconstruction than the women in the BR group (p&lt; 0.001). Patients had less opportunity to talk about their fears with their surgeon in the mastectomy group (19.4% vs 66.1% p&lt;0.001).

Conclusions: Providing dedicated information at the time of initial support is crucial in the choice of BR for women over 65. Patients' surgeons played a central role in the decision, but their GPs and husbands also provided important input. This dedicated information should help women over 65 to conclude that their age should not be a limiting factor for the decision to attempt breast reconstruction.

Citation Format: Quemener J, Wallet J, Boulanger L, Hannebicque K, Giard S, Chauvet MP, Regis C. Determinants in decision-making process of breast reconstruction in women over 65 years old [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 P4-13-07.

Abstract P4-13-03: Variations in breast reconstruction rate in France according to patient and site characteristics: A nationwide retrospective study of nearly 20,000 patients

Background: Breast reconstruction (BR) for women who undergo mastectomy for cancer offers psychological benefits and improves quality of life. However its use remains limited, especially for women over 65 years, with a large degree of international variation. The aim of this study was to find out factors influencing the surgical decision of BR in France where cancer related healthcare costs are fully reimbursed.

Methods: We used the French medico-administrative database to identify all primary mastectomies for breast carcinoma in 2012 and studied the rate of immediate (IR) or delayed breast reconstruction (DR) up to December 2015.

Variations of BR rates were evaluated according to

- patient age, social deprivation index,

- profile of the hospital where the mastectomy was performed: type of hospital (cancer center, CC; university hospitals, UH; private, PrivH; or public, PubH), and hospital activity (surgical acts for breast cancer in 2012);

- disparities across administrative regions in terms of number of CC or UH, number of plastic surgeons, gynecologist-obstetrician surgeons and general surgeons in the region.

A hierarchical three-level logistic regression was used with SAS GLIMMIX to model the probability of BR taking into account clustering of observations (patients in hospitals, hospitals in regions). Splines were used to explore the functional form of the relationship between continuous variables and BR rate. Akaike information criterion was used for model selection.

Results: Among the 19,466 women who had a mastectomy in 2012, 5,328 (27.4%) subsequently had a BR: IR for 13.7% and DR for 13.7%. The BR rate significantly varied with age (p&lt;0.0001), resulting in a much smaller BR rate in patients older than 65 compared to younger (7.5% vs 42.1%, p&lt;0.0001). In case of BR, IR was more frequent than DR in older patients (66% of BR), whereas both were equally balanced before 65. BR rates decreased with increasing social deprivation index (from 32.7% to 21.5%, from the first to the fourth quartile of the distribution). BR rates significantly varied according to hospital type (35.0% in CC, 29.8% in UH, 25.9% in PrivH and 18.6% in PubH). BR rates were significantly lower in small activity hospital (varying from 13.4% in hospital with &lt;=50 annual breast surgery to 35.1% in hospitals with &gt;500), especially in older patients (varying from 3.1% to 10.3%). We also observed important heterogeneity of BR rates across administrative regions, but these variations were not explained by the number of CC or UH, the number of plastic surgeons, the number of gynecologist-obstetrician surgeons or the number of general surgeons in the region. In multivariate analysis, BR rate was significantly associated with age (p&lt;0.0001), social deprivation index (p&lt;0.0001), type of hospital (p=0.002) and hospital activity (p&lt;0.0001), with persistent heterogeneity across administrative regions.

Conclusions: We identified substantial variations in BR rates across the French hospitals. Controlling for possible confounders, older patients have less breast reconstruction. This apparent heterogeneity can be part of women choice, however it suggests unequal access to high quality procedures for older women with breast cancer.

Citation Format: Regis C, Le J, Le Teuff G, Cucchi M, Boulanger L, Hannebicque K, Giard S, Chauvet M-P, Quemenr J, Ledeley M-C. Variations in breast reconstruction rate in France according to patient and site characteristics: A nationwide retrospective study of nearly 20,000 patients [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 P4-13-03.

Abstract P5-22-18: Withdrawn

This abstract was withdrawn by the authors.

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 P2-01-23: Long-term follow-up of persistent breast dermopigmentation after sentinel lymph node identification using superparamagnetic iron oxide particles (SIENNA+®)

Background

The French Sentimag study evaluated a non-invasive method for the localization of breast cancer sentinel lymph nodes (SLN) using SIENNA+®, a superparamagnetic iron oxide particles (SPIO), in addition to conventional techniques (radiotracer and blue dye). SIENNA+® was injected subcutaneously into the breast and detected by the SENTIMAG® handheld magnetometer probe. The results showed a good SLN identification performance but a skin discoloration was noted during this study after the SIENNA+® injection. This aim of this study was to assess the long-term duration and appearance of this dermopigmentation.

Methods:

56 patients had participated in Sentimag study in our Center, 6 patients who had undergone mastectomy were excluded. We selected 50 patients who had undergone breast conservative surgery. For these patients, SLN localization was performed by both the conventional method (radiotracer and /or blue dye) and magnetic tracer, SIENNA+®. 47 patients were reviewed retrospectively from January 2015 to April 2015, 1.5 to 2 years after surgery and were assessed for skin discoloration.

Results :

Of the 47 patients, a dermopigmentation, from grade 1 (light yellowing) to grade 3 (dark browning) remained visible at the site of injection of SIENNA+® after 20.2 months [14.4-25.9] in 36.1% of the patients (17/47). 6.4% of 47 patients seen had grade 3 skin discoloration and 29.7% had grade 1 or 2 skin discoloration. Interestingly, no patients reported that persistent staining was a cosmetic or psychological problem.

Conclusions :

The use of SIENNA+® appears as an alternative method to radioisotopes for SLN identification in early breast cancer, but it may result in a prolonged-dermopigmentation at the injection site. To avoid dermopigmentation, it would be interesting to compare different techniques of SIENNA+® injection into the breast (intra-tumoral injection or a deeper periareolar injection) through a randomized trial.

Citation Format: Hannebicque K, Boulanger L, Bogart E, Giard S, Chauvet MP, Houpeau JL. Long-term follow-up of persistent breast dermopigmentation after sentinel lymph node identification using superparamagnetic iron oxide particles (SIENNA+®) [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 P2-01-23.

Abstract P2-13-09: Is nipple-sparing mastectomy with implant reconstruction for breast cancer safe and worthwhile?

Background: Nipple-sparing mastectomy (NSM) is a standard for bilateral prophylactic surgeries. However for cancer treatment, the preservation of the nipple areolar complex (NAC) is still discussed because of suspected increase of local recurrence and surgical specific complications as nipple or mastectomy flap necrosis. The aim of the study was to investigate both the relapse risk associated with NSM for breast cancer and women's satisfaction with preservation of the NAC.

Methods: We included retrospectively all patients who had skin-sparing mastectomy (SSM) or NSM from 2007 to 2012 for breast cancer or ductal carcinoma in situ (DCIS). We compared NSM and SSM group for oncological (overall survival (OS) and disease-free survival (DFS)) and surgical outcomes. Patients' satisfaction and quality of life has been evaluated by a specifically designed questionnaire, addressed by mail and inspired by the Breast-Q questionnaire with specific assessment of global esthetic result, harmony with the native breast and need for psychological support.

Results: During the study, we operated 5600 patients for a breast cancer, among them, 152 had NSM (n=63 / 41.5%) or SSM (n=89 / 58.5%) with immediate implant breast reconstruction. Eighty-nine (58.6%) patients had DCIS, and the other had invasive disease (86.9% of T1). The mastectomy has been indicated for primary cancer (81%) or recurrence (19%). The two groups did not differ significantly according to histological type (p=0.10), grade (p=0.84), hormonal receptor (p=0.7), HER2 (p=1.00), Ki67 (p=0.75) or node metastases (p=0.64). Median follow-up was 42 (IQR: 18-58 ) months. No cancer-related death occurred during the study. Local recurrence rate was 1.7% (n=1) in NSM group and 0% in SSM group (p=0.35). The recurrence did not appear on the preserved nipple. Severe complication requiring surgery (Grade 3 of Clavien-Dindo classification) occurred in 9.9% of the cases. In the NSM group, one patient had complete NAC necrosis and three patients suffered partial necrosis. Severe skin-flap necrosis leading to implant removal was more frequent in the SSM group (SSM: 6.7% (n=6) ; NSM: 0% (n=0); p=0.042). One hundred and four (80%) patients answered the questionnaire. Satisfaction about the aspect of the NAC was higher in the NSM group compared to SSM with delayed reconstruction of the nipple (75% vs 59%, p=0.14). Patients with NSM needed less psychological support before (p=0.028) and immediately after surgery (p=0.14) than patients in the SSM group, which may suggest a better acceptation of the surgery in this group.

Conclusion: NSM for breast cancer surgery was not associated with significant increase of local recurrence rate or surgical complications. Patient's satisfaction was high. Therefore, nipple-sparing mastectomy with immediate implant reconstruction can successfully and safely be performed for pre-invasive and small invasive breast cancer. Besides esthetic aspects, preserving the nipple may ease the acceptation of these radical surgeries.

Citation Format: Regis C, Mesdag V, Tresch E, Chauvet MP, Boulanger L, Collinet P, Giard S. Is nipple-sparing mastectomy with implant reconstruction for breast cancer safe and worthwhile?. [abstract]. In: Proceedings of the Thirty-Eighth Annual CTRC-AACR San Antonio Breast Cancer Symposium: 2015 Dec 8-12; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2016;76(4 Suppl):Abstract nr P2-13-09.

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.

Pure flat epithelial atypia: is there a place for routine surgery?

PURPOSE

To determine whether it is appropriate to routinely undertake surgery if flat epithelial atypia (FEA) or pure flat epithelial atypia (pFEA) is found on large-core biopsy.

PATIENTS AND METHODS

Between 2005 and 2010, 1678 large-core biopsy procedures were carried out, which led to 136 FEA sites being identified, 63 of which across 59 patients were pFEA (four patients had two sites of pFEA each). Forty-eight patients underwent further surgical excision, equating to 52 excised sites of pFEA.

RESULTS

Of the 52 operated sites, there were 20 benign lesions (38%), 26 borderline lesions (56%), and three ductal carcinomas in situ (6%). The rate of histologic underestimation was put at 3.8%. Of the three cases that were underestimated, one was discarded because the definitive histology was not representative of the site from which microcalcifications had initially been taken. The other two cases that were underestimated were found in patients with an increased individual risk of breast cancer.

CONCLUSION

In patients with no personal or first-degree family history of breast cancer, after complete or subtotal excision under radiology of the radiological lesion, and while excluding images fitting BI-RADS 5, annual monitoring may be offered as an alternative to surgical excision in view of the absence of underestimation found in our study.

Abstract P5-21-01: pT1a, bpN0M0 breast cancer: clinicopathological characteristics and their impact on treatment decision. Central review of the prospective ODISSEE cohort

Background: The incidence of infra-centimetric breast cancer (BC) is increasing due to mass screening. The management remains controversial opposing locoregional treatment only based on low stage and potentially aggressive tumor biology (especially for triple negative and HER2 positive tumors). The objectives of the prospective multicenter ODISSEE study were i) to describe daily practice management of pT1ab BC, ii) to identify potential new biomarkers and iii) to describe long term outcome (10-year follow up).

Methods: 616 patients with unifocal pT1a, b pN0M0 BC were included after surgery from May 2009 to March 2010 in 116 centers. Paraffin blocks were available for central pathology review in 350 patients. Due to the small tumor size, tissue microarray (TMA) construction was finally achieved for 287 cases. Collection of additional tumor blocks is ongoing. Review of the cases was performed independently by two pathologists and discordant cases were reviewed under a multihead microscope. Histological characteristics (histological type, tumor size and grade, presence of in situ component, presence of lymphovascular invasion) were assessed on whole tissue sections. Immunohistochemical detection of ER, PR, HER2, Ki67, EGFR, cytokeratin 5/6, Bcl-2 was performed on TMAs.

Results: Clinicopathological characteristics of the 287 centrally reviewed cases were similar to those of the 616 patients included in the cohort. Median age: 60.1 years (range [31–89] years). Median tumor size: 7.8 mm (range [1–10] mm) with 11% pT1a and 89% pT1b. Histological types: 72% ductal, 11% lobular and 17% other types (among which 53% of tubular). Minor in situ component was found in 36% of the cases, and invasive carcinoma with an extensive in situ component in 1.9%. Most of tumors were histological grade I and II (52% and 40% respectively), 8% were grade III. Proliferation was low as assessed by mitotic count (low 82%, intermediate 13% and high 5%) or by Ki67 index (&lt;5% in 61% of the cases). Almost all tumors were HR (hormone receptors) positive (95%) and 4% were HER2 positive (HER2+). According to the intrinsic subtypes described by Cheang et al., 84% of the cases were classified as luminal A, 11.6% as luminal B, 1.5% as HER2 (HR−/HER2+), 2.5% as basal-like and 0.4% as triple negative non basal. Ki67 index was higher in the HER2 and basal-like subgroups (p &lt; 0,05). In contrast, Bcl-2 expression was higher in the luminal subgroup (p &lt; 0,001). All the HER2, triple negative basal like and 87% of the luminal B were pT1b. 20 patients received chemotherapy, mainly based on HER2+ or triple negative status (72.7% and 36.4% respectively). Furthermore, 72.7% of HER2+ BC patients received trastuzumab.

Conclusions: The pT1a, bpN0M0 BC ODISSEE patients were mainly grade I or II, low proliferative HR+/HER2− tumors (i.e. the so-called luminal A subtype). Adjuvant treatment decision was mainly based on the presence of an aggressive phenotype such as HER2+ and triple negative tumors. A further exploration of ER/luminal pathway (FoxA1, GATA3, androgen receptor, Cox-2) and of PI3K/Akt/mTOR pathway (eIF4E, 4EBP, p70S6) is ongoing and will be presented.

Citation Information: Cancer Res 2012;72(24 Suppl):Abstract nr P5-21-01.

Abstract P4-14-10: Atypical Ductal Hyperplasia diagnosed on directional vacuum-assisted biopsy: is surgical excision mandatory?

Background: The incidence of atypical ductal hyperplasia (ADH) is increasing due to mass screening. Because of the underestimation risk of malignancy, the management remains controversial. Our goal was to analyze clinicopathologic features of patients with ADH diagnosed on directional vacuum-assisted biopsy (DVAB). The objectives of this continuous retrospective study were to evaluate the underestimation rate of malignancy and to identify predictors of upgrade to carcinoma.

Methods: Between 2003 and 2010, 3159 patients underwent stereotactic DVAB in our institute. We retrospectively evaluate clinical, mammographic and pathological features of 298 cases of ADH who underwent surgical excision in our center (93.1%). Patients with concurrent history of breast cancer, intraductal carcinoma (DCIS) associated, or with no follow-up or surgical excision on place were excluded. Histological scar of macrobiopsy was systematically searched in surgical specimens. A pathologic upgrade was defined by presence of invasive cancer or DCIS on surgical specimen. Statistical tests used were the chi-square or Fisher's exact test.

Results: Among the 298 studied DVAB, 224 ADH were isolated (75.2%), 46 associated to flat epithelial atypia (15.4%) and 28 to lobular neoplasia (9.4%). 98.4% patients presented microcalcifications at diagnosis. In 52 cases, lesions were upgraded to DCIS (n = 38) or invasive cancer (n = 14). The underestimated rate was 17.5%. In 67.3% cases, upgrade lesions were low or intermediate grade DCIS. Only the history of contralateral breast cancer was significantly correlated with the underestimated rate (p = 0.04). There was no statistical difference between these 52 cases and the 246 others for: family history, size of calcification, sampling number, histological lesion, and quality of calcifications removal.

Conclusions: In this study, DVAB may not be considered a therapeutic procedure in case of ADH, even in the case of complete removal of microcalcifications. It is still challenging to identify a subgroup of ADH cases with a low upgrade rate.

Citation Information: Cancer Res 2012;72(24 Suppl):Abstract nr P4-14-10.

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.

[Intraoperative molecular assessment of sentinel nodes in the breast cancer using the Gene Search BLN Assay technique: our experience about 126 patients]

INTRODUCTION

Intraoperative molecular assay Gene Search BLN Assay (BLN) detects sentinel lymph node (SLN) metastasis in breast cancer. Our objective was to compare BLN to the definitive conventional histologic methods and to experiment the management of BLN in routine.

MATERIAL AND METHODS

Each SLN was cut into alternate slabs. Half slabs were analysed with the intraoperative BLN molecular method, and the other slabs with the definitive histologic method.

RESULTS

Two hundred and thirty four SLN have been analysed (124 patients). Thirty-five SLN had metastasis for 29 patients (23.4%). BLN correctly identified 28 patients. Two cases of discordance between BLN and standard method were found, probably explained by a sample bias. The sensibility of BLN is 96.4%, the sensitivity is 99%, the predictive positive value is 96.4%, the predictive negative value is 99% and the concordance is 98.4%. The surgery time increases and there is a need to adapt the theatre organization accordingly.

CONCLUSION

The Gene Search BLN Assay gives a great interest for the patient, the surgeon and the pathologist because it increases the quality of the intraoperative analysis by comparison with the intraoperative conventional histology.

[Radiotherapy and combined therapy in breast cancer: standards and innovations in the adjuvant setting]

Due to the significant advances in the diagnosis and treatment of breast cancer seen in the last decades, increased survival rates and better outcomes of patients are being observed. The role of radiotherapy remains pivotal in the treatment of early breast cancer. In the adjuvant setting, whole breast irradiation remains the standard of care using a relatively well standardized radiation technique. The recent technology advances and 3D conformal radiotherapy allow for better volumes definition resulting to increased organ at risk--sparing and therefore treatment optimization. Sophisticated techniques and emerging options (such as accelerated partial breast irradiation) are not routinely used yet outside of a clinical trial. Moreover, new drugs and targeted therapies have recently been introduced to the clinical practice for treatment individualization according to the specific tumours' prognosis and/or prediction of the drugs' efficacy based on new biological tools. Regarding the synergistic effect of these molecules with ionizing radiation, rigorous prospective evaluation of combined therapy is important to ensure improved long-term benefit/risk ratio. In this review, the significant advances of radiotherapy and combined therapy in the new era of breast cancer management will be discussed.

[Role of MRI in the presurgical work-up of breast cancer: appropriate utilization of MRI as a complement to mammography and ultrasound]

The role of MRI for presurgical local staging of breast cancers amenable to conservative treatment has been the subject of multiple publications and tends to become a "validated" indication in routine practice. The purpose of the paper is to review the advantages and limitations of this imaging modality that is part of a comprehensive management that must be validated by clinical data especially with regards to local recurrence and survival. Knowledge of these elements combined with more precise indications should result in improved patient management while avoiding overtreatment or unnecessary anxiety-producing examinations.

[Follow-up of patients treated for localized invasive breast carcinoma]

The follow-up of patients treated for invasive breast carcinoma remains a major challenge because of breast cancer prevalence and the frequent patient's preferences for a regular follow-up. Concerning this last point, there is a lack of studies about the consequences of a systematic follow-up. Few decades ago, regular and systematic follow-up was considered as a dogma. In 1994, it was seriously questioned by two randomised Italian trials: they did not find any benefit in terms of survival and quality of life in patients who had a regular search of asymptomatic metastasis. Follow-up strategy after early breast cancer is still an unexplored field, despite higher performance of investigation tests and development of new treatments strategies that allowed a significant decrease of recurrences and increase of cancer care. Currently, the international guidelines deeply recommend a regular physical examination and mammography. But a systematic search for non-symptomatic metastases is unnecessary. We now need a coordination between practitioners to avoid useless tests, and to respond to patients' will.

Cervical assessment at 22 and 27 weeks for the prediction of spontaneous birth before 34 weeks in twin pregnancies: is transvaginal sonography more accurate than digital examination?

OBJECTIVES

This study compared the accuracy of ultrasound cervical assessment (cervical length and cervical index) and digital examination (Bishop score and cervical score) in the prediction of spontaneous birth before 34 weeks in twin pregnancies.

METHODS

In a prospective multicenter study, digital examination and transvaginal sonography were performed consecutively in twin pregnancies attending for routine sonography at either 22 weeks (175 women) or 27 weeks (153 women). The digital examination took place first, and the Bishop score and cervical score (cervical length minus cervical dilatation) were calculated. Ultrasound measurements were then made of cervical length and funnel length to yield the cervical index (1 + funnel length/cervical length). The association between each variable and delivery before 34 weeks was tested by the Mann-Whitney U-test. The receiver-operating characteristics (ROC) curves of the ultrasound and digital indicators were determined for both gestational age periods, and the areas under the ROC curves compared. The best cut-off values for each indicator were used to determine predictive values for delivery before 34 weeks.

RESULTS

The median gestational age at delivery among the women included in the 22-week examination period was 36.0 (range, 21-40) weeks; 10.9% (19) gave birth spontaneously before 34 weeks. The median cervical length was 40 (range, 6-65) mm. All four parameters were predictors of delivery before 34 weeks. The areas under the ROC curves for cervical index, cervical length, Bishop score and cervical score did not differ significantly. The median gestational age at delivery among the women in the 27-week examination period was 36.0 (range, 27-40) weeks; 9.2% (14) gave birth spontaneously before 34 weeks. The median cervical length was 35 (range, 1-57) mm. All parameters except the Bishop score were predictors of delivery before 34 weeks. The likelihood ratio of the positive and negative tests for cervical length < or = 25 mm was 5.4 (range, 3.2-9.0) and 0.3 (range, 0.1-0.7), respectively, compared with 2.3 (range, 1.3-4.2) and 0.6 (range, 0.3-1.1), respectively, for cervical score < or = 1. The area under the curve for the cervical index was significantly larger than that for the Bishop score (P = 0.008) or cervical score (P = 0.02).

CONCLUSION

Transvaginal sonography predicted spontaneous delivery before 34 weeks better than digital examination at the 27-week but not the 22-week examination.

Le ganglion sentinelle sans curage systématique dans le cancer du sein : bilan d'une expérience de 1000 interventions

OBJECTIVE

To assess daily practice of 1000 sentinel node (SN) biopsies in breast cancer.

PATIENTS AND METHOD

Prospective review of 1000 consecutive sentinel node biopsies between February 2001 and June 2004. Analyses concerned technical aspects of sentinel node detection, pathologic results of the tumor and sentinel node, treatment and follow-up.

RESULTS

Nine hundred and seventy-eight SN were detected (98.7%). In univariate analyses, age, pathologic tumor size (20 mm) and method of detection (blue dye or isotopic vs. combined) were statistically significant. One hundred and fifty-six cases (16%) underwent immediate axillary dissection (AD), whereas 116 (12%) had a delayed AD. There were 923 invasive or micro-invasive carcinoma with detected SN: 282 SN (30.5%) were involved, either with macrometastases (166) or with micrometastases (116), 34% had positive non-sentinel node. Age and metastasis size were predictive for AD involvement. Sixteen percent of micrometastatic SN had positive AD, there was no predictive factor for axillary involvement. After a median follow-up of 20 months, there were 4 axillary recurrences: 1 (0.1%) after negative SN without AD, 1 (0.1%) after positive SN with positive AD, 1 (4.3%) after micrometatastatic SN without AD, and 1 (8.3%) after macrometastatic SN without AD. There were 55 ductal carcinoma in situ and 54 micro-invasive cancer: positive SN (with negative AD) were detected in only 2 cases (2.3%). There were initially 112 ductal carcinoma in situ diagnosed by percutaneaous biopsy, 25 of them (22%) had invasive disease on definitive histology. Among there, 12 had involved SN (with 4 positive AD).

DISCUSSION AND CONCLUSION

With a high detection rate and low recurrence rate, SN biopsy is considered in our institute as a reliable procedure and is used to evaluate regional nodal status of early breast cancer. Thus, 70% of AD can be omitted.

Surgical implications of sentinel node with micrometastatic disease in invasive breast cancer

AIM

To assess the rate of positive axillary clearance (AC) when the sentinel node biopsy (SNB) contains micrometastatic disease in invasive breast cancer and to evaluate the factors that could predict positivity.

PATIENTS AND METHODS

This is a prospective study carried out on 542 successive women undergoing SNB for unifocal T0-T1 N0 invasive breast cancer without previous treatment.

RESULTS

Five hundred and twenty-five sentinel nodes (SN) were found, 142 contained metastases. Fifty-five of the positive SN contained micrometastatic disease only. Of them, 40 patients underwent completion of AC. Six out of 40 patients who had micrometastatic SN had a positive AC, five for micrometastasis between 0.2 and 2 mm (5/34), one for isolated cells in the SN (1/6). None of the studied factors (age, histological tumour size, histological grade, estradiol receptor (ER), histological tumour type, size and method of micrometastasis detection) could significantly predict the status of the AC.

CONCLUSION

As long as the results of ongoing prospective randomised studies are unknown, it remains necessary to perform AC when the SNB contains micrometastatic disease, whatever the size or the detection mode of the metastasis.

[Pancreatic tumor revealed by metastatic bilateral ovarian tumor with virilisation syndrome]

We report a case of a 38-year-old patient presenting with both pancreatic and a bilateral ovarian tumor revealed by a virilization syndrome. Clinically, both tumors were conceivably distinct. However, on histological examination, they were found to be morphologically similar, with neuroendocrine features, suggesting that pancreatic tumor was a primitive neoplasm and the ovarian one a metastatic spread of that lesion. The virilization syndrome was due to the functional status of the ovarian tumors that was confirmed by immunohistochemical detection of inhibin.

[Partial breast irradiation: high dose rate peroperative brachytherapy technique using the MammoSite]

In the conservative management of breast cancer, radiation therapy delivering 45 to 50 Gy to the whole breast, in 4.5 to 5 weeks, followed by a booster dose of 10 to 20 Gy is the standard of care. Based on the numerous studies which have reported that the local recurrences occurs within and surrounding the primary tumor site and in order to decrease the treatment duration and its morbidity, partial breast irradiation using several techniques has been developed. Partial irradiation may be considered as an alternative local adjuvant treatment for selected patients with favorable prognostic factors. Using external beam radiation therapy, the 3D-conformal technique is appropriate to deliver the whole dose to a limited volume. In UK, an intraoperative technique using a miniature beam of low energy of x-ray (50 Kv) has been developed (Targit). Milan's team have developed an intraoperative electrons beam radiotherapy using a dedicated linear accelerator in the operative room. In USA and Canada the MammoSite has been advised for clinical use in per-operative brachytherapy of the breast. These two last techniques are currently compared in phase III randomised studies to the standard whole breast irradiation followed by a tumour bed booster dose. In this review we will focus on the MammoSite technique and will describe the per-operative implantation procedure, radiological controls ad dosimetric aspects.

Mechanical properties of synthetic implants used in the repair of prolapse and urinary incontinence in women: which is the ideal material?

The authors review the literature concerning all types of synthetics implants used in prolapse repair or the treatment of stress urinary incontinence, and analyze the mechanical properties of and the tolerance to the various products used. Various synthetic implants are also studied, including their advantages and disadvantages, as well as outcome following implantation and tolerance by the host, with respect to the type of product and the type of intervention. A review of current implant products demonstrated that the perfect product does not exist at present. The most promising of theses products for applications in transvaginal surgery to restore pelvic function appears to be the synthetic prostheses made predominantly of polypropylene, which offer mechanical properties of durability and elasticity. Their properties of resistance are undisputed, but it remains to be shown whether they are well tolerated when inserted by the vaginal route. The technical modalities for their use are still under evaluation, which should enable a better identification of the respective indications for these products in prolapse repair and treatment of urinary incontinence by the vaginal route.

[Peritoneovaginal fistula after vaginal hysterectomy]

Peritoneovaginal fistula is a rare complication of hysterectomy. A patient with pelvic pain and vaginal discharge due to peritoneovaginal fistula, 6 months after hysterectomy, is presented. The laparoscopic approach with an intravaginal blue-test, provided the evidence of the peritoneovaginal fistula. The transvaginal approach offered a surgical closure of the fistula and a resolution of the symptoms. In addition, we have reviewed the literature, the symptoms, the differential diagnosis and the management of this problem.

Surgical staging of early invasive epithelial ovarian tumors

Early stage epithelial ovarian carcinoma is defined pathologically as a tumor strictly limited to one or both ovaries without any extra-ovarian disease (i.e., Stage IA or B of the International Federation of Gynecology and Obstetrics (FIGO) classification). This diagnosis can be obtained only after an exhaustive surgical staging procedure, performed as soon as the diagnosis of epithelial invasive ovarian carcinoma is established. This staging surgery currently encompasses a peritoneal cytology, the thorough inspection of all the visceral and parietal peritoneal surfaces with biopsy of any abnormality, total abdominal hysterectomy and bilateral salpingo-oophorectomy (TAH + BSO), random peritoneal biopsies, omentectomy, appendectomy and bilateral pelvic and para-aortic lymphadenectomies, up to the left renal vein. The results of this staging procedure and its indications are discussed. In all of the cases, the radical removal of the pathologic adnexa is indicated, along with the complete peritoneal and retroperitoneal staging. While fertility-sparing surgery (avoiding hysterectomy and contralateral adnexectomy, if possible) seems to be safe for young women, a TAH + BSO is the rule for the others. Adjuvant chemotherapy can be omitted in well-differentiated tumors with a negative staging operation, but currently it remains indicated in all other cases. Indeed, the ultimate goal in early stage ovarian carcinoma is to not impair by inadequate management the high chance of a cure.

[Antenatal diagnosis of limb body wall complex]

The "limb body wall complex" or LBWC is a rare polymalformative syndrome. Two distinct phenotypes of which were recently described: one form with "placento-cranial" adhesion and the other with "placento-abdominal" adhesion. Coelosomia is found in all cases, it variably coexists with encephalic, vertebral, visceral or limb anomalies. Three pathogenesis are proposed: the "early amnion rupture" theory and the "vascular" theory can explain the form with "placento-cranial" adhesion, conversely, the "defective folding process" allows for a better explanation of the form with "placento-cranial" adhesion. These theories do not exclude each other if we accept that this syndrome could be split: the first form would then be the original "LBWC" et could belong to "amniotic band syndrome", the mechanism of which is not precisely known, whereas the second could be named "body stalk syndrome" - "syndrome du cordon court". In any case, this syndrome should be better known so as to be studied and give a prognosis for a later pregnancy, because there is no recurrence.

[Role of laparoscopy in the management of uterine cervix cancer]

At the turn of this century, the evidence of the benefits of a concurrent chemo-radiotherapy in locally advanced tumors and the development of mini-invasive surgery (laparoscopic and radical vaginal surgery) are the two main advances in the management of cervical carcinomas. From a personal experience of 304 cervical carcinomas, the different techniques of laparoscopy used in cervical carcinomas are addressed and discussed. Their long-term results when involved in the management protocols of cervical carcinomas at different stages are reported. From this series, some conclusions are drawn: 1) laparoscopy can spare a laparotomy in early-stage node-negative patients with low tumoral volume; 2) it can spare a systematic extended-field radiation therapy in high-risk patients with node-negative para-aortic exploration; 3) it can spare surgery in patients with a centro-pelvic advanced stage or recurrence, possibly candidates for an exenterative procedure, if occult spread is found in the intra- or retroperitoneal areas. The more and more frequent combination of the mini-invasive surgery for staging and treatment and radiotherapy or chemotherapy explains the need for new protocols of a more and more complex and specialized management.

[Severe maternal and fetal situations during delivery]

If pregnancy is very frequently normal, severe complications can appear for fetus, mother or both. The etiologies are various but preeclampsia and its complications remain one of the leading causes. The management is discussed according to the etiology and the severity of the disease and also the level of maternity and neonatal unit which can accept the newborn. However, all situation is a case apart and any decision will not be taken without concertation between obstetricians and neonatologists. In France, a regionalization policy is taking place to improve the maternal and neonatanal management.