F. Rimareix

3D-conformal Accelerated Partial Breast Irradiation treatment planning: the value of surgical clips in the delineation of the lumpectomy cavity

BackgroundAccurate localisation of the lumpectomy cavity (LC) volume is one of the most critical points in 3D-conformal Partial breast irradiation (3D-APBI) treatment planning because the irradiated volume is restricted to a small breast volume. Here, we studied the role of the placement of surgical clips at the 4 cardinal points of the lumpectomy cavity in target delineation.MethodsForty CT-based 3D-APBI plans were retrieved on which a total of 4 radiation oncologists, two trainee and two experienced physicians, outlined the lumpectomy cavity. The inter-observer variability of LC contouring was assessed when the CTV was defined as the delineation that encompassed both surgical clips and remodelled breast tissue.ResultsThe conformity index of tumour bed delineation was significantly improved by the placement of surgical clips within the LC (median at 0.65). Furthermore, a better conformity index of LC was observed according to the experience of the physicians (median CI = 0.55 for trainee physicians vs 0.65 for experienced physicians).ConclusionsThe placement of surgical clips improved the accuracy of lumpectomy cavity delineation in 3D-APBI. However, a learning curve is needed to improve the conformity index of the lumpectomy cavity.

Outcome in breast molecular subtypes according to nodal status and surgical procedures.

BACKGROUND The purpose of our study was to evaluate the surgical treatment and outcome of breast cancer according to molecular subtypes. METHODS We identified 1,194 patients consecutively treated for primary breast cancer from 2004 to 2010. The type of surgery, pathological findings, local recurrence, and distant metastasis were evaluated for 5 molecular subtypes: luminal A and B, luminal HER2 (Human Epidermal Growth Factor Receptor 2), HER2 , and triple negative. RESULTS Breast-conserving surgery (BCS) was performed more frequently in luminal A (70.6%), triple-negative (66.2%), and luminal HER2 tumors (60.9%) (P < .001). A sentinel node biopsy was performed more frequently in luminal A (60%), and luminal HER2 (29.3%) types (P < .001). Among the 791 BCS, positive nodes were observed more often in HER2 (50%) and luminal B (44.9%) types (P = .0003). The number of local recurrences was higher in the node-negative luminal B subtype (3.4%). CONCLUSIONS Molecular subtypes exert an impact on BCS and nodal surgery rates. The local relapse rates are influenced by the molecular subtypes according to the nodal status.

The role of Oncoplastic Breast Surgery in the management of breast cancer treated with primary chemotherapy

OBJECTIVE The purpose of this study was to evaluate the benefit of Oncoplastic Breast Conserving Surgery (BCS) compared to standard BCS after primary CT, in terms of oncologic safety and cosmetic outcomes. BACKGROUND The development of new drugs has led to greater use of primary chemotherapy (CT) for bulky breast cancer (BC) and has allowed wider indications for conservative surgery. PATIENTS AND METHODS We identified 259 patients consecutively treated with BCS for primary BC from January 2002 to November 2010. All patients had undergone Oncoplastic Breast Surgery (OBS) or standard BCS after primary CT. Mastectomy rates, and oncological and cosmetic outcomes were compared. RESULTS A total of 45 OBS and 214 standard BCS were analyzed. The median tumor size was 40 mm in the two groups (p = 0.66). The median operative specimen volumes were larger in the OBS group than in the standard group (respectively, 180 cm3 and 98 cm3, p < 0.0001). Re-excision (9% vs. 2%) and mastectomy (24% vs. 18%) rates were similar (p = 0.22 and p = 0.30) in the standard BCS group and in the OBS group respectively. At a median follow-up of 46 months, local relapse (p = 0.23) and distant relapse (p = 0.35) rates were similar. CONCLUSION OBS allows excision of larger volumes of residual tumor after primary CT. OBS outcomes results were similar to those of standard BCS. Oncoplastic Breast Conserving Surgery (BCS) after primary chemotherapy allows wider breast resection than standard BCS. Survival and relapse probabilities are similar in both groups.

Principes généraux de la chirurgie oncoplastique du sein

After a conservative treatment for breast cancer, 75% of patients end up with a good aesthetic result, i.e. little or no residual asymmetry and minor postradiotherapy after-effects. In 20 to 25% of cases, the conservative treatment leaves lasting after-effects associated with surgery and radiotherapy. Such aesthetic after-effects are difficult to treat and they require additional plastic surgery in 5 to 10% of cases. Oncoplastic surgery, which combines large lumpectomy and remodeling procedure involving different plastic surgery methods, improves these cosmetic results after a partial mastectomy and widens the scope for conservative treatment. Today, these techniques are well codified. They range from simple reshaping to more sophisticated techniques involving a concomitant controlateral-breast-symmetrisation procedure. These surgical options must be elaborated in detail with the patient and depend on the patient, the type of the tumor, its position, the ratio between the volume of the tumor and that of the breast and the overall care given by a multispecialist team. Plastic surgery is now an integral part of the treatment of breast cancer, hence the use of the word: oncoplastic surgery.

Factors influencing the decision to offer immediate breast reconstruction after mastectomy for ductal carcinoma in situ (DCIS): The Institut Gustave Roussy Breast Cancer Study Group experience

BACKGROUND The increased rate of ductal carcinoma in situ (DCIS) is associated with a rise in indications for mastectomy and immediate breast reconstruction (IBR). The purpose of our study was to evaluate the factors affecting the indications for IBR and its modalities. STUDY DESIGN Data concerning two hundred and thirty-eight consecutive patients with DCIS who had undergone modified radical mastectomy and a sentinel lymph node biopsy (SLNB) between 2005 and 2011 were extracted from our database. We then conducted a comparative study between patients who had undergone IBR and those who had not, to determine which factors affected the decision to offer IBR (LOE II). RESULTS About 57.1% had IBR and 42.9% had no reconstruction. The most common reason why IBR had not been performed was that it had not been proposed by the surgeon (33.4%). Of the 136 patients offered IBR, an implant had been proposed to the majority of them (81.6%). The IBR rate was highest among women under 50 years (52.2%), and was lower among women with diabetes (0.7%) or obesity (8.8%). The choice of reconstruction was not affected by tobacco use or positive SLNB results. CONCLUSION Factors predictive of the IBR reflect the influence of surgeon counselling and, to a lesser extent, consideration of patient comorbidities. However, there is a need to improve patient information and physician referral.

The positive non-sentinel status is not the main decisional factor for chemotherapy assignment in breast cancer with micrometastatic disease in the sentinel lymph node.

Surgical and systemic treatment modalities for breast cancer (BC) patients with micrometastatic disease in the sentinel lymph node biopsy (SNB) are controversial. The aim of this study was to evaluate decisional factors associated with assignment of adjuvant chemotherapy (CT).

Axillary Padding without Drainage after Axillary Lymphadenectomy – a Prospective Study of 299 Patients with Early Breast Cancer

Background: After lymphadenectomy for early breast cancer, seroma formation is a constant event requiring a suction drainage. This drainage is the strongest obstacle to reducing the hospital stay. Axillary padding without drainage appears to be a valuable option amid the various solutions for reducing the hospital stay. Methods: We conducted a comparison between 114 patients with padding and 185 patients with drainage. Data were obtained from 2 successive prospective studies. Results: The mean hospital stay was 2.4 days (range 1–4) in the padding group and 4.2 days (range 2–9) in the drainage group (p < 0.05). There were fewer needle aspirations for seroma in the padding group (8.8 vs. 23%, p < 0.05). At 6 weeks, only 28% (32/114) of the patients in the padding group reported pain versus 51% (94/185) in the drainage group. The mean pain intensity at 6 weeks was 3 and 4.3 respectively (p < 0.0001). Conclusion: Axillary padding without drainage was associated with a better post-operative course than suction drainage in this historical comparison, and the hospital stay was significantly shortened. There are only few series published on this new technique but they all indicate good feasibility and good tolerance. A large randomised multicentric evaluation is now warranted.

Characteristics, Treatment, and Outcome of Breast Cancers Diagnosed in BRCA1 and BRCA2 Gene Mutation Carriers in Intensive Screening Programs Including Magnetic Resonance Imaging

BACKGROUND Breast magnetic resonance imaging (MRI) with conventional screening methods improves sensitivity in high-risk patients without benefits on specific survival. We evaluated the characteristics, treatments, and prognostic features of breast cancers diagnosed among BRCA1/2 mutation carriers either inside or outside screening programs that included MRI. PATIENTS AND METHODS Two groups of patients diagnosed with a new breast cancer between 2001 and 2007 were compared: group 1, patients included in an intensive screening program; and group 2, patients outside of this program. RESULTS Twenty-one patients met inclusion criteria for group 1, and 102 for group 2. Seventy-four percent and 65%, respectively, were BRCA1 mutation carriers. Tumors in both groups had the same characteristics (pN, grade, estrogen receptor, progesterone receptor, HER2 expression), except for smaller tumor size in group 1 (median, 6 mm vs. 22 mm; P < .0001). Group 1 patients had more frequent sentinel node procedures (57% vs. 28%; P = .021) and less commonly received chemotherapy (43% vs. 86%; P < .0001). The 3-year disease-free survival (93% vs. 74%; P = .1) and the 3-year overall survival (100% vs. 92%; P = .2) did not differ between groups. CONCLUSION MRI might provide improvement in BRCA1/2 carriers in terms of smaller tumor size and treatment morbidity. However, because of aggressive intrinsic characteristics, this does not turn into significant survival benefits.

Loco-regional Control After Neo-adjuvant Chemotherapy and Conservative Treatment for Locally Advanced Breast Cancer Patients

Breast‐conserving treatment (BCT) has been validated for breast cancer patients receiving adjuvant chemotherapy. Our objective was to evaluate the difference in loco‐regional recurrence (LRR) rates between BCT and mastectomy in patients receiving radiation therapy after neo‐adjuvant chemotherapy (NCT). A retrospective data base was used to identify all patients with breast cancer undergoing NCT from 2002 to 2007. Patients with initial metastatic disease were excluded from this analysis. LRR was compared between those undergoing BCT and mastectomy. Individual variables associated with LRR were evaluated. Two hundred eighty‐four patients were included, 111 (39%) underwent BCT and 173 (61%) mastectomy. Almost all patients (99%) in both groups received postoperative radiation. Pathologic complete response was seen in 37 patients, of which 28 underwent BCT (p < 0.001). Patients receiving mastectomy had more invasive lobular carcinoma (p = 0.007) and a higher American Joint Committee on Cancer (AJCC) stage (p < 0.001) at diagnosis than those with BCT. At a median follow‐up of 6.3 years, the loco‐regional control rate was 91% (95% CI: 86–94%). The 10‐year LRR rate was similar in the BCT group (9.2% [95% CI: 4.9–16.7%]) and in the mastectomy group (10.7% [95% CI: 5.9–15.2%]; p = 0.8). Ten‐year overall survival (OS) rates (63% [95% CI: 46–79%] in the BCT group; 60% [95% CI: 47–73%] in the mastectomy group, p = 0.8) were not statistically different between the two patient populations. Multivariate analysis showed that AJCC stage ≥ III (HR: 2.6; 95% CI: 1.2–5.8; p = 0.02), negative PR (HR: 6; 95% CI: 1.2–30.6, p = 0.03), and number of positive lymph nodes ≥3 (HR: 2.5; 95% CI: 1.1–5.9; p = 0.03) were independent predictors of LRR. Ten‐year OS was similar in the BCT and in the mastectomy group (p = 0.1). The rate of LRR was low and did not significantly differ between the BCT and the mastectomy group after NCT. Randomized trials assessing whether mastectomy can be safely omitted in selected breast cancer patients (nonstage III tumors or those which do not require adjuvant hormone suppression) which respond to NCT are required.

Toward a new strategy in desmoid of the breast

AIM To report initial results of observation as well as surgery in patients with desmoid tumors (DTs) of the breast, a rare tumor for which data are scarce. PATIENTS AND METHODS The initial approaches were categorized as either front-line loco-regional treatment [(surgery or radiotherapy group, SRG) n = 20] or initial observation [(no surgery/no radiotherapy group, NSRG) n = 11]. RESULTS A total of 27 women and 4 men were assessed between 1992 and 2013 and included in this study. Patient characteristics were adequately balanced in the 2 groups. Fifteen patients (48.4%) had a past history of breast surgery in the previous 24 months. The median initial DT size on MRI was 50 mm. The median follow-up was 36 months. In the SRG, 8/20 patients (40%) experienced recurrence. The median time to recurrence was 29 months. During the study period, 6 patients in the SRG (30%) received a mastectomy at the time of diagnosis (n = 3) or at relapse (n = 3), 7 patients (35%) received a thoracic wall resection and 8 patients (40%) received radiotherapy at the time of diagnosis (n = 2) or at recurrence (n = 5). In the NSRG, the median tumor size change was -4 mm (range -13 to +20). Three patients changed treatment strategies during the observation period; one received surgery, and 2 were administered anti-hormonal treatment. CONCLUSIONS Loco-regional treatments of breast DTs resulted in undesired disfigurement. Front-line observation yielded encouraging results and could enable the identification of patients who require loco-regional treatment. This strategy needs further evaluation.