Françoise Rimareix

The challenge of rapid diagnosis in oncology: Diagnostic accuracy and cost analysis of a large-scale one-stop breast clinic

PURPOSEnRapid diagnosis is a key issue in modern oncology, for which one-stop breast clinics are a model. We aimed to assess the diagnosis accuracy and procedure costs of a large-scale one-stop breast clinic.nnnPATIENTS AND METHODSnA total of 10,602 individuals with suspect breast lesions attended the Gustave Roussys regional one-stop breast clinic between 2004 and 2012. The multidisciplinary clinic uses multimodal imaging together with ultrasonography-guided fine needle aspirationxa0for masses and ultrasonography-guided and stereotactic biopsies as needed. Diagnostic accuracy was assessed by comparing one-stop diagnosis to the consolidated diagnosis obtained after surgery or biopsyxa0or long-term monitoring. The medical cost per patient of the care pathway was assessed from patient-level data collected prospectively.nnnRESULTSnSixty-nine percent of the patients had masses, while 31% had micro-calcifications or other non-mass lesions. In 75% of the cases (87% of masses), an exact diagnosis could be given on the same day. In the base-case analysis (i.e. considering only benign and malignant lesions at one-stop and at consolidated diagnoses), the sensitivity of the one-stop clinic was 98.4%, specificity 99.8%, positive and negative predictive values 99.7% and 99.0%. In the sensitivity analysis (reclassification of suspect, atypical and undetermined lesions), diagnostic sensitivity varied from 90.3% to 98.5% and specificity varied from 94.3% to 99.8%. The mean medical cost per patient of one-stop diagnostic procedure was €420.nnnCONCLUSIONSnOne-stop breast clinic can provide timely and cost-efficient delivery of highly accurate diagnoses and serve as models of care for multiple settings, including rapid screening-linked diagnosis.

Robotic da Vinci Xi-assisted nipple-sparing mastectomy: First clinical report

Nipple‐sparing mastectomy (NSM) is increasingly popular for the treatment of selected breast cancers and prophylactic mastectomy. Surgical scarring and esthetic outcomes are important patient‐related cosmetic considerations. Today, the concept of minimally invasive surgery has become popular, especially using robotic surgery. The authors report the first case of NSM using the latest version of the da Vinci Xi surgical system (Xi). The final incision used to remove the entire mammary gland was located behind the axillary line. In this position, hidden by the arm of the patient, the incision was not visible and was compatible with immediate breast reconstruction.

Quilting Sutures Reduces Seroma in Mastectomy

BACKGROUNDnDrainage duration and seroma formation occurring after mastectomy with or without axillary surgery lengthens hospitalization and delays adjuvant treatment. The aim of the study was to evaluate the effect of quilting in the prevention of seroma after mastectomy for breast cancer.nnnPATIENTS AND METHODSnEighty-two breast cancer patients about to undergo mastectomy with or without axillary surgery lymphadenectomy were enrolled in the study. We conducted an observational comparison between 41 patients in whom quilting with closed suction drainage was used and 41 patients in whom drainage only was used.nnnRESULTSnThe mean drained volume was significantly lower in the quilting group compared with the control group on days 1 and 2 (day 1: 107.1 mL vs. 156.5 mL; Pxa0= .02; dayxa02:xa0108.4 mL vs. 162.8 mL; Pxa0= .01). The mean drainage period was shorter in the quilting group (4.6 vs. 5.3 days; Pxa0= .046). There were fewer needle aspirations for seroma in the padding group (n = 14, 34.1% vs. n = 24, 58.5%; Pxa0=xa0.03).nnnCONCLUSIONnThe use of padding after mastectomy seems to reduce seroma formation, volume drained, and length of drainage time.

Nipple-Sparing Mastectomy and Immediate Reconstruction in Ductal Carcinoma In Situ: A Critical Assessment With 41 Patients

AbstractBackgroundNipple-sparing mastectomy (NSM) is increasingly popular for the treatment of select breast cancers and prophylactic mastectomy. This study aimed to analyze the authors’ 11-year experience with NSM and breast reconstruction in cases of ductal carcinoma in situ (DCIS) with an emphasis on indications, complications, and cancer recurrence rate.nMethodsBetween January 2000 and December 2010, 41 NSMs were performed in 41 women for DCIS. The mean age of the women was 49.7xa0±xa08.7xa0years (range, 33–66xa0years). The indications for NSM were tumor size greater than 3xa0cm (18 cases), multifocal tumor (16 cases), and tumor recurrence (7 cases). In all cases, the tumor was located more than 2xa0cm from the nipple–areola complex (NAC), as shown by preoperative radiologic imaging. Histologic results, secondary NAC resection, complications, and cancer recurrence rates were recorded.ResultsThe NAC was lost in seven cases (17xa0%) due to postoperative necrosis. In another 10 patients (25xa0%), the NAC was secondarily removed due to proximity of the tumor to the resection margin. Five patients were lost to follow-up evaluation (12xa0%). The authors report the long-term follow-up data for the remaining 19 patients (46xa0%). In this group, they observed one local recurrence (5.3xa0%) and one case of ovarian cancer.ConclusionDespite the low locoregional recurrence rate for DCIS, NSM remains controversial because of the nipple necrosis observed and the irradical tumor excisions. Given the ethical impossibility of conducting randomized controlled studies to compare NSM with conventional or skin-sparing mastectomy in DCIS, only long-term follow-up evaluations can demonstrate the safety of NSM.Level of Evidence IVThis journal requires that authorsn assign a level of evidence to each article. For a fullndescription of these Evidence-Based Medicine ratings,nplease refer to the Table of Contents or the onlinen Instructions to Authors www.springer.com/00266.

Use of Low-Thrombin Fibrin Sealant Glue After Axillary Lymphadenectomy for Breast Cancer to Reduce Hospital Length and Seroma

Background Axillary lymphadenectomy for primary breast cancer produces a non‐negligible rate of postoperative lymphorrhea, prolonged hospital stays, and multiple seroma punctures. We evaluated the impact of low‐thrombin fibrin sealant glue on surgical wounds in patients undergoing axillary lymph node dissection for breast cancer. Methods We conducted an observational study of 149 patients who underwent axillary lymphadenectomy for primary breast cancer between January 2014 and December 2015. Data were obtained from 2 successive prospective studies. The hospital stay length and morbidity (seromas, punctures) were compared between 2 groups: patients who had padding sutures and low‐thrombin fibrin sealant glue without drainage (n = 49) and patients with drainage alone (n = 100). Hospital costs were assessed from the hospital perspective. Results The mean hospital stay length was shorter in the fibrin sealant group (2.6 vs. 4.7 days; P < .001). Seroma magnitude and punctures were similar in patients treated with fibrin sealant compared with patients with drainage alone. The rate of needle aspiration for seroma was similar irrespective of whether or not a drain or fibrin sealant was used (30.6% vs. 33.0%, P = .77). Conclusion Low‐thrombin fibrin sealant glue does not significantly reduce the amount of fluid produced in the axilla after breast surgery; however, its systematic use may help reduce hospital stays and costs. Micro‐Abstract A prospective evaluation of 149 axillary lymph node dissection (ALND) procedures in 2 groups using either drainage or a drainless procedure with fibrin glue and a padding technique was performed. No difference was observed in seroma punctures, but an interesting significantly reduced postoperative hospital stay length. Quilting sutures and fibrin glue after ALND is a promising technique for reducing hospital stays and costs.

The Role of Blue Dye in Sentinel Node Detection for Breast Cancer: A Retrospective Study of 203 Patients

Objective: We aimed at examining the potential benefits of blue dye in sentinel node biopsy (SNB) in comparison with its proven drawbacks. Patients and Methods: In 2007, 203 T1 primary breast carcinomas had been operated on in our institute. The patients had undergone a lumpectomy and SNB. Sentinel node (SN) detection was exclusively isotopic (ISO) in 77 patients and performed with blue dye combined with a radioactive isotope (COMBI) in 126 patients. We compared the number of SNs and the rate of SN positivity in both groups. Results: The detection rate was 99% in both groups: 76/77 in the ISO group and 125/126 in the COMBI group. The mean number of SNs was 2.14 and 1.91 in the ISO group and the COMBI group, respectively (difference not significant (NS)). SN positivity was found in 26.1% and 24.6% in the ISO group and the COMBI group, respectively (NS). Only 1 SN had been removed in 26% of the patients in the ISO group versus 45.2% of the patients in the COMBI group (p = 0.004). No significant differences were observed in the tumor characteristics. Conclusion: The systematic use of patent blue dye combined with isotopic detection does not appear to increase the overall performance of the SNB technique in this retrospective study.

Robotic Prophylactic Nipple-Sparing Mastectomy with Immediate Prosthetic Breast Reconstruction: A Prospective Study

BackgroundRobotic nipple-sparing mastectomy (RNSM) could be a significant advancement in the treatment of breast cancers and prophylaxis because the mastectomy is performed without leaving any scar on the breast. The aim of this study was to assess the feasibility and the safety of RNSM with immediate prosthetic breast reconstruction (IPBR).MethodsIn this prospective study, RNSM with IPBR was offered to patients with breast cup size A, B or C and ptosis grade ≤u20092. In case of oncologic surgery, RNSM was proposed only if the tumor was located more than 2 cm away from the nipple-areola complex (NAC) and if postoperative radiation was not indicated. In case of prophylactic surgery, RNSM was proposed only if a high-risk genetic mutation had been identified. The primary endpoint was the rate of skin or NAC necrosis. The rate of conversion to open technique, the duration of the procedure, and postoperative complications were also analyzed.ResultsSixty-three RNSM with IPBR were performed in 33 patients. There were no cases of mastectomy skin flap or NAC necrosis. We had to convert to an open technique in one case (1.6%). Three infections occurred (4.8%), one leading to implant loss (1.6%). No other major complications were observed.ConclusionsPreliminary data attest to the feasibility, the reproducibility, and the safety of this approach. However, long-term data are needed to confirm the oncological safety and the esthetic stability of the result.Trial registration identifier NCT02673268.

Comparison of the Explantation Rate of Poly Implant Prothèse, Allergan, and Pérouse Silicone Breast Implants within the First Four Years after Reconstructive Surgery before the Poly Implant Prothèse Alert by the French Regulatory Authority

Background. In March 2010, ANSM (Agence Nationale de Sécurité du Medicament), the French Medical Regulatory Authority, withdrew Poly Implant Prothèse (PIP) breast implants from the market due to the use of non-medical-grade silicone gel. The aim of this study was to compare the removal rate (and reasons thereof) of breast implants produced by different manufacturers before the ANSM alert. Materials and Methods. From October 2006 to January 2010, 652 women received 944 implants after breast cancer surgery at the Gustave Roussy Comprehensive Cancer Center, Paris (France). The complications and removal rates of the different implant brands used (PIP, Allergan, and Pérouse) were evaluated and compared. Results. PIP implants represented 50.6% of the used implants, Allergan 33.4%, and Pérouse 16%. The main reasons for implant removal were patient dissatisfaction due to aesthetic problems (43.2%), infection (22.2%), and capsular contracture (13.6%). Two years after implantation, 82% of Pérouse implants, 79% of PIP, and 79% of Allergan were still in situ. There was no difference in removal rate among implant brands. Conclusion. Before the ANSM alert concerning the higher rupture rate of PIP breast implants, our implant removal rate did not predict PIP implant failure related to the use of nonapproved silicone gel.

Permeability of expander breast implants: In vitro and in vivo analyses

INTRODUCTIONnThe biocompatibility of the polysiloxane breast implant has been studied moderately. The aging of these implants due to lipid penetration and the release of polymerization impurities, such as Platine or octamethylcyclotetrasiloxane (named D4), has already been documented. Since these studies, manufacturing procedures have been improved; thus, the security of breast implants has also improved. Although polymerization and the choice of monomer influence the shell properties, few studies have compared these together in breast implants. Our study compares the permeability and mechanical resistance of 3 breast expander shells after in vivo and in vitro aging.nnnRESULTSnIn vitro, all tested shells quickly sorbed linear molecules, such as fatty acids, and released siloxane impurities. The penetration of a molecule with steric hindrance, such as cholesterol, is slower. Allergan shells have the highest rates of molecule sorption and siloxane release. In vivo, after implantation, Allergan shells lost their initial mechanical properties over time. This observation was not found for mentor shells. For all brands, many biological molecules penetrate the shells, among which cholesterol and fatty acids are always present.nnnDISCUSSIONnThe aging of polysiloxane shells depends on the sorption of many biological molecules and the release of siloxane impurities. The siloxanes are impurities and / or degradation products that are due to aging. Moreover, according to our results, the shells act as matrices that separate molecules according to their chemical and physical properties.nnnCONCLUSIONnNot all polysiloxane expander shells have the same properties during aging. The manufacturing procedures and the choice of siloxane monomers are the two most probative factors that explain the observed differences.

Indications and Controversies in Partial Mastectomy Defect Reconstruction

Breast cancer surgical treatment nowadays includes oncoplastic surgery. It is a reliable oncologic surgical treatment, which also prevents functional and aesthetic sequelae, thus improving the patients quality of life and satisfaction. Numerous techniques have been described, with different levels of complexity and technicality. Their indications differ depending on the global breast volume and the degree of ptosis, on the tumor volume compared with the breast volume, and on the tumor location. This article describes the authors many years of experience of breast cancer treatment using oncoplastic surgery. They also established a decision-making guide, whose implementation enables treatment of every patient.