M. Fournier

L’examen cytologique a-t-il encore sa place dans l’analyse extemporanée du ganglion sentinelle dans le cancer du sein ?

Intraoperative examination of sentinel lymph nodes (SLN) in breast cancer can avoid a new surgical procedure in case of positive SLN, but its value, efficacy and the methods used are still controversial. The aim of our study was to evaluate the imprint cytology intraoperative method of SLN analysis performed at our institution. We did a retrospective study of the sentinel lymph node procedures performed during a period of 24  months on cT1N0 unifocal breast cancers. Intraoperative procedure was mainly by imprint cytology (touch prep). A SLN procedure was performed on 187 women with 360 SLN. Two hundred and seventy-seven SLN among 156 women were analyzed intraoperatively by touch prep. 19/48 positive SLN were detected by intraoperative touch prep (sensitivity 39.6%; specificity 100%; positive predictive value 100%; negative predictive value 88.7%, accuracy 89.5%). False negative rate of cytological intraoperative examination of SLN was 11,2% by SLN and 18,3% by patient. By univariate analysis, this rate significantly increased with lymphovascular invasion, tumor size cT1b and c and histological SBR grade 2 or 3. By multivariate analysis, only lymphovascular invasion was a predictive factor of intraoperative touch prep failure (OR = 3.3; IC 1.3-8.4). Intraoperative imprint cytology of SLN in breast cancer is associated with a high rate of false negativity that questions its use in this setting.

Reconstruction mammaire chez les patientes âgées : études des pratiques de l’institut Bergonié 2005–2015

INTRODUCTION The objective of our study is to describe the practices of breast reconstruction in patients aged 70 years and over undergoing a radical mastectomy at institut Bergonié. MATERIAL AND METHODS We performed a detailed single-site retrospective study from January 2005 to December 2015. Through a computerized review, we have identified and analyzed all patients aged 70 years and over who underwent a breast reconstruction. RESULTS Five hundred and ninety patients underwent a radical mastectomy during the period. Twenty-eight patients (4.7%) benefited from a breast reconstruction. Nineteen patients (67.9%) had an immediate breast reconstruction and 9 patients (32.1%) had a delayed breast reconstruction, within an average time of 2 years. Sixteen patients (57.1%) benefited from the insertion of an expander replaced by a permanent implant. Five patients (17.9%) benefited from the immediate placement of an implant. Six patients (21.4%) had a reconstruction by autologous latissimus dorsi flap and 1 patient (3.6%) by exclusive lipofilling. Four patients (14.3%) presented postoperative complications without the need for removal of an implant or flap loss. Twenty patients (71.4%) were satisfied with their final reconstruction. CONCLUSIONS Breast reconstruction in elderly patients is possible. Further studies are needed to better describe French practices.

Ganglions sentinelles et carcinome canalaire in situ

The diagnosis of ductal carcinoma in situ (DCIS) using core biopsy (CB) does not ensure the absence of invasion on final excision. The risk of invasion and upstaging ranges from 8% to 42.7% in various studies. The role of sentinel lymph node biopsy in patients on CB of DCIS has been the subject of debate. Furthermore, SLN is not usually required in all cases of DCIS but may be indicated in such specific cases: 1) where mastectomy is performed; 2) with large lesions or palpable mass; 3) with high grade tumours; 4) and where the pathologist cannot rule out micro-invasion. Pure DCIS patients do have tumour positive findings, but a majority of these are isolated tumour cells (ITCs) or micro-metastases. SLN positive does not affect the outcomes of DCIS patients.RésuméLe diagnostic de carcinome canalaire in situ (CCIS) est le plus souvent réalisé sur les biopsies préopératoires. Cela expose au risque de sousestimation qui varie de 8 à 42,7 % en fonction des séries. Le rôle du ganglion sentinelle (GS) est sujet à caution, il n’est indiqué que dans quelques cas particuliers: 1) toujours en cas demastectomie; 2) en cas de lésions étendues ou de masses palpables; 3) en cas de CCIS de haut grade; 4) enfin, lorsque le pathologiste ne peut pas éliminer formellement une micro-invasion sur la biopsie. Le GS peut être positif en cas de CCIS pur, mais le plus souvent sous la forme de cellules tumorales isolées (CTI) ou de micrométastases, sans impact sur la survie de ces patientes.

Abstract P5-16-23: Rapid germline BRCA screening for locally advanced breast cancer changes surgical procedure after neoadjuvant chemotherapy

Introduction Neoadjuvant chemotherapy (NAC) is proposed in case of locally advanced breast cancer (LABC) to improve breast conservative treatment (BCT). In the case of germline BRCA mutated (gBRCAm) patients, risk-reducing prophylactic surgical strategies in France are mastectomy for pre-symptomatic. On the other hand, BCT is proposed to all patients after NAC according to clinical response, regardless their gBRCAm status. Moreover, in the case of BRCA mutation, local recurrence risk at 15 years is higher in the BCT group (23%) vs mastectomy (5%) (Pierce 2010). The aim of this retrospective one-institution analysis is to evaluate if the knowledge of gBRCAm status impact surgical decision. Patients and methods All patients who underwent BRCA genetic testing during NAC for ≥ 3cm breast cancer between 2012 and 2015 were included. BRCA testing was decided with each patient based on age, familial history of breast or ovarian cancer and histological characteristics of the tumor. Rapid germline BRCA mutation screening was performed through targeted next generation sequencing with a 25-genes panel including full coding sequence of BRCA1 & 2. Deleterious mutations were detected using MiSeq reporter and confirmed by Sanger sequencing before giving the results to the clinical geneticist, and finally used for the choice of surgical strategy. At the end of NAC (6 three-weeks cycles in our center), a shared-decision making for surgical procedure was performed, based on pre and post-NAC clinical and radiological features, and results of the genetic testing. Results A total of 25 patients (including three with bilateral cancer) were tested during NAC: mean age 38 years (26-64); mean clinical size 46 mm (20-130mm); histological types: triple negative (n=14), HER-2 positive (n=7), luminal (n=7). A germline BRCA mutation was detected in 10 patients (40%) : 8 BRCA1 and 2 BRCA2, including 8 patients among the 14 patients with a Manchester score > 20 (6 BRCA1 & 2 BRCA2). Two patients were secondarily excluded (one being metastatic and one died during NAC), one of them having a gBRCAm status. All the 23 patients evaluable for the surgical procedure after NAC could be eligible for a BCT. All the 9 patients with gBRCAm status choose mastectomy in the shared-decision making procedure while a BCT was performed in 12 of the 14 remaining patients without BRCA mutation. Discussion In this highly selected subgroup of patients, gBRCAm rate is higher (40%) than the usual rate for BRCA testing (17% in our center). Regarding the rationale for BCT or mastectomy procedure in LABC or pre-symptomatic gBRCAm patients, the duration of NAC allows rapid germline BRCA screening that looks very useful considering the high incidence of mutation we observed and the impact on surgical final decision. Furthermore, in the group of high Manchester score (>20), patients without BRCA mutation harbored incidental mutation, currently under analysis, especially on other genes involved in hereditary breast cancer, that could also be used as a compelling argument for mastectomy. Citation Format: Tunon de Lara C, Bonnet F, Debled M, Lafon D, Breton-Callu C, Rarouk-Simonet E, Fournier M, Petit A, Bubien V, Quenel-Tueux N, Lagarde P, Longy M, Macgrogan G, Sevenet N. Rapid germline BRCA screening for locally advanced breast cancer changes surgical procedure after neoadjuvant chemotherapy [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 P5-16-23.

Évaluation du capitonnage de la loge de prélèvement du lambeau de grand dorsal : à propos d’une série de 54 patientes

Le serome posterieur lors d’une reconstruction mammaire par lambeau de grand dorsal est la complication la plus frequente puisque son incidence peut atteindre 79 % dans certaines series [1]. Des facteurs de risque de formation des seromes dorsaux ont ete clairement identifies tels que l’age superieur a 43 ans, un IMC superieur a 23 kg/m2 ainsi qu’une taille de lambeau superieur a 450 grammes [2]. Differentes techniques ont ete decrites dans la litterature pour prevenir son apparition. La plupart de celles-ci consistent a obliterer la loge de prelevement soit en utilisant de la colle biologique [3], soit en realisant un capitonnage de la loge par des points.

Faisabilité de la recherche du ganglion sentinelle en cas de rechute locale

La prise en charge d’une rechute locale dans un sein traite par chirurgie conservatrice et radiotherapie est en pleine mutation, premierement du fait de la taille initiale des lesions en constante decroissance depuis plusieurs annees, deuxiemement l’absence de chirurgie axillaire remplacee par la recherche du ganglion sentinelle (GS) et enfin grace au progres de l’imagerie qui permet, d’une part, un diagnostic precoce de la rechute et, d’autre part, des bilans d’extension de plus en plus performants.