P. Martel

Prospective Multicentric Randomized Study Comparing Periareolar and Peritumoral Injection of Radiotracer and Blue Dye for the Detection of Sentinel Lymph Node in Breast Sparing Procedures: FRANSENODE Trial

PURPOSE To determine the optimal injection path for blue dye and radiocolloid for sentinel lymph node (SLN) biopsy in early breast cancer. PATIENTS AND METHODS A prospective randomized multicentric study was initiated to compare the peritumoral (PT) injection site to the periareolar (PA) site in 449 patients. RESULTS The detection rate of axillary SLN by lymphoscintigraphy was significantly higher (P = .03) in the PA group (85.2%) than in the PT group (73.2%). Intraoperative detection rate by blue dye and/or gamma probe was similar (99.11%) in both groups. The rate of SLN detection was somewhat higher in the PA group than in the PT group: 95.6% versus 93.8% with blue dye (P = .24) and 98.2% versus 96.0% by probe (P = .16), respectively. The number of SLNs detected by lymphoscintigraphy and by probe was significantly higher in the PA group than in the PT group, 1.5 versus 1.2 (P = .001) and 1.9 versus 1.7 (P = .02). The blue and hot concordance was 95.6% in the PA group and 91.5% in the PT group (P = .08). The mean ex vivo count of the SLN was significantly higher in the PA group than in the PT group (P < .0001). CONCLUSION This study strongly validates the PA injection technique given the high detection rate (99.1%) of SLN and the high concordance (95.6%) between blue dye and the radiotracer, as well as higher significant ex and in vivo counts, improving SLN probe detection.

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

PURPOSE Predictive factors of non-sentinel lymph node (NSN) involvement at axillary lymph node dissection (ALND) have been studied in the case of sentinel node (SN) involvement, with validation of a nomogram. This nomogram is not accurate for SN micrometastasis. The purpose of our study was to determine a nomogram for predicting the likelihood of NSN involvement in breast cancer patients with a SN micrometastasis. METHODS We collated 909 observations of SN micrometastases with additional ALND. Characteristics of the patients, tumours and SN were analysed. RESULTS Involvement of SN was diagnosed 490 times (53.9%) with standard staining (HES) and 419 times solely on immunohistochemical analysis (IHC) (46.1%). NSN invasion was observed in 114 patients (12.5%), whereas 62.3% (71) had only one NSN involved and 37.7% (43) two or more NSN involved. In multivariate analysis, significant predictive factors were: tumour size (pT stage < or = 10 mm or >11 and < or = 20 or >20 mm [odds ratio (OR) 2.1 and 3.43], micrometastases detected by HES or IHC [OR 1.64], presence or absence of lymphovascular invasion (LVI) [OR 1.76], tumour histological type mixed or not [OR 2.64]. The rate and probability of NSN involvement with the model are given for 24 groups, with a representation by a nomogram. CONCLUSION One group, corresponding to 10.1% of the patients, was associated with a risk of NSN involvement of less than 5%, and five groups, corresponding to 29.8% of the patients, were associated with a risk < or = 10%. Omission of ALND could be proposed with minimal risk for a low probability of NSN involvement.

Feasibility of sentinel lymph node biopsy in multiple unilateral synchronous breast cancer: results of a French prospective multi-institutional study (IGASSU 0502)

BACKGROUND To prospectively determine the feasibility of sentinel lymph node biopsy (SLNB) in preoperatively diagnosed multiple unilateral synchronous invasive breast cancers. PATIENTS AND METHODS The Interest of Axillary Sentinel Lymph Node Biopsy in Multiple Invasive Breast Cancer (IGASSU) study was a prospective multi-institutional study with initial breast surgery, SLNB, and systematic axillary lymph node dissection (ALND). Patients eligible for the IGASSU study had an operable invasive multiple synchronous tumor (MST), defined as two or more physically separate invasive tumors in the same or different quadrant. RESULTS From 1 March 2006 to 31 August 2007, 216 patients were prospectively included from 16 institutions. Of these patients, 211 were assessable. The SLNB-identified rate was 93.4% (197 of 211). The false-negative rate (FNR) was 13.6% (14 of 103) [95% confidence interval (CI) 7% to 20%], and the accuracy was 92.9% (183 of 197) (95% CI 89% to 96%). In a univariate analysis, tumor location (only external location versus other location) was the only clinicopathological factor influencing the FNR [22% (11%-33%) versus 7% (4%-10%)], even then median aggregate histological tumor size was smaller in external tumors [17 mm (range 12-80 mm) versus 34 mm (range 8-90 mm), P = 0.016]. CONCLUSION With a FNR of 13.6%, we do not recommend SLNB as a routine procedure for MST, even for small tumor.

Modified posterior pelvic exenteration for ovarian cancer.

Introduction: A modified posterior pelvic exenteration (MPE) might be needed to reach an optimal tumoral reduction. The issue of this study is to relate a multicentric experience of this kind of resection. Materials: Three hundred five patients who needed an MPE were analyzed from 9 French cancer centers. One hundred sixty-eight MPEs were performed during initial surgery (55.1%), 69 during interval surgery (22.6%), 36 after chemotherapy (11.8%), and 32 for recurrences (10.5%). Results: Three hundred two colorectal anastomoses were realized with a protective stoma in 59 (19.5%) of cases and a stoma closure in 76.5% (51). The rate of functional anastomosis was 96% (290/302). Complications occurred in 26.9% (82/305) of the patients, with a fistula in 25 (8.2%). The reintervention rate was 8.8% (27/305). The median length of hospitalization was 15 days. The absence of a macroscopic residual disease was obtained in 58% (173/303) of cases. A residual disease that was 1 cm or smaller was observed in 73 cases (24%) and 2 cm or smaller observed in 36 (11.9%). Postoperative chemotherapy was started with a median time of 32 days. Postoperative death occurred in 1 patient (0.33%). The survival rates were 62.7% and 27.6% at 2 and 5 years, respectively. With a multivariate analysis, the 2 significant prognostic factors were residual disease and time of surgery (P < 0.0001). Conclusions: A rectal invasion should not be an obstacle to reach the aim to obtain a macroscopic minimal residual disease or, if possible, the absence of one. An MPE is useful in those cases to reach optimal cytoreduction, with comparable results whatever the patients age is. A temporary protective stoma should be considered only exceptionally.

Combined laparoscopically harvested omental flap with meshed skin grafts and vacuum-assisted closure for reconstruction of complex chest wall defects.

Background:Chest wall reconstruction after radiation damage is a challenge in oncologic and plastic surgery. The defect can be reconstructed with laparoscopically harvested omental flap and meshed skin grafts. Our aim was to evaluate the use of vacuum-assisted closure (V.A.C.) in combination with laparoscopically harvested omental flap and meshed skin graft for treating these complex wounds. Methods:Between October 2003 and December 2004, 11 patients underwent a chest wall reconstruction with laparoscopic omentoplasty and V.A.C. treatment of severe chest wall radionecrosis after breast cancer treatment (n = 10) or for locally advanced breast cancer treated first by irradiation (n = 1). Results:Laparoscopic harvesting was uneventful in 10 cases. One patient had a laparoscopic transverse colic resection because of a middle colic artery injury. Mean time of the laparoscopic procedure was 53 minutes (range: 35–120). Wound surface area averaged 360 cm2 (range: 80–750). The mean duration of V.A.C. treatment was 9.3 days (range: 6–16). Nine patients showed primary wound healing without adverse events. Complications occurred in 3 patients. One developed a pulmonary infection and died after healing during the postoperative course. One presented a partial flap loss, leading to delayed healing after 45 days. One patient with severe radiation damage and a complete brachial plexus paralysis required a shoulder amputation after an extensive necrosis. All but 1 patient are alive and resumed their normal daily activities. Conclusions:Combination of laparoscopic omentoplasty and V.A.C. can successfully be used for reconstruction of complex chest wall radiation damage.

Factors predicting the sentinel node metastases in T1 breast cancer tumor: an analysis of 1416 cases.

AIM To determine the factors associated with the metastatic involvement of sentinel lymph node (SLN) biopsy in patients with early breast cancer. STUDY DESIGN This was a retrospective study of patients with T1 invasive breast cancer who underwent SLN biopsy at Claudius Regaud Institute between January 2001 and September 2008. RESULTS 1416 patients were recruited into this study. SLN metastases were detected in 368 patients (26%). Younger age, tumor size and location, histological type, nuclear grade, and lymphovascular invasion appear to be significant risk factors of SNL involvement. In multivariate analysis, tumor size, tumor location, histological type and lymphovascular invasion are significant factors. When the tumor size is >20 mm, the OR is 6.6 compared to a T1a tumor (3.145-14.175, p<0.001, confidence interval 95%). When the tumor is found in the inner quadrant, the risk of SLN involvement is reduced compared to external locations with an OR of 0.53 (0.409-0.709, p<0.001, confidence interval 95%). Non-ductal/lobular compared to infiltrative ductal cancer have a lower risk of SLN involvement with an OR of 0.423 (0.193-0.927, p<0.03, confidence interval 95%). Lymphovascular invasion increase the risk of positive SLN with an OR of 2.8 (1.9-4.1, p<0.001, confidence interval 95%). CONCLUSION It appears reasonable to avoid axillary lymph node dissection in older patients with T1a tumors of good histopathological type and in the absence of lymphovascular invasion.

Les mélanomes du tronc ont-ils un pronostic individualisable? À propos d'une série de 77 cas

AIMS Truncal melanoma is characterized by lymphatic drainage to single or multiple basins, affecting different anatomic regions. Since the introduction of sentinel lymph node biopsy (SLN) several questions have aroused in regard to this particular drainage. However, published data available on SLN anatomic distribution and on the prognostic value of multiple-nodal drainage is controversial. The aim of the present study was to provide further evidence based on our own experience. METHODS From January 2003 through December 2006, a total of 77 melanoma of the trunk were diagnosed and treated at our institution. Systematic lymphoscintigraphy was obtained for all patients, followed by removal of SLN and in-transit lesions. When SLN metastasis was detected a complete lymphadenectomy was performed and adjuvant immunotherapy with interferon was administered. Statistical analysis was performed using Chi2 and Fishers exact tests for categoric variables and Kaplan-Meier curves for survival. RESULTS Lymphoscintigraphy visualized 70.1% of single and 28.6% of multiple-nodal drainage (uninterpretable data). The rate of SLN macrometastasis ranged from 7.8 to 14.3%. Micrometastasis were found in 6.5% of patients. Positive SLN were discovered in 12.9% (17/54) of single-nodal and 18.6% (2/22) of multiple-nodal drainage. Melanomas topography significantly influenced lymphatic drainage distribution, with 28.6% of single-nodal and 71.4% of multiple-nodal drainage for central tumors, and with 79.4% of single-nodal and 19.1% of multiple-nodal drainage for lateral tumors. The group with multiple-nodal drainage was associated non-significantly with primary tumor ulceration, 39 vs 24%. The Breslow thickness did not associate to multiple-nodal drainage. There were no differences in the rate of lymph node metastasis between both groups, 18 vs 12.9%. After a median follow-up of 47 months, prognosis was similar regardless of SLN status, with 80.3% overall survival for negative SLN and 81.3% for positive SLN. Single or multiple drainage did not affect survival rates significantly, with 84% survival for single-nodal drainage and 95% for multiple-nodal drainage. CONCLUSIONS Primary tumor location (medial location) was the principal risk factor for multi-nodal drainage: lymphoscintigraphy was the best technique for lymphatic drainage assessment. Primary tumor location with single or multi-nodal drainage did not influence the rate of positive SLN and had similar disease-free and overall survival. For us, truncal melanoma has not a different prognosis than melanoma of extremities.

Place du ganglion sentinelle dans les carcinomes canalaires in situ étendus traités par mastectomie. Résultats de Protocole CINNAMOME

La recherche du ganglion sentinelle (GS) dans les carcinomes canalaires in situ (CCIS) du sein est le plus souvent negative avec 2 % d’atteinte ganglionnaire. Cependant, il n’est pas rare en cas mastectomie realisee dans le cadre d’un CCIS diagnostique par macrobiopsie, de decouvrir sur la piece operatoire un carcinome infiltrant ou micro-infiltrant.

Ganglion axillaire sentinelle et cancer du sein de plus de 2 cm : PHRC GAS2plus

Evaluation de la technique du ganglion sentinelle (GAS) pour les cancers du sein d’une taille superieure a 2 centimetres.

Les mélanomes du tronc ont-ils un pronostic individualisable? À propos d'une série de 77 casAn individualized prognosis for truncal melanoma? A series of 77 cases

AIMS Truncal melanoma is characterized by lymphatic drainage to single or multiple basins, affecting different anatomic regions. Since the introduction of sentinel lymph node biopsy (SLN) several questions have aroused in regard to this particular drainage. However, published data available on SLN anatomic distribution and on the prognostic value of multiple-nodal drainage is controversial. The aim of the present study was to provide further evidence based on our own experience. METHODS From January 2003 through December 2006, a total of 77 melanoma of the trunk were diagnosed and treated at our institution. Systematic lymphoscintigraphy was obtained for all patients, followed by removal of SLN and in-transit lesions. When SLN metastasis was detected a complete lymphadenectomy was performed and adjuvant immunotherapy with interferon was administered. Statistical analysis was performed using Chi2 and Fishers exact tests for categoric variables and Kaplan-Meier curves for survival. RESULTS Lymphoscintigraphy visualized 70.1% of single and 28.6% of multiple-nodal drainage (uninterpretable data). The rate of SLN macrometastasis ranged from 7.8 to 14.3%. Micrometastasis were found in 6.5% of patients. Positive SLN were discovered in 12.9% (17/54) of single-nodal and 18.6% (2/22) of multiple-nodal drainage. Melanomas topography significantly influenced lymphatic drainage distribution, with 28.6% of single-nodal and 71.4% of multiple-nodal drainage for central tumors, and with 79.4% of single-nodal and 19.1% of multiple-nodal drainage for lateral tumors. The group with multiple-nodal drainage was associated non-significantly with primary tumor ulceration, 39 vs 24%. The Breslow thickness did not associate to multiple-nodal drainage. There were no differences in the rate of lymph node metastasis between both groups, 18 vs 12.9%. After a median follow-up of 47 months, prognosis was similar regardless of SLN status, with 80.3% overall survival for negative SLN and 81.3% for positive SLN. Single or multiple drainage did not affect survival rates significantly, with 84% survival for single-nodal drainage and 95% for multiple-nodal drainage. CONCLUSIONS Primary tumor location (medial location) was the principal risk factor for multi-nodal drainage: lymphoscintigraphy was the best technique for lymphatic drainage assessment. Primary tumor location with single or multi-nodal drainage did not influence the rate of positive SLN and had similar disease-free and overall survival. For us, truncal melanoma has not a different prognosis than melanoma of extremities.